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Supervising Family Therapy Trainees in Primary Care Medical Settings: Context Matters

Posted on: Sunday, 15 January 2006, 03:03 CST

By Edwards, Todd M; Patterson, Jo Ellen

The purpose of this article is to identify and describe four essential skills for effective supervision of family therapy trainees in primary care medical settings. The supervision skills described include: (1) Understand medical culture; (2) Locate the trainee in the treatment system; (3) Investigate the biological/ health issues; and (4) Be attentive to the self-of-the-therapist. Recommendations are also made to help supervisors become better prepared for the questions. medical family therapy trainees bring to supervision.

Since the publication of Medical Family Therapy (McDaniel, Hepworth, & Doherty, 1992), there has been an eruption of interest in the integration of family therapy and medicine, which has been noticeably apparent in marriage and family therapy (MFT) training programs. Many accredited MFT programs are starting courses, creating specialized tracks, and developing full curricula devoted to the practice of family therapy in medical settings. Once exposed to the diverse problems and patients in medicine and the effectiveness of a collaborative care model (Blount, 2003), students flock to training opportunities that set the stage for a career committed to practicing alongside medical professionals and helping patients and families coping with a variety of health-related concerns.

As more family therapy students pursue clinical training in medical settings, an important question emerges: What specialized training are supervisors receiving in medical family therapy supervision? Although much has been written about the skills needed by medical family therapists (Blount, 1998; McDaniel & Campbell, 1996,1997; McDaniel et al., 1992; Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002; Rolland, 1994; Seaburn, Lorenz, Gunn, Gawinski, & Mauksch, 1996), little attention has been given to the skills supervisors need when training medical family therapists.

Just as the context of a client is important to appreciate in therapy (e.g., family interactions, neighborhood, community), we believe the context of training (e.g., clinical setting and characteristics) is critical for the supervisor to understand. This is especially important for contexts that are less familiar to family therapists, such as the context of medicine. Similar to the challenges in many graduate psychology training programs (Pisani, Berry, & Goldfarb, 2005), family therapy training programs are often separated physically, administratively, and culturally from medical settings. Further, it is rare to find family therapy supervisors with clinical or administrative experience in medical settings. Training in medical family therapy supervision has the potential to narrow this gap between family therapy and medicine and benefit therapists-in-training.

In this article, we describe four essential skills for supervisors of students training in primary care medical settings. The clinical skills needed by family therapists in primary care have been discussed elsewhere and are beyond the scope of this paper (Edwards & Patterson, 2003; Gawinski, Edwards, & Speice, 1999; McDaniel, Doherty, & Hepworth, 1997; Seaburn et al., 1993). Although the supervision skills described here could apply to other medical settings, such as inpatient settings, they are most relevant for primary care.

TRAINING FAMILY THERAPISTS IN MEDICAL SETTINGS

To date, the literature on medical family therapy training has focused on the skills needed by trainees. Several excellent articles have been written on the experiences of trainees and supervisors in medical family therapy internships (Gawinski et al, 1999; Hepworth, Gavazzi, Adlin, & Miller, 1988; Muchnick, Davis, Getzinger, Rosenberg, & Weiss, 1993). In addition, models on the joint training of family therapists and family physicians have provided guidance for family therapy educators (Edwards, Patterson, Grauf-Grounds, & Groban, 2001; Patterson, Bischoff, Scherger, & Grauf-Grounds, 1996; Patterson, Bischoff, & McIntosh-McIntosh-Koontz, 1998). In an editorial on training for collaboration, McDaniel et al. (1997) describe the fundamental skills needed by family therapy trainees, which include conceptual skills (e.g., biopsychosocial theory), clinical skills (e.g., the ability to partner with patients, families and medical professionals) and personal awareness skills (e.g., health and illness countertransference).

How do MFT graduate programs, specifically the supervisors in MFT programs, teach the fundamental clinical skills necessary in medical settings? The required curriculum content of accredited MFT programs provides a glimpse into how MFT faculty prepare students for work in medical settings. The current curriculum standards from the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE, 2003, version 10.3) require training in collaboration between disciplines, the effects of physical health on families, psychopathology, and psychopharmacology. These are significant content areas for the preparation of trainees to work in medical settings. However, research has raised questions about how this content is presented.

