Family Therapy


Posted on January 25, 2010. Filed under: Family Therapy, Public Health | Tags: , , , , |

In my previous post, Public Health and the Elderly, I highlighted a few issues that family therapists could inquire about during clinical sessions.  A very important issue facing the elderly is caregivers.  The CDC has made caregiving a public health priority.  The CDC has recognized the discrepancy between those who will need caregiving and those who are caregivers.  The Administration on Aging has published a profile on older Americans since 1999 simply called, Profile of Older Americans. The current profile (2009) has projected future growth, through the year 2030, in the USA will have approximately 71 million adults over the age of 65 which is a growth of 2.3% per year.  Yet, Mack and Thompson (2001) of the Center on an Aging Society reported that family members available to be caregivers will only grow at a rate of 0.8%.  This means that there will be less familial caregivers leading to an increased population in nursing home and/or increased stress for familial caregivers.

This is especially so for ethnic minority populations for two reasons.  First, caregiving as a cultural responsibility is more prominent for African Americans, Latinos, and Native Americans.  This results in an informal network of support (e.g., friends, neighbors, family) rather than formal network (e.g., nurses, nursing homes).  For example, California Health Advocates highlighted a study in which White elders were morel likely to utilize the Medicare hospice benefit. Second, exposure to health disparities over a lifetime, ethnic minority elders tend to have higher issues of morbidity in the final months of their lives.

Another concern is the gender inequity in caregiving.  California did a survey in 2003 called, A Profile of Family Caregivers (this link will open the report) and found that 75% of family caregivers were women with an average age of 51 AND 31% had a child under the age of 18 living at home (nationally this number is higher, 41%).  A recent New York Times article She Works. They’re Happy suggested that the rise of women in the workplace has had an effect of heterosexual marital stability.  One has to wonder how this stability will be maintained if she has to care for her or his parents.  This should not read as women needing to leave the workforce but instead men need increase their engagement around familial caregiving.

The data all point to one fact, there are not going to be enough caregivers leading to significantly more stress for families (especially for ethnic minority women).  There is already evidence that caregivers of today have more mental and physical health problems when compared to non-caregivers.  Family therapists have an opportunity to begin the conversation with their clients about caregiving.  If possible, this conversation should occur prior to the need.  Have families had conversations about caregiving?  Who is going to be the primary caregiver?  With whom will the person needing caregiving live?  How will siblings contribute to caregiving?  How will couples share the responsibility?  How will caregivers recognize they are “over their heads” and need help from more formal networks?  This conversation can take place during an initial assessment, while constructing a genogram, or be part of therapeutic thread.  Below is a list of resources for family therapists as well as a number of resources to share with clients.  If you have any suggestions, comments, or stories you would like share, please leave a comment.  Take care.



Administration of Aging Programs (A number of Federal Programs funded under the Older Americans Act)

American Association for Marital and Family Therapy Consumer Update-Caregiving for the Elderly

California Healthcare Advocates (Focuses on Medicare Issues in California but has some interesting research)

Center for Disease Control and Prevention-Caregiving

Center for Disease Control and Prevention-Caregiving Resources

Family Caregiver Alliance (This is a very rich resource for therapists and clients)

Many States have an Office of Aging.  Google “Office of Aging” to find you local office.

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Public Health and the Elderly

Posted on January 19, 2010. Filed under: Family Therapy, Health | Tags: , , , |

A test of a people is how it behaves toward the old. It is easy to love children. Even tyrants and dictators make a point of being fond of children. But the affection and care for the old, the incurable, the helpless are the true gold mines of a culture.~Abraham J. Heschel

The field of family therapy has not fully explored the area of mental health issues with elderly or their caregivers.  There are some wonderful family therapists that work with aging adults yet there is not a lot of literature to help guide therapists.  This post is not a critique of the family therapy field.  Nor will it highlight all the key public health areas that affect healthy aging.  Instead, I will use the next few posts to highlight just a few public health issues that therapists could address with families.

