A NATIONAL SURVEY OF FAMILY PHYSICIANSPERSPECTIVES ON COLLA.docx

A NATIONAL SURVEY OF FAMILY PHYSICIANS:
PERSPECTIVES ON COLLABORATION WITH
MARRIAGE AND FAMILY THERAPISTS
Rebecca E. Clark
Lifespan Family Healthcare, Newcastle, Maine
Deanna Linville
University of Oregon
Karen H. Rosen
Virginia Polytechnic Institute and State University
Recognizing the fit between family medicine and marriage and
family therapy (MFT),
members of both fields have made significant advances in
collaborative health research
and practice. To add to this work, we surveyed a nationwide
random sample of 240 family
physicians (FPs) and asked about their perspectives and
experiences of collaboration with
MFTs. We found that FPs frequently perceive a need for their
patients to receive MFT-
related care, but their referral to and collaboration with MFTs
were limited. Through
responses to an open-ended question, we gained valuable
information as to how MFTs
could more effectively initiate collaboration with FPs.
Despite the success of medical family therapists in providing
integrative, collaborative

healthcare, we know little about how commonly family
physicians (FPs) and marriage and fam-
ily therapists (MFTs) collaborate in routine patient care. To our
knowledge, there have been
no studies published from the perspective of the FP that
describe the extent to which FPs seek
the collaboration of MFTs, the degree to which they are aware
of MFT as a field, their per-
ceived need for their patients to receive MFT, or their attitude
toward MFT as a potential
resource for patient treatment.
Leaders in family medicine and MFT recognize the common
occurrence of mental health
concerns arising in a medical visit. In fact, it has been estimated
that more than 60% of patient
visits to primary care physicians (PCPs) include mental health
concerns (Moon, 1997), and
many of these concerns may not be the presenting complaint
(Jackson & Tisher, 1996;
Schurman, Kramer, & Mitchell, 1985). Several MFT ⁄ FP teams
have developed models for col-
laboration (Doherty & Baird, 1983; Dym & Berman, 1986;
Hepworth & Jackson, 1985; Sea-
burn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). Other
researchers and practitioners have
written books that serve as a guide to other mental health
practitioners for how to be effective
collaborators with other healthcare practitioners (e.g., Seaburn
et al., 1996).
The specialty of family medicine, which arose in the 1960s,
embraces a systemic, biopsy-
chosocial perspective to illness that stresses the importance of
caring for the whole person
within his or her family, social context, and life cycle stage

(Chung, 1996; Fischetti &
McCutchan, 2002). It is not surprising that FPs regularly treat
their patients’ mental health
problems. By definition of their specialty, FPs are trained to
integrate behavioral science con-
cepts with their biomedical training (AAFP, 2000; Seaburn et
al., 1996) as well as to manage
Rebecca E. Clark, MS, Lifespan Family Healthcare, Newcastle,
Maine; Deanna Linville, PhD, Couples and
Family Therapy Program, Department of Counseling Psychology
and Human Services, University of Oregon;
Karen H. Rosen, EdD, Marriage and Family Therapy Program,
Department of Human Development, Virginia
Polytechnic Institute and State University, Northern Virginia
Center.
Address correspondence to Rebecca Clark, Lifespan Family
Healthcare, 80 River Road, Newcastle, Maine
04553; E-mail: [email protected]
Journal of Marital and Family Therapy
April 2009, Vol. 35, No. 2, 220–230
220 JOURNAL OF MARITAL AND FAMILY THERAPY April
2009
psychotropic medication. The American Academy of Family
Physicians (AAFP, 2000) recom-
mended curriculum guidelines delineate how family medicine
residents must understand the

individual in the context of his or her family, as well as the
emotional impact of illness, and be
able to evaluate and diagnose mental health disorders from a
biopsychosocial perspective. For
decades, authors in family medicine and collaborative
healthcare journals have published
literature regarding the use of MFT techniques such as family
systems thinking, the use of gen-
ograms, meeting with the entire family, brief therapy
techniques, and when to refer patients for
family therapy (Bader, 1990; Bloom & Smith, 2001; Bullock &
Thompson, 1979; Christie-Seely,
1981; Davis, 1988; Frank, 1985; Lang et al., 2002; Mayer et al.,
1996; Tomson & Asen, 1987).
Additionally, organizations such as the Collaborative Family
Healthcare Association (CFHA;
see http://www.cfha.net) and the Society for Teachers of Family
Medicine (STFM; see http://
www.stfm.org) continue to promote research, education, and
practice in collaborative health-
care. Given family medicine’s emphasis on family systems, the
family as the unit of care, and
biopsychosocial perspective, it seems that MFTs would be a
logical, and even sought-after,
complement to FPs in providing comprehensive patient care.
As a specialty of MFT, medical family therapy (MedFT) has
already made significant
advances in this area. Particularly helpful for chronic illness,
MedFT has enabled MFTs to
skillfully integrate the biopsychosocial-spiritual perspective, a
systemic integration of physical
and emotional health, familial ⁄ social relationships, and
spiritual belief systems, with a family
systems framework (McDaniel, Hepworth, & Doherty, 1992a;
Rolland, 1994; Weihs, Fisher, &

Baird, 2002). Specifically trained medical MFTs have
effectively collaborated with medical prac-
titioners to provide care for families struggling with chronic
medical illnesses such as infertility
(Burns, 1999; McDaniel, Hepworth, & Doherty, 1992b), cancer
(Yeager et al., 1999), childhood
asthma and diabetes, cardiovascular and neurological disorders
(Campbell & Patterson, 1995),
obesity (Campbell & Patterson, 1995; Flodmark, Ohlsson,
Ryden, & Sveger, 1993), somatoform
disorder (McDaniel, Hepworth, & Doherty, 1995), dual
diagnosis (Harkness & Nofziger, 1998),
and anorexia nervosa (Dare & Eisier, 1995).
Roadblocks to Identifying and Managing Patient Psychosocial
Concerns
There is a range of limitations to the quantity and quality of
psychosocial care FPs can
deliver to their patients. Researchers have identified lack of
training (Christie-Seely, 1981;
Fosson, Elam, & Broaddus, 1982), time (Glied, 1998; Rost,
Humphrey, & Kelleher, 1994;
Tomson & Asen, 1987), patient reluctance (Kainz, 2002;
Williams et al., 1999), managed care
(DeGruy, 1997; Fisher & Ransom, 1997), and lack of
confidence (Gerdes, Yuen, & Frey, 2001;
Williams et al., 1999) as roadblocks to FPs and other PCPs
identifying and treating patient
mental health needs.
Roadblocks to referral. Regardless of to whom they refer,
physicians identify several road-
blocks when referring patients to mental health professionals.
These have included patient
reluctance, the unavailability of appropriate mental health

professionals in rural communities,
lack of affordability of mental health, significant lag time
between referral and appointment
availability, lack of adequate feedback from mental health
professionals, the stigma patients
attach to mental healthcare, and poor communication from the
mental health professional
(Kainz, 2002; Kushner et al., 2001; McCulloch et al., 1998;
Reust, Thomlinson, & Lattie, 1999;
Rost et al., 1994; Williams et al., 1999).
The purpose of this exploratory study was to discover FPs’
views of MFTs as potential
collaborators on the healthcare team. Specifically, this study
seeks to answer three research
questions:
(1) Do FPs view MFTs as a resource for patients with
psychosocial needs?
(2) Are FPs interested in collaborating with MFTs?
(3) What would make MFTs more helpful collaborators?
April 2009 JOURNAL OF MARITAL AND FAMILY THERAPY
221
METHODS
This study was a national survey of 240 FPs. A questionnaire
was mailed to 240 board cer-
tified FPs who were randomly selected from the AAFP
directory. The inclusion criteria were
engagement in the practice of family medicine, graduation from
a U.S. medical school, comple-
tion of residency after 1969, and residence within a U.S. zip

code.
Participants and Procedures
After obtaining IRB approval, a randomly selected mailing list
was obtained from the
AAFP. Questionnaires were mailed along with an introductory
letter describing the study,
a brightly colored sticky note with a brief hand-written note,
and a self-addressed stamped
envelope. Each questionnaire was numbered to enable a follow-
up mailing to nonrespondents.
During the first wave, 104 questionnaires were returned. After 4
weeks the same material
was re-mailed to nonrespondents. After two mailings we
received 153 responses, representing
a 64% response rate. Of those responses, 16 questionnaires were
excluded from analyses
because respondents were no longer practicing family medicine
full time. Consequently, there
were a total of 137 usable questionnaires (57%). We received
responses from FPs in 37 out of
42 states as well as an FP in Puerto Rico and a deployed
military FP. Respondents had been
in practice for an average of 12 years and were an average age
of 46. Table 1 depicts demo-
graphic data such as gender and geographical distribution of
respondents. The four major
census regions of the United States as well as U.S. territories
and military were represented in
the sample. Based on the AAFP 2002 census of their members
(AAFP, 2003), the sample
appears representative of both the gender and regional
distribution of FPs throughout the
United States.

