The influence of individual,marital, and family therapy on high utilizers of health care

Research has shown that people reduce their use of health care after individual, marital, and family therapy, which is known as the "offset effect." However, little research has been done to learn if high utilizers of health care reduce health care usage after therapy. Medical records of research participants (n = 65) from a health maintenance organization (HMO) were randomly selected and examined for 6 months before, during, and after therapy. Persons who received individual, marital, or family therapy all reduced their health care use after therapy, with the largest reductions coming from those participants who had some form of conjoint therapy.     

Individual versus family psychotherapy in managed care: comparing the costs of treatment by the mental health professions

In an effort to understand how psychotherapy is practiced in the "real world," outpatient claims data were examined to determine the cost of individual and family therapy provided by marital and family therapists, master's nurses, master's social workers, medical doctors, psychologists, or professional counselors. Claims for 490,000 unique persons over 4 years were obtained from CIGNA. Family therapy proved to be substantially more cost-effective than individual or "mixed" psychotherapy. Physicians provided care in the fewest sessions, marital and family therapists had the highest success (86.6%) and lowest recidivism rates (13.4%), and professional counselors were the least costly. Outcomes were overwhelmingly successful, with 85% of patients requiring only one episode of care.     

THE MARITAL AND FAMILY THERAPY EXAMINATION PROGRAM: A SURVEY OF PARTICIPANTS

Participants in the Examination in Marital and Family Therapy between November 1994 and May 1996 were surveyed to ascertain who took the examination, how they prepared for it, whether they thought that it was fair, and how these variables related to scores. Two-thirds of the respondents were female. Most were taking the examination for the first time, were relatively young, were Caucasian, and spoke English as their primary language. They primarily practiced marital and family therapy and had completed master's level university programs in marital and family therapy, counseling, and psychology. Most were sitting for the examination relatively soon after completing their training in marital and family therapy. Individual study was the preparation method of choice for half of the sample. Demographic variables had a modest but ambiguous effect on test score. Educational background had none. However, a relatively short latency between graduation and examination was related to a higher score, as was the use of multiple preparation procedures. With regard to fairness, the participants largely agreed that the examination was moderately difficult, but that the problems were realistic and they had enough time to complete the test.     

THE MARGINALIZATION OF FAMILY THERAPY: A HISTORICAL AND CONTINUING PROBLEM

Family therapy, and marital and family problems, are mariginalized in the larger fields of mental and physical health care, which is a misfortune both for family therapy and for other mental health professions. The early family therapists, who had multidisciplinary backgrounds, attempted toestablish a new, nondisciplinary paradigm and also tried to expand the perspectives of the more traditional mental health disciplines. More recently, family therapists have exerted greater effortsto establish marriage and family therapy as a differentiated, autonomous profession. These alternatives each involve dilemmas for the family therapy field. The positive side of becoming a distinctive profession is greater internal strength and clear professional identy; the downside is the threat of increased marginalization in rlation to the other professions, a tendency toward intellectual isolation, and hence restricted opportunities for invigorating new challenges. Family therapy now needs to develop new modes of interchange, collaboration, and selective integration with otherhealth care professions. Such interchange will be beneficial both to family therapy and to other professions.     

Defining the psychomedical and systemic paradigms in marital and family therapy

A framework for defining paradigms within the field of marital and family therapy is presented. The term "paradigm" is critically analyzed as applied to mental health services. Paradigm crisis in marital and family therapy is described as resulting primarily from practical-theoretical, professional, andpolitical concerns rather than scientific anomaly. Subsequently, two paradigms are defined as related to marital and family therapy: the psychomedical and the social systems (systemic) paradigms. Both paradigms are defined according to basic propositions and methodological tenets. The need for, and the design of, critical paradigmatic experiments of the psychomedical paradigm against the systemic paradigm are addressed. Critical paradigmatic experiments are viewed as an offshoot of a postpositivistic empiricism in keeping with a contextual view of knowledge.     

Residency training and the later use of marital and family therapy in psychiatric practice

Marital and family therapy training during psychiatry residency was compared to later use, in practice, for 87 psychiatrists. Respondents reported modest to minimal amounts of training in residency but practiced marital and family therapy with a variety of problems, identified a spread of effect to other treatment modalities, and preferred marital and family therapy second only to individual therapy. These results suggest a trend towards incorporating marital and family therapy into psychiatry and also indicate levels of training which must be exceeded in order to achieve basic competency.     

