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MARCH/APRIL 2018
Caring for
Elderly Family
REDEFINING ASPECTS OF CAREGIVING:
Addressing the needs of family caregivers
of dementia | page 06
HOARDING AND THE AGING POPULATION:
A growing crisis | page 18
APPROACHING THE END OF LIFE:
Making the most of precious time | page 10
Also in this issue
ETHICS & LEGAL
24 Assisted Client Suicide
Benjamin E. Caldwell, PsyD
PERSPECTIVES
27 Matching Clients with Student Clinicians of
Similar Backgrounds Lisa Rene Reynolds, PhD
MARCH / APRIL 2018 VOLUME 17, NO.2
CONTENTS
Departments
02 A MESSAGE
FROM THE CEO
04 NOTEWORTHY: Family Therapists in
Healthcare Settings // Michigan’s BCBS
Victory // Data Note // Letter to the Editor
Approaching the End of Life:
Making the Most of Precious Time
In our clinical training and practice, we have tiptoed around
the profound challenges at life’s end for patients and their
loved ones. Our compassionate engagement with them can
ease passage, enrich bonds, and foster resilience as survivors
grieve and move forward in life.
Froma Walsh, PhD
Addressing the Needs of
Family Caregivers of Dementia
Dementia caregiving has become a costly and time-
consuming role for both family members and healthcare
providers, but over the years, the landscape of caregiving
has been rapidly changing and roles are being redefined.
Max Zubatsky, PhD
10
06
AAMFT’s Campaign for Medicare
For over 30 years, AAMFT has been advocating for the inclusion
of MFTs as billable behavioral health providers under Medicare
Part B. Much has been accomplished, but many challenges are
still to be met.
Roger Smith, JD
Hoarding and the Aging Population:
A Growing Crisis
Hoarding disorder has taken center stage as one of mental
health’s newest and most provocative diagnoses—one that
disproportionally affects seniors at a rate almost twice as high
as younger adults.
Jennifer Sampson, PhD
18
15
ftm
FAMILY THERAPY
MAGAZINE
The editorial team would like to thank Max
Zubatsky, PhD, for his guidance and assistance
in producing the content for this issue.
2 FAMILY THERAPY MAGAZINE
LETTERS TO THE EDITOR
We encourage members’ feedback on issues
appearing in the Family Therapy Magazine. Letters
should not exceed 250 words in length, and may
be edited for grammar, style and clarity. We do
not guarantee publication of every letter that is
submitted. Letters may be sent to FTM@aamft.org
or to Editor, Family Therapy Magazine, 112 South
Alfred Street, Alexandria, VA 22314-3061.
EXECUTIVE EDITOR
Tracy Todd
SENIOR EDITOR
Kimberlee Bryce
DIRECTOR OF STRATEGIC INITIATIVES
AND OUTREACH
Amanda Darnley
ADVERTISING
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DESIGN AND PRINT
Good Printers, Bridgewater, VA
Family Therapy Magazine (ISSN 1538-9448)
is published bimonthly (January, March, May,
July, September, November) by the American
Association for Marriage and Family Therapy,
Inc., 112 South Alfred Street, Alexandria, VA
22314-3061. Printed in the USA. Periodical
mailing from Alexandria and additional entry
points. ©2018 by the American Association for
Marriage and Family Therapy (AAMFT), Inc. All
rights reserved. Written permission for reprinting
and duplicating must be obtained through the
Copyright Clearance Center at www.copyright.
com.
The articles published in the Family Therapy
Magazine are not necessarily the views of the
association and are not to be interpreted as
official AAMFT policy.
Manuscripts may be submitted electronically
to FTM@aamft.org or mailed to: Editor, Family
Therapy Magazine, AAMFT, 112 South Alfred
Street, Alexandria, VA 22314-3061. Telephone:
(703) 838-9808. Concise articles (1800 words
or less) are preferred. Authors should allow at
least two months for a decision.
Single issues of FTM can be purchased for $10
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Advertising materials are due approximately
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Please call (703) 253-0447 or write to
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and all advertising questions. All advertising
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POSTMASTER:
Send address changes to:
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Thirty percent of this paper is post-consumer
recycled material and preserves 17.49 trees,
saves 7,429 gallons of wastewater flow,
conserves 12,387,806 BTUs of energy, prevents
822 lbs of solid waste from being created, and
prevents 1,618 lbs net of greenhouse gases.
Environmental savings calculated from Mohawk.
A MESSAGE
FROM THE CEO
WHEN STAFF JOIN AAMFT, they are quite impressed, and oen
inspired, by interacting with members and hearing the energy and dedication
to systemic family therapy. For those with background at other associations,
they oen express that this level of fervor is out of the norm for their member
interaction. To help oer context to this, every couple of years the oice has
“MFT 101” lunch and learn meetings. The primary purpose is to help sta better
understand where the zealousness of MFTs comes from.
This time around, I’m hosting the MFT 101. Of
course, I started with the AAMFT’s Inuential
Figures by Bruce Kuehl. Highlighting the
treatment settings, professional challenges,
and the fundamental paradigm of the
profession begins to impress upon sta how
MFTs must ght a good ght for legitimacy
alongside other mental health professions.
It is apparent the profession has certainly
come a long way. We have achieved licensure
in all 50 U.S. states and recognition in 2
Canadian provinces; are recognized as one of
the core mental health providers by the U.S.
Health Resources and Services Administration
(HRSA); and were even asked to participate in
the controversial DSM-5 review and testing.
As I was reading this issue’s articles, I couldn’t
help wonder what Lester Dearborn, Paul
Popenoe, or Ernest Groves might think about
the profession and its stature among the eld.
Certainly, the early innovators of systemic
family therapy faced extremely challenging
clinical issues and I’m reasonably sure that
MFTs participated in assisted suicide long before legal changes created ethical
conundrums more than legal complications. Having an article not only about
a new DSM-5 category (hoarding), and implying that LMFTs can diagnose such
disorders, reects substantial regulation gains. Michigan had the equivalent of
“hell freezing over” when aer many years of wrangling, BCBS nally recognized
LMFTs as service providers.
These articles are lled with intrigue and interest. Yet, the underlying tenant
that ties them all together is that each reects treatment services that systemic
Paul Popenoe
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3
INFLUENTIAL FIGURES IN COUPLES AND
FAMILY THERAPY HISTORY
,
-
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.
National Council
on Family Relations
Paul Sayre
Marriage Guidance Council,
England
Vera Mace
David Mace
Emily Mudd
Marriage Council
of Philadelphia
Ernest Groves
Family Sociology
Groves Conference,
Eastern U.S.
Lester Dearborn
Initiated AAMC idea,
Massachussetts
Mangus Hirschfeld
Sexual Reform,
Germany Family Life Education
Sex Counseling,
California
Theodore Lidz
Psychoanalytic Family
Therapy. Connecticut
John Bell
Family Group
Therapy
Massachussetts
Christian Midelfort
PsychoanalyticTherapy,
Wisconsin
Lyman Wynne
Disordered
Communica-
tion, Maryland
Intergenerational,
Pennsylvania
Murray BowenCarl Whitaker
Experiential
Family Therapy,
Wisconsin
Nathan Ackerman
Psychoanalytic Family
Therapy, New York
Ivan
Boszormenyi-Nagy
James Framo
Contextual Family Therapy, Pennsylvania
Gregory Bateson
Jay Haley
John Weakland
Richard Fisch
Don Jackson
Virginia Satir
Paul Watzlewick
Structural Family
Therapy, Pennsylvania
Salvador Minuchin
Milton Erickson
Brief Therapy,
Arizona
Jay Haley Cloe Madones
Strategic,
Washington, DC
Susan Johnson
Emotion-Focused
Couples Therapy,
Canada
Monica
McGoldrick
Multiculturalism
Intergenerational,
New Jersey
Lynn Hoffman
Multifaceted
Collaboration,
Massachussets
“The Women’s Project”
Collaborative Language Systems, Texas
Harlene Anderson
Harry Goolishian
Steve deShazer Insoo Kim Berg
Solution-Focused, Wisconsin
Narrative , Australia, New Zealand
Michael White David Epston
Bill O’Hanlon
Solution-Oriented,
Nebraska
Michelle
Weiner-Davis
Solution-Oriented,
Illinois
Ken Hardy
Multiculturalism,
New York Neil Jacobson
Integrative
Couples Therapy.