Table 1
Demographics
Variable
Percentage
of respondents
Percentage
of random
sample
Percentage
of 2002
National
AAFP
Censusa
Region
Northeast 15 13 15
South 35 33 33
Midwest 27 33 28
West 21 20 21
U.S. territory ⁄ Army Post Office 2 2 3
Gender
Male 66 71b
Female 34 29b
Note. n = 137. aMembership (U.S., U.S. Territories, and
Military; AAFP, 2003). bActive
AAFP members (this percentage includes 138 Canadian
members and 350 foreign members
that were not part of the sampled population). AAFP =
American Academy of Family

Physicians.
2009
The questionnaire, which contained both closed and open-ended
questions, was based on a
review of literature and in consultation with MFTs and FPs. In
the development phase, the
questionnaire was administered to five FPs and revised based on
their feedback.
Analysis
Quantitative data analyses were completed using SPSS for
Windows, v10.0 (Norusis, 2000).
Qualitative data were analyzed using a modified version of the
constant comparative method
described by Strauss and Corbin (1990). Each segment of the
written responses to the open-
ended questions was coded independently by both authors to
identify and name major themes.
Once a list of major themes was developed, content analysis
(Patton, 2002) was used to deter-
mine how frequently each theme was mentioned by respondents.
RESULTS
In this section, each research question is addressed in turn.
When qualitative data gene-
rated noteworthy themes, the themes are identified and quotes
provided for illustration.
Do FPs View MFTs as a Resource for Patients With

Psychosocial Needs?
This research question was addressed by five questions on our
questionnaire. Respondents
were asked to estimate the percentage of their patients with
identified psychosocial concerns
who they believed could benefit from marital and ⁄ or family
therapy. Respondents were also
asked to estimate their referral practices. On average,
respondents estimated that 48% of their
patients could benefit from marital and ⁄ or family therapy and
that they referred 12% of their
patients for mental health services. However, respondents
estimated that they referred 5% of
their patients specifically for marital and ⁄ or family therapy–
related care. We specified marital
and ⁄ or family therapy–related care rather than MFT because at
that time several states did not
license MFTs (three of the states represented in this survey did
not).
Additionally, respondents were asked to check all that applied
from a list of potential
roadblocks encountered when referring patients for MFT-related
care. As can be seen in
Figure 1, ‘‘Patient reluctance’’ was checked by 85% of the
respondents, ‘‘HMO ⁄ Insurance’’ by
65%, ‘‘unavailability of appropriate therapists’’ by 40%,
‘‘time’’ by 34%, ‘‘lack of awareness of
appropriate therapists’’ by 33%, and ‘‘don’t feel this type of
therapy is helpful’’ by 4%.
Although 24 respondents provided written answers in response
to ‘‘other please specify,’’ no
new categories of roadblocks to referral emerged.
Figure 1. Roadblocks encountered by FPs when referring

patients for marriage and family
therapy–related care (n = 136).
223
Finally, respondents were asked if they were aware that MFTs
are licensed mental health
professionals ‘‘trained in psychotherapy and family systems and
licensed to diagnose and treat
mental and emotional disorders within the context of marriage,
couples, and family systems.’’
While 83% of respondents checked ‘‘yes’’ to this question, 64%
reported that prior to receiving
our survey they did not recognize the initials ‘‘LMFT’’ as
credentials for a Licensed Marriage
and Family Therapist.
Are FPs Interested in Collaborating With MFTs?
This research question was addressed by five questions on our
questionnaire. Respondents
were asked, ‘‘Have you ever consulted with a mental health
professional regarding a patient
case?’’ All of the respondents checked ‘‘yes’’ to this question.
When respondents were asked
whether or not they had ever consulted with an LMFT regarding
a patient or family, 47% of
the respondents checked ‘‘yes,’’ while 53% of the respondents
indicated they either had not or
were not sure if they had consulted with an LMFT.
Additionally, respondents were given a list of collaborative
modes and asked to check all

that applied to their experience of collaborating with MFTs or
comparable mental health pro-
fessionals in their community. ‘‘Infrequently receive reports’’
was checked by 49% of the FPs,
‘‘phone call ⁄ email with a MFT’’ by 43%, ‘‘informal
consultation with a MFT’’ by 40%, ‘‘no
patient-care contact with MFTs’’ by 20%, ‘‘regularly receive
reports’’ by 19%, and ‘‘regular
meetings with MFTs’’ by 3%.
Respondents were asked to describe how helpful they found
patient-care consults with
MFTs. The collaborative interactions with MFTs were indicated
by 82% of the respondents to
be either ‘‘very helpful’’ or ‘‘somewhat helpful.’’ Five percent
checked either ‘‘somewhat
unhelpful’’ or ‘‘very unhelpful,’’ while 12% checked ‘‘not
applicable.’’
Finally, respondents were asked to describe their interests in
collaborating with LMFTs or
comparable mental health professionals when identifying
patients’ psychosocial needs by check-
ing all that applied from a list of collaborative approaches. The
mode of collaboration pre-
ferred by most of the respondents was ‘‘referral out with
continuing collaborative
communication’’ (84%). Some respondents also indicated that
they would be interested in
‘‘inviting a family therapy provider to a patient’s appointment’’
(15%) or ‘‘meeting regularly
with a MFT regarding complex patients’’ (11%). Only 7% of the
respondents indicated they
were ‘‘not interested’’ in collaborating with MFTs.
What Would Make MFTs More Helpful Collaborators?

This research question was addressed by an open-ended
question. Respondents were asked
to ‘‘briefly describe what would make MFT providers a more
helpful resource when treating
patients with psychosocial issues, OR if you don’t consult with
an MFT, why not?’’ Eighty-nine
respondents (65% of sample) answered this question, offering a
total of 141 coded responses. A
content analysis produced six primary themes: (a) ideal
collaborative practices, (b) barriers to
referral, (c) MFT specialty awareness, (d) let us know who you
are, (e) barriers to collaboration,
and (f) attitudes toward MFTs. Quotes are included to better
illustrate the themes and
subthemes.
Ideal collaborative practices. Fifty-four responses were coded
as relating to collaborative
practices that would make MFTs more helpful resources. These
included proximity (‘‘I wish I
had a family therapist in my office’’), ease of referral (‘‘Be
available to my patients within
2 weeks of the request’’), collaborative communication (‘‘More
communication after [patient]
evaluation,’’ ‘‘Regular feedback’’), topical ⁄ specialty
information (‘‘Suggestions on what I can do
to help further the therapeutic goals,’’ ‘‘A specialist who could
incorporate issues related
to aging’’), and religious ⁄ faith-based (‘‘Faith-based, a plus!’’
‘‘I would like to work with a
Christian marriage and family therapist’’).
2009

Barriers to referral. We coded 33 comments as barriers
respondents face when making
referrals to MFTs, including patient reluctance (‘‘Difficulty
convincing patients that therapy can
help them and sometimes even that there is a problem’’),
managed care (‘‘Many patients don’t
have mental health coverage,’’ ‘‘I do use other therapists when
driven by insurance’’), do not
know the therapist (‘‘hard to refer when don’t know
therapist’’), and lack of availability (‘‘Ther-
apists not available in my rural area,’’ ‘‘If one were more
readily available, this would be an
excellent resource’’). Only one of the responses indicated that
the respondent encountered no
barriers to referral.
MFT specialty awareness. We coded 15 responses as relating to
respondents’ awareness of
MFT as a specialty. Many of these respondents indicated they
were either completely unaware
of MFT as a distinct field or were unclear about the professional
role of an MFT (‘‘I didn’t
know there was a family ⁄ marriage therapy specialist’’). Other
respondents asked for more infor-
mation about MFTs and the types of services they provide.
Some indicated that they had not
differentiated between the various mental health professionals
with whom they worked (whether
they be MFTs, social workers, or psychologists).
Let us know who you are. We coded 14 responses as indicating
respondents wanted to be
able to identify the MFTs in their communities. Responses
placed in this category suggested

