Medical Family Therapy and Family Medicine Residency Cross Training Jay Brieler, MD Max Zubatsky, PhD, LMFT Saint Louis University

Disclosures No financial conflicts of interest No off label uses No residents or graduate students harmed during the creation of this presentation

Objectives Define the discipline of Medical Family Therapy. List training activities that have been most effective for Family Medicine residents and MedFT graduate students. Describe a process to customize training based on the resources and system characteristics of the clinic environment and needs of their patient population.

Medical Family Therapy Defined A meta-framework that integrates biopsychosocial and family systems approaches of care when working with patients and families around mental health and medical issues. This framework prepares clinicians to work in integrated care settings and collaborate with other professionals to effectively treat to whole person. What differentiates MedFTs from “traditional mental health professionals” in care settings: –Seeing the family as the unit or context of treatment –Understanding the clinical, operational and financial worlds of health care –Linking health to larger systems outside of the patient and/or family (community, culture, institution, etc.)

Medical Model Biopsychosocial Model A deductive way of assessing and determining criteria for a diagnosis. Taking a patient’s background information to make a final determination about their health based on biomedical information. An inductive way to take a specific diagnosis or condition, and exploring the “holistic” perspective of the patient. Now, more family/systemic/community connections around one’s condition are explored.

Beyond the Medical Model Medical Model Individual Diagnosis (DSM-V) Psychopharmacology Risk Assessment Referral

Beyond the Medical Model Biopsychosocial Model Family Systems Conceptualization Psychotherapy Psychosocial determinants of health Integrated Services

Structure of our Collaboration Saint Louis University Family and Community Medicine Saint Louis University Family and Community Medicine SLU Medical Family Therapy SLU Medical Family Therapy SLU Family Medicine Residency SLU Family Medicine Residency Family Care Health Center Family Care Health Center St. Mary’s Hospita l St. Mary’s Hospita l Center for Counseling and Family Therapy Behavioral Health Team Behavioral Health Team

Matching Local Needs to Local Resources Unique skill sets of available learning opportunities  FCHC – fully mature BHI system  SLU Care – developing BHI  Wide variety of mental health professionals  Multiple settings – inpatient, outpatient, counselling center Address wide range of learner goals and needs  Graduate students have wide variety of previous experience and eventual careers  Residents with an interest in underserved care, large range of support and skill needs

Goals of Resident BH Training Understand normal and abnormal psychosocial growth and development. Recognize, initiate treatment for, and utilize appropriate referrals for mental health disorders. Evaluate patients for mental health disorders using appropriate techniques to enhance the doctor-patient relationship. Have sensitivity to and knowledge of the emotional aspects of organic illness. Be able to intervene effectively and professionally in emergent psychiatric, domestic violence, child abuse, and disaster situations. Understand the impact of mental health disorders on the family unit. AAFP. Recommended Curriculum Guidelines for Family Medicine Residents. Human Behavior and Mental Health. Accessed 4/7/

Resident Activities Auditing MedFT Classes Attachment Theory Affect Regulation Family Systems Assessment Genograms Relational dynamics

Resident Activities Acting as Behavioral Health Consultant  Integrated roles (LCPC, MedFT, PhD, Peds, Adult)  MD medical consult role  Brief intervention  Work with schools  SBIRT  Mindfulness, relaxation

MedFT Graduate Student Activities  Inpatient Rounding  Multi-professional discussion  Resident team  Pharmacy  Case Management  Direct patient contact in hospital setting  Family assessments / genograms  Behavioral interventions

Resident Activities Reflecting Teams 45 minutes Resident and therapy team view a family therapy session behind one way mirror 15 minutes Family/Therapist and team switch, where the family hears the resident and therapy team reflect on the case. 15 minutes Family/therapist and team switch again, where the family reflections on the professional summaries, strengths and suggestions. 15 minutes After patient leaves, the therapist, therapy team and resident process the session. The resident and therapy team give the therapist a session evaluation

MedFT Graduate Student Activities Practicum  Family Care Health Center  Act as general BHC  Act as Family Therapist resource for clinic Community Health Resource Center Consultant with medical students/residents SLUCare

Ongoing Research Study of Resident Experiences and Self- Rated BH Competencies QI project on how integrated care is delivered at three primary care clinics (between MedFTs, physicians, nurses, MAs and coordinators)

Challenges Scheduling Wide backgrounds of learners Lexicon and language of each other’s discipline Resistance from the medical model One’s cultural beliefs about care

Opportunities Increased exposure to high yield activities Learning how to work in a team environment Improving competencies on behavioral health rotations for residents Making MedFT graduates more viable and competitive for behavioral science faculty positions

PGY-2 Resident Experience “It was really interesting. I refer patients for therapy all the time, but I had never actually sat in on a session.” “I was lost at first but began to learn some of the terms.” “Everyone remembered me and made a point to include me in the educational sessions.”

Med FT Graduate Student Experience “ I have a deeper appreciation for medical providers after working at FCHC. The residents remained open and curious about behavioral health throughout my time there, and I believe the most rewarding experience of integrative care was when the residents shadowed me during my therapeutic work. Same day hand-offs were also great opportunities to enhance collaboration with providers as well as provide crisis interventions to patients in need. FCHC has influenced my desire to work within an integrative care setting, and I learned through my team at FCHC how to broaden the conversation of our partients' well-being. ”

Lessons Learned Create shared language Use learners to teach each other Expand residents’ conceptualization of BH Provide broad based exposure for grad students Match activities to available resources and specific learner needs

Contact Info Max Zubatsky, PhD, LMFT Jay Brieler, MD

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