Washington
Doug Sprenkle
(COAMFTE Programs)
Training, Scholarship
and Service
Virginia Satir
Experiential
California
Mara Selvini
Palazzoli Gianfranco Cecchin
Guiliana Prata Luigi Boscolo
Strategic (Milan), Italy
Harry Aponte
Multiculturalism,
Pennsylvania
Tom Anderson
Refl ecting Team,
Norway
All approaches continue to be practiced in some form today as described in biographies section of this issue.
ST R U C T U R E /F U N C T I O N A L I S M L O G I C A L -P O S I T I V I S T R E A L I S T C O N S T R U C T I V I S T P O S T -S T R U C T U R A L P O S T M O D E R N C O N S T R U C T I O N I S T
MA N A G E D C A R E /E M P I R I C A L L Y V A L I D A T E D T R E A T M E N T S
Peggy Penn
Collaborative
Questions,
New York
Marianne
Walters Betty Carter Peggy Papp Olga Silverstein
Nancy Boyd-
Franklin
Multiculturalism,
New Jersey
Richard Schwartz
Internal Family
Systems, Illinois
MARCH / APRIL 2 0 1 8 3
family therapists were not, at one time, permitted to provide.
Deconstructing each article will lead to a period where advocacy
eorts played a role in MFTs being permitted to engage in specic
treatment services. Many members contributed many hours to
achieve these advancements in our profession.
Even with all our achievements, today the MFT profession remains
in a precarious position. If you reside in such states as Delaware,
you have the privilege of a strong scope of practice; if you reside
in such states as Michigan, you are hampered by a weaker scope
of practice. Canada just recently started to achieve regulation and
recognition of the profession. My point, the right to practice is not
uniform throughout the USA and Canada. Unlike a time in our
development where every member in every state was rallying for
the advancement of the profession, the circumstances are now
where only a portion of our members are urgently rallying around
advocacy because many reside in states where the profession is on
nearly equal footing with other mental health professions. Therein
lies the rub…a false sense of security.
It was a very close call in Texas aer the Texas State Board of Examiners
of Marriage and Family Therapists, Texas Association for Marriage and
Family Therapy, and AAMFT needed three rounds of legal appeals
before the Texas Supreme Court nally airmed that LMFTs could
diagnose. Other states are experiencing challenges with consolidating
licensing boards, de-licensing possibilities, and substantive portability
barriers. Although there will always be challenges, AAMFT will continue
the hard-fought battle to achieve Medicare Part B recognition that our
members and the public deserve.
AAMFT’s Director of Government and Corporate Affairs, Roger
Smith, provides a great overview (page 15) of the status of AAMFT’s
current Medicare efforts. An important note, AAMFT is receiving
increased support from the following organizations:
• National Council for Behavioral Health—NCBH unies over 2,900
members organizations serving adults, children and families living
with mental illness and addiction (www.thenationalcouncil.org/
about)
• Association for Behavioral Health and Wellness—the national voice
for payers of behavioral health insurance benets that cover over
175 million people (www.abhw.org/about)
• Interdepartmental Serious Mental Illness Coordinating
Committee—ISMICC reports to Congress and federal agencies on
serious mental illness and emotional disturbance (www.samhsa.
gov/about-us/advisory-councils/ismicc).
I was extremely pleased when I learned that one of the 45 ISMICC
recommendations to Congress was to remove exclusions that
prevent LMFTs from serving as Medicare providers. This report was
the rst in recent history that involved a federal agency making
recommendations to include LMFTs in Medicare.
Oen, MFTs and members express disinterest in the passage of
legislation allowing MFTs to provide treatment under Medicare. I
have heard reasons such as, “I won’t be providing services to the
Medicare population,” or “I’m not going to accept Medicare rates.”
Being recognized as Medicare providers involves so much more than
reimbursement and services. This important piece of U.S. Federal
recognition is vital in advancing and protecting the profession at
every level. Although not obligated, federal, state, and governmental
agencies, such as the VA, would have extreme diiculty in arguing
that systemic family therapists are not qualied to provide ser vices
on par with other mental health disciplines such as psychology and
social work with our inclusion in Medicare Part B. LMFT recognition
is a pivotal bastion to legitimacy among mental health professions.
I hope that as you enjoy this issue of FTM, you give some
thought to those MFTs who fought long and hard to place our
profession in this position. Further, I hope you will consider
how you can help the profession take the valuable next
steps on our path to true parity. Please consider joining the
Family TEAM or nancially contributing to the AAMFT Practice
Protection Fund.
Sincerely.
TRACY TODD, PHD
stay informed and contribute:
TWITTER twitter.com/theaam // FACEBOOK www.facebook.com/TheAAMFT // LINKEDIN http://tinyurl.com/AAMFTLI &
http://tinyurl.com/AAMFTpage // INSTAGRAM instagram.com/theaam // WEBSITE www.aam.org // BLOG blog.aam.org
AAMFT NETWORKS networks.aam.org // AAMFT RESEARCH & EDUCATION FOUNDATION www.aamfoundation.org
www.aam.org/practicefund.asp
www.aam.org/familyteam
4 FAMILY THERAPY MAGAZINE
NOTEWORTHY
DATA NOTE
Percentage of adults aged
50 or older who in the
past 30 days experienced
mental distress
Starting in 2013, a team of family therapists came together to initiate
the design and development of core competencies for family therapists
working in healthcare settings. They were responding to an increasing
number of family therapists seeking and being sought aer for positions
in such settings.
As the healthcare industry expands its interest in incorporating
behavioral providers into conventionally-biomedical settings, it has
compelled major changes in workforce training across all behavioral
health disciplines. Several such disciplines have responded to this by
creating competencies that guide their members in developing the
knowledge, skills, and abilities necessary for delivering care.
Download AAMFT’s new, FREE, Competencies for Family Therapists
Working in Healthcare Settings to acquaint yourself with the knowledge
and skills to provide care.
www.aam.org/healthcare
NEW: Competencies for
Family Therapists Working in
Healthcare Settings
Michigan scores
major Blue Cross
Blue Shield Victory
Exciting news in Michigan as Michigan’s
largest insurance company, Blue Cross Blue
Shield, which serves 4.5 million people in
Michigan and 1.6 million in other states
announces direct reimbursement for
Marriage and Family Therapists.
0% – 7%
7% – 9%
9% – 10%
10% – 14%
Michigan advocacy leader John Becker
details the journey it took to achieve this
victory at http://blog.aam.org/2018/02/
bcbs-announces-direct-reimbursement-for-
ms-in-michigan.html
ON THE WEB>>
SOURCE: CENTERS FOR DISEASE CONTROL, 2006 (PERCENTAGES ARE ROUNDED)
MARCH / APRIL 20 1 8 5
LETTER TO THE EDITOR
The well-addressed article, “Assisting Immigrant
Families in an Age of Uncertainty,” in the January/
February 2018 issue by E. R. Blandon, JD, is so
important to the future of MFTs. As an LMFT who
provides mental health assessment reports to assist
immigrants to remain in the U.S, it is imperative that
more MFTs get involved in this process. Aside from
providing therapy services to immigrants, MFTs need
to get involved at the other end of the process, which
is writing psycho-social evaluations to help those who
have been victims of spousal abuse remain in the U.S.
I have been involved in this process for nearly 10 years.
While this was not my focus, to conduct psychological
assessments, an attorney in my area contacted me
and inquired if I had an interest in conducting these
types of services for his clients. I must admit, the
initial challenge was understanding the “how-to’s” in
structuring these reports. However, as Blandon opines,
collaborating with an immigration attorney is crucial to
the success of these reports. I have written well over a
thousand of these reports to help immigrants achieve
the “Great American Dream.” Due to our specialized
training in family systems, we are well equipped to
understand the needs of immigrants, as well as the
impact that it may have on their children. I strongly
encourage more MFTs to get involved in conducting
these types of assessments.
DEBORAH C. MOORE, PHD, LMFT,
CLINICAL FELLOW, NEW YORK, NY
6 FAMILY THERAPY MAGAZINE
Patient
Invisible
Addressing the Needs of
Family Caregivers of Dementia
The
MARCH / APRIL 20 1 8 7
Max Zubatsky, PhD
THINK OF A TIME when you attended a
medical appointment for a close friend or family
member with a substantial health issue. While sitting
in the sterile waiting room reading a magazine, you
begin to formulate potential questions to ask the
nurse, physician or medical provider. When you walk
in the room, you are polite and comply with the role
of the active listener, as the provider lists off a series
of questions to the patient. As the appointment
draws to a close, you may have answered one
question or politely interrupted the conversation
to add your perspective. You leave the ofce
wondering, “how much am I actually included in the
care of this person?” Furthermore, the care member
is left with very little information or resources to
help this person through the journey of the illness.