that respondents were either unaware of MFTs, had no
professional contact with MFTs in
their communities, or were less likely to work with therapists
they had not met (‘‘Probably
meeting face to face [would be helpful]’’).
Barriers to collaboration. We coded 13 responses as describing
barriers to collaboration.
Subcategories of this theme are the following: time
(‘‘Unfortunately we seem to have less time
to [collaborate]’’), managed care (‘‘HMO . . . typically listed an
800# to call . . . made commu-
nication very difficult between the anonymous therapist and
I’’), lack of therapist feedback
(‘‘Helpful to get reports back from therapists, but it often
doesn’t happen’’), and interest (‘‘I
like to refer but don’t necessarily feel I need to receive
reports’’).
Attitudes toward MFTs. We coded 12 responses as relating to
FPs’ attitudes regarding
MFTs. Seven responses had positive overtones (‘‘They are
already a helpful resource for me—I
can’t think of any way to improve this presently’’). Two
responses suggested an uncertain or
even negative mind-set toward MFTs (‘‘most of the MFT people
only have a Master’s . . . for
more complex cases, I might choose psychiatry or doctoral
psychology background’’). Three
responses made reference to the importance of a philosophical
fit.
DISCUSSION
The primary theme emerging from this study is that FPs are
interested in referral and col-

laboration, in some form, but face barriers. This theme is
illustrated by the quantitative and
qualitative data. The data suggest that there is a considerable
gap between the percent of
patients FPs identified as potentially needing MFT (48%) and
the percent of patients actually
referred for MFT (5%). This may, in part, be understood by the
roadblocks to referral (e.g.,
patient reluctance, HMO restrictions, unavailability of
appropriate therapist, and time) faced
by FPs in this study as well as in previous research studies
(Kainz, 2002; Orleans, George,
Houpt, & Brodie, 1985; Rosenthal, Shiffner, & Panebianco,
1990; Rost et al., 1994; Williams
et al., 1999).
Secondly, FP respondents in this study reported that they are
often unaware of MFTs in
their community or unfamiliar with the discipline of MFT.
Likewise, Kainz (2002) found that
physicians would be more likely to refer to the mental health
providers with whom they had
met and developed a good relationship or of whom they had
heard a good report from either
colleagues or patients. It may be that FPs are also uncertain of
the scope of MFTs’ training
and practice.
225
Thirdly, the FPs in this study appeared receptive to referring to
and collaborating with
MFTs, but collaboration is limited in its occurrence. In this

study, HMOs, time limitations,
and lack of therapist-initiated communication have been
identified as significant barriers to col-
laboration. These barriers that were identified by FPs are
similar to the collaboration barriers
identified by MFTs. Research articles and books written on
collaboration give considerable
attention to the issues around HMO-related barriers (e.g.,
DeGruy, 1997; McCulloch et al.,
1998; Seaburn et al., 1996). Other potential barriers to
collaboration may be attributed to
patient reluctance to accepting a mental health referral. Reust et
al. (1999) found that patient-
identified barriers to following through with a physician-
initiated mental health referral are
comparable to the barriers identified by FPs in this study.
Finally, FP respondents reported that they want feedback from
MFTs to whom they refer
a patient. This finding is consistent with the findings of other
studies on collaboration (Kainz,
2002; Rosenthal et al., 1990; Rosenthal, Shiffner, Lucas, &
DeMaggio, 1991) which have identi-
fied regular feedback to be essential, with the majority
describing this feedback ideally to be a
brief intake report or progress note. With these themes in mind,
we make suggestions for
enhancing collaboration between FPs and MFTs.
Suggestions for MFTs
Specific training in MedFT will facilitate MFTs’ ability to
collaborate and provide compre-
hensive, biopsychosocial care in conjunction with a client’s FP
or other medical practitioner
(McDaniel et al., 1992a). As with any relationship, it is

important to take a learning stance in
order to begin forging collaborative relationships with FPs.
Researchers and practitioners in
healthcare collaboration underscore the importance of
understanding how the cultural and
structural differences between the two professions present
unique challenges for collaboration
(McDaniel et al., 1992a; Patterson, Peek, Heinrich, Bischoff, &
Scherger, 2002). Knowledge of
the culture of family medicine or other medical specialties will
add to MFTs’ abilities to
approach collaboration with sensitivity and confidence. To
build mutual respect, MFTs should
communicate a desire to understand the needs of FPs and their
patients. Overall, constant
investments of time, communication, respect, and goal
clarification are important for develop-
ing successful collaborative relationships (McDaniel et al.,
1992a; Seaburn et al., 1996).
We found that some FPs are either unaware of MFT as a unique
discipline within the
mental health field or unaware of MFTs’ availability in their
community. In response to this
finding, MFTs might introduce themselves to local FPs,
especially those whose patients they
are already counseling. Recognizing that it may be intimidating
to make the initial contacts,
McDaniel et al. (1992a) suggested finding venues for
introduction such as through another
medical colleague or inviting the medical practitioner to lunch.
At this time it may be helpful
to offer a business card, rolodex insert, and brochure describing
areas of specialty in order to
facilitate future contact or referral from the FP.

As MFTs learn about the types of patient psychosocial concerns
that FPs commonly
encounter, it may be helpful to create fact sheets addressing
these concerns, offer brief work-
shops, or even participate on grand rounds in local hospitals.
FPs in this study suggested that
information on specific psychosocial issues would be helpful.
They most commonly requested
suggestions for reducing patient reluctance to MFT care. MFTs
might consider American Asso-
ciation for Marriage and Family Therapy (AAMFT) brochures
addressing specific mental
health issues as a resource to offer FPs or referred patients.
These brochures have a space for
professional contact information and are available for purchase
from AAMFT (see http://
www.aamft.org/store/shop/category.asp?catid=9). Also, MFTs
can regularly participate on
healthcare teams by obtaining releases from clients to exchange
information with the referring
physician. If a client declines to release his or her information,
the MFT may want to send a
brief note acknowledging and thanking the FP for the referral
and discuss with the client the
goals and potential benefits of a team approach.
2009
Beyond the routine collaborative communication, MFTs can
look for ways to maintain con-
tact and develop the relationship. For instance, MFTs might
locate current journal articles or
other brief materials for FPs that may pertain to collaboration,

mental health issues, or behavioral
health techniques. Due to the demands of patient care, FPs have
limited time for researching
issues in mental health and may appreciate this collaborative
gesture (E. Ng, MD, personal
communication, December 3, 2003). Experienced collaborators
underscore the importance of the
long-term efforts necessary to maintain collaborative
relationships. MFTs may also be interested
in joining a collaborative healthcare organization such as the
CFHA (which includes a subscrip-
tion to the journal Families, Systems, and Health) or
participating in other like-minded events such
as the Conference on Families and Health sponsored by the
STFM and CFHA.
Implications for Clinical Training and the MFT Field
Professionals in the field of MFT must continue to look for
ways to bridge the gap
between these two compatible fields. Based on our findings, it
seems that MedFT and collabo-
rative training programs offer skills necessary to collaborate
with FPs in comprehensive,
systemic care. These trainings are offered in academic settings,
in fellowship training programs,
professional associations, professional journals, and community
interactions (for information
on training programs, see www.cfhcc.org/pages/education-and-
training/; see also a list of pro-
grams in Seaburn et al., 1996, pp. 270–272). It may be
necessary for MFT training programs to
add collaboration training or MedFT to their curriculum.
William Doherty (personal communi-
cation, March 22, 2003) stated that professionals most often
collaborate with whom they train

or know personally. Since most MFTs do not have the
opportunity to know FPs personally, a
collaborative component early in MFT training would offer an
opportunity for students to
interact with health professionals from other disciplines and for
medical health professionals in
the community to learn about MFT and meet future MFTs.
Students could be encouraged to
seek internships in medical settings or to conduct research
relevant to both fields and to publish
in family medicine journals.
Numerous associations (such as the AAFP, AAMFT, Health
Psychology Division of the
American Psychology Association, CFHA, and STFM) offering
workshops and conferences
provide additional opportunities for MFTs and FPs to interact
and increase their collaboration
skills. As MFTs learn to connect with FPs, it is possible that
MFTs and FPs will find ways to
work together to promote marketing and to advocate for
managed care policy change. Man-
aged care corporations may respond to pressure placed on them
by organized, collaborating
FPs and MFTs to ensure reimbursement for mental healthcare.
Limitations
When interpreting the results of the study, it is important to be
mindful of the following
limitations. First, the questionnaire has not been tested for
reliability or validity. While the sur-
vey method is an efficient mode for data collection,
questionnaires are self-administered tools
in uncontrolled settings. Thus, it is possible for the participants
to misinterpret questions. To

address these limitations, this survey was scrutinized by several
FPs, and qualitative questions
were included to add depth and clarity to the findings.
Secondly, although the size of our sample is sufficient to
produce a confidence interval of
about ±6% (Rea & Parker, 1997), it is still a relatively small
sample compared to a population of
over 53,000 FPs. Readers are encouraged to consider the margin
of error when interpreting results.
However, this study’s response rate (64%) is remarkable when
compared with physician response
rates to other surveys with and without incentives (VanGeest,
Wynia, Cummins, & Wilson, 2001).
Suggestions for Future Research
More research is needed to enhance our understanding of what
increases the likelihood of
successful collaboration between FPs and MFTs. One approach
to this may be for researchers
227
to examine collaborative relationships that are working. What
types of training in an MFT
program or FP residency are linked to increased collaboration?
What current practices of col-
laboration are most effective and why? Additionally, another
member of the collaborative triad,
the patient, could be a valuable source of information about the
helpfulness of FP ⁄ MFT col-
laboration. The patient’s perspective of the risks ⁄ benefits of

his or her FP and MFT working
together may be useful in establishing a link between
psychosocial care and cost-effective
healthcare that would interest managed care companies.
Despite the barriers and limitations to FP ⁄ MFT collaboration
identified in this study, our
findings suggest that FPs think many of their patients could
benefit from MFT and are inter-
ested in collaborating with MFTs. It is our hope that this study
will encourage interdisciplinary
discussion that continues to bridge the gap between FPs and
MFTs and ultimately promote
more effective care for the patient ⁄ client.
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2009