The Center for Disease Control and Prevention published a report in 2007 called The State of Aging and Health in America.  This report examined 15 key health indicators across four areas; Health Status, Health Behaviors, Preventive Care and Screening, and Injuries.  In 2008, the CDC updated this report with the State of Mental Health and Aging in America.  This report examined 6 key indicators that included Social and Emotional Support, Life Satisfaction, Frequent Mental Distress, Current Depression, Lifetime Diagnosis of Depression, and Lifetime Diagnosis of Anxiety Disorder.  If you are a researcher in the field of gerentology, these reports are vital to your research but there are some very interesting facts here for clinicians.   Here are some interesting points:

  • Adequate social and emotional support is associated with reduced risk of mental illness, physical illness, and mortality.
  • Life satisfaction is the self-evaluation of one’s life as a whole, and is influenced by socioeconomic, health, and environmental factors.
  • Life dissatisfaction is associated with obesity and risky health behaviors such as smoking, physical inactivity, and heavy drinking.
  • Older adults with frequent mental distress were more likely to engage in behaviors that can contribute to poor health, such as smoking, not getting recommend amounts of exercise, or eating a diet with few fruits and vegetables
  • Anxiety, like depression, is among the most prevalent mental health problems among older adults. The two conditions often go hand in hand, with almost half of older adults who are diagnosed with a major depression also meeting the criteria for anxiety.

There are three points that should be stressed.  First, the vast majority of the elderly are doing well.  Many aging adults report feeling supported, being satisfied with life, and do not struggle with depression or anxiety.  Next, it is important to stress that this is a population based survey.  This means that clinical and non-clinical aging adults were surveyed.  Since we work with clinical populations, we should expect to see more reports of depression, anxiety, and lack of social support.  Lastly, we know that racial & ethnic health disparities occur across the life span & they can have a cumulative effect.  One way to improve health for aging minority adults is to improve health for minority groups. The State of Aging and Health in America reported, “The care of older adults who are chronically ill, poor, and members of an ethnic community is an increasingly urgent health priority” (p.3).

When family therapists are doing an initial interview, collecting information for an assessment, or doing a genogram we need to make sure that we are asking how aging adults in the family are doing (regardless of who the “client” is).  While the vast majority of the elderly have a positive outlook and social support, we need to make sure that those who do not get the help they need.  Below are a list of public health resources for additional information.  My next post will focus on caregivers and public health.  Please leave a comment, share a story, or offer some new resources.  Take care.



Administration on Aging

Center on an Aging Society

Center for Disease Control and Prevention

Center for Medicare & Medicaid Services

National Institute of Aging

US Department Health and Human Services

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Should Environmental Justice be Part of Family Therapy?

Posted on January 10, 2010. Filed under: Environmental, Family Therapy, Health, Pollution, Public Health | Tags: , , , , |

This post is an addendum to my “Is it ADHD or Expose to Toxins?”  I was reminded by a friend at the Adler Institute of Social Exclusion that exposure to pollution or toxins do not occur evenly throughout the population.  Poor people and ethnic minorities are more likely to be exposed to pollution and toxins.  Within the public health sphere, there is a term called Environmental Justice.  The EPA has a page devoted to Environmental Justice and the EPA defines it as:

Environmental Justice is the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies. EPA has this goal for all communities and persons across this Nation. It will be achieved when everyone enjoys the same degree of protection from environmental and health hazards and equal access to the decision-making process to have a healthy environment in which to live, learn, and work.

Environmental justice is an important piece of addressing health disparities.  I will discuss some of the key issues of environmental justice and then highlight what family therapists can do to address issues of environmental injustice.

Environmental justice is rooted in the civil rights movement of the 1960’s as black leaders become concerned about the connection between their communities and environmental risks (Click HERE for a timeline).  Community leaders were concerned about what they termed environmental racism.  Environmental racism occurs when policies, regulations, and/or practices that put people of color or low income communities at risk for being exposed to toxins.  There are many historical examples but all we need to do is to look at Hurricane Katrina and Dickson, TN to see that issues of environmental injustice are still around.  Some other startling facts from a United Church of Christ 2007 report (they have done some remarkable work in this area):

  • More than 870,000 of the 1.9 million (46 percent) housing units for the poor, mostly minorities, sit within about a mile of factories that reported toxic emissions to the Environmental Protection Agency (p. 4).
  • More than 600,000 students in Massachusetts, New York, New Jersey, Michigan and California were attending nearly 1,200 public schools, with largely African Americans and other children of color, that are located within a half mile of federal Superfund or state­identified contaminated sites (p. 4).
  • Neighborhoods with a hazardous waste facility in Arizona, California and Nevada are majority Hispanic or Latino. Other states with very large disparities in Hispanic or Latino percentages include Colorado, Connecticut, Florida, Illinois, Kansas and Utah (p. 58-59).
  • While Race and SocioEconomic Status are important variables in predicting the location of a hazardous waste site, Race appears to be more important (p. 62).  Indicating that hazardous waste sites are located in middle class and affluent Black neighborhoods.