Denton, Patterson, and Van Meir (1997) report that most MFT training programs teach their students to use the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000), for example, but primarily for pragmatic reasons, rather than to promote an integrative paradigm. Distrust of DSM criteria by family therapy trainees and educators can contribute to problems in communication with physicians. The mental health assessment training of primary care physicians usually includes recognition of clinical syndromes, such as depression and anxiety. Their language and diagnostic criteria are based on DSM nomenclature and conceptualization. If a family therapy trainee does not know the DSM or is reluctant to use the DSM language in describing a client's problems, he or she may be handicapped in efforts to collaborate.

The lack of information on the skills needed by medical family therapy supervisors and questions about the ways in which supervisors adapt their approaches to medical settings are the impetus for this article. Understanding the medical context of a trainee's clinical experience is an important component of effective supervision. The supervision skills described below are a first step towards articulating the issues for supervising trainees in primary care.

SUPERVISING MFT TRAINEES IN PRIMARY CARE: FOUR ESSENTIAL SKILLS

The essential skills described next are intended to emphasize areas that need attention in family therapy supervision with trainees in primary care medical settings. They are not offered in any order of importance, nor are they exhaustive. Possessing these skills alone does not qualify someone to supervise MFT students in primary care medical settings. Through the American Association for Marriage and Family Therapy (AAMFT)-Approved Supervisor designation, the field of family therapy defines competent supervision and describes the process of demonstrating competent supervision. Being an Approved Supervisor provides a general foundation for the skills described below.

Understand Medical Culture

The biggest challenge trainees face in medical settings is getting acclimated to the culture. If trainees have had clinical experience prior to their work in a medical setting, it is likely that they practiced in an environment that included an office with minimal noise and interruption, and office space that is typically devoted for therapy. Medical settings are vastly different than traditional mental health settings.

Space and time are at a premium in most medical settings. Exam rooms often double as therapy rooms, which can present challenges when meeting with multiple family members. Further, interruptions from medical staff are not uncommon (e.g., knocks on the door; announcements on the overhead speaker). A general chaos is present, with health care professionals rushing from one patient to the next.

The primary care medical environment dictates a different role for family therapy trainees. In addition to seeing patients and their families in typical hour-long therapy sessions, trainees are often asked by health care professionals for immediate help with patients who present with a variety of needs. For example, a trainee may be asked to assist a physician seeing a patient with suicide ideation.

In addition, trainees must also get acclimated to a new language. The language of family therapy, which includes terms such as parentification, enmeshment, and circular causality, is foreign to health care professionals and coexists with another language, including myocardial infarction and irritable bowel syndrome. Trainees quickly learn that they need to adapt their methods of discussing clients with other medical professionals and learn the language of primary care medicine to construct chart notes. Trainees quickly learn that they need to give brief reports to busy physicians.

In addition to space, time and language, another significant cultural difference that trainees notice is paradigm. Although segments of family medicine strongly advocate for a family-oriented approach to health care (McDaniel, Campbell\, Hepworth, & Lorenz, 2005), many primary care settings are individually focused, with different family members seeing different doctors. Patterson, Edwards, and Wilson (2002) report that the vast majority of referrals in one family medicine setting were for individuals experiencing depression and anxiety. Referrals for individual therapy are frequently sent with limited information and requests for "stress management" or "cognitive-behavioral therapy." Trainees may need help applying systems thinking in situations different than those they were exposed to in their coursework. They also need help advocating for a family approach in settings that often ignore the effects of illness on the family and the role family members can play in contributing to improved health (McDaniel et al., 2005).

Another difference between primary care and mental health settings is the patient's motivation for therapy. Although many mental health settings provide services for involuntary clients, most clients voluntarily contact the mental health clinic and request services. In primary care, the physician is usually the person suggesting counseling services. Often, patients do not follow through on a physician's referral. In a study of referrals in one medical clinic over an 8-month period, Reust, Thomlinson, and Lattie (1999) found that the no-show rate for mental health referrals was 33%. The most common reasons for not keeping appointments were financial issues, transportation difficulties, illness-related reasons, motivation, and previous negative experiences with a mental health professional.

When patients do follow through on a physician's referral, therapy and the role of a therapist is sometimes foreign. Patients may report that they "have to come" to therapy so their doctor will simultaneously provide psychotropic medication. Not only are these patients unfamiliar with therapy, they look to the therapist to assume responsibility for the therapy. Trainees already feel a pressure to perform; some patients in primary care exacerbate this pressure. However, the client without experience in therapy, who would never darken the therapist's door without a nudge from her personal physician, can sometimes become the most rewarding and grateful client.