TRAINING FOR COLLABORATION: COLLABORATIVE
PRACTICE SKILLS FOR MENTAL HEALTH
PROFESSIONALS
Richard J. Bischoff, Paul R. Springer, Allison M. J. Reisbig
University of Nebraska-Lincoln
Sheena Lyons
Devereux
Adriatik Likcani
Kansas State University
The purpose of the study was to identify skills that mental
health practitioners need for
successful collaborative practice in medical settings. Known
experts in the field of collabo-
rative health care completed a survey designed to elicit their
suggestions about what is
needed for successful collaborative care practice. Through
qualitative analysis, a set of 56
skills was developed. These skills are organized into three
general categories of compe-
tency: (a) skills for working in a medical setting; (b) skills for
working with patients;
and (c) skills for collaborating with healthcare providers.
In their landmark text, Medical Family Therapy, McDaniel,
Hepworth, and Doherty (1992)
introduced an approach to health care delivery based on the
Engel’s (1977) biopsychosocial
(BPS) model. The foundation of medical family therapy
(MedFT) is an acknowledgment that
‘‘all human problems are BPS systems problems: there are no

psychosocial problems without
biological features and no biomedical problems without
psychosocial features’’ (McDaniel
et al., 1992, p. 26). The authors reasoned that treatments will be
more effective and outcomes
more positive when biological and psychosocial dimensions of
functioning are considered and
addressed simultaneously. This is facilitated by maximizing the
collaboration between physi-
cians and mental health therapists.
While the scholarship of the practice of collaborative health
care predates the publication
of this text, it has increased dramatically since 1992. Other
texts promoting the practice of
MedFT have been written (e.g., Blount, 1998; Patterson, Peek,
Heinrich, Bischoff, & Scherger,
2002; Prouty-Lyness, 2003; Seaburn, Lorenz, Gunn, Gawinski,
& Mauksch, 1996), giving stu-
dents of the approach a library of literature on the practice.
While started in 1983, the journal
Families, Systems, and Health has since become a premiere
journal in this specialty area of
mental health care. Research has established the link between
biological, social, and psychologi-
cal systems (see Campbell & Patterson, 1995) and the positive
impact of psychotherapy, espe-
cially relational approaches to treatment, on health outcomes
(Cambell, 1996; Crane &
Christenson, 2008; Law, Crane, & Berge, 2003). The
Collaborative Family Healthcare Associa-
tion, an association devoted to collaborative care practices that
are characteristic of MedFT,
has matured into a multidisciplinary association giving those
interested in collaborative care
practices a place to come together to share ideas and advance

the practice, research, and theory
of medical family therapy (Bloch & Doherty, 2001). It would be
difficult to imagine that one
could graduate from a clinical training program in marriage and
family therapy, psychology, or
Richard J. Bischoff, PhD, is a Professor and Director in the
Marriage and Family Therapy Program at
University of Nebraska-Lincoln; Paul R. Springer, PhD and
Allison M. J. Reisbig, PhD, are Assistant Professors in
the Marriage and Family Therapy Program at University of
Nebraska-Lincoln; Sheena Lyons, MS, Devereux,
Arizona; Adriatik Likcani, MS, is a Doctoral candidate in the
Marriage and Family Therapy Program at Kansas
State University.
Address correspondence to Richard J. Bischoff, Marriage and
Family Therapy Program, University of
Nebraska-Lincoln, PO Box 830800, Lincoln, Nebraska 68583-
0800; E-mail: [email protected]
Journal of Marital and Family Therapy
doi: 10.1111/j.1752-0606.2012.00299.x
June 2012, Vol. 38, No. s1, 199–210
June 2012 JOURNAL OF MARITAL AND FAMILY THERAPY
199
social work without an understanding of the BPS model,
collaborative care practice, and Med-

FT. However, even with the existence of several degree granting
and postdegree training pro-
grams in MedFT and many more programs that have emphases
in medical family therapy and
collaborative health care, little is known about the competencies
needed to practice MedFT.
It is clear from reading any of the several texts on the subject
that MedFT is different from
the traditional mental health care practice. Those practicing
MedFT need to have the same
skills that are needed for traditional practice environments as
well as many other skills unique
to the collaborative health care environment. However, as yet,
these skills have not been orga-
nized nor explicitly identified. The development of a succinct
set of skills, similar to that of the
American Association for Marriage and Family Therapy
(AAMFT) core competencies (Nelson
et al., 2007), would be a step in the direction of developing
training and practice guidelines for
this rapidly developing approach to health care. This is
particularly important in this age of
outcomes-based educational standards (Maki, 2004; Miller,
Todahl, & Platt, 2010; Nelson
et al., 2007).
The purpose of this study was to develop a set of skills that
would aid educators and train-
ers interested in preparing mental health therapists for practice
in collaborative health care set-
tings. This was achieved through a qualitative design that began
with inductive qualitative
inquiry with leaders of collaborative care practice in an effort to
understand the competencies
that mental health therapists need to work effectively in

collaborative health care settings.
METHODOLOGY
Participants
After receiving Institutional Review Board approval, a
purposive sampling strategy was
used to invite experts in MedFT to participate in this study. To
be identified as an expert, indi-
viduals had to meet one of the following criteria: (a) the person
was an author on a minimum
of two peer-refereed journal articles directly related to
collaborative care practice or training or
(b) the person was identified as an expert by someone meeting
the two publication criterion.
The first criterion allowed for the inclusion of those identified
as experts because they were
advancing the field through publication. The second criterion
allowed for the inclusion of prac-
titioners who have influence on the development of the practice
of MedFT through clinical
practice. Thirty-three experts were invited to participate, and 25
contributed data for the study
(a response rate of 76%). Sixty percent of the participants were
men and 80% were over
35 years old. Sixty-eight percent reported that they had more
than 5 years of experience work-
ing collaboratively in a medical setting practicing the principles
identified in the research, and
24% reported more than 15 years of experience. Sixty percent
reported their primary place of
employment as a medical setting (11 respondents worked in a
medical residency program, three
in a medical school, and one in a primary care medical setting).
The remainder reported that

their primary employment setting was a university-based mental
health training program. Fif-
teen respondents identified their primary professional affiliation
as MFT. Other respondents
were primary care physicians (5), psychiatrists (2),
psychologists (2), and one nurse.
Survey
A survey consisting of 13 questions was developed for the
purposes of this study. Six open-
ended questions were designed to elicit skills needed for
successful collaborative practice. These
questions elicited data about knowledge (biomedical and mental
health) and clinical skills
needed for successful practice in medical settings. Participants
were also asked to relate an inci-
dent that exemplifies successful medical, mental health
collaboration. Six closed-ended questions
elicited demographic information. The final question requested
that the respondent identify oth-
ers who they would consider to be experts on collaborative care
practice and who might be able
to provide useful information. In an effort to facilitate
participation, participants either could
choose to complete the survey on-line through a secure,
password-protected website or through
a paper version that was mailed to them. Potential respondents
were contacted both by email
(if an email address was available) and by a letter sent via US
mail requesting participation in
the survey.
200 JOURNAL OF MARITAL AND FAMILY THERAPY June
2012