While these issues are usually addressed by community organizations, family therapists should inquire about exposure to toxins to understand possible causes or contributors to psychological, behavior, or emotional problems.  These issues should be part of every intake form.  We might be “treating” ADHD when in fact someone has lead poisoning.  And while family therapists cannot change the SES circumstances of our clients, we can provide information on how their housing or community is connected to their health (read physical and mental).

In a previous post I highlighted some questions that family therapists can ask about toxins in the environment.  Here are some other things that family therapists can do:

  • Use the EPA’s website as a source of information about the communities that your clients live in.  Go to the EPA’s Where You Live website and click on the region where your clients reside.  This will give you information about the EPA’s work in your region.
  • Go the Environmental Justice Geographic Tool to see what issues are in the neighborhoods of your clients.  Once you get the region you will need to choose which features you would like to explore.  Here is a link to what Utica, NY looks like.  I chose all the regulated sites (Click on the +) and Schools under Places.
  • If you learn about a possible exposure (e.g., lead, mercury) have them contact their health care provider immediately OR their local Public Health Office. You can locate federally funded health care sites from here by clicking HERE.

I have just touched the surface of this issue.  There are some great resources out there for people wanting to learn more about Environmental Justice.  I will list some resources below and let me know if you have more.  Please leave a comment, concern, or story.  I will respond to all of them.  As always, take care.



Democracy Now: Interview with Dr. Robert Bullard

Environmental Justice Resource Center at Clark Atlanta University (EXCELLENT SITE.  This is really all you need to see what the current key issues are).

Interagency Working Group (11 federal agencies and several White House offices working to integrate environmental justice into its individual programs)

National Black Environmental Justice Network

Pollution Issues: Environmental Racism

Social Science Research Council: Toxic Soup Redux

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January is Cervical Cancer Month

Posted on January 7, 2010. Filed under: Family Therapy, Health, Public Health | Tags: , , , |

I am going to stray away from my current thread on Housing Quality and discuss an important public health issue for women.  January is Cervical Cancer month for the National Cervical Cancer Coalition.  The National Cancer Institute (NCI) estimates that there will be over 11,000 new cases of cervical cancer and over 4,000 women will die from this cancer.  Many women will not have symptoms which is why the NCI recommends women getting their first pap smear within 3 years of first experience of sexual intercourse or at the age of 21.  This type of cancer is easily detected and has a high cure rate if detected early. In addition, there are preventive measures that women can take to decrease their chances of developing cervical cancer.

And while the population cure rate is high for cervical cancer, there are some racial and economic disparities associated with cervical cancer. According to the American Cancer Society (ACS), NCI, and Garner (2003):

  • Cervical cancer has a higher incidence in Latinas, (twice the rate of non-Hispanic women).
  • African American women develop Cervical Cancer 50% more than non-Hispanic women and twice as likely to die from it.
  • Women from lower socioeconomic backgrounds get diagnosed at later stages and have a higher mortality.
  • Vietnamese women have the highest incidence.
  • Immigrant women have low rates of screening related to language barriers, mistrust of medical system, and cultural beliefs (e.g., modesty).

These disparities can be contributed to lack of access to care, mistrust of the healthcare system, patient cultural beliefs, or providers not asking the right questions.

As mental health practitioners we have the unique opportunity to inform our clients, their families, our communities about issues that directly affect their care.  As we work with our clients this month, I ask that we ask  questions to raise awareness.  We can ask women if they talk to their health care provider about cervical cancer.  We can ask women when they had their last pap smear.  We can inform women that January is Cervical Cancer month and give them resources for them to explore these issues (listed below).  We can ask men in relationships with women to raise this issue with their partners.  We can ask parents to talk to their daughters about the importance of early detection and preventive measures.  As noted above, we might be working with women who don’t have access to health care or don’t trust their health care.  The Center for Disease Control and Prevention (CDC) has the National Breast Cancer and Cervical Cancer Early Detection Program so that underserved women can have access to care.  Click on the early detection program link to find a local program.

Again, these questions usually don’t take much time and if they do maybe you stumbled upon an important therapeutic issue.  These questions also convey a wholistic approach to our clients.  That we are interested in the range of their experiences that can affect their lives.  I look forward to any comments, suggestions, or stories that you might want to share.  Take care.



