Collaborative Perspectives: A Selection of CFHA's Best Blogs From 2009 to 2015

By CFHA

The rich diversity of voices within the community of the Collaborative Family Healthcare Association is reflected in the creativity and passions of the CFHA blogs. We have carefully selected a collection of these blog posts that cover a very wide range of topics including clinical practice, research, policy, personal reflection, cultural and family issues, operational and financial issues, workforce and professional development, and the history and evolution of CFHA itself. The “CFHA Blog” was started on August 31st, 2009. Since then, CFHA has published over 500 posts which some have received attention in clinical and policy circles. One post by Carol Levine and Barry Jacobs was picked up by the New York Times and received over 2,000 hits. Another post by Mara Laderman was highlighted in the newsletter for the Institute for Healthcare Improvement, a major convener of health care leaders and practitioners.

• Language: English
• Publisher: BookBaby
• Release date: Dec 19, 2016
• ISBN: 9781483590738

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CFHA HISTORY

COLLABORATIVE CARE NEEDS A THEME SONG

Posted by Randall Reitz, Monday, August 31, 2009

MUSIC AMPLIFIES AND animates our experience. Who can think of Rocky without hearing the theme song Gonna Fly Now? Tom Cruise and Kelly McGillis’ horizontal silhouettes from Top Gun will forever excite my mind with Take My Breathe Away beat-beating in the background. An Irish rock band provided healing to my American heart after 9/11.

Most couples can identify their song—a song that stirred their emotions during limerence or that was powerfully present during a DTR moment in their coupling (reference the boombox scene in Say Anything).

Similarly, music provides a context and a narrative to the political, cultural, and philosophical movements of our time. People who made it through the hippy era (and ended up as the founding fathers and mothers of the collaborative care movement—you know who you are) have a number of anthems from the era: Blowin’ in the Wind, Love the One You’re With, Turn Turn Turn. The feminist and gay pride movements both embrace We are Family. Lee Greenwood’s retirement comfort is made possible by the revival of Proud to be an American whenever our courageous soldiers defend us in war.

And, of course, recent political campaigns have linked themselves to music. Can you name which candidates used which songs?

The denizens of collaborative care world don’t have a theme song. Perhaps someone who was present at the first CFHA conference in 1995 in Washington DC can tell me if a song crystallized the moment for them, but I’m not aware of it.

This is to our detriment. We need a rallying cry to blast at our national conferences, to boost our steps as we scurry between exam rooms, to wail over beer when healthcare reform evaporates in the August heat, and to chant in the boardrooms of the powerful interests. Unfortunately, I can’t say that the perfect song has come to mind yet, so I’m asking for your recommendations.

In the absence of a serious option, here are a few tongue-in-cheek suggestions:

Vanilla Ice’s Ice, Ice Baby, the only song to successfully incorporate the word collaborate in it’s lyrics (Stop, Collaborate, and Listen!)

My kids suggest that if we’d just replace the word Wonderpets with Collaborate in their favorite cartoon’s theme song, we’d have a great possibility that embodies our underdog spirit (What’s gonna work? Teamwork! Collaborate! Collaborate! We're on our way, To help a friend and save the day. We're not too big and we're not too tough, but when we work together we've got the right stuff. Go, collaborate, yeah!)

And, of course, you can never go wrong with John Lennon (You may say that I'm a dreamer, but I'm not the only one. I hope someday you'll join us and the world will be as one.)

Randall Reitz, PhD, LMFT is the executive director of CFHA and the behavioral science faculty at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.

FOR PATIENTS' SAKE…LET'S GET ON WITH COLLABORATION

Posted By Roger Bland, Thursday, March 24, 2011

PRIMARY CARE, PROVIDED that it is accessible and available, improves population health. Primary care includes, but is not limited to, family physicians. In Alberta, 95% of all patients diagnosed with a mental health disorder were seen by a family physician; 78% were seen by a family physician only; 14% were seen by a psychiatrist. Over a three-year period, 35% of the adult population of Alberta was seen for a mental health disorder. Of that 35%, 93% were seen by a family physician and had a major diagnosis of an anxiety disorder, mood disorder, substance use disorder, schizophrenia and psychosis or cognitive impairment.