Data Analysis
Data were initially analyzed using a process similar to the
constant comparison qualitative
data analysis method (Miles & Huberman, 1994) by the primary
researcher and a research
assistant. Using this method, content analyses were performed,
and a preliminary codebook of
themes or skills was inductively identified. Specifically, each
participant’s response was read in
its entirety to understand the skills being emphasized by each
respondent. Each reader kept a
list of skills that emerged from the data. They then met to
review and compare their separate
lists and come up with a consensus list. No skills identified by
readers were eliminated from the
list. Both the primary researcher and the research assistant then
separately returned to the data
to carefully examine the responses to each question. All
responses to question number one were
read, identifying support for the skills identified on the list and
adding new skills to the list by
comparing incidents in the data with all others. Question
number two was then analyzed simi-
larly, and so on. Subsequent responses were compared with
those preceding them in the analy-
sis, with the result being the addition of new skills or the
addition of evidence for skills already
noted, as appropriate.
The validity, or substantive significance, of the data was
established through analyst trian-
gulation (Patton, 2002). Using a deductive method, three
secondary coders reviewed and vali-

dated the presence and salience of each theme identified by the
primary coder and his research
assistant. Skills that lacked clear support in the data were
discussed and compared with all
other skills that had been identified. This process helped
establish the validity of the primary
researcher’s and the graduate assistant’s preliminary coding of
the data. The primary researcher
and secondary coders then collapsed and sorted each theme or
skill into categories and subcate-
gories. The result of this process ensured that all categories and
subcategories were examined
and agreed upon by all coders. In addition, this process ensured
that the interpretation of the
data was comprehensive and accurate.
RESULTS
Qualitative analysis of the survey responses resulted in a set of
56 skills that uniquely char-
acterize MedFT. It is evident from the data that while the
practice of MedFT includes compe-
tence in the practice of psychotherapy, it also includes skills
unique to working in medical
settings and to collaborating with medical providers and other
professionals. Consequently, the
identified skills have been clustered into three categories that
represent logical groupings of
these skills: (a) skills for working in a medical setting; (b)
unique skills for working with
patients in medical settings; and (c) skills for collaborating with
healthcare providers. Skills
within each category are further broken down into
subcategories. The skills are presented by
category in Tables 1–3. Each category is described below.

Skills for Working in a Medical Setting
Participants were careful to explain that working in medical
settings is different from work-
ing in traditional mental health practice settings. In describing
this difference, one respondent
explained that the medical setting is ‘‘a fast paced environment
that has an organizational
structure entrenched in traditional biomedical influence.’’
Others created lists such as: ‘‘differ-
ences in language, pace, communication styles, confidentiality
expectations, team roles, and
documentation.’’ Differences such as these require those
practicing MedFT to demonstrate
competence in working within this unique practice environment.
These skills can be organized
according to those relating to (a) the unique practice culture of
the medical setting, (b) medical
knowledge, (c) accommodating to the medical setting, and (d)
nurturing one’s professional
identity.
The unique practice culture of the medical setting. When
stepping into a medical setting,
one is stepping into a unique culture; one that is different from
traditional mental health care
practice. Those practicing MedFT recognize this work to
understand the culture, and to prac-
tice in culturally sensitive ways. One respondent counseled that
‘‘It is important for the mental
health professional to recognize that he or she is entering a
different culture.’’ Another respon-
dent explained that ‘‘a medical setting is part of the culture of
medicine. It has a language, a

201
history, a set of shared myths and archetypes like any culture.’’
The data suggest that it is par-
ticularly important for mental health therapists to attend to the
following characteristics of this
unique culture.
Language. Respondents explained that the language of medical
settings has been devel-
oped to facilitate the work of medicine and that this language is
unique and different from that
found in traditional mental health care settings. One respondent
explained,
Bridging the language barrier is [important]. Many MHPs
[Mental Health Providers]
enter into a medical setting speaking therapy and not
understanding medicalease.
[Developing a common language] means abandoning the terms
that we learned in
graduate school for more user friendly words that medical
professionals understand.
Another respondent explained that ‘‘The language is
instrumental and action oriented. [It]
mirrors the kind of expectations that the [medical provider] may
have of mental health provid-
ers (what can you do rather than what do you think).’’ Another
respondent succinctly wrote
that there is a ‘‘preference for concreteness over abstractions.’’
The importance of the language
used applies equally to verbal and written (e.g., charting)
communication. Several respondents

explained that mental health therapists ‘‘should understand the
abbreviations for medication
Table 1
Skills for Working in a Medical Setting
The unique practice culture of medical settings
Medical family therapists . . .
Recognize that medical settings have a unique practice culture
Recognize and respect the professional hierarchy in medical
settings
Respect the differences between medical and mental health
providers in scope of
practice, practice patterns and strategies, approach to patient
care, etc.
Know the difference between primary, secondary, and tertiary
care
Respect and value the contributions of the biomedical approach
to care
Are curious and willing to learn about unfamiliar, new, and
nontraditional approaches
to healing and promoting wellness
Know the services that are available and how to utilize them
Are visible within the medical environment as an active
participant of the care team
Medical knowledge
Speak the language of the medical setting (e.g., medical terms,
abbreviations, jargon)
Access and use medical and pharmacological information from
reliable sources

Know the diagnostic tests and treatments that are commonly
used for patient medical
care
Accommodations to the medical setting
Match the pace of the medical setting
Are comfortable with frequent interruptions by medical staff
during treatment sessions
Are flexible in working with patients and families in
examination rooms and
other nontraditional settings
Accommodate to how confidentiality is handled in medical
settings
Document patient progress consistent with medical setting
protocols
Have the ability to be an excellent short-term interventionist
Nurturing professional identity
Are willing to be shaped in professional identity and role
Stay connected with mental health colleagues
2012
(e.g., QID, QD, PO)’’ and should be able to document
psychotherapy consistent with medical
charting protocols and in a way that will make this information
useful to medical providers.

Time management. It is important to attend to the pacing of the
medical setting and in
how medical providers manage time with patients. One
respondent explained that ‘‘MDs
[Medical Doctors] carry a case load of several thousand and see
a minimum of [four] patients
per hour.’’ Another explained that ‘‘The medical clinician is
usually working with [two] patients
at one time.’’ This use of time can be disconcerting for the
naı̈ ve mental health therapist. But,
echoing the sentiment of others, one respondent wrote, ‘‘MDs
must be action oriented. This
time crunch should never be interpreted as evidence that the MD
does not care about his ⁄ her
patients.’’
The team approach to patient care. Contrary to the independence
and autonomy that are
hallmarks of traditional mental health practice, treatment in
medical settings is typically charac-
terized by a team approach where health care providers from
various specialties and disciplines
work together in caring for a patient. There are two noteworthy
consequences of this approach
for mental health therapists. First, the mental health care is
often not the primary focus of the
treatment. As one part of the overall care plan, the mental
health treatment must support and
complement the other parts of the care plan, some of which have
greater immediacy and
demand more attention than the mental health concerns. Second,
the therapist may not occupy
a primary role in direct patient care and may at times not even
see the patient. There is a
Table 2

Skills for Working with Patients
The practice lens
Conceptualize pathology from the biopsychosocial perspective
Medical knowledge
Have a basic understanding of biochemical processes and
pharmacology
Have a basic understanding of anatomy and physiology
Know about the biological processes of diseases
Know the medical conditions that commonly have psychosocial
comorbidity
Know mental health conditions that commonly manifest through
physical symptoms
Know common psychiatric medications, names and
abbreviations, doses, and side effects
Patient care
Are skillful in working with a wide variety of treatment
modalities (e.g., couple, family,
individual, group)
Assess and diagnose mental disorders using the current DSM
and ICD
Provide patient psychoeducation in both individual and group
formats
Engage patients who do not see the connection between their
medical conditions and
other areas of functioning
Respond to a wide range of patient responses to illness and

medical treatment
Organize and conduct family meetings
Know when and how to effectively intervene in the physician-
patient relationship to
improve treatment outcomes
Facilitate patient groups including psychoeducational groups
Are able to manage chronic illness and stress
Effectively apply evidence-based brief psychotherapies
Effectively apply evidence-based psychotherapies to the
treatment of specific problems
Teach mind–body techniques
Understand that the medical provider may be more invested in
the patient’s mental
health treatment than the patient
203
hierarchy within the medical setting that must be respected to
honor the team approach to care.
One respondent simply stated: ‘‘You are part of a team, but
your work is not at the center [of
patient care].’’ Another provider pointed out: ‘‘You are likely
to feel one-down, and you should
not take this personally, but see it in part as part of the culture
of medicine.’’ Third, there is an
expectation that necessary information will be readily shared
among professionals. Each per-
son’s job in patient care is dependent on information obtained
by other members of the care
team. One respondent explained:
It is . . . normal for treatment in medical settings to be done in