Clients in older adulthood, who historically have a sense of personal propriety and privacy, match this description of the inexperienced client. In fact, recent research on collaborative care suggests that offering psychotherapy to older adults in a primary care setting is far more effective than the traditional model, which assumes that older adults will seek mental health services from a mental health clinic (Brace, Ten Have, & Reynolds, 2004; Unuetzer, Katon, & Callahan, 2002). Supervisors can help trainees to appreciate the differences between a 30-year-old, depressed mother seeking traditional mental health treatment for her depression and a 70-year-old recent widower who "is having a little trouble sleeping" and seeks help from his physician.

Supervisors will benefit from understanding medical culture in general and the medical setting in particular. Just as student therapists need to accommodate to the culture of medicine, so do supervisors. Ideally, supervisors acculturate to medical settings though their own clinical work in medical settings. Because many supervisors have not had these opportunities, they need to learn about medical culture through immersion experiences and continuing education. Whether a supervisor has clinical experience in medical settings or not, gaining first-hand knowledge of a supervisee's medical setting is a necessity. The following example helps to illustrate a process of accommodation to medical culture.

Dr. Smith, a faculty member in a family therapy master's program, was supervising Jessica, a student completing her field placement in a family medicine clinic affiliated with a medical school in a large metropolitan city. Dr. Smith did not have any work experience in medical settings, nor had she supervised anyone training in a medical setting. After three meetings with Jessica, Dr. Smith noticed that the names of medical staff (both clinical and administrative) were coming up frequently in supervision. Further, she was curious why her supervisee was having to see clients in tiny exam rooms, with family members occasionally having to sit on exam tables. Because of her unfamiliarity with Jessica's field placement site, she decided to contact Jessica's on-site supervisor, Dr. Collins, a family therapist and director of behavioral science education for a family medicine residency. Dr. Smith explained some of the differences she was noticing in supervision with Jessica. Dr. Collins attempted to respond to Dr. Smith's questions, such as why a designated counseling room was not available, and encouraged Dr. Smith to participate in a few activities in their setting to get more familiar with the staff and medical culture. Dr. Smith was invited to: (1) attend lectures presented by medical staff; (2) shadow a physician during a morning patient session to increase her knowledge of a physician's work; and (3) schedule supervision with Jessica in designated space at the medical setting. On one occasion, a physician sharing care with Jessica participated in part of a supervision meeting.

Learning about medical culture is similar to learning about any culture (Falicov, 1988); it requires curiosity, time spent in that culture, and interactions with members of that culture (McDaniel & Hepworth, 2004).

Trainees will come to supervision with a long list of questions about what they observed in their settings (e.g., physical wounds, uncertain diagnoses, physical pain associated with illness) and with whom they interacted (e.g., doctors, nurse practitioners, office staff); they benefit from informed, direct recommendations in response to these questions. A failure to understand and acknowledge these issues can diminish the quality of training and potentially damage the relationship with the training site, which undoubtedly affects the beginning therapist's training experience and the patients served.

Locate the Trainee in the Treatment System

One key reason that physicians value family therapy is the therapist's accessibility. When a therapist is on site, physicians can make immediate referrals to a person they know and expect frequent contact and communication (often absent when referring patients to a foreign, distant mental health clinic). Also, the patient will be seen in the doctor's office; this physical proximity facilitates the treatment triangle-physician, therapist, and patient (including the patient's family). However, three-way communication does not automatically occur. It is not uncommon to hear physicians say that they sent a referral to the on-site therapist, but never heard whether the patient was contacted. Further, it is possible for therapy to proceed without any communication between the therapist and referring physician. If a supervisor is not aware of the critical importance of the therapist-physician relationship, it will be difficult for the trainee to learn this lesson on her own.

There are two obstacles to getting these relationships established. First, physicians can intimidate trainees. We have often heard trainees express concerns that they are "bothering the doctor because she looks so busy." In addition, a trainee can be apprehensive about talking with a physician, because the trainee is afraid that she will struggle to communicate her concerns. Therapists-in-training already struggle with confidence (Bischoff, Barton, Thober, & Hawley, 2002); medical settings can exacerbate this struggle. In contrast, trainees are often cast in the role of psychosocial expert, which can feel daunting, particularly when they do not feel like experts. Students need help overcoming their intimidation and communicating their knowledge base to contribute to the health care team.

Even when intimidation is absent, some trainees struggle with making connections with physicians, which is often the result of "parallel play." In other words, trainees are referred clients and have an ongoing working relationship with clients, but limit their contact with their patients' physicians. Each professional treats the patient independently, which Doherty, Baird, and Becker (1987) refer to as practicing in a split biopsychosocial model. The physician and therapist work in the same location but have limited or no interaction.