The World Health Organization has nevertheless drawn attention to this treatment gap: the high proportion of people even in developed countries who have a treatable disorder but do not get treatment. The severity of cases and the diagnoses of those seen in primary care differ from those seen in specialist care yet the diagnostic systems and criteria are more oriented to specialist practice than to primary care. Family physicians in Canada have highlighted problems with the mental health system, including lengthy delays for consultations, inaccessibility of psychiatrists, and poor communication following referral.

The Canadian Psychiatric Association and the College of Family Physicians of Canada have worked together to improve care for patients with a mental health disorder and have strongly advocated for shared care or collaborative care in which psychiatrists and mental health practitioners work closely with primary care physicians and services. There are several goals associated with this, including facilitating early treatment, achieving better outcomes, reducing stigma, and ensuring that patients are receiving the most appropriate service in a timely fashion in a setting that is congenial and avoids stigma. Considerable effort has gone into ensuring that specialists’ services support primary care and primary care physicians rather than meeting the needs of specialist programs,

Several different models have emerged. One model uses a relocated consultation service. Although it may perhaps be the simplest concept, it has not necessarily proved to improve services or outcomes. Another type of service includes placing mental health workers into primary care practices. Reports on this are variable depending on whether the services are designed to collaboratively support primary care or are just embedded in primary care but functioning relatively independently..

One of the better models is one in which a psychiatrist and/or other mental health professional are attached on a full-or part-time basis to a primary care practice or practices and provide ongoing formal and informal consultation and support along with other aspects of psychiatric patient care. Integral to any of these services is that the treating professionals involved need to get to know each other and build trust and confidence. It is clear that, when the various components are well coordinated, patients feel greater satisfaction about the service.

Research evidence is available but limited. When a particular disorder--for example, depression--is being treated with a standardized protocol and ample supports, it is clear that patient outcomes are improved. Often the research project ends and then those involved do not continue to follow the same protocol. When there is close collaboration, patient satisfaction studies tend to show positive results, which is also often the case when additional service availability (for example counseling or housing services) is built into the primary care setting. Clearly, role definitions are important. Specialty mental health services will continue to play a significant role in the management of difficult cases--specifically those in which patient needs are very high, such as psychoses and dementias.

For cooperation to be successful, there need to be strong positive attitudes on the part of the practitioners involved and good administrative support, including financial support from healthcare funders. The rapid growth of collaborative care arrangements in Canada suggests that there is a strong belief that this approach can help those with mental health problems.

Dr. Bland is Professor Emeritus and former Chair of the Department of Psychiatry at the University of Alberta. His research interests have included epidemiological studies, long term outcomes and mental healthcare utilization including collaborative care. He has served as a CPA member of the CWGSMHC for the last decade.

CFHA: HEED THE PROPHET; CLINICIAN: CORRUPT THYSELF

Posted By Randall Reitz, Thursday, June 30, 2011

LIKE RELIGIONS, ACADEMIC fields are led by both prophets and administrators. Collaborative care’s prophet is undoubtedly CJ Peek. His prophetic bona fides include his Yoda-like gravitas, his universal devotion from our movement’s founders, his unmatched ability to distill arcane doctrines into teachable articles of faith, and his usage of language that is equally inspirational and apocalyptic.

While prophets generally only preach one worldview, collaborative care is sufficiently pluralistic that our prophet is best known for his three-world view:

1."If care is clinically inappropriate, it fails.

2.If care is not operationalized properly, it also fails.

3.If care does not make reasonable use of resources, the organization, its patients, or society eventually go bankrupt and thousands of patient-clinician relationships are disrupted" (Peek, 2008).

This dark prophecy is fulfilled daily in collaborative care settings where the financial corrupts the operational and the operational corrupts the clinical.