teams . . . Information
flows freely on the team because life and death matters are
often involved. This may
pose a problem for mental health professionals who have a more
traditional view of
how confidentiality should be dealt with. The mental health
provider must think of
him ⁄ herself as part of a treatment team; that communication
within the team is as
important as anything else the mental health provider may do,
that his ⁄ her role may
be consultative as often as it will be treatment oriented, that he ⁄
she may need to be
flexible with regard to availability.
Table 3
Skills for Collaborating with Medical Providers
Relationship building
Understand the importance of relationship building to effective
collaboration
Build relationships with medical providers and office staff
Are available, accessible, and visible to healthcare providers
and flexible in style
of working
Actively collaborate with health care providers as a member of
the care team
Place self in the traffic pattern without getting in the way
Collaborative communication skills
Work within multidisciplinary teams, keeping lines of

communication open to
coordinate treatment
Communicate with medical providers in an efficient and clear
manner
Fluently use appropriate medical terminology
Talk about mental health problems in a way that is easily
understood by health care
providers and that is respectful of all perspectives
Keep medical providers informed of progress and changes in
care
As invited, feel comfortable to provide feedback on the work of
medical provider
colleagues in the treatment of their patients
Interpersonal expertise
Understand that many medical providers become frustrated
when dealing with chronic
mental health problems
Perceive medical provider distress and respond appropriately to
alleviate the distress
Monitor and appropriately respond to emotional reactivity in
oneself and in medical
providers
Think relationally, not just in conceptualizing patients’
experiences, but also in
conceptualizing the relationships among providers
Assess one’s own participation in and contributions to the
relationship with medical
providers

Evaluate the effectiveness of the collaborative relationship
among care team members
and among treatment providers and patients
2012
Many respondents explained that they use their skills as a
family therapist in their interac-
tions in the multidisciplinary team in culturally sensitive ways.
Similar to others, one
respondent wrote that to be successful in the practice of MedFT
‘‘we need to use our
therapeutic skills in order to join with this new system just like
we would with a new family in
therapy . . .’’ Another respondent emphasized: ‘‘MH providers
need to JOIN, JOIN, JOIN with
the culture and the providers.’’
Medical knowledge. Medical knowledge is the foundation of the
language of medical set-
tings. While mental health therapists do not need to be medical
experts, it was consistently
underscored that they need to have enough knowledge that they
can have sufficient conversa-
tional fluency to participate as team members in patient care.
This includes knowing basic
information about diseases, disease processes, course, and
treatments, including pharmacologi-
cal treatments. They should have a basic understanding of
pharmakinetics and psychopharma-
cology and know how and where to access medical and
pharmacological information on an

on-going basis. They should be able to discuss the impact of
commonly used medications on
patient functioning and should recognize that medical providers
may want to consult with
them about pharmacological treatments. A few respondents
indicated that it is important to
know the ‘‘difference between primary and tertiary care and
understand the domains of vari-
ous specialties (e.g., neurology, endocrinology, oncology,
obstetrics and gynecology, rheuma-
tology).’’ Familiarity with most commonly used medical terms,
abbreviations, and jargon in
medical settings was also cited as important. One provider
wrote:
I don’t think the person has to be an expert or even very
authoritative in all of these
areas, especially in the beginning of the collaborative
relationship. But an acknowledg-
ment of their importance and a willingness to continue learning
are crucial.
Accommodating to the medical setting. Mental health therapists
trained to work in tradi-
tional mental health care settings need to accommodate their
style of practice to fit the practice
environment of the medical setting. One respondent wrote:
‘‘The medical system is bigger than
us. MHP-s are the ones that need to do the cross-over learning
and bridge the two cultures.’’
Several respondents were careful to point out that not all
medical settings are alike, even
though the culture of medicine is common to each. Medical
settings differ according to spe-
cialty, treatment emphasis, population served, and other factors.

The therapist’s ability to adapt
their own way of working to match that of the setting is a key to
success. Most respondents
identified attributes that facilitate adaptability including
‘‘humility, patience, curiosity, non-
judgmental attitude toward physician behavior, empathy, and
willingness to take risks,’’ ‘‘lots
of flexibility,’’ ‘‘self-motivation, persistence,’’ ‘‘openness,’’
and ‘‘a sense of humor.’’ These attri-
butes allow therapists to adapt their approach and apply their
expertise to the unique medical
practice setting within which they are working.
Mental health therapists cannot succeed if they treat it as a
traditional mental health
care practice setting, nor can they succeed if they attempt to
practice traditional psychother-
apy. Two representative examples from the data describe the
types of accommodations that
need to be made. First, the fast-paced nature of the practice of
medicine places constraints
on traditional mental health treatments. Respondents
emphasized the importance of applying
brief focused therapies that match the problem-focused,
outcomes-oriented approach of med-
icine. Second, the respondents pointed out the need to adapt the
traditional role of the
therapist as a treatment provider. A respondent explained that in
these settings, therapists
need to
Be able to expand [their] sense of mental health treatment
beyond the 50-minute ses-
sion, for example, to see the opportunities such as being
available for informal consul-
tations, joining an MD in a medical visit with a challenging

patient, considering issues
related to the general mental health of the staff and work
relationships, attending to
the relationship between the health care providers and patients,
etc.
Nurturing one’s professional identity. Mental health therapists
working in medical settings
can expect to experience a challenge to their professional
identity, which could result in a redefini-
205
tion of how they see themselves as professionals and in how
they see themselves in relation to
their peers who are not working in medical settings. One of the
respondents related the following:
One should expect a redefinition of one’s professional identity.
When I started in this
setting . . . I thought of myself as a family therapist. But over
the years that has
proven to be an inadequate designation. I see individuals as
much as anything else.
Often the main focus of the treatment I provide is to help the
MD ⁄ patient relation-
ship. I consult and educate as much as provide therapy. My
most important interven-
tions often have little to do with what goes on in the therapy
hour (which is often not
an hour!). I think that mental health professionals who want to
work in collaborative
settings must realize that the setting will shape them, and this

can be very exciting and
enriching, but it can also be disorienting.
Respondents explained they found it important to stay
connected and involved with other
mental health colleagues and with their professional
organization. Another respondent cau-
tioned: ‘‘Establish a support network with other mental health
folks, either on site or in other
settings. Share experiences. Consult regarding systems issues,
and support each other. Take care
of yourself. Have fun.’’ Staying connected to and grounded in
the mental health discipline
helped these respondents stay oriented and helped them preserve
a coherent sense of professional
identity. It also allowed them to test out their evolving ideas, to
stay abreast of advances in men-
tal health treatments, and to ensure that they were engaging in
ethical mental health practice.
Skills for Working With Patients
All the competencies needed for traditional mental health care
practice are needed for work
in medical settings. Respondents explained that mental health
therapists practicing MedFT
need ‘‘sound therapy skills, including individual, couple, and
family’’ and ‘‘excellent interview-
ing skills.’’ But, working with patients in a medical setting also
requires the use of unique skills
in patient care.
Conceptualizing patient problems. Participants uniformly
identified the BPS model as the
most useful conceptual model when providing direct patient
care. They explained that those

practicing MedFT need to recognize that most patients get
mental health treatment only after
seeking help for medical conditions or relief from biological
symptoms. Often the mental health
problem is co-occurring with a biological health problem, and
both must be considered in order
for mental health treatment to be successful. The patient
perspective, like that of the medical
provider, is first biological and then (if at all) psychosocial.
Knowing about the patient’s medical condition. Respondents
acknowledged that patients
expect mental health therapists working in medical settings to
be part of the health care team.
Therapists demonstrate that they are part of the team through
their comfort with biomedical
language and knowledge and curiosity about biomedical
conditions. It is expected that they will
use language that, while it may not be the same as that used by
the medical provider, is at least
consistent with that used by the medical provider. The therapist
should be familiar with the
patient’s medical condition and the diagnostic tests and
treatments associated with that condi-
tion. While they do not need to know everything about it, they
should ‘‘know enough of the
medical condition and treatments in order to explain it to
patients.’’ What the therapist does
not know, they should be willing to learn. One respondent
wrote:
I think that there is a difference between what information a
mental health profes-
sional should know and what they should be willing and able to
learn. . . . So, in a
sense, I believe that would serve the mental health professionals