Two supervision questions to assess the trainee's interactions with the health care team include: (1) Who referred the patient and/ or who is the patient's doctor? and (2) What is the doctor's perspective on the patient's presenting problem? If trainees are unable to regularly respond to these questions with substantive responses, it may be important to further assess a trainee's efforts to collaborate with the health care team.

A second obstacle to collaboration is confidentiality, particularly regarding documentation. Writing in the patient's chart can present confidentiality dilemmas: Should there be two charts (one medical, one mental health), one chart with section dividers for mental health and medical health, or one chart with physician and therapists notes intermingled? Answers to these questions vary depending on the medical setting and the changing laws regarding confidentiality. However, supervisors must be aware of the dilemmas that medical family therapists face, compared with family therapy in traditional mental health settings. Collaboration implies sharing information; confidentiality encourages protecting information.

Confidentiality in primary care has been addressed extensively elsewhere (Bischof, Lieser, Taratuta, & Fox, 2003; McDaniel et al., 1992; Patterson et al., 2002; Seaburn et al., 1996), but it deserves restating that physicians and mental health professionals have contrasting views on p\atient privacy. The medical approach to confidentiality is rooted in a commitment to team care. Medical professionals expect confidentiality to be protected within the team, but not from the team, although HIPAA is changing this practice. Mental health professionals are taught to share information with no one. If information is to be shared, it is only with informed consent of the patient. Even with a release of information, therapists, in general, are accustomed to providing less rather than more information. The greater openness among team members in medical settings can be unsettling for trainees who have been immersed in the clearly stated rules of confidentiality espoused by professional mental health organizations and licensing boards. Supervisors are veterans of these rules and can help their trainees reconcile these apparent polarized positions.

Working in a medical setting need not mean abandonment of confidentiality. However, trainees need help balancing the protection of client privacy and the mission of collaborative care that emphasizes shared decision making. This balance is often achieved by encouraging trainees to discuss with patients the unique aspects of providing mental health services in a medical setting and the benefits of regular contact between a therapist and a physician. This discussion includes an understanding of what is acceptable and unacceptable to share and a signed consent form. If case notes are shared, supervisors can help trainees chart with their audience in mind (the healthcare team and patient), while also recording important information. Patients are typically pleased with the idea that their health care providers are talking to each other. Without appropriate guidance from a supervisor, trainees may apply the rules of confidentiality in a restrictive manner, which will shut down collaboration and frustrate the referring physicians.

Supervisors need to help trainees develop and maintain relationships with physicians. The trainee is sharing care. Promoting teamwork is associated with better continuity of care, access to care, and patient satisfaction (Grumbach & Bodenheimer, 2004). The notion of sharing care is very different than therapy in nonmedical settings in which the therapist is often the only on- site professional involved in the care of a particular client. The following example helps to illustrate the importance of close collaboration.

Jordan, a first-year MFT trainee, arrived in supervision expressing concerns about a client he was seeing at an urban primary care clinic. According to Jordan, his client, Mrs. Fimbres, a 52- year-old Hispanic woman, was referred to him by her family physician for treatment of anxiety and depression. At the first session with Mrs. Fimbres and her adult daughter, Jordan learned that Mrs. Fimbres moved from Mexico City to the United States 2 months ago. According to her daughter, Mrs. Fimbres was hospitalized in Mexico for "being out of control," which included instances of Mrs. Fimbres "wandering the streets, sometimes without her clothes." Mrs. Fimbres was taking medication for Tourette's Syndrome, which had been diagnosed when she was 33. In supervision, Jordan stated that her symptoms, which included apparent psychosis, suicidal ideation, and verbal abuse of others, did not appear to be explained by Tourette's alone. Jordan's supervisor asked him if he had reviewed Mrs. Fimbres' medical chart and talked with the referring physician. Jordan stated that he had not reviewed the physician's notes nor had he spoken with the physician. In his review of the notes, Jordan learned about the results of a physical exam. Mrs. Fimbres' exam showed evidence of dyskinesia; the physician reported that her symptoms were likely due to Haldol prescribed by another medical provider. The physician changed her medication, which was gradually a helpful change for Mrs. Fimbres. Next, Jordan spoke with the physician to summarize his work and concerns and inquired about the physician's impressions and treatment decisions.

As coordinator of a patient's health care, the physician should be viewed as an important part of the system that deserves acknowledgement and active involvement. Knowledge about the physician's perceptions, expectations, and ongoing involvement is an important part of therapy in medical settings. In addition, physicians are often viewed as the person legally responsible for coordination of the patient's overall care. Their liability may be greater than the therapist's if something goes awry for their shared patient. Supervisors should be aware of these legal issues and help the therapist-in-training demonstrate respect for the physician's increased risk.