Think this scenario is too far-fetched? In the case
of dementia care, this hypothetical is all too much a
reality in our healthcare system.
Dementia caregiving has become a costly and
time consuming role for both family members
and healthcare providers. It is established that
over 15 million individuals care for a loved one with
Alzheimer’s disease (AD) or dementia-related
disorders, with over $230 billion in unpaid services
(Alzheimer’s Association, 2017). These caretakers
often assume dedicated tasks for their spouse
or partner, parent, or friend with AD that are
normally executed by paid healthcare and service
professionals (Feinberg, 2016).
Patient
8 FAMILY THERAPY MAGAZINE
As a result, caregivers are prone to
increased mental health and physical
risks, including cardiovascular problems,
hypertension, and chronic pain. Because
these demands can be so burdensome,
caregivers also feel resentment and
dissatisfaction of the caretaking role over
time (Brodaty & Donkin, 2009).
Caregivers have been largely neglected by
healthcare providers in the United States,
often seen as the “hidden patients” of
geriatrics and dementia care. Still holding
onto a reductionist view of patient care, the
medical field has often viewed families as a
practice hindrance, due to time constraints,
complexity of issues or management of
multiple problems. As a result, caregivers
may lack a true “medical home” for the
care of loved ones with a dementia-related
diagnosis. Families who are not part of
the care process may continually see
loved ones re-admitted to the hospital
multiple times for preventable reasons.
Furthermore, behavioral health and other
social service entities are not brought into
the treatment process until it is too late.
Re-defining aspects of caregiving
The landscape of caregiving, especially for
older adults with chronic diseases such as
dementia, has been rapidly changing over
previous years. The perception that every
family has one primary caregiver to handle
any of the health burdens of its members
is simply not true. With higher rates of
chronic diseases and individuals living
longer, many people are now assuming
the dual “patient/caregiver” role, where
personal health issues are minimized to
attend to the needs of their loved one.
During my training in memory clinics,
there were a number of chronically ill
child caregivers who continued to sacrifice
20-30 hours per week of unpaid time to
care for an older parent with dementia.
In one case, a man in his late 80s with
heart disease and a recent triple bypass
continued to attend support groups and
educational talks to find suggestions in
caring for his wife suffering from memory
loss. The sacrifices these individuals
make are significant and oftentimes
unacknowledged by the healthcare system.
The role of caregiving is not only
limited to just family members. An
increase of professional caregiving
careers has addressed certain gaps that
family members and friends cannot
always fill. Several training programs
and workshops are now adequately
preparing professionals to understand
the responsibilities, demands and
complications of the diagnosis. Although
professionals may not be a part of the
individual’s family, a significant amount of
burnout is often associated with the strains
and demands placed on this role over time
(Droes et al., 2006). A larger workforce
of professionals attending to the needs of
older adults will need to keep pace with
the rising rates of chronic illness in aging
adults, including dementia.
Caregiving is not always accomplished in
close proximity to a loved one. The rapidly
growing trend of long-distance caregiving
for chronic health issues has shown that
families are demographically more diverse
than ever. Many individuals must try
to coordinate services and care for their
diagnosed family member from afar, often
through technology or even long hours of
commuting. There are even mental health
(Schultz & Sherwood, 2008) and medical
risks (Roth, Fredman & Haley, 2015)
associated with long-distance caregiving
for a loved one with dementia. Family
members from a distance must coordinate
a number of tasks, including contact with
providers about copies of medical reports,
setting schedules from providers to come
into the home, and locating respite services
for the primary caregiver in the family.
Generational trends have even impacted
who takes care of older family members
with health issues. Not too long ago,
the typical caregiver was a middle-aged
family member who would provide care
for a parent, parent-in-law, or elder in the
family. Unlike previous generations, baby
boomers can expect to provide personal
care and financial assistance for family
members for up to 40 years, with greater
role strains in taking care of multiple
members (Fingerman, Pillemer, Silverstein
& Suitor, 2012). A greater percentage
of millennials are now starting to take
care of older adult family members with
certain health issues. Seen as a generation
with a reputation to be independent and
self-involved, almost 25% of caregivers
in the U.S. fall in the 18-34 range, often
sacrificing their own career and/or
educational advancement (National Center
on Caregiving, 2015).
Too close for comfort
My recollections of work with families
with dementia always draw me back to
one particular case that I saw during my
post-doctoral training. The patient, who I
will call Sarah, was a dementia caregiver in
her mid 40s. She was an only child, where
there were three generations of only-child
daughters in her family lineage. Sarah
lived in a side-by-side townhouse next to
her mother, who required some assistance
with activities of daily living. Her mother
was diagnosed with Alzheimer’s disease,
experienced periodic bouts of depression,
and was a smoker for over 35 years. Sarah
also had a daughter who was a senior in
high school at the time, and was concerned
about Sarah’s high anxiety and stress from
the caregiving experience. The daughter
was so close to the situation, that she
was considering forgoing an academic
scholarship to a major university to help
care take at home for a year.
The family reported some bad experiences
with the previous mental health provider,
where Sarah’s needs and concerns were
never heard. In fact, the provider often
only wanted to see Sarah’s mother
alone in the room to conduct screening
assessments. Sarah was relieved that she
could address not only the communication
problems with her mother, but some of the
family history that impacted her style of
caregiving. Sarah stated that women were
always seen as strong and independent
in her family, but resisted any type of
help for their medical issues. During
our initial sessions, Sarah’s mother was
a little hesitant to talk about the issues
surrounding the relationship with her
daughter. The tension-filled sessions led
me to believe that there was more behind
the scenes than just caretaking for medical
issues. Sarah was tearful quite often,
feeling defeated and unsure about whether
she was even being a good daughter to her
mother, let alone a good caregiver.
Over time, Sarah and her mother were
able to negotiate some strategies for not
only more effective ways to communicate,
but setting firm boundaries around what
Sarah needed to do for her own personal
care. Working from the tenets of Bowen
and Nagy, I was able to help the family
identify how patterns of caregiving and
maintenance around health issues have
MARCH / APRIL 20 1 8 9
carried a strong legacy in this family. Sarah
was carrying historical generations of
family secrets, disengaged parenting, and
tension-filled households on her shoulders.
We worked through how Sarah’s loyalty
to her family would always be a strength,
regardless of how she feels perceived
by her mom as an “average caregiver.”
Sarah also learned through our sessions
to embrace the “good enough” days of
caregiving, doing only what was within
her control surrounding the ongoing
symptoms of the mother’s dementia.
In my reflections in working with
dementia caregivers, I’m always drawn
back to one of Pauline Boss’ (2001) terms to
describe the caregiver’s experience of the
unknown course around dementia, called
delicious ambiguity. Caregivers are often
perplexed by the symptoms of dementia
and on high alert as to when their loved
one’s health might get worse. Boss’ concept
helps caregivers embrace the unknowns of
the disease, where small setbacks or lapses
in memory can be kept in context over
time. Providers often mistake caregivers’
anxiety as a symptomatic flaw in their
behavior or thinking, instead of a normal
response to a largely ambiguous disease
that has no time clock.
The importance of MFTs and
dementia care
With the emergence of more family
therapists trained to work in medical
settings, the field’s exposure to dementia
and geriatric cases is increasing. MFTs
are starting to assume more prominent
roles in memory clinics, assisted living
facilities, hospitals and specialty care
clinics with dementia-related issues.
While most of the medical needs of the
diagnosed individual are often seen in
medical settings, more caregivers are
seeking traditional psychotherapy services
for certain emotional and mental health
issues. Beyond just depression or anxiety,
caregivers are coming to therapy seeking
strategies and skills to make their loved
one’s life better. They may also raise more
complex family issues, such as boundary
setting with family members, transitioning
a parent into long-term care, or even
negotiating the caregiving process.
MFTs can help expand the range of skills
offered to families with dementia in the
following ways:
• Helping doctors and geriatricians
communicate the diagnosis and findings
in a more effective manner to caregivers
and family members
• Providing psychoeducation to families
about the progression of dementia and
the anticipated issues involved.