Allow me to explain myself. Just like any church, the collaborative care pews are filled with fervent believers, practicing adherents, and devilish apostates:

•Front-line clinicians are the true believers. We are the ones who have enough faith in the cause to work outside of our areas of training for less money than could be made for less effort elsewhere. Had we practiced 2000 years ago, it would have been said of us: It is harder for a clinician to leave a collaborative clinic as a rich man than it is for a camel to walk through the eye of a needle (Matthew 19:24).

•Operational administrators are the practical adherents. They find that our model makes sense even if the reimbursement pays only cents. However, they distract our daily pilgrimage with banalities, such as efficiency and HIPAA compliance.

•Financers are the devilish apostates. I propose a corollary to the Peter Principle, which I’ll call the Judas Judgment. It states that, Clinicians keep the faith until they are advanced enough in their careers to hold the money bag. Then all they decree is no margin, no mission as they cut collaborative care positions. It’s worse at the governmental and healthcare payor-levels where the virulent vestiges of carve-outs eviscerate our sustainability.

This same corruption happens on a personal level. Collaborative care is very demanding operationally. It’s not enough to have great clinical acumen; we also need keen operational awareness. Before entering the primary care world, I would regularly attend clinical conferences: AAMFT, narrative therapy intensives, the Erik Erickson symposium. Since entering primary care, I have only been to operational/financial conferences, such as CFHA. I fear that, if I weren’t teaching the behavioral sciences to family medicine residents, my clinical skills and knowledge would have atrophied completely.

Wait a minute. Did I just describe CFHA as an operational/financial conference? Now there’s a heresy. Well, look at last year’s Louisville conference: The plenaries were political (Jonathan Cohn), corporate (Grundy/James) and operational (Scherger). Similarly, of the 5 pre-conference workshops, only the counselor and physician orientations could be described as remotely clinical. All this being true, I’m not convinced that it is proof of CFHA’s apostasy.

Just as I have needed to focus more on the operational and eventually the financial as my career has developed, our field has needed to follow the same developmental path. CFHA’s archives reveal that our association was founded at a meeting of family therapists and family physicians who attempted to answer this question: No matter how financed, what should a thoroughly modern healthcare delivery system look like at the clinical level? No matter how financed? Really? Now there’s a mantra for a congregation of true believers. While it served us well as we consolidated our vision in safety-net and academic settings, this myopia limited our growth to these same settings.

However, in the larger healthcare system, it’s not only money that matters. There’s also size and science.

Size matters. A movement based on the combined efforts of family therapists and family physicians who like to collaborate is bound to be a small movement. That being said, once the circle expanded to include other like-minded (though not doctrinally pure) groups, the model invariably evolved. For example, just as CFHA’s conference is not really about clinical skills anymore, it’s also not really about family. In the heart of this family therapist, this is a real loss. Similarly, collaborative care has swung above its weight by aligning itself with other movements—most notably, the Patient-Centered Medical Home (PCMH). While PCMH shares many of our tenets, its current language is far too physician-centric to appeal to the nurse practitioners and some of the more ardent behaviorists among us.

Science matters—and will also corrupt our model. The problem for true believers is that faith and science have clashed for centuries. While collaborative care will never be financially sustainable without a strong empirical case, engaging in honest science forces us to surrender control of what the evidence reveals. For example, by my count, first-tier medical journals (JAMA, NEJM, BJM) have only published two or three articles on our model. However, while the authors of these articles called what they studied collaborative care, a close reading reveals that they are care management models which don’t make prominent usage of any sort of behavioral therapist. While their strong findings advance our cause beyond no matter how financed idealism, they are markedly different than what the founders envisioned when they first asked the question.

So there we have it. To survive in the worlds of money and science, we need to leave the church and gain comfort in the world of publicans and sinners, and-- dare I say--Republicans and rich corporate winners. With this challenge, I’ll still cast my lot with the true believers. CFHA and collaborative care were built by clinicians and we will be the ones to justify our movement’s place in the healthcare mainstream. But, as Brother CJ predicted, our clinical skills are insufficient in this endeavor. As clinicians become leaders, we need to corrupt our clinical purism with the realities of operations and finances. In our role as leaders, we’ll need to wield our motivational skills in the unholy pursuits of lobbying politicians and negotiating with insurance companies.