American Cancer Society: Learn about Cervical Cancer

Center for Disease Control and Prevention Cervical Cancer Page

Cervical Cancer: What Vietnamese Women Should Know

Garner, E.I.O. (2003). Cervical cancer: Disparities in Screening, Treatment, and Survival. Cancer Epidemiology, Biomarkers & Prevention March 2003 12; 242s

General Information About Cervical Cancer (Healthcare Provider Version)

General Information About Cervical Cancer (Patient Version)

General Information About Cervical Cancer (Patient Version-Spanish)

National Breast Cancer and Cervical Cancer Early Detection Program

National Cancer Institute: Cervical Cancer Home Page

National Cancer Institute: Cervical Cancer Home Page in Spanish

National Cervical Cancer Coalition Home Page

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Is it ADHD or Exposure to Toxins?

Posted on January 4, 2010. Filed under: Environmental, Family Therapy, Housing Quality, Pollution, Public Health | Tags: , , , |

In my December 20, 2010 blog I asked if mental health therapists are asking about Housing Quality. The CDC has linked housing quality to health. There are ranges of issues that therapists could be asking but today I will focus on Indoor Pollution. But first, lets explore the issue.

The Environmental Protection Agency (EPA) has reported that people from Industrialized Nations spend up to 90% of their time indoors. This number makes sense when we think about the time we spend at work, socializing, buying (i.e., groceries, mall), and hanging out in our homes. When we think about small children and the elderly, this number may be even higher. Because of this time spent indoors, people are more likely to be exposed to pollution and toxins in their homes rather than from the outside. The EPA, CDC, and Physicians for Social Responsibility (PSR) list a number of indoor pollutants that are of concern. They include; second-hand smoke, lead, radon, biological contaminants (e.g., bacteria, molds, mildew, animal dander, house dust mites, cockroaches, pollen), carbon monoxide, nitrogen dioxide, organic chemicals (e.g., paints, aerosol sprays, pesticides, disinfectants, air fresheners, hobby supplies, dry-cleaned clothing), and asbestos. This list is overwhelming!!

And while we might be concerned with these issues, we might think that someone else should explore these issues. There are a number of reasons why a therapist should ask about Indoor Pollution. First, children and the elderly are highly susceptible to toxins. Children like to crawl around, put things in their mouth, and have increased metabolisms. The Elderly are more likely to stay inside thus increasing their expose to molds, mildew, radon, and pesticides. Reactions to indoor pollution can mimic psychological issues. For example, children exposed to lead attention deficits, increased impulsiveness, reduced school performance, aggression, and delinquent behavior. These exposures may also mimic cognitive deficits like memory loss. As therapists we might be missing a key contextual factor that plays a significant role in the issue that brought a client to us. Next, exposure to a range of indoor pollutants is harmful to expectant mothers. Exposure to lead, mercury, alcohol, second-hand smoke, and pesticides can adversely affect fetus development. Lastly, parents are concerned about these issues but their primary care providers are not addressing environmental health issues. Physicians for Social Responsibility highlighted a report in the journal Environment Health Perspective in which pediatricians stated that doing an environmental assessment was important but due to lack of training did not feel confident to do one.

Hopefully you agree that therapists could play a pivotal role and one that does not take too much time. So here is what you can do:

  • Ask about the occupation of all people in the household that work? What do they do? Do they think they might be exposed to chemicals on the job? Employers are required by federal law to keep a list of all chemicals that are harmful to employees. This is important because workers can bring chemicals back into their homes. This information could be collected during the intake.
  • Ask about if they have any hobbies that include solvents (e.g., glue, paints, paint thinners, art materials)? Where are they stored? Do kids have access to them?
  • Ask about their diet. Do they eat a lot of fish? Where do they get their fish? Fish can contain high levels of mercury.
  • Is there lead paint in the home? Homes built prior to 1978 used lead paint. Older apartments can have lead paint.
  • Any hazardous sites near their homes? Click HERE for an EPA website.
  • Where do they get their drinking water? This is especially important for your rural clients.
  • When was the last time they had their heating system serviced? Does not matter the type of heating? This is also related to my previous post on Home Fires.
  • Have they talked to your Primary Care Provider about environmental health issues?

I know there is a lot of information above but the conversation you have with a client might only take a few minutes. If you or your clients are curious or have more questions, you can check out the website below. Leave a comment, questions, or concern below and thanks for following.


RESOURCES (Click on the links)

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Do Family Therapists ask about Fire Safety?