• Helping to connect family members and
patients to the appropriate resources in
their communities
• Integrating family members into
treatment plans for patients, including
family-centered communication goals
and skills to work on at home
• Providing in-home services to families
to not only address the challenges of
dementia, but other safety and risk issues,
as well
• Identifying resilience strategies of
families through the adverse times of the
disease
• Coordinating family meetings to discuss
transitions of care or potential end of life
issues around dementia
• Intervening with families to help with
continuity of care when patients are
discharged from the hospital
As systemically-trained thinkers, we’re
well equipped to handle many of the
complications of challenges of caregivers
that often fall outside of traditional mental
health diagnoses. With caregiver stress
becoming a population health crisis, this
is an ideal time for MFTs to be at the
forefront of family-oriented care around
dementia. Policymakers and researchers
are starting to see the utility of family-
based interventions to help curb the rising
costs and complications associated with
the care for this disease. Failing to address
these critical caregiving issues of dementia
will only complicate the burdens and
challenges for future generations to come.
Max Zubatsky,
PhD, LMFT, is an
assistant professor in
the Medical Family
Therapy Program at
Saint Louis University
and an AAMFT
Clinical Fellow. He also directs the Memory
Clinic, a specialty service for older adults
with memory issues in the Center for
Counseling and Family Therapy.
References
Alzheimer’s Association. (2017). Alzheimer’s disease facts and figures.
Retrieved from https://www.alz.org/documents_custom/2017-
facts-and-figures.pdf.
Boss, P. (2011). Loving someone who has dementia: How to find hope
while coping with stress and grief. John Wiley & Sons.
Brodaty, H., & Donkin, M. (2009). Family caregivers of people with
dementia. Dialogues in Clinical Neuroscience, 11(2), 217.
Dröes, R. M., Boelens-Van Der Knoop, E. C., Bos, J., Meihuizen,
L., Ettema, T. P., Gerritsen, D. L., Hoogeveen, F., De Lange, J., &
SchöLzel-Dorenbos, C. J. (2006). Quality of life in dementia in
perspective: An explorative study of variations in opinions among
people with dementia and their professional caregivers, and in
literature. Dementia, 5(4), 533-558.
Feinberg, L. F. (2016). The dual pressures of family caregiving and
employment. Washington, DC: AARP Public Policy Institute.
Fingerman, K. L., Pillemer, K. A., Silverstein, M., & Suitor, J. J.
(2012). The baby boomers’ intergenerational relationships. The
Gerontologist, 52(2), 199-209.
National Center on Caregiving. (2015). Fact sheet: Selected caregiver
statistics. San Francisco, CA: Family Caregiver Alliance.
Roth, D. L., Fredman, L., & Haley, W. E. (2015). Informal caregiving
and its impact on health: A reappraisal from population-based
studies. The Gerontologist, 55(2), 309-319.
Schulz, R., & Sherwood, P. R. (2008). Physical and mental health
effects of family caregiving. Journal of Social Work Education,
44(sup3), 105-113.
Providers often mistake
caregivers’ anxiety as a
symptomatic flaw in their
behavior or thinking, instead
of a normal response to a
largely ambiguous disease
that has no time clock.
10 FAMILY THERAPY MAGAZINE
Approaching the
End of Life
Froma Walsh, PhD
In my late twenties, I was not prepared for my
mother’s death. Pursuing my career and relational
commitments, like many peers, I had moved
far from home. Doctors were vague about my
mother’s serious health condition and decline.
I was conflicted about meeting the needs of
families in my clinical setting while not there for
my own parents. I shuttled back and forth across
the country, spending a few days with them and
attending to my demanding schedule. My father
and I only realized my mother was dying when she
was hospitalized in a coma, too late to share our
loving goodbyes. The day after her funeral, I flew
right back, not missing a beat at work and praised
for being so “resilient.” That was a faulty notion of
resilience—just bounce back and put loss behind
you. Only later did I begin to deal with her death.
Approaching the
End of Life Making the Most of Precious Time
Froma Walsh, PhD
MARCH / APRIL 20 1 8 11
12 FAMILY THERAPY MAGAZINE
In our clinical training and practice, like
our culture’s aversion to facing death,
we have tiptoed around the profound
challenges at life’s end for patients and
their loved ones. Anxieties are aroused
for us, as well as for them. There is no
safe boundary: We all must face the loss
of loved ones and our own mortality.
Yet, I have found helping families with
death and loss to be among my most
deeply meaningful and inspiring clinical
work. Our compassionate engagement
with them can ease passage, enrich
bonds, and foster resilience as survivors
grieve and move forward in life.
From an individual focus to
a systemic lens
Most attention to death and loss has
focused on individual grief reactions.
A systemic framework is needed to
understand the emotional shockwaves
with a significant death throughout the
family network, affecting all members,
their relationships, and the family
unit (Walsh & McGoldrick, 2004).
The death of an elder entails multiple
losses in unique relationships for each
member—a spouse, siblings, adult
children and grandchildren. The loss of
functional roles—a matriarch or primary
caregiver—can leave a hole in the
fabric of family life. A death in highly
conflicted or estranged relationships
may be intensely painful because it is too
late to repair bonds.
Working with families as they face
end-of-life challenges can be valuable
in addressing concerns, deepening
bonds, and preventing complicated loss
issues for survivors. Facilitating open
communication is crucial for sharing
feelings, with empathic support and
respect for members’ varied responses.
We can encourage direct contact with
the dying person and efforts to shift
priorities to make the most of limited
time. We can help those distancing
from the painful reality of death.
Conversations can be opened to include
the preferences of the dying person in
difficult decision-making and future
planning for survivors. Facilitating
shared meaning-making efforts can
help members begin to gain a coherent
perspective on the death and loss over
time, fostering a sense of continuity
with their life course. Through these
processes, members build relational
resilience and often forge new purpose
in life. Our systemic practice may
flexibly combine individual, couple, and
family sessions with the dying person
and loved ones.
Addressing cumulative strains
in social context
Our work with end-of-life issues must
be attuned to the growing diversity
and complexity of family life and
the importance of multigenerational
relationships over an expanded life
course. With smaller families and later
childbearing, adults at midlife—the
so-called “sandwich generation”—face
multiple pressures with job demands,
childrearing, and eldercare. With
medical advances, more elders are
living longer and dying from chronic
health conditions, posing caregiving
and financial strains. The end of long
suffering and struggle may bring relief,
yet often guilt tinged for survivors.
The toll of cumulative stresses impacts
relationships, for instance, straining a
couple’s bond if a spouse caring for a
dying parent feels unsupported or the
partner feels neglected. Women have
been disproportionately overburdened
by societal expectations as primary
caregivers. A systemic approach can
seek to involve important family
members, near and far, to contribute
in their own ways, as a mutually
supportive caregiving team.
It is important to identify potential
resources and mobilize extended kin,
social, and community supports. Family
therapists can be supportive allies for
patients and families in obtaining vital
medical information, attentive care,
and links to palliative and hospice
services, especially for those facing social
and economic barriers. Our advocacy
is urgently needed for family medical
leave policies.
Facilitating vital conversations
In cases of terminal illness, Rolland
(2018) counsels therapists to help family
members share information, clarify
the prognosis and options, and support
each other through their challenges. In
initially facing heightened risk of death
and anticipatory loss, it is important
not to undermine their hopes. With
increasing probability of death, and even
when death is certain, the length of time
one will live may be unclear. Drawing up
and discussion of wills, living wills, and
directives by all adult family members
(not only the patient) are advised.
Sensitivity is needed in helping families
to discuss feelings of hopelessness,
helplessness, and despair. We can help
them reorient their vision of hope
from an outcome beyond control to
practice “reasonable hope” (Weingarten,
2010), encouraging their best efforts
for optimal well-being and quality of
life. Members can redirect their hopes
and efforts to amelioration of pain and
suffering, enhanced comfort, emotional
and relational well-being, and dignity
and peace of mind in the dying process.
Families need wise counsel as they
grapple with personal, cultural, and
spiritual matters at life’s end. Vital
conversations with patients and their
loved ones are encouraged (Gawande,
2017), exploring their understanding
of a condition, their goals if it worsens,
their fears, and the trade-offs they are
willing to make (or not). Most important
are conversations about their priorities:
Some want to live long enough for a
project completion or a special family
event; others might prefer to end
pain and suffering and forgo further
treatments.
Increasingly, families face agonizing end-
of-life dilemmas. Decisions to maintain
or withhold life support efforts raise
fundamental questions of a “natural
death,” when life ends, and who should
MARCH / APRIL 20 1 8 13
determine that end, involving legal,
ethical, and religious considerations.
Families can be torn apart by abrupt
decisions or opposing views. Clinicians
can facilitate discussion of complicated
situations, weighing options, and coming
to terms with decisions taken.