As we move away from orthodoxy and orthopraxy, how will we know when we have completely lost our way? I suggest that a reasonable test is to compare the models we currently practice with the model described in CFHA’s mission statement:

CFHA promotes a comprehensive and cost-effective model of healthcare delivery that integrates mind and body, individual and family, patients, providers and communities. CFHA achieves this mission through education, training, partnering, consultation, research and advocacy.

I believe this is a mission trip that all of us true believers can continue to take every day.

Randall Reitz, PhD, LMFT is the executive director of CFHA and the behavioral science faculty at St Mary’s Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have 3 children: Gabriela, Paolo, and Sofia.

V-FORMATION

Posted By Ajantha Jayabarathan MD, Wednesday, March 14, 2012

V-FORMATION EVOKES a vision of Canada Geese flying in arrowhead-shaped flocks as they journey to and from the United States and Canada. These annual migrations take place as an adaptation to the changing seasons and enhance their health and likelihood of survival.

Having practiced family medicine during the past 20 years, I can attest to the strong and positive influence that shared mental health care in Canada has had on my medical practice. In 2010, I discovered CFHA and, within its ideology and membership, found my flock. Working with like-minded individuals who understand human suffering and are motivated to work together and share their skills, experience and talent has renewed my hope and optimism for the future.

Working together, helping each other, inspiring one another, and taking turns as leaders as we fly towards better health and care for all—this is the essence of working collaboratively.

Honk, Honk!

Ajantha Jayabarathan (AJ) is a Family Doctor practicing in Halifax, Nova Scotia. She is well recognized in the Atlantic region of Canada due to her columns on television. She is an Assistant Professor at Dalhousie University and co-chaired the organization of the 12th Canadian Conference on Collaborative Mental Health care in Halifax 2011. She also co-leads the advocacy coalition, Healthynovascotians.com

AN INTERVIEW WITH DONALD A. BLOCH, MD

Posted By Administration, Tuesday, October 14, 2014

DON BLOCH, MD DIED on September 18, 2014 at 91 years of age. He founded the Collaborative Family Health Care Association and its affiliate journal, Families, Systems and Health (formerly Family Systems Medicine). He was a funny, creative, authentic human being, one of the original family therapists who saw the importance of applying systemic approaches to healthcare. Don was a generative visionary who found and nurtured new talent and created organizations, journals, even health care movements through recruiting and harvesting the energy of many colleagues.

In this CFHA blog, we republish with permission an interview with Don that was originally published in 1996, one year after the first CFHA conference. Don remained heavily involved in CFHA into his early 80s after founding CFHA at the young age of 72.

With gratitude and deep respect for Don,

Larry Mauksch, M.Ed,

Susan McDaniel, PhD.,

and Jeri Hepworth, PhD

An Interview with Donald A. Bloch, M.D. by Eric Weiner, Ph.D., M.S.W.

Families, Systems, & Health 14:95-105, 1996

Prediction is difficult, especially about the future.

—Chinese saying

Let's begin by having you tell us what you believe is most noteworthy about your career.

I think what I value in myself is having a fairly good early sense of what will be important in the midterm. This meant abandoning psychoanalysis for family therapy in the mid-1950s and recognizing the unfolding importance of systems issues in healthcare in the early 1980s. In connection with the development of each of these fields, family therapy and collaborative family healthcare, I have been the editor of the two key journals for important periods: I edited Family Process for the volume years 1970-82, 13 years in all, when family therapy quite literally burgeoned. Similarly, I have edited Family Systems Medicine from its founding in 1983 up to the completion of 1995, again 13 years, and again I think those were critical years for the early delineation of the field.

Tell us about your early family years.

