Fair Winds and Squalls: The Health Impact of Family Legacies Across the Lifespan

1. Fair Winds and Squalls: The Health Impact of Family Legacies Across the Lifespan Session #F4 (Track 1) Amy Davis, MD Caroline Dorman, MD Scott Sibley, PhD, LMFT, CFLE Alex Schmidt, PhD, LMFT-A CFHA 18th Annual Conference October 13-15, 2016  Charlotte, NC U.S.A.

2. Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • Describe the ways in which family of origin interactions influence patients’ expectations of healthcare experiences and mental and physical health outcomes. • Apply principles of family legacies to the biopsychosocial management of various chronic and acute illnesses. • Develop an individualized plan for integrating the concept of family legacies into assessment and history taking, rapport building, and biopsychosocial intervention.

4. References • Boszormenyi-Nagy, I., & Krasner, B. R. (1986). Between give and take: A clinical guide to contextual therapy. New York, NY: Brunner/Mazel. • Burgess, E. W. (1931). Family tradition and personality. In K. Young (Ed.), Social Attitudes (pp. 188-207). New York, NY: Henry Holt. • Carman, K. L., Dardess, P., Maurer, M., Sofaer, S., Adams, K., Bechtel, C., & Sweeney, J. (2013). Patient and family engagement: A framework for understanding the elements and developing interventions and policies. Health Affairs, 32(2), 223-231. • Carteret, M. (2011a). Cultural values of Latino patients and families. In Latino Cultures. Retrieved from http://www.dimensionsofculture.com/2011/03/cultural-values-of-latino-patients-and-families/ • Carteret, M. (2011b). Cultural barriers to treatment and compliance. Cultural Health Beliefs and Behaviors. Retrieved from http://www.dimensionsofculture.com/2011/03/cultural-barriers-to-treatment-and-compliance/

5. References • Imber-Black, E., Roberts, J., & Whiting, R. (1988). Rituals in families and family therapy. New York, NY: Norton. • Itkowitz, C. (2016, March 2). Harvard researchers discovered the one thing everyone needs for happier, healthier lives. Retrieved from https://www.washingtonpost.com/news/inspired-life/wp/2016/03/02/harvard-researchers-discovered-the-one-thing-everyone-needs-for-happier-healthier-lives/?postshare=4551457534055875&tid=ss_mail • Nussbaum, A. M. (2016). The finest traditions of my calling: One physician’s search for the renewal of medicine. New Haven, CT: Yale. • Pyatak, E. A., Florindez, D., Peters, A. L., & Weigensberg, M. J. (2014). “We are all gonna get diabetes these days”: The impact of a living legacy of type 2 diabetes on Hispanic young adults’ diabetes care. Diabetes Educator, 40(5), 648-658.

6. References • Walsh, F. (2003). Family resilience: A framework for clinical practice. Family Process, 42(1), 1-18. • Wolff, J. L., & Roter, D. L. (2011). Family presence in routine medical visits: A meta-analytical review. Social Science & Medicine, 72(6), 823-831. • Wright, L. M., Watson, W. M., & Bell, J. M. (1996). Beliefs: The heart of healing in families and illness. New York, NY: Basic Books.

7. Learning Assessment • A learning assessment is required for CE credit. • Questions are welcome throughout the presentation.

9. Our Team

10. Emotional Bonds Hereditary Bonds

11. (Itkowitz, 2016)

13. Family Culture • “Whatever its biological inheritance from its parents and other ancestors, the child receives also from them a heritage of attitudes, sentiments, and ideals which may be termed the family tradition, or the family culture.” (Burgess, 1931)

14. Expressing Culture • Rituals • Daily routines • Family traditions • Celebrations • Life cycle rituals • (Imber-Black, Roberts, & Whiting, 1988)

15. (Carteret, 2011a)

16. Family Legacies • “It is the task of the present generation to sort out that which is beneficial and translate it into terms of benefits for future generations.” (Boszormenyi-Nagy & Krasner, 1986, p. 129)

22. How do these experiences influence what patients expect from the healthcare system and from their care team?

23. Family Beliefs • Role of patient vs. role of physician • Confidence to engage in health maintenance behaviors • Patient and family engagement (Carman et al., 2013) • Causes of illness • “Why do you believe you are ill?” (Nussbaum, 2016, p. 263)

24. Family Beliefs • Development of social support system • Preferences for: • Physical, task-oriented assistance • Emotional support • Organization of roles within the family • Patient vs. caregiver role (Friedemann & Buckwalter, 2014; Rolland, 1994) • Family engagement in medical decision-making (Wolff & Roter, 2011) • Openness to assistance from health agencies

25. (Wright, Watson, & Bell, 1996)

26. Family Beliefs • Providers’ role • Remain curious about the impact of beliefs on treatment decisions and follow-through on patient goals • Help patients maintain solid, constructive beliefs that promote holistic wellbeing • Help patients remain flexible in adjusting beliefs when they’re no longer useful (Wright, Watson, & Bell, 1996)

27. Routine Habits and Behaviors (Pyatak et al., 2011)

28. Routine Habits and Behaviors

29. Health States • Presence or absence of disease • Severity of symptoms • Development of complications • Shared genetics vs. shared environment

31. Crafting a Family Legacy • “If you were to change one aspect of your family’s health culture, what would it be? How I can partner with you to work towards that goal?” • OR • “What is one aspect of your family’s health culture that has worked well for you? What’s been beneficial about this for you?” Crafting a Family Health Legacy

32. Crafting a Family Legacy • “What is something you think your family does a good job of to be healthy and set up good habits? How can you keep making that a priority?” Crafting a Family Health Legacy

33. Crafting a Family Health Legacy • “Who in your family do you think would share that goal? How can you enlist their help?” • “What might stand in the way of you creating this new, more positive story about your health?”

34. Considerations for Team-Based, Integrated Care • How will you introduce these questions into clinic workflow? • Whose job will it be to ask these questions? • How do you ensure these questions are followed up on in a meaningful way in future encounters with the patient? • How do you engage patients’ family members in these questions and activate the resources they offer? • How do you incorporate the idea of a “legacy” into advanced care planning and other medical decisions across the lifespan?

36. Susan Comstock and Her Legacy of Tragedy • 52 year old woman with strong family history of suicide and opiate abuse • Presents with uncontrolled pain after shoulder surgery and neck surgery for problems related to an inflammatory arthritis • Taking 180 morphine equivalents of opiates plus benzodiazepines for sleep • Over 8 years the story emerges: • Her father killed himself after a long history of opiate abuse. Stepfather abused alcohol and herbrother hung himself in his teens. • Her husband and father of her two daughters killed himself when they were little. Found by one of her daughters. • Daughter hangs herself at age 21, infant and toddler daughters to be raised by heroin-addicted ex-husband.

38. Discussion Questions • What is the legacy the patient has identified in her family and health history? • How would you work to elicit this “history” in a much shorter time than the 8 years it took to learn this information? • How could we assist this patient in redefining the direction of her family destiny?

41. Pearls • Be emphatic in encouraging questions about cultural beliefs and family legacy – give silence a chance (Carteret, 2011) • Effective history taking must include an intentional inquiry into cultural beliefs and patients’ health legacies • Legacy is a moving target – must be dynamic and flexible to adjust to changing demands

45. Session Evaluation Please complete and return the evaluation form before leaving this session. Thank you!

46. Alexandra.Schmidt@rmhp.orgIntegrated Behavioral Health Advisor