It’s important to explore and respect
each family’s cultural and faith beliefs
at life’s end. Spiritual matters commonly
come to the fore (Walsh, 2009). We
might ask, “What are your beliefs
about what happens at death?” Belief
in passage to an afterlife and reunion
with deceased loved ones commonly
bring solace and comfort. Families can
be encouraged to draw on spiritual
resources within or outside religious
affiliation, as fitting their preferences.
This might involve a supportive
faith community, traditional rites of
passage, or more personal expressions
through meaningful memorial
rituals, connectedness with nature, or
compassionate social action to benefit
others.
Faith concerns sometimes arise in facing
a loved one’s death, such as not following
prescribed rites or condemnation for
unrepented sins or nonconforming
gender identity or sexual orientation.
With deep spiritual distress beyond our
expertise, therapists can link families
with pastoral professionals. With secular
clients, concerns about the meaning and
significance of their lives and the finality
of death may be important to address.
Making the most of precious time
Later life, amid decline and loss, holds
potential for personal and relational
gains. As the end of life looms on the
horizon, therapists can support efforts
by older adults and their families to
integrate their varied experiences
over time into a coherent sense of self,
family identity, and a meaningful life.
A conjoint family life review (Walsh,
2016) can assist members in gaining
greater understanding and a fuller,
evolutionary perspective of family
life and relationships. In sharing
reminiscences, both the highs and the
lows, family members can incorporate
varied subjective experiences of their
shared life passage, enlarging the family
story and strengthening bonds. Legacies
of resilience in family histories, stories,
and role models of courage, tenacity,
and ingenuity in dealing with painful
adversities can offer inspiration. Facing
loss often heightens appreciation of
loved ones and spurs efforts to repair
grievances. Elders approaching life’s end
are often more forthright about shame-
laden family issues and remorseful
for earlier transgressions, offering
opportunities to heal old wounds.
The end of life may hold unexpected
gifts when family members fully
engage and make the most of precious
time. James, age 52, came to talk with
me about his unbearable sorrow at
his mother’s terminal cancer. We
explored his complex feelings. A devout
Catholic, she had kept her family intact
through an abusive marriage and many
uprooting relocations due to his father’s
drinking and repeated job loss. After
the father’s recent death, James had
bought a new home for his mother so
she could enjoy her later years in peace
and comfort. He was distraught that
her illness shattered these dreams. “It’s
unjust! She deserved some good years.”
James and his sisters had scattered
around the country in adulthood,
keeping little contact. Since their
mother’s cancer diagnosis, she had
uncharacteristically asked them to make
several trips to visit her. A few weeks
after our first meeting, he was in despair.
She had just called them together, he
feared, for their last goodbyes.
On his return, James seemed
transformed—his inner turmoil had
subsided, although his mother, indeed,
had died during the visit.
He told me:
I knew my mother was a strong woman,
but she was most amazing as she faced her
own death—she deliberately brought me
and my sisters to visit, time and again,
In sharing reminiscences, both the highs and the lows,
family members can incorporate varied subjective
experiences of their shared life passage, enlarging the
family story and strengthening bonds
14 FAMILY THERAPY MAGAZINE
to knit us back together. Her final request
made sure we’ll keep connected. She told
us she didn’t want to be buried where she
lived, far from her children. Instead, she
wanted to be cremated and for us to take
the urn with her ashes, go together to each
town where our family had lived, and
scatter some ashes in a beautiful place we
had enjoyed. Her courage inspired us to
honor her wishes even further. We told her
we’d save a portion of the ashes and make
a trip together to Ireland and scatter the
last remains in the town of her ancestors,
where she had always dreamed of visiting.
She was so pleased and died peacefully
a few hours later, as we sat around her
singing Irish ballads she had loved.
In my own family, I vowed to be there
for my father when his time came.
When he was diagnosed with terminal
cancer, despite my responsibilities with
a new deanship and a small child, I
mobilized resources to travel and care
for him. Yet, the final weeks were
emotionally challenging. I kept wanting
to run errands and had to calm my
anxieties to be fully present at my dad’s
bedside. It was the most precious time
we ever shared.
As therapists, our ability to be fully
present with families facing the end of
life is constrained by our clinical field’s
focus on problem-solving. But death
is not a problem to solve and healing
from loss is a journey. In our practice,
we can bear witness to patient and
family suffering, with compassion for
their struggle, and encourage their
best efforts. Engaging with them open
heartedly can make all the difference
for the well-being of the dying and the
healing and resilience of the bereaved.
Froma Walsh, PhD,
is co-director, Chicago
Center for Family
Health and Mose
& Sylvia Firestone
Professor Emerita,
University of Chicago.
She is an AAMFT
Clinical Fellow, Approved Supervisor, past
editor of JMFT, and recipient of the Award
for Distinguished Contributions to the
Field of Marriage and Family Therapy.
References
Gawande, A. (2017). Being mortal: Medicine and what matters in the
end. New York: Henry Holt.
Rolland, J.S. (2018). Helping couples and families navigate illness
and disability: An integrated approach. New York: Guilford Press.
Walsh, F. (Ed.). (2009). Spiritual resources in family therapy (2nd ed.).
New York: Guilford Press.
Walsh, F. (2016). Strengthening family resilience (3rd ed.), New York:
Guilford Press.
Walsh, F., & McGoldrick, M. (Eds.) (2004). Living beyond loss: Death in
the family (2nd. ed). New York: Norton.
Weingarten, K. (2010). Reasonable hope: Construct, clinical
applications, and supports. Family Process, 49, 5–25.
In our practice, we
can bear witness to
patient and family
suffering, with
compassion for
their struggle, and
encourage their best
efforts. Engaging
with them open
heartedly can make
all the difference for
the well-being of the
dying and the healing
and resilience of the
bereaved.
MARCH / APRIL 20 1 8 15
AAMFT’s Campaign
for Medicare
Medicare is the largest healthcare program in the United States,
covering over 56 million people in 2016 and accounting for 15% of
total federal spending (Kaiser Family Foundation, 2017). Created in
1965, Medicare is a federal program administered by the Centers
for Medicare and Medicaid Services (CMS). The Medicare program
includes coverage for hospitalization (Part A coverage), coverage for
services by healthcare providers (Part B coverage), and prescription
drug coverage (Part D coverage). >>
Roger Smith, JD
16 FAMILY THERAPY MAGAZINE
Under current law, for outpatient
care, Medicare only recognizes
certain providers who are eligible
for reimbursement under Medicare
Part B for providing covered
mental health services to Medicare
beneficiaries, including physicians,
clinical psychologists, clinical social
workers, clinical nurse specialists, nurse
practitioners, and physician assistants
(CMS, 2015). For over 30 years, AAMFT
has been advocating for the inclusion
of MFTs as billable behavioral health
providers under Medicare Part B. For 20
years, AAMFT has supported legislation
that would include MFTs as providers
eligible for payment for services provided
under Medicare Part B. There has
been some movement in passing this
important legislation. The Senate has
twice approved legislation recognizing
MFTs under Medicare, in 2003 and 2005,
while the House also has twice approved
such legislation, in 2007 and in 2009.
Currently, there is bipartisan legislation in
the House and Senate to expand Medicare
to include MFTs as covered mental health
professionals, as well as licensed mental
health counselors (LMHCs). These bills are
the Mental Health Access Improvement
Act of 2017 (HR 3032), introduced by
Rep. John Katko (R-NY) and Rep. Mike
Thompson (D-CA), and the Seniors Mental
Health Access Improvement Act of 2017
(S 1879), introduced by Sen. John Barrasso
(R-WY) and Sen. Debbie Stabenow (D-MI).
As of March 1, 2018, 49 Members of the
House of Representatives have sponsored
or cosponsored HR 3032, and 10 Senators
have sponsored or co-sponsored S 1879.
Both HR 3032 and S 1879 are eligible for
consideration by Congress at any time until
the end of 2018.
Within the last year or two, AAMFT has
noticed some increased awareness of MFTs
and increased support for including MFTs
and MHCs as Medicare providers. This is
primarily due to an increased awareness
by Congress on behavioral health issues,
support for the MFTs in Medicare
legislation by other organizations, and
more attention on this issue by the federal
government and policymakers.