(and the PCP [Primary
Care Providers] and patient) the best to ‘‘know’’ how to access
this information.
Patient care. Respondents wrote that mental health therapists
working in medical settings
are expected to assess and diagnose patients using the approved
nosology found in the current
versions of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) and Interna-
tional Statistical Classification of Diseases and Related Health
Problems (ICD). They are
expected to know the evidence-based protocols and have
competency in applying accepted
2012
treatments to specific mental health diagnoses. One respondent
described this expectation in the
following way:
Medical providers are interested in problem-based knowledge.
They are not interested
in one’s conceptual framework, they are interested in what
problems you can address.
The biggest problem is depression. Other problems are anxiety,
substance abuse, pain
management, smoking cessation, weight loss, ADHD. I think
that these problems pre-
dominate because they are very challenging for MDs to treat.
All these problems
require an understanding of DSM IV categories. It is fine to
treat these problems in a

family systems modality, but it is vital that the mental health
professional feel comfort-
able with traditional diagnostic categories. MDs expect mental
health professionals to
be able to assess, diagnose, treat, and make recommendations to
the physician regard-
ing how to manage these patients in office visits. They expect
the kinds of things they
would expect from any specialist.
Mental health therapists can also expect that they will be asked
to work with the most
difficult patients. One respondent explained that therapists need
to be prepared to work with
‘‘somatically-oriented, drug-seeking, dependent, hopelessly
depressed, and chronically mentally
ill patients.’’ These are patients who are often unwilling to
accept that there are psychosocial
problems co-occurring with (or in some cases, superseding) the
biomedical ones. They should
be able to creatively work with these and other patients who
may not be interested in even
acknowledging a mental health problem, let alone willing to
accept a referral to a mental health
therapist.
It was common for respondents to explain that while this work
with difficult patients is
designed to improve patient functioning, that much of the
mental health therapist’s work with
these patients is to provide relief and support for the medical
provider. One respondent
explained: ‘‘You are a resource to clinicians for their own
development of comfort with
patients.’’

Skills for Collaborating With Medical Providers
It is clear from the data that multidisciplinary collaboration is a
hallmark and essential
characteristic of MedFT. Collaboration is facilitated as mental
health therapists (a) build rela-
tionships with medical providers, (b) ensure frequent and
accurate communication about
patients, and (c) objectively attend to relationship processes.
Building relationships with medical providers. Mental health
therapists working in medical
settings must recognize that the relationship among providers is
the foundation for collabora-
tive health care and that they must attend to these relationships
if they are to be successful.
One of the respondents wrote: ‘‘The most important key to
success is the relationship between
providers.’’ Another added that relationships among providers
‘‘are the basis for referral and
collaboration.’’
Respondents emphasized that medical providers are problem-
focused and action-oriented.
Mental health therapists build relationships by being available
to medical providers, by showing
a willingness to accommodate to the pace of the work
environment, and by actively participat-
ing with medical providers in their patient care activities, such
as rounds, care team meetings,
and patient interviews. They should be flexible in their style of
working (e.g., accepting inter-
ruptions during treatment sessions, curbside consultations), and
they should be able to place
themselves in the traffic pattern without getting in the way.

Collaborative communication. Frequency, length, and content of
communication character-
ize collaborative relationships in medical settings. Respondents
indicated that medical providers
expect regular communication about patients and treatment
progress and that this communica-
tion should be of sufficient frequency that medical providers
can feel they are included in the
treatment, that they have not lost their patient. ‘‘Once the
collaborative medical professional
refers a patient he or she will also want to be updated regularly
and be included as part of the
treatment process.’’ This level of communication respects the
hierarchy within the medical
setting and acknowledges that the medical provider is ‘‘in
charge’’ of patient care.
207
Because the use of language in medical settings is instrumental
and action-oriented, the
mental health therapist should match this communication style.
Messages should be efficient
and clear. One respondent explained that ‘‘most collaboration
occurs through interactions that
last <5 min. These are the bumps in the hall.’’ Because of this,
being ‘‘accessible’’ and ‘‘visible’’
were repeatedly mentioned as essential to effective
communication and collaboration.
Several respondents stressed that medical providers expect to
hear ‘‘what works and what
one can do rather than what one thinks.’’ The caution to

traditionally trained mental health
therapists is to limit theoretical explanations and to stick to
what is directly relevant to the care
plan. One respondent counseled: ‘‘Don’t bore people with
details that don’t impact patient
management.’’ Similar advice was given by another who wrote:
‘‘Be able to be concise and jar-
gon free about what you believe is going on in a case.’’ Another
wrote: ‘‘willingness to talk the
medical language as much as possible and minimize
psychobabble.’’ Another respondent even
went as far as to caution well-intentioned therapists to be
careful not to ‘‘proselytize’’ or
become too ‘‘psychosocially fixated.’’ Yet another wrote that a
successful mental health thera-
pist is ‘‘one who does not feel he ⁄ she needs to preach systems
to those who work in the setting;
very off- putting.’’
Communicating in this way requires mental health therapists to
be ‘‘comfort[able] with their
own skills [without a] continuous need to prove oneself [and an]
ability to function without a lot
of . . . validation.’’ As participants in the communication
dynamic within a medical setting, thera-
pists are confident, assertive, patient, flexible, and
accommodating. The respondents explained
that this stance leads medical providers to ‘‘confidently value
the role you play.’’
Be relationship experts. It is clear from the data that one of the
roles played by mental
health therapists, as relationship experts, is to attend to the
relationships among providers and
between providers and patients, and to intervene in a way that
improves collaboration and

health outcomes.
Respondents explained that medical providers expect the mental
health therapist to objec-
tively observe these relationships and to intervene
appropriately.
DISCUSSION
This study results in a greater understanding of the practice of
MedFT, and the unique
skills needed to engage in this practice. It is clear from the data
that the practice of MedFT is
different from traditional mental health care practice. There
appear to be two primary differ-
ences. First, in addition to requiring competency in the practice
of psychotherapy, MedFT
requires additional competencies unique to working within the
culture of medicine. Second,
some competencies, while perhaps not unique to MedFT, are
noteworthy because they are
uniquely prominent in the practice of MedFT. So, for example,
while all MFTs should have
competency in multidisciplinary collaboration, it is uniquely
prominent in the practice of Med-
FT where therapists must negotiate daily professional
relationships in a multidisciplinary envi-
ronment that is inherently hierarchical.
These two types of unique competencies are most likely an
outgrowth of the application of
the BPS model that requires therapists to consider multiple
systems of functioning simulta-
neously. In the practice of MedFT, the curative work of the
therapist includes both interactions
with the patient and family as well as interactions with medical

providers and others involved
in the patient’s care. A true acknowledgment of the biological
system begs multidisciplinary col-
laboration just as a true acknowledgment of the social system
begs family involvement in treat-
ment. Consequently, the application of the BPS model expands
the practice and the treatment
to include interactions with other systems and people. This
requires competencies in addition to
those expected of skilled marriage and family therapists.
Multidisciplinary collaboration appears to be a hallmark of
MedFT. The modern medical
system is inherently collaborative, while the modern mental
health care system is not. Medical
systems generally adopt a leadership model of collaboration that
has a clear hierarchy with
physicians, and in some cases, mid-level medical providers in
the leadership role. It is clear
from the data obtained from those experienced in the practice of
MedFT that if MFTs are to
succeed in a medical system, they must understand and respect
the leadership model of
2012
collaboration. They may need to change their way of practicing
to accommodate to the system
rather than try to change the system to fit their way of doing
things. This may even include the
way that psychotherapy is practiced. Participants frequently
extolled the importance of flexibil-
ity in practice, curiosity about new ways of doing things, and

willingness to learn.
The results of this study are the next step in articulating the
competencies mental health
therapists need to have to practice what has come to be known
as MedFT. It would be a mis-
take to assume that the set of competencies generated through
this study is exhaustive. Perhaps
if we would have returned to the participants to request
additional competencies, others would
have emerged. We know through the literature that other skills
have been identified that were
not mentioned in the data that we obtained. For example, some
authors have expanded the
BPS model to include the spiritual dimensions of patient
functioning (e.g., Prest & Robinson,
2006), yet none of our participants acknowledged the spiritual
dimension nor skills specific to
working within this dimension. Also, while participants
indicated that it was important to be
curious about nontraditional approaches to care, only one
participant made even passing refer-
ence to mind–body techniques. Yet, the literature suggests that
these techniques are particularly
efficacious (Astin, Shapiro, Eisenberg, & Forys, 2003) and
within the scope of practice of mar-
riage and family therapists (McCollum & Gehart, 2010). We are
aware of some therapists
working in medical settings who regularly teach mind–body
techniques to their patients and to
medical students (Saunders et al., 2007). Other skills not
mentioned include the importance of
knowing how patients move through the medical system and
being able to intervene on the
patient’s behalf, skills specifically related to making referrals
so that the biological dimensions