Investigate the Biological/Health Issues

A large majority of the patients seen by students in primary care are coping with some kind of health problem (Gawinski et al., 1999; McDaniel et al., 1992; Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002). In family medicine, these health problems include chronic pain, diabetes, irritable bowel syndrome, and chronic mental illness, such as depression and anxiety. They also are commonly taking a variety of medications. Because students are accustomed to addressing familiar mental health or relationship problems, they frequently struggle with questions about how to be helpful in areas that appear "biological." These struggles may lead trainees to ignore the clients' health problems.

Both supervisors and trainees may be reluctant to consider these biomedical issues because of several beliefs: (1) They are not trained to assess and treat medical issues; (2) the assessment of medical issues is legally outside their scope of practice; and (3) therapists believe that the physician will care for the medical part of the patient. However, in reality, a patient's biomedical and psychosocial struggles are intertwined. In addition, many biomedical problems present as psychosocial problems or vice versa.

Supervisors can ask questions and help trainees consider the role of medical issues and their impact on an individual and family. Examples of these questions include:

* What physical health problems are present in the family?

* What is the history of health problems in the family?

* How is the patient coping with health problems?

* How is this affecting the doctor-patient relationship?

Supervisors can also encourage trainees to ask questions of the physician when they do not understand the biomedical aspects of a patient's health concerns. Further, the trainee can ask the patient for his subjective experience of the illness (Kleinman, 1988).

In addition to these questions, supervisors can use the Internet as a resource during supervision. The Internet has made it easy for therapists to gain rudimentary knowledge about almost any medical problem. Supervisors can take time during supervision to do a quick Internet search for patient education material, evidence-based treatments or any other educational sources. Because of the varying quality and accuracy of information on the Internet, we make sure that students search reputable sites, such as the Journal of the American Medical Association, the National Institutes of Health, and other well-known sites. Just as supervisors encourage trainees to be curious about family dynamics, they can also encourage trainees to be curious about biomedical illnesses and their effects on patients' lives. The following case helps illustrate the role of health and illness in a family's life.

The Martinez family (Hector, 9-year-old son; Sara, mother; Maria, aunt/sister) arrived for counseling services at an urban free clinic and reported the following concerns to a MFT trainee: Maria stated that Sara has significant problems with memory and "hit" Hector for no apparent reason. For example, when Hector tried to take a piece of food from Sara's plate, she immediately reacted by slapping him in the face. She also reported incidents of Sara pulling Hector's hair. Sara's behavior had been a concern for several months following an incident of domestic violence involving her ex- husband. She was hospitalized for 2 weeks in Mexico City for a head injury that left her in a coma. Prior to this incident, Sara had been hospitalized for overdosing on pills and alcohol. When asked for her perspective on the problem, Sara stated that she was here to apply for a job and did not think there was anything wrong with her or her family.

The trainee took a break from her session and consulted with her supervisor. The trainee started her presentation with general concerns about the parent-child relationship and specific concerns about child abuse. These concerns resulted in a report to Child Protective Services. The supervisor reflected these concerns and punctuated their importance. The supervisor then initiated a more focused conversation about the mother's medical status; both the supervisor and trainee agreed that Sara needed immediate attention and arranged a medical evaluation for the same afternoon. An evaluation by a double-boarded family physician/psychiatrist concluded that Sara had a history of hypoxic brain injury with consequent significant cognitive impairment, which explained her impulse control problems in her role as a parent. Sara was given Trazedone to treat her difficulties with impulse control. The trainee continued to work with the family to understand the head injury and its effects on individuals and families, as well as dealing with the emotional after effects of the domestic violence.

In the spirit of being helpful, the trainee could have focused her attention exclusively on the family conflict. The supervisor reflected the importance of the family conflict but accentuated the relevance of the medical concerns, which resulted in the inclusion of a physician on the health care team.

Be Attentive to the Self-of-the-Therapist

All training settings provide their fair share of stress a\nd anxiety, especially when trainees are new in the role of therapist (Bischoff & Barton, 2002; Bischoff et al., 2002). Unique stressors in primary care can include: (1) professional isolation and (2) feelings of helplessness and loss related to caring for patients and families coping with serious illness and death (Gawinski et al, 1999). Each of these stressors can be present in any setting, but they commonly occur in medical settings.