Private Sector
In order to more effectively advocate for
legislation to include MFTs and MHCs
as Medicare providers, AAMFT has
partnered with other groups in a coalition
effort. AAMFT’s coalition partners are
the California Association of Marriage
and Family Therapists (CAMFT), the
National Board for Certified Counselors,
the American Mental Health Counselors
Association, the American Counseling
Association, the National Council for
Behavioral Health, and the Association
for Behavioral Health and Wellness.
In addition, AAMFT and CAMFT are
partnering to share the costs of hiring
a federal lobbyist to lobby for MFTs in
Medicare, as well as for greater inclusion
of MFTs as providers in the Department
of Veterans Affairs. AAMFT greatly
appreciates the work of its longstanding
coalition partners.
In addition to the coalition members, other
organizations have supported the Medicare
legislation in the past. However, in the last
couple of years, AAMFT and its partners
have received support and direct lobbying
efforts by outside groups in support of this
critical legislation, such as from companies
that own or represent behavioral health
clinics and other payers. Members working
as employees for behavioral health
clinics and other institutional providers
may find that their employers are very
receptive to legislation that would add
MFTs and MHCs as eligible providers.
Healthcare researchers and policymakers
also support the inclusion of MFTs as
Medicare providers. Unlike when AAMFT
started advocating for MFTs in Medicare
legislation, the idea of including MFTs as
Medicare providers is not controversial
with Members of Congress, other mental
health organizations, or other healthcare
policymakers.
Congress
Like with much of society, Congress has
traditionally viewed behavioral health as
a secondary concern. However, in recent
years, behavioral health has received
greater recognition and attention by
Congress. This change is due to the
persistence of advocates, such as Patrick
Kennedy, a former Member of Congress,
and behavioral health organizations,
including AAMFT, that have advocated
for mental health parity. The increase
in mass shootings in the United States
has brought more attention to mental
health, particularly the lack of adequate
mental health funding. Perhaps the most
significant reason for this change by
Congress is the opioid epidemic, which
has impacted every state and every
congressional district.
In 2016, bipartisan legislation that would
reform behavioral healthcare, the 21st
AAMFT Practice Protection Fund
The AAMFT Practice Protection Fund (PPF) is a
voluntary member driven fund created in 2013
to help pay for items related to defending the
profession and propelling it forward. Donations
to the PPF allows AAMFT to seize opportunities,
such as adding MFTs to Medicare. Help AAMFT
continue this great advocacy work by donating
today. Visit aamft.org/PPF to make your
contribution!
Family TEAM
Passionate about adding MFTs to Medicare?
Do you wish to contribute to advancing the
MFT profession? Join
AAMFT’s grassroots advocacy
network, the Family Therapy
Education and Advocacy
Movement (TEAM) to amplify
the voices of MFTs! Check
out aamft.org/JointheTEAM
to learn more.
These programs help AAMFT advocacy make an impact!
MARCH / APRIL 20 1 8 17
Century Cures Act, was signed into law
(Paulson, 2016). This bill provided $6.3
billion in funding to addressing the opioid
epidemic and other behavioral health
issues. In February 2018, Congress passed
a budget deal that includes $6 billion in
funding to tackle the opioid epidemic.
Although the overall funding levels
are lower than recommended by the
behavioral health community, Congress
is considering additional funding for
behavioral health treatment. AAMFT
has positioned MFTs as having a role in
addressing the opioid epidemic and other
behavioral health challenges identified by
Congress.
Public Sector
Entities within the federal government
have been willing to consider including
MFTs as Medicare providers. One example
is the Interdepartmental Serious Mental
Illness Coordinating Committee (ISMICC).
Established by the 21st Century Cures
Act, the ISMICC is a federal advisory
committee responsible for providing
guidance and recommendations to
Congress and federal agencies. This is the
most important federal mental health
committee since the President’s New
Freedom Commission on Mental Health in
2003. The ISMICC is comprised of federal
agency officials and at least 14 non-federal
members with significant standing in
the mental healthcare community. One
non-federal member is Paul Emrich, PhD,
Undersecretary of Family and Mental
Health Services for the Chickasaw Nation,
and an AAMFT Clinical Fellow.
On December 14, the ISMICC delivered its
first official report to Congress. The report
includes 45 recommendations put forth by
the non-federal members, including the
recommendation to remove exclusions that
prevent LMFTs and LPCs from serving
as Medicare providers and providers in
other federal programs (ISMICC, 2017).
This is the first significant federal report in
many years to recommend MFT inclusion
in Medicare, and the first major federal
committee to ever recommend inclusion of
MFTs in Medicare.
Federal agencies are also considering
alternative methods for addressing the
behavioral health needs of Medicare
beneficiaries. CMS has a unit, the CMS
Innovation Center, that is responsible
for designing and testing new payment
and service delivery models to improve
healthcare quality and access while
lowering the cost of care for Medicare
beneficiaries with behavioral health
conditions. This Center is responsible
for developing Medicare accountable
care organizations. The Innovation
Center’s projects differ from traditional
Medicare in that the models are not
fee-for-service payments, and that the
Center’s projects can avoid many of the
traditional restrictions found in Medicare,
including the restriction on MFTs serving
as Medicare providers. In 2017, the
Innovation Center announced that it is
considering developing a new behavioral
health payment and service delivery
model. AAMFT is advocating that the
Innovation Center consider developing a
model that would include MFTs and MHCs
as Medicare providers. Outreach with the
Innovation Center will continue.
2018 and beyond
We believe that the outlook is good for the
eventual inclusion of MFTs in Medicare.
This spring, AAMFT will bring in several
AAMFT members to advocate for HR
3032 and S 1879, the MFTs in Medicare
legislation, with their Members of
Congress. If you have not already done so,
please contact your Members of Congress
and urge them to cosponsor HR 3032 and
S 1879.
Roger Smith,
JD, is the director
of AAMFT’s
Government and
Corporate Affairs
department and
serves as senior
counsel.
References
Centers for Medicare & Medicaid Service. (2015). Mental health
services. Retrieved from https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-MLN/MLNProducts/
Downloads/Mental-Health-Services-Booklet-ICN903195.pdf.
Interdepartmental Serious Mental Illness Coordinating Committee.
(2017). The way forward: Federal action for a system that works for
all people living with SMI and SED and their families and caregivers.
Established by the 21st Century Cures Act. Retrieved from https://
store.samhsa.gov/product/PEP17-ISMICC-RTC.
Kaiser Family Foundation. (2017). An overview of Medicare.
Retrieved from https://www.kff.org/medicare/issue-brief/an-
overview-of-medicare.
Paulson, A. (2016, December 7). In rare bipartisan success, Congress
passes major mental health bill. Christian Science Monitor. Retrieved
from https://www.csmonitor.com/USA/Politics/2016/1207/In-rare-
bipartisan-success-Congress-passes-major-mental-health-bill.
W I T H
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18 FAMILY THERAPY MAGAZINE
Jennifer Sampson, PhD
HOARDING
AND THE AGING POPULATION: A GROWING CRISIS
JANUARY / FEBRUARY 2018 19
Clinical Challenges
from a Complex
Legal Environment
Damir S. Utržan, PhD
Howard “Sam” Myers, III, JD
WE’VE ALL KNOWN THAT NEIGHBOR WITH
the overly cluttered yard or had a stubborn family member with a house so
full of stuff that we just looked the other way, saying, “That’s just Uncle Joe.
He lived through the Great Depression.” The accumulation of possessions
in our culture is omnipresent, as we live in a world where stuff gives us
meaning. For better or worse, in our culture, acquiring possessions gives us a
sense of identity, accomplishment, and even purpose.
However, for two to five percent of the populatino (Iervolino et al., 2009;
Samuels et al., 2008), this accumulation of things is extremely problematic,
preventing upwards of 16 million Americans from having functional use of
their homes. With the rise of reality television placing sensational focus on
people who have too much stuff, hoarding disorder has taken center stage
as one of mental health’s newest and most provocative diagnoses—one
that disproportionally affects seniors at a rate almost twice as high as
younger adults (Samuels et al., 2008).
With the number of Americans age 65 and older projected to reach nearly
100 million by 2060 (Mather, Jacobsen, & Pollard, 2015), it is critical that
mental health professionals be educated about best practices in screening,
assessment, and treatment of hoarding disorder (HD) in aging populations.
HOARDING
20 FAMILY THERAPY MAGAZINE
What is hoarding disorder?