Reply to Sloan [on proxies for birth control

Sloan (1984) argues that annual changes in marital fertility of Swedish wives aged 35-39 between 1911 and 1974 is not a result of annual changes in the use of birth control, but is due to changes in health conditions that increase or decrease marital fertility. As evidence of the lack of effect of contraceptive practice on fertility Sloan cites a study published in 1916 whose author concluded that contraceptive use or nonuse had no effect on family size. Sloan is unaware of the shroud of ignorance that blinded such research in the distant past. There was no accepted methodology to determine contraceptive effectiveness until the 1930s, and scientists did not know key elemental facts about human reproduction. For example, the relationship of ovulation to the risk of pregnancy was unknown in 1916, and was to remain a mystery for more than a decade thereafter. Sloan's "declining health" explanation of low fertility in the West is merely a variant of an older attempt to explain low fertility as a result of high protein intake. Sloan's view that modern couples do not contracept to reach a desired family size and that changes in family size preference will not affect birth control practice among older (or younger it appears as well) couples seems to us to be an idiosyncratic view at best and directly opposed by all survey research. Couples do contracept most effectively when they are trying to prevent an additional birth. The view that failure of some Western couples to reproductively compensate for their child deaths as explained by poor reproductive health seems to assume that couples in non-Western population do so compensate, but this is wrong. The idea that such bereaved couples should have another child is so insensitive to tragedy as to defy further reply. Sloan's acceptance and use of reports that some couples say they wanted more children than they had ignores massive research findings of unwanted fertility among couples in populations with long histories of birth control practice. Further, it is difficult to have much faith in such responses since about 1/2 the couples in the Whelpton el al. study cited by Sloan also said they were fecund. These responses mean that couples may say that they want more than they actually had, but they deliberately did not have such a large and "ideal" family size because of other factors not considered by Sloan. Since it appears that Sloan was unable to find another authority, he cites a 3 page comment of his own in support of the hypothesis of deteriorating environment. He does not actually empirically link age patterns of chronic disease with fecundity loss; his view also ignores research indicating improved health conditions, at least among US women, after the mid-1930s that increased fecundity and then fertility. Thus, his argument that factors other than voluntary birth control could explain annual change in Swedish marital fertility among older couples is unsupported by empirical evidence. His remarks are also irrelevant to the use made in the author's article concerning marital fertility rates as a proxy for the use of annual birth control change among younger unmarried women. The marital rate varies, as does the illegitimacy rate. Annual increases in marital fertility are related to annual increases in illegitimacy; annual declines in marital rates to annual declines in illegitimacy. Sloan's hypothetical trends in fecundity have no bearing on our empirical study of annual change in Swedish illegitimacy rates. Finally, Sloan's claim that social demographers do not view a changing environment as problematic is unsupported and unjustified.     

Marital Therapy,EMDR, Herman's Model of Recovery from Trauma The Journey of One Woman and Her Family

Judith Herman (1992, page 183) delineates a three stage model of recovery from trauma: 1) Safety, 2) Remembrance and Mourning, 3) Reconnection. She criticises current treatment methods for their failure to make a difference in the “constrictive symptoms of numbing and social withdrawal … and marital, social and work problems do not necessarily improve”. Family therapy has been criticised often for insufficient focus on emotion and general sensations. This case analysis will illustrate how these shortcomings can be successfully addressed with the use of marital counselling and EMDR. The use of multiple treatment approaches contributed to one client's resolution of recent trauma due to a car accident, of past crises due to marital infidelity and early childhood abuse, with significant changes for her in her current family as well as in her family of origin. Theoretical implications for “family therapy” are raised.     

What Explains Divorced Women's Poorer Health? The Mediating Role of Health Insurance and Access to Health Care in a Rural Iowan Sample

Economic restructuring in rural areas in recent decades has been accompanied by rising marital instability. To examine the implications of the increase in divorce for the health of rural women, we examine how marital status predicts adequacy of health insurance coverage and health care access, and whether these factors help to account for the documented association between divorce and later illness. Analyzing longitudinal data from a cohort of over 400 married and recently divorced rural Iowan women, we decompose the total effect of divorce on physical illness a decade later using structural equation modeling. Divorced women are less likely to report adequate health insurance in the years following divorce, inhibiting their access to medical care and threatening their physical health. Full‐time employment acts as a buffer against insurance loss for divorced women. The growth of marital instability in rural areas has had significant ramifications for women's health; the decline of adequate health insurance coverage following divorce explains a component of the association between divorced status and poorer long‐term health outcomes.     