As was mentioned earlier, primary care settings are busy and fast- paced. Trainees can feel alone in this crowded space. Trainees in primary care settings are often the only mental health professional, or one of only two or three mental health professionals, on staff. Much of the work in primary care is committed to caring for patients' physical health problems. Mental health is valued but sometimes considered peripheral to the daily care of patients' biomedical illnesses. Marriage and family therapy trainees can feel like outsiders. A trainee might need emotional support to cope with a physician who rejects overtures to collaborate or a patient who expects the therapist to cure her chronic pain. However, support can sometimes be hard to find in a busy medical office. Feelings of isolation ideally diminish with time but deserve questioning and conversation in a practicum, internship, or fellowship.

In addition to professional isolation, a trainee is often exposed to the emotional and physical pain associated with a variety of patient illnesses, such as fibromyalgia, diabetes, congestive heart failure, cognitive disorders, and others. Further, it is not uncommon for patients to die during the course of a trainee's practicum. Trainees must help family members to cope with grief and loss, as well as face their own feelings of grief and loss (Rolland, 1990). Although these cases can be stimulating, they also take an emotional toll on trainees.

Understanding a trainee's family illness history is critical in medical family therapy supervision as the supervisor and trainee attempt to understand the bidirectional effects of a patient's illness and the illness narratives of a trainee (McDaniel et al., 1997). The following example helps illustrate this point.

Brian, a MFT trainee, arrived for supervision with the following presentation: Dr. Barrett, a family physician, invited Brian to participate in the care of Beverly, a patient in the Intensive Care Unit (ICU). Beverly just had another heart attack and was becoming increasingly disabled-because of limited cardiac function and uncontrolled diabetes. Brian made his first visit to the ICU as a family therapist. His previous immersion in the ICU occurred when he was 10 years old. His father suffered from complications related to Type-I Diabetes and spent much time in the ICU during the last year of his life. When Brian arrived at supervision, Beverly had returned home, and was adapting to a variety of lifestyle changes and a heightened sense of her mortality. Working with Beverly raised many questions for Brian that he had not considered earlier. He imagined his father in Beverly's situation and reflected on the following questions: "If my father had returned from the hospital, would he be as disabled as Beverly? How would his doctor care for him? How would his doctor involve my family in my father's care, and how would she/ he help us to prepare for my father's death?" Following discussions in supervision, it was decided that Brian would call Beverly's sister, Daisy, and inquire about the kind of support Daisy could give her sister now that she was home. Daisy assured Brian that she would do whatever she could to help Beverly. Even though Beverly was at home, everyone (physicians, sister and Beverly) knew her health would probably continue to deteriorate. She would not return to the hospital if things became grave. She wanted to die at home. In supervision, Brian talked about the distance he felt from his father during his illness and hospital stays. His family did not openly discuss his father's illness, which included silence about inevitable death and how the family would spend their remaining moments together. Brian acknowledged that his approach to the care of Beverly and her family was based partly on his systemic perspective and partly on his experience in his family, which he wished had been different. Brian and his supervisor had a supportive discussion about monitoring expectations of clients and the need to stay focused on what this particular family needed, rather than what Brian needed as a 10-year-old boy, with the understanding that in some ways the needs may be similar.

Supervisors need to attend to the self-of-the-therapist issues presented or suggested by their trainees. Many therapists have family-of-origin issues activated during the course of their work. Trainees may be attracted to medical family therapy because of their own experiences with illness and medical care. These feelings are important to explore in the trainee's work.

RECOMMENDATIONS

Supervisors play a pivotal role in transitioning trainees to medical settings and helping them to adjust to the twists and turns of clinical work, both with clients and their medical colleagues. In this section, suggestions are provided to help supervisors become better prepared for the questions medical family therapy trainees bring to supervision.

1. Shadow a physician. An effective way to get quickly immersed in medical culture is to shadow a physician in an outpatient or inpatient setting. Observing the physician interact with patients gives a supervisor a better understanding of the problems presented in a particular setting. More important, it provides a glimpse in to the daily work life of a physician and can give a supervisor an appreciation for the differences between traditional mental health and medical settings. When looking for shadowing opportunities, academic medical settings are a good place to start.

2. Visit the medical setting. Visiting the medical setting where students are placed is important at the beginning of an internship and throughout a trainee's internship. A supervisor could visit the setting for a number of reasons, including live or case report supervision and to attend lectures on a variety of topics. Such contact allows the supervisor to know the key players interacting with the trainee and be known by these same key people. It is not enough to just know the on-site family therapy supervisor. Physicians will hopefully interact frequently with family therapy trainees and occasionally serve as cross-disciplinary supervisors. Supervisors need to know the professionals that trainees depend on in their internship settings.