In 2013, hoarding disorder was
categorized as a standalone psychiatric
disorder in the Diagnostic and Statistical
Manual (5th ed.; APA, 2013) with the
following criteria:
A. Persistent difficulty discarding or
parting with possessions, regardless
of their actual value
B. This difficulty is due to a perceived
need to save the items and distress
associated with discarding them
C. The difficulty discarding possessions
results in the accumulation of
possessions that congest and clutter
active living areas and substantially
compromises their intended use. If
living areas are uncluttered, it is only
because of the interventions of third
parties, such as family members,
cleaners, or authorities
D. The hoarding causes clinically
significant distress or impairment
in social, occupational, or other
important areas of functioning
(including maintaining a safe
environment for self and others)
E. The hoarding is not attributable
to another medical condition (like
brain injury, cerebrovascular disease,
Prader-Willi syndrome, etc.)
F. The hoarding is not better explained
by the symptoms of another mental
disorder (such as obsessions seen
in obsessive compulsive disorder,
decreased energy in major depressive
disorder, delusions in schizophrenia or
another psychotic disorder, cognitive
deficits in major neurocognitive
disorder, or restricted interests in
autism spectrum disorder)
Hoarding disorder is a complex, systemic
diagnosis with a variety of vulnerability
factors at play in its development,
including genetic predisposition (Pertusa
et al., 2008), cognitive dysfunction (Slyne
& Tolin, 2014), and core beliefs about
one’s identity and adequacy (Steketee
& Frost, 2007). HD tends to be chronic
in its lifelong course and progression,
and though it typically does not become
problematic until later life, it usually
begins in late childhood or early
adolescence and almost always before
the age of 40 years (Ayers, Saxena,
Golshan, & Wetherall, 2010; Tolin,
Meunier, Frost, & Steketee, 2010).
Cognitive deficits have also been
reflected in research on hoarding
populations, helping to explain some of
the impaired characteristics of hoarding
behavior, including decision making,
low insight, excessive acquiring and
saving behaviors, diminished cognitive
function, impaired use of reward
reinforcements to guide behavior,
maladaptive attachment to objects, and
negative emotional responses during
decision-making (Slyne & Tolin, 2014).
To add to the complexity, HD has
extremely high comorbidity rates, with
other mental health diagnoses occurring
in up to 92% of individuals with HD
(Frost, Steketee, & Tolin, 2011). The most
common comorbid conditions include
anxiety disorders, depressive disorders,
personality disorders, PTSD, and
substance use disorders (Roane, Landers,
Sherratt, & Wilson, 2017).
Unique challenges for older adults
Given the chronic nature and functional
limitations associated with HD, older
adults are particularly vulnerable to
these consequences. Severe hoarding
can be especially dangerous for older
adults due to increased risk of falling,
fire, avalanche, impaired functional
ability, food contamination, and
medication mismanagement (Ayers, et
al.,; Ayers, Schiesher, Liu, & Wetherell,
2012). Structural conditions of the
home, exposure to hazardous mold and
dust, and rodent and insect infestations
contribute to the overall risk.
HD can also result in medical problems
and activities of daily living impairment
due to the cluttered home environment
(Ayers, Schiesher, Liu, & Wetherell, 2012;
Ayers et al., 2013). One large-scale study
found that approximately 63% of HD
patients reported at least one chronic and
severe medical problem and increased risk
for chronic and severe medical conditions
when compared to a control group (Tolin,
Frost, Steketee, Grey, & Fitch, 2008). Other
commonly diagnosed comorbidities include
obesity, hypertension (61%), head injury
(39%), and arthritis (28%; Ayers, Saxena,
Golshan, & Wetherell, 2010).
Hoarding in older adults has also been
associated with neurocognitive disorders
(Ayers et al., 2013), including organic brain
disease, such as dementia. The prevalence
rate of hoarding behaviors in dementia
cases is high, occurring in 15 to 49% of
dementia patients (Tompkins, 2015).
Hoarding disorder can also precipitate
homelessness by placing housed
individuals at risk of eviction (Tolin,
Frost, Steketee, Grey, & Fitch, 2008).
Hoarding behaviors can result in
public health and safety problems
when clutter violates building codes,
leading property managers or neighbors
to file complaints, resulting in legal
proceedings and eviction (Frost, Steketee,
Youngren, & Mallya, 1999). Rodriguez
and colleagues (2012) found that in 115
individuals seeking help for housing
problems, 22% of the participants met
criteria for HD. Of these individuals,
nearly one-third were facing imminent
eviction and one-fifth had been
previously evicted.
Screening and assessment
Because of HD’s recent introduction to
the DSM, it is common for clinicians to
be unaware of screening protocols. It is
important for therapists to learn to listen
for “red flags” of HD, including feeling
overwhelmed because of housekeeping
duties, conflict with loved ones about
the level of clutter at home, difficulties
restraining oneself from shopping,
or struggles parting with objects.
Clients who report such challenges
might indicate a need for further HD
assessment. Diagnostic tools, such as
the Structured Interview for Hoarding
Disorder (Nordsletten et al., 2013) can
be beneficial in walking practitioners
through the diagnostic process.
Assess for levels of risk and
mental capacity
Just as with every client, assessment
for basic safety in HD clients should be
prioritized and conducted during a home
visit (Steketee & Frost, 2007). While most
therapists are not adequately trained to
do a functional home assessment, helpful
tools, such as the Uniform Inspection
Checklist (Matthews, 2014), can be easily
utilized to determine basic standards of
health and safety in the home.
MARCH / APRIL 20 1 8 21
With older adults who hoard, it is
also imperative that mental health
professionals conduct a thorough
assessment of mental health, which
includes assessing for diminished
capacity (ABA & APA, 2008). While it
is appropriate to preserve the client’s
right to self-determination to accept
or proceed with treatment if mental
capacity is high, it may be prudent to
intervene in more directive ways in
order to ensure the client’s safety if the
client’s mental capacity is low.
Develop a treatment plan,
prioritizing safety and functional
limitations
Studies suggest that practitioners
lean toward honoring individuals’
self-determination even when they
see dangers presented by hoarding
behaviors (Koenig, Leiste, Spano, &
Chapin, 2012). If, during your risk
assessment, you determine that a client’s
home poses health and/or safety risks,
these issues must be addressed before
beginning therapeutic work. This
process must be navigated with care
however, as forced cleanout situations
for people with HD are not only
ineffective, but can also be traumatizing
(Sampson, 2015). Working cooperatively
with the client and supportive team
members, including family, support staff,
and caregivers, will aid in this process
and make it much more effective for
client outcomes in terms of sustainability
and psychological well-being.
For clients who are at high risk due to
safety issues and have low functional
capacity, such as clients with dementia,
a harm reduction approach to managing
the safety risks is likely the best option
for treatment. Harm reduction for severe
hoarding is a set of practical strategies
aimed not at eliminating the hoarding
behavior itself, but at minimizing the
negative, unwanted consequences that
accompany it (Tompkins, 2015). This
approach does not require the individual
to have insight into their reasons for
hoarding, but only to recognize the
potential for harm to themselves, others,
or neighbors, and agree to minimize
the risk. Working collaboratively with
family members and caregivers to
develop a harm reduction plan is vital.
For those elders with moderate levels of
mental capacity who are living in a high
risk situation, the goal of intervention
should be aimed at reducing the client’s
resistance to help, reducing the physical
and health risks in the home, and
focusing clinical work on increasing the
client’s functional capacity.
Once safety is addressed, it is important
to recall the co-occurring nature of
HD. If a client presents with multiple
diagnoses, clinicians must prioritize
treatment goals in order of severity of
symptoms. It is likely that addressing
hoarding-related behaviors and
cognitions will be considerably easier
if symptoms of co-occurring disorders,
such as low motivation due to depression
or hypervigilance from a trauma-
response, are first addressed.
For clients with higher capacity, cognitive
behavior therapy (CBT) has been found
to be moderately helpful for older adults
with hoarding behavior. CBT for HD
includes components of building insight,
problem-solving training, increasing
motivation, organizational skill building,
cognitive restructuring, decision making,
and exposure to acquiring and discarding
(Steketee & Frost, 2007). Treatment
adaptations in CBT for older adults who
hoard may include remediating executive
functioning deficits, providing simplified
homework assignments, and decreasing
emphasis on cognitive restructuring
techniques (Ayers et al., 2014).
Collaborate, collaborate, collaborate
Because of the complex nature of
hoarding situations and the diversity in
agencies that may be needed to address
all of the related issues in a single
hoarding case, it is generally believed
that a collaborative and multidisciplinary
approach is needed for developing
successful responses to hoarding
(Abramson, 2005; Frost, Steketee, &
Williams, 2000). Collaborative work
across disciplines presents a variety
of challenges, but it is well worth
the time and effort, as attempting to
manage hoarding cases alone can be
overwhelming.