In many ways, the family I grew up in was typical of the second-generation, Jewish immigrant families that arrived on these shores in the late 1880s. All four of my grandparents immigrated here as youngsters, met here, married and had their four children: two boys and two girls in each instance. Both grandfathers started out as itinerant workers, one a peddler, the other a painter. They opened small stores, worked heroic hours to hoard up protection against the anxiety and dread that they brought with them from Eastern Europe. They raised their families in the often described atmosphere of gemiitlichkeit, guilt, and ambition that characterized immigrant Jewish families. My father, as oldest son, married a youngest daughter, as did I—twice. He became an attorney and ultimately, after many anxious years and before Alzheimer's struck, walked into the 20-year sunlight of his true vocation as a judge—a role that played to the best of his intrinsically sweet and thoughtful disposition. Truthful, quick sketches of my mother and sister are beyond me. My mother, like countless numbers of her sisters, certainly was an under-utilized woman, and angry and depressed about that—but still with a wonderful capacity for love and humor. My sister Barbara was and is my lifelong friend—at least after I recovered from the dark sense of gloom that attended her arrival when I was five, and the hot Oedipal love affair I was having with our mother was disrupted.

What about college and medical school?

My college years were very turbulent, continuing a pattern that had been established in high school. At the personal level, I was struggling with what I would later come to see as major difficulties in leaving my family of origin. I lived at home and went to college, riding the subway like so many New York City kids—just as I had done for high school. I had a hunger for knowledge and a total inability to conform to the official demands of education because that was what my parents were pushing—an evil combination. My adolescence was often chaotic and painful. Confusion and guilt abounded along with an idealistic yearning to be connected to the great causes of the world. Unfortunately, family therapy had not been invented yet.

It sounds as if politics would have been important to you under these circumstances.

Left-wing politics, with which I became heavily involved as a college student, was God-sent. The Spanish Civil War began in 1936 when I was 14, and the heroic struggle between good and evil—the Loyalists and the Franco Falangists, as transmuted and romanticized through the writings of Hemingway—was the stuff of my adolescent dreams. Heroism and sexuality: an unbeatable combination. Later on in college, I could be so busy selling the Communist newspaper, The Daily Worker, that there was no time for school work—actually I had a goodly number of devices for avoiding school work. The whole enterprise terrified my parents, but they could not do much more than leave me alone and hope for the best. I was frightened myself, but also fascinated and really enjoyed the endless discussions and the political work.

My first serious girlfriend was a Young Communist. She later persuaded me to straighten up and become a pre-medical student as a contribution to the class struggle. She correctly assessed that I could parlay a middle-class background from a working-class school into a rare and much sought after admission to medical school.

When I began to think about going to medical school, I turned into a model student. The possibility of being a doctor wove together a multitude of strands in my life. Physicians were revered in my family and, it seems to me, there was a strong delegation for me to be the physician in my generation of the extended family, which had already had several distinguished doctors in earlier years. More than that, I had been asthmatic as a child and often had severe ear infections—painful and debilitating in the days before antibiotics, when deafness and mastoiditis were not uncommon sequelae. My mother was certainly the best nurse/mother any child could have--an expert at creating a cozy counterpane world that almost made the extremely painful eardrum lancing for my many middle-ear infections endurable. My mother and I made the tightest of bonds around my illnesses. And, since I was a voracious reader, the romance of medicine and the high adventure of science captured me in a heady swirl.

During the war, students were enrolling in the military, either the Army Medical Corps or the Navy V-12 program, so as to avoid being shipped overseas. I was accepted for the more desirable Navy program, very strange and somewhat embarrassing even at this remove because there was so much privilege involved. The intentions were good--not to tie attendance at medical school to the student's financial situation. But, of course, the majority of those admitted had the advantage of education and class background.

You married first at about this time?

I was married just a couple of weeks before medical school started. Natalie and I were just 21 years old. Among other things, she introduced me to psychoanalysis in a form that was understandable and palatable to me, mostly through the writings of Karen Horney, whose most influential book was The Neurotic Personality of Our Time.