of mental health problems are addressed, and understanding
how payment and billing occur
within the medical setting in which one is working (Patterson et
al., 2002).
Emphasized in our data was the importance of cultural
competence in relation to the culture
of the medical system. Given that this was such a prominent
theme, we found it curious that we
were not able to find references to the importance of
demonstrating competency with the culture
of the patient’s system. Similarly, while participants were
careful to identify the importance of
recognizing and negotiating power imbalances in the medical
setting, they did not identify the
importance of being sensitive to how these same power
dynamics impact patients and families
and the role of the therapist in helping them navigate these
power imbalances. That these two
seemingly important skills were not mentioned may be a
function of how the questions were
worded; we specifically asked for unique knowledge and skills
to the practice of MedFT. It may
be that participants see these competencies as important to the
practice of marriage and family
therapy and psychotherapy in general and not unique to the
practice of MedFT.
It is possible that had we asked specifically about these, and
other techniques gleaned from
the literature and experience, that we would have been able to
develop a more comprehensive
list. But, then we might have sacrificed coming to understand
those competencies that are spe-
cifically unique to the practice of MedFT. Additional research
is needed to further refine and

expand this list of skills. Specifically, it is possible that the
application of a Delphi methodology
(Stone Fish & Busby, 1996) could be helpful in clarifying those
skills that are particularly
important to the practice of MedFT. This method has been used
successfully by others to
develop lists of skills, most notably the list that has become the
AAMFT core competencies
(Nelson et al., 2007).
Implications for Training and Practice
Identifying competencies is a first step toward developing
learning and assessment activities
that will expedite student learning (Maki, 2004). A logical next
step is to develop learning and
assessment activities, similar to what has been carried out with
regard to the AAMFT core
competencies (Hodgson, Lamson, & Feldhousen, 2007; Miller,
Linville, Todahl, & Metcalfe,
2009; Openshaw et al., 2006; Perosa & Perosa, 2010). The
results of this research will facilitate
the development of these learning and assessment activities.
Developing these activities in light
of learning outcomes will lead to training that is more focused
and efficient and that will better
prepare students for the realities of collaborative care practice.
The results will also help experi-
enced therapists interested in expanding or changing their
practice to include work in medical
settings and medical, mental health collaborations. These
therapists can use this research to
209

understand the skills unique to the practice of MedFT.
Attending to these unique skills will
help them appropriately incorporate these skills into their
practice, thereby increasing the likeli-
hood that the transition in their practice will be successful.
Those already working in medical
settings will find that these results provide them with literature
that will help to document and
articulate the competencies needed for MedFT. This may be
particularly important in attempt-
ing to described MedFT to those who may not be familiar with
it. It may also help by provid-
ing a useful organization of these skills and practices unique to
MedFT. These and other
implications are important to the advancement of the practice of
MedFT.
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O R I G I N A L P A P E R
‘‘Is Our Daughter Crazy or Bad?’’: A Case Study
of Therapeutic Assessment with Children
Francesca Fantini • Filippo Aschieri • Paolo Bertrando
Published online: 28 March 2013

� Springer Science+Business Media New York 2013
Abstract In this paper we present a new model of intervention
with documented efficacy
that combines psychological tests and assessment methods with
therapeutic techniques to
promote change in clients. We will discuss Therapeutic
Assessment of Children and their
families (TA-C) through the case of a 4-year-old girl, Clara, and
her family. Clara’s parents
were distressed by her uncontrollable rage outbursts and feared
she might be ‘‘crazy’’. The
treatment helped to shift the narrative the parents had about
Clara and give new meanings
to her behaviors. We describe in detail the steps of the
assessment and provide a theoretical
discussion of the therapeutic processes involved.
Keywords Assessment � Family � Children � Therapy
Within systemic therapy, skepticism about the tools and
methods typical of psychological
assessment has been fostered both by the social constructionist
stance that prevailed within
the field in recent year, and by prejudices about the very nature
of testing, i.e., the idea that
psychological tests pertain to the domain of naı̈ ve realism and

tend to give an account of
clients’ problems framed in a positivistic view. In such a
context, psychological assessment
is viewed as an effort to measure the ‘‘true reality’’ of clients’
problems, thereby mini-
mizing their own experiences, views, and hypotheses (Brown
1972). While this underlying
philosophy may characterize the traditional approach to
psychological assessment, in
recent years new ways have been developed of integrating the
tools and methods of the
assessment practice in a therapeutic and post-modern
framework. This is the case of
Therapeutic Assessment (TA), a semi-structured form of brief
integrative intervention
(Kaslow 2000) developed by Finn and his colleagues (Finn and
Tonsager 1992, 1997; Finn
2007) over the last 20 years. TA combines psychological
assessment with techniques and
F. Fantini � F. Aschieri (&)
European Center for Therapeutic Assessment, Università
Cattolica del Sacro Cuore, Via Nirone 15,
20123 Milan, Italy
e-mail: [email protected]
P. Bertrando
Private practice, Milan, Italy

123
Contemp Fam Ther (2013) 35:731–744
DOI 10.1007/s10591-013-9265-3
principles of interpersonal and systemic psychotherapy. TA has
proved to be effective with
different types of clients such as adult outpatients (Finn and
Tonsager 1992; Newman and
Greenway 1997), couples (Durham-Fowler 2010), families with
children (Tharinger et al.
2009; Smith et al. 2010), and adolescents (Ougrin et al. 2008).
Research has focused on the
effectiveness of TA with different types of problems, i.e., self-
harm (Ougrin et al. 2008);
internalizing symptoms, (Aschieri and Smith 2012);
externalizing symptoms (Smith et al.
2010); disorganized attachment (Smith and George 2012); and
developmental trauma
(Tarocchi et al. in press).
Therapeutic Assessment with Children and Their Families
TA with children and their families (TA-C) involves a
suggested series of steps described

in various publications (Aschieri et al. 2013; Smith et al. 2009;
Tharinger et al. 2008a; Finn
2007). In summary, after the initial phone contacts, the assessor
meets the parents to co-
construct assessment questions that capture their main puzzles
and worries about their
child or their relationship with their child (Step 1). By focusing
on the parents’ questions,
the assessor aims to involve parents as active participants from
the beginning of the
process. Assessment questions are used to build an alliance
around parents’ motivations
and goals, and to foster their curiosity about their child. Also,
the clear formulation of the
assessment goals as focused on their puzzles and worries has
the effect to lower the
parents’ anxiety about the assessment. The assessor also works
to gather background
information about the family and uses assessment questions as
guides to chose which
themes the parents are open to discuss and don’t find
threatening. In fact, besides the
explicit goal of collecting parents’ questions, the assessor also
works to build a secure

relationship with them, based on experiences of emotional
attunement, collaborative
communication and the repair of possible disruptions (Finn
2012). The creation of a such a
relationship is considered essential for a therapeutic change to
occur. The child being
assessed may have his/her own questions too, and these are
collected in the second session,
usually scheduled with the whole family. Afterwards, the
assessor begins the testing phase
with the child to collect useful information relevant to the
assessment questions. The
parents are usually asked to observe test administration or the
unstructured activities (i.e.
drawings) that are part of this phase from behind a one-way
mirror, over a video link, or
from the corner of the testing room (Step 2). Later, the assessor
and parents discuss their
observations and their relevance to the parents’ assessment
questions (Tharinger et al.
2008b). Different from other systemic collaborative
interventions (see, for example,
Teixeira et al. 2011), in TA-C the parents are involved directly
as co-assessors, observing

and interpreting their children’s behaviors during the testing.
Next the assessor schedules
one or more family sessions, the so called intervention sessions;
these represent occasions
to work even more on the systemic aspects of the child’s
problem and to work with the
family members on possible new ways of interacting (Tharinger
et al. 2008a) (Step 3).
Finally, the assessor meets the parents for a summary/discussion
(i.e., feedback) session,
where the main results of the assessment are summarized and
discussed (Finn 2007;
Tharinger et al. 2008b) (Step 4). The assessor also gives
feedback to the child about the
assessment results in the form of an individualized fable
(Tharinger et al. 2008c) (Step 5).
TA-C can be done by one clinician or by two, depending on the
presence of a colleague
trained in the approach and on the financial aspects of the
assessment. Clearly, one of the
main advantages of working with a co-therapist is that during
the testing phase, while one
clinician works with the child, the other can stay behind the
one-way mirror with the

732 Contemp Fam Ther (2013) 35:731–744
123
parents. There, the second clinician can support the parents
emotionally and begin com-
menting with them on what is happening in the assessment room
with the child.
A recent review of the research on TA by Finn et al. (2012)
revealed fewer empirical
studies supporting TA-C than TA with adult clients. However,
the results available so far
are promising. An aggregate group study by Tharinger et al.
(2009) assessed the overall
effectiveness of the TA-C model with 14 families with
preadolescent children referred for
emotional and behavioral problems. The study showed that TA-
C reduced symptoms in
both parents and children, increased communication and
positive emotions, and decreased
negative emotions and conflicts within the family. Also,
participants reported high
engagement in the assessment and satisfaction with the services.
Tharinger and Pilgrim

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