Posted on December 26, 2009. Filed under: Family Therapy, Fire Safety, Housing Quality, Public Health | Tags: , , , , , |

In my previous post I wondered how many family therapists ask questions about the quality of their clients’ housing.  One particular topic in the area of housing quality is fire safety.  This is an important topic to ask families around this time of year.  Home fires increase during the holiday season and due to the financial difficulties families might have this year, public health officials are concerned of an increased risk of home fires.  It goes without saying that home fires are devastating and traumatic for those who experience it, even if everyone escapes safely.  But home fires can be deadly for a number of populations.  According to the Fire website:
  • Children younger than 5 have a higher risk of fire injury and death than older children.
  • Adults 65 and older are twice as likely as any other age group to die in a home fire. The death rate for those 85 and older is five times the national average.
  • African Americans are twice as likely to die in a fire than the general population. For American Indians, the risk of fire death is 30% higher than the general population.
  • Income level is inversely related to fire death risk, with the highest risk among the poorest population groups.
  • Death rates in rural communities are more than twice the rates in large cities and more than three times higher than rates in large towns and small cities.
An important point to remember is that house fires are preventable.  Family therapists have a unique opportunity to help prevent house fires by simply asking some questions.  Here are some questions you can ask ALL of your clients:
  • Do you have any smoke alarms in the house? For those who can’t afford them, check you local firehouse for programs that install free smoke alarms.
  • When was the last time you tested your smoke alarms?
  • If there was a fire in the house, does everyone know what to do? Ask about evacuation plans.  Help your families create an escape plan and ask them to practice it for homework.  Click here for escape plan information.
  • Do you  know where they can get reliable information on how to keep your house safe from fires? Here are some great consumer friendly websites:
Asking these simple questions and sharing information is all that is needed to help your clients prevent a house fire.  If you need further information, please check out the CDC’s website.  Let me know if you have additional questions that are important and please leave a comment.  Take care.
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Asking About Housing Quality

Posted on December 20, 2009. Filed under: Family Therapy, Housing Quality, Public Health | Tags: , , , , |

Family therapists ask many questions about family composition (blood and fictive kin) and the quality of these familial relationships.  One significant question that gets overlooked during intake or throughout therapy sessions is the quality of a family’s housing.  This might be related to some of the social taboos of asking people about the quality of their living quarters but this should not deter family therapists about asking about the quality of a family’s housing.  According the Center for Disease Control and Prevention healthy housing is key in understanding the health status of family members (CDC Healthy Housing Executive Summary).  This makes a lot of sense when you think about the variety of environmental issues that can affect the quality of housing.  Some of these issues include toxic chemicals, pests, waterborn diseases, noise, crowding, and indoor pollution.  And this is just a partial list of how housing could affect a person’s health.

To begin the conversation about housing, family therapists should directly state why this information is important.  The quality of one’s housing is directly tied to one’s health, physical and mental Thus it is important to understand where the family lives.  You are not there to judge them but to help them and understanding the context of their lives, which includes housing.  There are a number of areas that should be explored (e.g., Housing Structure, Indoor Pollution and Toxic Materials, Water Quality, Environmental/Neighborhood Pollution, Housing Safety).  These different areas with questions will be explored in future posts.

If you include Housing Quality as part of your therapy, let me know how you do it.  If you do not, what prevents you from exploring this issue?  For further information, please visit the CDC and the Health Housing Manual at CDC Health Housing Manual

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The Beginning

Posted on December 1, 2009. Filed under: Family Therapy, Public Health | Tags: , , , |

The field of public health focuses on population health while the field of family therapy focuses on systemic change in small systems (e.g., couples, families).  While the two fields seem to operating at different levels, it is my belief that these two fields can collaborate together to help individuals, couples, families, and communities create the healthy environments they desire. 

I have been working with individuals, couples, families, and communities as a family therapist for over 15 years.  An important part of my work has been to provide culturally sensitive care to those I serve.  In my quest to educate myself I came across public health literature that proposed a connection between the behavior of health providers and health disparities.  I went back to school to obtain my M.P.H. from Drexel University to better understand the world of public health.

During this time in school I become increasingly aware of how family therapists have an unique opportunity to let their clients know of important public health issues that affect their social, emotional, psychological, and physical health.  Equally important is how family therapy theories can help public health officials understand community behaviors that could influence public health policy.

Family Therapy IS Public Health blog will be a place in which the literature of public health and family therapy is examined, explored, and elaborated upon.

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