Remember that the 1930s was the decade of the Great Depression. It is almost impossible to convey the impact of this on the lives of ordinary people. To say that one out of four workers was unemployed does not begin to convey the dread people felt. A sense of personal identity and any feeling of self-worth dissolved. Later, when I came to know Nathan Ackerman and to reconstruct some of his history, I learned how much his thinking was molded by the experience of the Depression, not only in his own family but also in his work as a young psychiatrist.

The appearance on the scene of the social science-oriented psychoanalysts permitted psychoanalysis and my political and social interests to come together, and psychiatry as a profession began to make sense to me. It was also very evident, at the personal level, that I needed some help since I was faced with the stress of leaving home, a new young marriage, and the assault of medical school. Deciding to become a psychiatrist and psychoanalyst legitimized my getting into personal analysis in medical school, and undoubtedly helped keep me somewhere close to sanity.

My first analyst was both a political Marxist and a psychoanalytic radical-- Bernard Robbins. As I reconstruct him now in my memory, Robbins had the early intuition of an idea that has dominated my own thinking over the years. At that time, most theory was devoted to considering how personality unfolded from within and was modified by traumatic events. Against this background, it was a major dislocation to think that social responses to individuals played a significant part in maintaining the continuity of personality, and that individuals were active in constructing and modulating these responses.

You trained at Chestnut Lodge, did you not?

Chestnut Lodge Sanitarium, where I went as a first-year resident, was a small, private psychiatric hospital just outside of Washington, DC in Rockville, Maryland. It was then the premier psychoanalytic hospital for treatment of psychotics and severe behavior disorders. Frieda Fromm-Reichmann, the remarkable refugee psychiatrist who was the central figure in the novel, I Never Promised You a Rose Garden, was on the staff and one of my teachers. The brilliant and eccentric American psychiatrist Harry Stack Sullivan--who defined psychiatry as the study of interpersonal relations--was a consultant and taught at the Washington School of Psychiatry where we all were students. It probably seems weird to the reader of today, but this small hospital--in many ways precious and self-involved--was a significant crossover location for the evolving field of what was to become systemic psychiatry.

The Lodge had started life in suburban Maryland, just outside of the District of Columbia, as a drying-out place for congressmen and others of their ilk. Somehow, Dexter Bullard, the owner, on inheriting the place from his psychiatrist father, had the glorious notion to turn it into a psychoanalytic hospital—just at the time when American psychiatry was being pumped up to previously unimaginable heights by the influx of refugee analysts interacting with the returning young doctor war veterans who were trying to find a place for themselves in a rapidly changing medical world. The residency appealed to me because it provided the opportunity to work intensely with a small number of patients. The custom was to see patients four, five times a week for one-hour analytic sessions; the focus of the work was on examining the interpersonal field constructed in the transference relationship—an effort to bridge interpersonal and classic analysis. I believe a persistent trend was established there, and that it has provided structures supporting the collaborative family healthcare movement some 40 years later.

Why do I give it such importance? This hospital and the Washington School of Psychiatry were committed to understanding and treating psychosis in interpersonal terms. A broader view of this enterprise, and particularly of the idea that the treatment system included the therapist as much as the patient, is so powerful that we are still only at the beginning of understanding its importance—although the idea of collaborative family healthcare captures that notion in action. It provided the logical foundation for the transition from exclusive concern with intrapsychic events to a broader interpersonal and eventually an ecosystemic view of mental life.

The influence of these ideas can best be illustrated by research that went on there—ultimately published in the still interesting book The Mental Hospital by the sociologist Morrie Schwartz and the psychiatrist Alfred Stanton. In what is still a model of research strategy, they attacked the problem of psychotic excitements. These days, heavily medicated patients are not likely to show the fearsome combination of behaviors covered by the term psychotic upset or excitement—grueling and dangerous outbreaks for patients and staff. These were patients in extreme psychic pain, restless, disoriented, combative, self-damaging. We did not have any medications available except for chloral hydrate and phenobarbital; Thorazine had not yet come on the market. We used cold, wet-sheet packs to help people quiet down, and we provided a tremendous amount of nursing for patients. But it was still a major source of distress for patients and staff.

In what