Personal Reflections of A Family Therapist*

In this informal paper I discuss my personal evolution as a family therapist, developments in the field, the politics of a systems approach in conventional settings, resistances to family and marital therapy by other professionals, some still puzzling aspects of family therapy, whether family or marital therapy works and what do we mean by working, directions my own work has taken, some comments about the nature of family life, the satisfactions and frustrations and stresses of being a family therapist, some hidden agendas of family therapy practices, how one's own personal family relationships affect and are affected by this kind of work, the casualties among family and marital therapists, and, finally, whether family therapists should have family therapy for themselves and their own families.     

The healing power of dogs: Cocoa's story

Animals bring a sense of "at homeness" and even normalcy to people who are hospitalized or live in health care facilities. Illnesses, separation from family, fear, loneliness, and even depression may be lessened for those who receive a therapy dog visit by providing a welcome change in routine and something to look forward to. Individuals are often more active and responsive during and after a visit. Just stroking and petting a dog requires the use of hands and arms, as well as the motions of stretching and turning. Dogs are also unconcerned with age or physical ability; they accept people as they are. This alone causes many to reach out and interact with dogs. Animals provide a focus for conversation and a common interest. As Cocoa's human partner can attest, a pet also makes it easier for strangers to talk. Cocoa is known by so many people at the facilities she visits that residents' family members often stop to talk with "Cocoa's mom" when they meet her in the community, asking questions about how Cocoa is doing. When Cocoa is no longer able to perform her services, many in her community will mourn. Cocoa's story, as well as the limited research literature, supports the positive physical and psychological effects of animals, but continued research on the effect of therapy animals on health outcomes is needed. As advocates for clients, nurses are in key positions to facilitate the inclusion of animals in clients' care. Although not for everyone, including those who react negatively to animals or who are allergic, pet therapy offers important possibilities for providing holistic care that extends not only to clients, but also to family members and staff, and to the pets themselves.     

Family Experiences of Caring for Relatives Who Have Received Electroconvulsive Therapy (ECT)

The research literature on family members’ experiences of the use of electroconvulsive therapy (ECT) is limited. This article explores the perspectives of family members whose relatives had received ECT. Drawing on a social constructionist perspective, this qualitative study collected data using in-depth interviews with nine families in South Australia, to examine how family members constructed the supports and challenges they experienced. The research found that families experienced a range of social and service system barriers, including social stigma and isolation, and limited support from health professionals. They had to negotiate caring expectations within a social context that stigmatised both mental illness and ECT. A need for ECT-specific mental health support groups was identified.

IMPLICATIONS

• Social workers’ roles in Australian hospitals could be further expanded to accommodate supporting families whose relatives have received ECT, referring families to community support, and advocating for specialist support post-ECT treatment.

• Social workers can further articulate their unique contribution to community care post-ECT treatment and advocate for supporting families.

• Increased focus on ongoing and preventative care for supporting families is a potential growth area for social workers in mental health.

     

A Mixed Methods Exploration of Single Session Family Therapy in a Child and Adolescent Mental Health Service in Tasmania,Australia

Single session therapy (SST) is grounded in the belief that clients and families can effect change after one therapeutic encounter, using their own resources, with brief support and assistance from therapists. SST has been found to be an effective intervention for children, young people, and their families presenting with a wide range of difficulties. Research in child and adolescent mental health has shown that over 50% of families find one SST encounter is enough with no need for further specialist input. This study aims to explore family member experiences of SST (undertaken as single session family therapy and termed hereafter SSFT) as an initial intervention in a regional child and adolescent mental health service (CAMHS), specifically in terms of worry, confidence, and satisfaction outcomes. An exploratory, mixed methods convergent design was utilised using a combination of open questions and Thurstone scales. All eligible family members were invited to complete questionnaires before and after the SSFT, asking about level of worry, confidence, and overall satisfaction with SSFT. Quantitative and qualitative findings indicated most family members had a positive experience of SSFT, although differences were found between young people, parents, and siblings. Overall, family members’ level of worry decreased, while only parental confidence in managing the presenting issue(s) increased. Over half of the families did not require further contact with CAMHS following the SSFT. Our findings support previous research that SSFT is an effective, family-inclusive, and well received intervention for a variety of mental health issues facing children and young people. SSFT could be considered a beneficial and well received first response for the majority of CAMHS clients, which prioritises a family-inclusive approach. Future research could focus on attaining a more in-depth understanding of individual family member experiences with a view to improving SST delivery.     

The Case for Insurance Reimbursement of Couple Therapy

A case is made for why it may now be in the best interest of insurance companies to reimburse for marital therapy to treat marital distress. Relevant literature is reviewed with a considerable focus on the reasons that insurance companies would benefit from reimbursing marital therapy – the high costs of marital distress, the growing link between marital distress and a host of related physical and mental health problems, as well as the availability of empirically supported treatments for marital distress. This is followed by a focus on the major reasons insurance companies cite for not reimbursing marital therapy, along with a discussion of advances in several growing bodies of research to address these concerns. Main arguments include the direct medical offset costs of couple and family therapy (including for high utilizers of health insurance), and the fact that insurance companies already find it cost effective to reimburse for prevention of other health and psychological problems. This is followed by implications for practitioners and researchers.     

