The Future of Psychology in Family Medicine

Psychology has been integral to the field of family medicine since its inception as a medical specialty in the 1960s. Psychologists and other behavioral scientists contribute to family medicine in teaching clinical skills, in defining research questions, in developing research methodology, and in creating integrated physical/mental health care delivery systems. Future developments in the field of psychology in family medicine are likely to emphasize development and evaluation of screening measures which identify mental health problems in primary care, development of early intervention for those mental health problems, and more precise measurement of process and quality of care and health outcomes. Psychologists have an important role to fulfill in educating physicians on alternatives to pharmacologic and medical interventions for common presenting problems in primary care. However, current economic forces shaping the practice of medicine may work against further enhancing the efficacy of the physician in dealing with psychosocial issues. The future role of psychology in family medicine is not yet delineated, and while the move toward parity of reimbursement for mental and physical health care delivery may enhance this collaboration, there is a need to continue to evaluate how the psychological well-being of patients is influenced in the evolution of new models of care delivery.     

The value history: A necessary family document

Patients' wishes regarding health care and dying must be taken into consideration by their physicians. Competent patients need to record directives about their care in advance of a crisis situation. The primary care physician, seeing the patient at the time of a routine office visit, is in a favorable position to explore and record attitudes. A patient's value system should be part of a medical history before hospital admission. Details in a Value History Questionnaire facilitate guiding an incompetent patient through a terminal illness in accordance with wishes previously expressed. An instrument in the form of a questionnaire was designed to record the attitudes of 200 patients regarding health care and dying. Respondents ranged in age from 17 to 84 years, and all were members of one family practice. They reacted positively to the opportunity to record their values, opinions, and wishes about their health care and process of dying. They clearly indicated that, in the absence of prior directives, they would want their families consulted about crucial decisions.     

Connections between Family Centered Care and Medical Homes of Children with Neurodevelopmental Disabilities: Experiences of Diverse Families

Cultural issues tied to race/ethnicity are important aspects in delivering medical home services to children with neurodevelopmental disabilities and their families. To better understand family satisfaction with family centered care (FCC) in medical homes of children with disabilities, this study investigated whether family race/ethnicity, in addition to parent and child characteristics, significantly influenced family perceptions of FCC in three areas: family-provider partnership, care setting practices and policies, and community coordination and follow-up. Based on the life course theory for optimizing children's developmental trajectories, examining connections between family race/ethnicity and satisfaction with health care allows for identification of strengths and weaknesses in medical home services delivery, and offers opportunities for family support and improvement in outcomes for children with disabilities. This study developed an original empirical survey using a structured questionnaire developed by Family Voices, a national advocacy organization dedicated to promoting the well-being of children with disabilities and their families. The study collected data for 122 families in a large urban area in the northeastern United States. Multivariate analyses revealed that family race/ethnicity significantly contributed to the prediction of parental satisfaction with medical homes of children with disabilities, and to families' perceptions of FCC in care setting practices and policies, and community coordination and followup, but not to family provider partnership. Non-White families reported significantly lower satisfaction. Discussion emphasizes that health care providers need to become more vigilant in providing culturally sensitive care. To enhance FCC practices and policies, the study advances a checklist of ten essential areas that promote culturally sensitive interactions between families of children with disabilities and their medical and non-medical health care providers.     

The family covenant and genetic testing

The physician-patient relationship has changed over the last several decades, requiring a systematic reevaluation of the competing demands of patients, physicians, and families. In the era of genetic testing, using a model of patient care known as the family covenant may prove effective in accounting for these demands. The family covenant articulates the roles of the physician, patient, and the family prior to genetic testing, as the participants consensually define them. The initial argument defines the boundaries of autonomy and benefit for all participating family members. The physician may then serve as a facilitator in the relationship, working with all parties in resolving potential conflicts regarding genetic information. The family covenant promotes a fuller discussion of the competing ethical claims that may come to bear after genetic test results are received.     

“I Fired My Last Doctor for Not Taking Me Seriously”: Collaborating With a Difficult Medical Patient in a Multidisciplinary Primary Care Facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.     

"I fired my last doctor for not taking me seriously": collaborating with a difficult medical patient in a multidisciplinary primary care facility

We present the case of a multidisciplinary primary care assessment of a 32-year-old woman with multiple medical and psychological complaints. Following the collaborative care model, this assessment was conducted by a team consisting of a clinical health psychologist, Dr. J. L. Skillings, and a family physician, Dr. W. J. Murdoch. We describe the primary care environment in which this referral was made including the methods that were utilized to insure a successful professional collaboration. We report the results and recommendations from a comprehensive biopsychosocial assessment; we place emphasis on the psychological diagnosis and pain symptoms. We also describe the feedback session in which the assessment results were provided to the patient and her spouse by both physician and psychologist. Multiperspective commentary about the assessment is offered by the patient and her husband as well as the physician and psychologist assessors.     