3. Read the foundational medical family therapy texts and journals. The Appendix provides a list of key books and journals devoted to the practice of family therapy in medical settings.

4. Attend multidisciplinary conferences. The Collaborative Family Healthcare Association (CFHA), The Society of Teachers of Family Medicine (STFM), and Society of Behavioral Medicine (SBM) organize conferences focused on families in health care and multidisciplinary treatment in medical settings. Family therapists who work as behavioral scientists in family medicine residency programs regularly attend the Families and Health Care Conference sponsored by STFM.

5. Have access to resources on pharmacology. A common way in which therapists and physicians interact is when they are both treating the same problem(s) but with different tools. For example, the patient is being treated for diabetes and family conflict. Generally, the therapist offers family therapy and psychoeducation and the physician offers medication, health education, and ongoing medical care.

Having access to resources that provide information on medications taken by particular patients can facilitate collaboration. Completing a course or reading recent books on psychopharmacology could be especially useful. Often, physicians are willing to educate therapists about why a particular drug is chosen, how the drug choice might be modified and what the physician is watching for-in terms of both positive and negative effects of the medication.

FINAL THOUGHTS

The training period of a young professional's life is ideal for developing attitudes and habits that are conducive to collaboration with professionals from multiple disciplines. Unstated assumptions and hidden agendas about other disciplines can be addressed directly and indirectly while working side-by-side with medical professionals. New professionals can experience their limits and the strengths of other disciplines in interdisciplinary training settings.

Borrowing from the nomenclature of developmental psychology, supervisors are in the privileged position of working with trainees during a critical period for imprinting (Patterson, 2001). Trainees look to their supervisors for instruction, reflection, and modeling. A supervisor's philosophy and approach to interdisciplinary collaboration and training helps set the stage for a trainee's career. Because context is such an important part of medical family therapy practice, supervisors trained in systems thinking are ideally positioned to help trainees apply systems thinking to the biopsychosocial needs of their patients, as well as the larger systems issues outside of the therapy room.

REFERENCES

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: Author.

Bischoff, R. J., & Barton, M. (2002). The pathways toward clinical self-confidence. American Journal of Family Therapy, 30, 231-242.

Bischoff, R. J., Barton, M. B., Thober, J., & Hawley, R. (2002). Events and experiences impacting the development of clinical self- confidence: A study of the first year of client contact. Journal of Marital and Family Therapy, 28, 371-382.

Bischof, G. H., Lieser, M. L., Taratuta, C.G., & Fox, A. D. (2003). Power and gender issues from the voices of medical family therapists. Journal of Feminist Family Therapy, 15, 23-54.

Blount, A. (1998). Integrated primary care: The future of medical and mental health collaboration. New York: Norton.

Blount, A. (2003). Integrated primary care: Organizing the evidence. Families, Systems and Health, 21, 121-134.

Bruce, M. L, Ten Have, T. R., & Reynolds, C. F. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. Journal of the American Medical Association, 291, 1081-1091.

Commission on Accreditation for Marriage and Family Therapy Education. (2003). Manual on accreditation, version 10.3. Washington, DC: American Association for Marriage and Family Therapy.

Denton, W. H., Patterson, J., & Van Meir, E. S. (1997). Use of the DSM in marriage and family therapy programs: Current practices and attitudes. Journal of Marital and Family Therapy, 23, 81-86.

Doherty, W. J., Baird, M., & Becker, L. (1987). Family medicine and the biopsychosocial model: The road toward integration. Marriage and Family Review, 10, 51-70.

Edwards, T. M., & Patterson, J. (2003). A 'golden girl' tarnishied: Amplyifying one patient's (and family's) voice through collaborative care. Journal of Feminist Family Therapy, 15, 75-88.

Edwards, T. M., Patterson, J., Grauf-Grounds, C., & Groban, S. (2001). Psychiatry, MFT, & family medicine collaboration: The Sharp behavioral health clinic. Families, Systems and Health, 19, 25-36.

Falicov, C. J. (1988). Learning to think culturally. In H. A. Liddle & D. C. Breunlin (Eds.), Handbook of family therapy training and supervision (pp. 335-337). New York: Guilford Press.

Gawinski, B. A., Edwards, T. M., & Speice, J. (1999). A family therapy internship in a multidisciplinary healthcare setting: Trainees' and supervisor's reflections. Journal of Marital and Family Therapy, 25, 469-485.