Quantity and Quality: A More Nuanced Look at the Association Between Family Work and Marital Well-Being

The current study uses family systems and gender theories to look at three forms of family work (housework, emotion work, and child care) and their association with marital satisfaction and burnout. Data were taken from a sample of dual-earner mothers and fathers parenting preschool-age children. First, relationships between the quantity of family work performed and marital well-being were established. Then, measures related to the perceived “quality” of child care provided by a spouse (childcare appraisals and, for wives, maternal gatekeeping) were added to the statistical model. Overall, emotion work was the most influential predictor of women’s marital well-being. For fathers, the perceived quality of care provided by mothers was most significant for marital well-being.     

Preliminary estimates of cost-effectiveness for marital therapy

Cost‐effectiveness of marital therapy was examined beginning with a simple question: If government or health insurers paid for the screening and, where indicated, empirically supported treatment of 100,000 randomly selected married persons (i.e., 50,000 couples) from the general population, would the financial benefits outweigh costs? Two empirically supported forms of marital therapy, behavioral marital therapy and emotionally focused therapy, were considered in aggregate as possible treatments of choice. Marital therapy appears to be cost‐effective when paid for by government to reduce public costs of divorce or when paid for by insurers to offset the increased health‐care expenses associated with divorce. Implications and specific needs for future research to substantiate these conclusions are discussed.     

The development of core competencies for the practice of marriage and family therapy

In response to a series of national policy reports regarding what has been termed the "quality chasm" in health and mental health care in the United States, in January 2003, the American Association for Marriage and Family Therapy convened a task force to develop core competencies (CC) for the practice of marriage and family therapy (MFT). The task force also was responding to a call for outcome-based education and for the need to answer questions about what marriage and family therapists do. Development of the CC moves the field of MFT into a leading-edge position in mental health. This article describes the development of the CC, outcomes of the development process for the competencies, and recommendations for their continued development and implementation.     

Dementia Caregiving in the Context of Late‐Life Remarriage: Support Networks,Relationship Quality,and Well‐being

Caregiving research has not accounted for increasingly diverse and complex marital and family histories of older Americans. The authors examined social relations and care‐specific positive and negative support networks among late‐life remarried wife dementia caregivers (N = 61) to determine associations among network structure, relationship quality with and support received from network members, and global assessments of family and stepfamily disagreement on caregiver well‐being. Own family and friends predominated in the social relations and positive networks. Although over half (54%) of respondents included a stepfamily member in their positive networks, stepchildren comprised the largest group (35%) in the negative networks. Larger negative networks and actively negative interactions were related to greater caregiver burden, and more global disagreement with stepfamily was associated with greater depression and burden. The findings illustrate the complex nature of support and the value of targeted examinations of caregiving support dynamics among late‐life remarried older adults and stepfamilies facing health demands.     

Military spouses speak up: A qualitative study of military and Veteran spouses’ perspectives

ABSTRACT

The purpose of this qualitative study was to examine military family life through the lens of military and Veteran spouses. Twenty-two female, active-duty military and Veteran spouses provided extensive written responses to essay questions as part of an online survey that were analyzed with qualitative data analysis methods. Findings revealed seven main themes: how military life has influenced health care access, spouses’ identities as caregivers, marital relationships, health outcomes, social support, spouses’ educational and career opportunities, as well as their personal growth. In summary, their experiences indicate that military service affects all aspects of their lives. Spouses gave numerous suggestions as to how service providers can address their unique experiences to improve the supports they offer military families, including ensuring the spouse is involved in health care, and providing support programs that focus on the entire family.     

CURRICULUM CHANGES TO MEET CHALLENGES: PREPARING MFT STUDENTS FOR MANAGED CARE SETTINGS

Fledgling therapists who graduate from family therapy traning programs will have to navigate the world of managed care. In this article, faculty of University of San Diego share changes in its accredited training program that prepare students for practice in an increasingly multidisciplinary world where health maintenence organizations and other versions of managed care predominate. The paper touches on contextual issues, provides a detailed outline of coursework presenting basic knowledge and skills involved in clinical pracice in a managed care environment, and comments on clinical placements and the challenge of helping the next generation of clinicans "fit" into the future of health care delivery while maintaining their unique identity as family therapists.