The Family Covenant and Genetic Testing

The physician-patient relationship has changed over the last several decades, requiring a systematic reevaluation of the competing demands of patients, physicians, and families. In the era of genetic testing, using a model of patient care known as the family covenant may prove effective in accounting for these demands. The family covenant articulates the roles of the physician, patient, and the family prior to genetic testing, as the participants consensually define them. The initial agreement defines the boundaries of autonomy and benefit for all participating family members. The physician may then serve as a facilitator in the relationship, working with all parties in resolving potential conflicts regarding genetic information. The family covenant promotes a fuller discussion of the competing ethical claims that may come to bear after genetic test results are received.     

The futures of physicians: Agency and autonomy reconsidered

The corporatization of U.S. health care has directed cost containment efforts toward scrutinizing the clinical decisions of physicians. This stimulated a variety of new utilization management interventions, particularly in hospital and managed care settings. Recent changes in fee-for-service medicine and physicians' traditional agency relationships with patients, purchasers, and insurers are examined here. New information systems monitoring of physician ordering behavior has already begun to impact on physician autonomy and the relationship of physicians to provider organizations in both for-profit and ‘not-for-profit’ sectors. As managed care practice settings proliferate, serious ethical questions will be raised about agency relationships with patients. This article examines health system dynamics altering the historical agency relationship between the physician and patient and eroding the traditional autonomy of the medical profession in the United States. The corporatization of medicine and the accompanying information systems monitoring of physician productivity is seen to account of such change, now posing serious ethical dilemmas.     

The Unmet Educational Agenda in Integrated Care

One of the reasons integrated care has not become a dominant service delivery model is the unmet training agenda. This article argues that the typical mental health professional is not trained to adequately address the challenges of integrated care. To insure competency both a macro and clinical training agenda are needed. At the macro-level, mental health professionals need to understand healthcare economics and basic business principles as any integrated care service delivery system is embedded and driven by economic forces. Integrated care practitioners also need some basic business skills to understand these forces and to create and manage a financially viable system, given the future flux of the system. Traditional mental health professionals also do not have the clinical skills to implement integrated care. Integrated care is not simply placing a traditionally trained mental health professional and letting them practice specialty mental health in a medical setting. Thus, the special skills needed in integrated care are enumerated and discussed. Finally, a new degree program is described as it is time given the huge need and advantages of integrated care to develop specialty training in integrated care.     

A Community‐Responsive Adaptation to Reach and Engage Latino Families Affected by Maternal Depression

As family researchers and practitioners seek to improve the quality and accessibility of mental health services for immigrant families, they have turned to culturally adapted interventions. Although many advancements have been made in adapting interventions for such families, we have yet to understand how the adaptation can ensure that the intervention is reaching families identified to be in greatest need within a local system of care and community. We argue that reaching, engaging, and understanding the needs of families entails a collaborative approach with multiple community partners to ensure that adaptations to intervention content and delivery are responsive to the sociocultural trajectory of families within a community. We describe a cultural adaptation framework that is responsive to the unique opportunities and challenges of identifying and recruiting vulnerable families through community partnerships, and of addressing the needs of families by incorporating multiple community perspectives. Specifically, we apply these principles to the cultural adaptation of an intervention originally developed for low‐income African American and White families facing maternal depression. The new intervention, Fortalezas Familiares (Family Strengths), was targeted to Latino immigrant families whose mothers were in treatment for depression in mental health and primary care clinics. We conclude with key recommendations and directions for how family researchers and practitioners can design the cultural adaptation of interventions to be responsive to the practices, preferences, and needs of underserved communities, including families and service providers.     

Global Mental Health: A Call for Increased Awareness and Action for Family Therapists

Global mental health (GMH) is an emerging field that focuses on the need for culturally sensitive mental health services in low‐ and middle‐income countries (LMICs). While many new initiatives have been established worldwide to understand GMH needs and to provide care in LMICs, family therapists have primarily worked with families in high‐income countries. The few existing family‐based initiatives in GMH focus on psychoeducation and are typically not based on general systems theory. However, emerging trends in family therapy may enable family therapists to impact mental health issues in LMICs. These trends, which are shared interests of both family therapy and GMH, include collaborative care, a growing emphasis on the importance of culture in understanding and treating mental health issues, recognition of the ability of families to support or impede recovery from mental illness, and the use of strength‐based and evidence‐based treatments. This paper describes ways for family therapists to become active in the GMH community.     

Personality and values as predictors of medical specialty choice

Research rarely considers the combined influence of personality traits and values in predicting behavioral outcomes. We aimed to advance a germinal line of inquiry that addresses this gap by separately and simultaneously examining personality traits and physician work values to predict medical specialty choice. First-year medical students (125 women and 119 men) responded to measures of personality and physician work values. After graduation, participants' residency choices were identified. Results indicated that personality traits predict person- or technique-oriented medical specialty choice. Physician work values, whether used alone or in tandem with personality traits, however, did not significantly predict specialty choice. Implications for practice and research are discussed.     