Grumbach, K., & Bodenheimer, T. (2004). Can health care terms improve primary care practice? Journal of the American Medical Association, 281, 1246-1251.

Hepworth, J., Gavazzi, S. M., Adlin, M. S., & Miller, W. L. (1988). Training for collaboration: Internships for family therapy students in a medical setting. Family Systems Medicine, 6, 69-79.

Kleinman, A. (1988). The illness narratives: Suffering, healing and the human condition. New York: Basic Books.

McDaniel, S. H., & Campbell, T. L. (1996). Editorial: Training for collaborative family healthcare. Families, Systems and Health, 14, 147-150.

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McDaniel, S. H., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005). Family-oriented primary care (2nd ed.). New York: Springer.

McDaniel, S. H., Doherty, W. J., & Hepworth, J. (1997). The shared experience of illness: Stories of patients, families, and their therapists. New York: Basic Books.

McDaniel, S. H., & Hepworth, J. (2004). Family psychology in primary care: Managing issues of power and dependency through collaboration. In R. G. Frank, S. H. McDaniel, J. H. Bray, & M. Heldring (Eds.), Primary care psychology (pp. 95-112). Washington, DC: American Psychological Association.

McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books.

McDaniel, S. H., Doherty, W. J., & Hepworth, J. (1997). The shared experience of illness: Stories of patients, families, and their therapists. New York: Basic Books.

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Patterson, J., Peek, C. J., Heinrich, R. L., Bischoff, R. I, & Scherger, J. (2002). Mental health professionals in medical settings: A primer. New York: Norton.

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Seaburn, D. B., Lorenz, A. D., Gunn, W. B., Gawinski, B. A., & Mauksch, L. B. (1996). Models of collaboration: A guide for mental health professionals working with health care practitioners. New York: Basic Books.

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Todd M. Edwards and Jo Ellen Patterson

University of San Diego

Todd M. Edwards, PhD, and Jo Ellen Patterson, PhD, Marital and Family Therapy Program, University of San Diego.

Interviews with the following supervisors were integral to the identification of skills described in this article: Richard Bischoff, PhD, Barbara Gawinski, PhD, Claudia Grauf-Grounds, PhD, Layne Prest, PhD, and David Seaburn, PhD.

Address correspondence to Todd M. Edwards, PhD, Associate Professor and Director, Marital and Family Therapy Program, School of Leadership and Education Sciences, University of San Diego, 5998 Alcala Park, San Diego, California, 92110; E-mail: tedwards@sandiego.edu

APPENDIX

Key Medical Family Therapy Books and Journals

Books

Blount, A. (1998). Integrated primary care: The future of medical and mental health collaboration. New York: Norton.

Frank, R. G., McDaniel, S. H., Bray, J. H., & Heldring, M. (2004). Primary care psychology. Washington, DC: American Psychological Association.

McDaniel, S. H., Doherty, W. J., & Hepworth, J. (1997). The shared experience of illness: Stories of patients, families, and their therapists. New York: Basic Books.

McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical family therapy: A biopsychosocial approach to families with health problems. New York: Basic Books.

Patterson, J., Peek, C. J., Heinrich, R. L., Bischoff, R. J., & Scherger, J. (2003). Mental health professionals in medical settings: A primer. New York: Norton.

Rolland, J. (1994). Families, illness and disability: An integrative treatment model. New York: Basic Books.

Seaburn, D. B, Lorenz, A. D., Gunn, W. B., Gawinski, B. A., & Mauksch, L. B. (1996). Models of collaboration: A guide for mental health professionals working with health care practitioners. New York: Basic Books

Journals

Annals of Behavioral Medicine. Published by the Society of Behavioral Medicine.

Families, Systems and Health. Published by the Educational Publishing Foundation, part of American Psychological Association Publications.

Journal of Clinical Psychology in Medical Settings. Published by Kluwer Academic/Plenum Publishers.

Health Psychology. Published by the American Psychological Association.

The International Journal of Integrated Care. Published by Utrecht Publishing.

Journal of Medical Psychotherapy. Published by the American Board of Medical Psychotherapists and Psychodiagnosticians.

Websites

Collaborative Family Healthcare Association

http://www.chfcc.org

Counselling in Primary Care Trust

http://www.cpct.co.uk

Primary Mental Health Care Australian Resource Center

http://som.flinders.edu.au/FUSA/PARC

Society of Behavioral Medicine

http://www.sbm.org

Society of Teachers of Family Medicine

http://www.stfm.org

Copyright American Association for Marriage and Family Therapy Jan 2006

Source: Journal of Marital and Family Therapy

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