Psychologists' role in family-centered approach to practice, training, and research with young children

Family-centered, community-based, coordinated care for children with special needs is presented as the best practice model for providing services to children and families. Psychologists must learn to play an active role in this frame-work that both integrates psychology with other health and education disciplines and uses the broad spectrum of psychological knowledge about families, development, community organization, and intervention strategies. Key principles of family-centered child psychology affect practice research and training. The psychologist becomes part of a team created to support families as the primary care-givers of their children. Training programs must reorganize the types of experiences both in the classroom and the field to train new psychologists within this model. As mandates for family-centered care affect policies at the state and federal levels, research will remain a critical factor in understanding the effects of these policy shifts on child and family functioning and the delivery of services.     

The Context of Caretaking in Rural Areas: Family Factors Influencing the Level of Functioning of Seriously Mentally Ill Patients Living at Home

After the deinstitutionalization of psychiatric hospitals, many families became primary caregivers for seriously mentally ill individuals. Mental health services became further reduced with the advent of managed care and reductions in health and mental health care. The dearth of community-care options often results in psychiatric patients being quickly stabilized in hospital units and discharged to live with their families. The lack of community resources is particularly acute in rural areas. Given these realities the current study sought to determine if family caretaking variables are related to patient outcomes. Family factors including the perception of burden, expressed emotion (EE), and primary caregivers’ social support were tested in a model of caretaking that examines the relationship between these factors and patients’ symptom expression and social and occupational functioning. The sample includes 49 predominantly African American families living in a rural area and with a chronically ill family member who had been previously diagnosed with a psychotic disorder. Primary caregivers and patients were interviewed using adapted measures of burden, EE, and social support. Patients were administered a revised version of the Brief Psychiatric Rating Scale. Results suggest less perceived burden, increased caregiver support and, to a lesser extent, EE explain approximately one-fifth of the variance in patient functioning. These results support previous research demonstrating the importance of family factors for seriously mentally ill patient outcomes. Results are discussed in terms of implications for assisting families in the current era of diminished resources.     

A Summary Report of the Cost-Effectiveness of the Profession and Practice of Marriage and Family Therapy

This purpose of this paper is to provide a summary of the cost-effectiveness research for the profession and practice of marriage and family therapy. Studies based on four sources of data were considered: (1) a western United States HMO covering 180,000 subscribers; (2) the Kansas State Medicaid system with over 300,000 beneficiaries; (3) Cigna, a large Unites States health insurance benefits management company with more than nine million subscribers; and (4) a marriage and family therapy training clinic in the western United States serving approximately 300 individuals and families a year. Results from the studies support the potential for a medical offset effect after couple or family therapy, with the largest reduction occurring for high utilizers of health care. The studies also show that covering family therapy as a treatment option and marriage and family therapists as a provider group is not associated with significantly higher treatment costs. An application of cost-effectiveness methodology to medical family therapy is also considered.     

Family therapy with Spanish-heritage immigrant families in cultural transition

Increasing numbers of Spanish-heritage immigrant families in the United States are beginning to seek therapy for family conflicts related to their adapation to the new country/culture. This paper focuses on the difficulties experienced by these families and presents issues specific to therapy with them. Effective therapy with these families requires that therapists focus on clarification of the differential adaptation rates of family members and facilitate a resolution of the family's transitional conflicts(s). Six cases involving such families are presented.David A. Baptiste, Jr., PhD, is a Psychologist and Marital and Family therapist in the counseling center at New Mexico State University and in private practice, Las Cruce, NM.Revision of a paper presented to the International Round Table for the Advancement of Counseling, Annual Conference, Utrech, The Netherlands, July, 1985. The author expresses appreciation to Judith Landau-Stanton for her helpful review of an earlier draft of this paper.     

Ethical issues and the family doctor

Issues recognized as having ethical or moral components are becoming increasingly common, for society in general, the health care system and for general practitioner/family physicians in particular. Some of the peculiar problems for GP's relate to the provision of continuing, comprehensive, primary medical care to large numbers of individuals who provide extensive potential for conflict between all the involved elements: patients, physicians, families, consultants and societal attitudes. There is a need for more formal education programs.     

Variations in physician practice and covert rationing

The use of recent research on variations in medical practice to promote competitive market oriented cost containment strategies is critically examined. Research demonstrating widespread variations in physician practices for similar patient populations undermines the medical profession's claims about the scientific objectivity of medical practice and indicates the existence of widespread waste and inappropriate utilization of health care resources. Cost containment programs which rely on market-based care avoidance incentives, such as Medicare prospective payment or cost sharing plans, attempt to impact medical practice variations by creating economic barriers between doctor and patient. An alternative interpretation of research on practice variations is presented, emphasizing containing costs while improving quality of care and achieving greater equity through planning and regulation of medical supply factors.