It is important for therapists to learn to listen for “red
flags” of HD, including feeling overwhelmed because of
housekeeping duties, conflict with loved ones about the
level of clutter at home, difficulties restraining oneself
from shopping, or struggles parting with objects.
22 FAMILY THERAPY MAGAZINE
Engaging family members can also
be a valuable asset to treatment. It is
likely that family relationships have
been damaged as a consequence of the
hoarding behaviors (Sampson, 2012), but
working to support loved ones through
psychoeducation and supportive services
(Sampson, Yeats, & Harris, 2012) can be
beneficial to healing these bonds and
creating positive treatment supports for
the client.
Hoarding is challenging work for
everyone involved. However, clinicians
can ease this burden by working to
educate themselves about the disorder,
screening, assessment, and treatment
processes for working with HD clients.
Research in the area of hoarding is
booming due to its recent introduction to
the DSM, which means it is vital that we
stay up-to-date on hoarding literature in
order to best serve our aging clients.
Jennifer Sampson,
PhD, LMFT, is the
program chair of
Antioch University
Seattle’s COAMFTE
Couple and Family
Therapy Program.
She specializes
in training and consultation with
multidisciplinary professionals on taking
a systemic and collaborative approach
to working with clients who hoard
and their families. She has presented
nationally and published on her work
with hoarding disorder. Sampson is a
Clinical Fellow of AAMFT.
References
Abramson, B. (2005). The inter-disciplinary team approach to
addressing hoarding cases. Madison, WI: Wisconsin Department
of Health and Family Services.
American Bar Association, & American Psychological
Association. (2008). Assessment of older adults with diminished
capacity: A handbook for psychologists. American Psychological
Association.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders. Ed. 5. Arlington, VA:
American Psychiatric Publishing.
Ayers, C. R., Saxena, S., Espejo, E., Twamley, E. W., Granholm,
E., Wetherell, J. L. (2014). Novel treatment for geriatric hoarding
disorder: An open trial of cognitive rehabilitation paired with
behaviour therapy. American Journal of Geriatric Psychiatry, 22,
248-252.
Ayers, C. R., Saxena, S., Golshan, S., & Wetherell, J. L. (2010). Age
at onset and clinical features of late life compulsive hoarding.
International Journal of Geriatric Psychiatry, 25, 142-149.
doi://10.1002/gps.2310.
Ayers, C. R., Schiehser, D., Liu, L., & Wetherell, J. L. (2012).
Functional impairment in geriatric hoarding participants.
Journal of Obsessive-Compulsive and Related Disorders, 1,
263-266.
Ayers, C. R., Wetherell, J. L., Schiehser, D., Almklov, E., Golshan,
S., & Saxena, S. (2013). Executive functioning in older adults
with hoarding disorder. International Journal of Geriatric
Psychiatry, 28, 1175-1181.
Frost, R. O., Steketee, G., & Tolin, D. F. (2011). Comorbidity in
hoarding disorder. Depression and Anxiety, 28(10), 876-884.
Frost, R. O., Steketee, G., & Williams, L. (2000). Hoarding: A
community health problem. Health and Social Care in the
Community, 8, 229-234.
Frost, R. O., Steketee, G., Youngren, V. R., & Mallya, G. K. (1999).
The threat of the housing inspector: A case of hoarding. Harvard
Review of Psychiatry, 6, 270-278.
Iervolino, A. C., Perroud, N., Fullana, M. A., Guipponi, M.,
Cherkas, L., Collier, D. A., Mataix-Cols, D. (2009). Prevalence and
heritability of compulsive hoarding: A twin study. American
Journal of Psychiatry, 166, 1156-1161.
Koenig, T. L., Leiste, M. R., Spano, R., & Chapin, R. K. (2012).
Multidisciplinary team perspectives on older adult hoarding
and mental illness. Journal of Elder Abuse & Neglect, 25(1), 56-
75. DOI: 10.1080/08946566.2012.712856
Mather, M., Jacobsen, L. A., & Pollard, K. M. (2015) Aging in the
United States. Population Bulletin, 70(2). Retrieved from http://
www.prb.org/pdf16/aging-us-population-bulletin.pdf.
Matthews, M. J. (2014). Uniform inspection checklist.
Retrieved from http://thecluttermovement.com/wp-content/
uploads/2017/11/Uniform-Inspection-Checklist.pdf.
Nordsletten, A. E., Fernández de la Cruz, L., Pertusa, A.,
Reichenberg, A., Hotopf, M., Hatch, S. L., & Mataix-Cols, D.
(2013). The Structured interview for hoarding disorder (SIHD):
Development, further validation, and pragmatic usage. Journal
of Obsessive-Compulsive and Related Disorders, 2(3), 346–350.
Pertusa, A., Fullana, M. A., Singh, S., Alonso, P., Menchon,
J. M., & Mataix-Cols, D. (2008). Compulsive hoarding: OCD
symptom, distinct clinical syndrome, or both? American
Journal of Psychiatry, 165(10), 1289-1298. doi:10.1176/appi.
ajp.2008.07111730.
Roane, D. M., Landers, A., Sherratt, J., & Wilson, G. S. (2017).
Hoarding in the elderly: A critical review of the recent literature.
International Psychogeriatrics, 29(7), 1077-1084. doi: 10.1017/
S1041610216002465
Rodriguez, C. I., Herman, D., Alcon, J., Chen, S., Tannen, A.,
Essock, S., & Simpson, H. B. (2012). Prevalence of hoarding
disorder in individuals at potential risk of eviction in New York
City: A pilot study. Journal of Nervous and Mental Disease,
200(1), 91-94. doi:10.1097/NMD.0b013e31823f678b
Sampson, J. M. (2012). The lived experiences of family members
of persons who compulsively hoard: A qualitative study.
Journal of Marital and Family Therapy. doi:10.1111/j.1752-
0606.2012.00315.x
Sampson, J. M. (2015, September). Safety day: An application
of disaster psychology to hoarding cleanouts. Conference
workshop presented at North Shore Center for Hoarding and
Cluttering Conference.
Sampson, J. M., Yeats, J. R., & Harris, S. M. (2012). An evaluation
of an ambiguous loss based psychoeducational support
group for family members of persons who hoard: A pilot study.
Contemporary Family Therapy, 34, 566-581. doi:10.1007/s10591-
012-9214-6
Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B., Riddle,
M. A., Liang, K., Easton, W. W., & Nestadt, G. (2008). Prevalence
and correlates of hoarding behavior in a community-based
sample. Behaviour Research and Therapy, 46(7), 836-844.
doi:10.1016/j.brat.2008.04.004
Slyne, K., & Tolin, D. F. (2014). The neurobiology of hoarding
disorder. In R. O. Frost & G. Steketee (Eds.), Oxford handbook of
hoarding and acquiring. New York, Oxford University Press.
Steketee, G., & Frost, R. O. (2007). Compulsive hoarding and
acquiring: Therapist guide. New York: Oxford University Press.
Tolin, D. F., Frost, R. O., Steketee, G., Grey, K. D., & Fitch, K.
E. (2008). The economic and social burden of compulsive
hoarding. Psychiatry Research, 160, 200-211.
Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G. (2010).
Course of compulsive hoarding and its relationship to life
events. Depression and Anxiety, 27, 829-838. doi: 10.1002/
da.20684
Tompkins, M. A. (2015). Clinician’s guide to severe hoarding. A
harm reduction approach. New York: Springer.
Severe hoarding can be especially dangerous for older
adults due to increased risk of falling, fire, avalanche,
impaired functional ability, food contamination, and
medication mismanagement
MARCH / APRIL 20 1 8 23
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24 FAMILY THERAPY MAGAZINE
LEGAL+ETHICAL
Benjamin E. Caldwell, PsyD
MFT Perspectives on
Assisted Client Suicide
Sandy Bem was a renowned professor of psychology and a pioneer in
the eld of gender studies. Facing the mental deterioration that comes
with Alzheimer’s disease, she chose to end her own life in 2014 rather
than waiting for the disease to kill her. In the months before her death,
she spoke at length with her husband, her sister, and other family
members about her plans. Some of them tried to stop her. Others,
initially shocked by the news, eventually came to support her decision.
MARCH / APRIL 2018 25
The New York Times Magazine
article, “The Last Day of Her Life”
(Marantz Henig, 2015), is a moving
portrait of the months leading up
to Bem’s death. For all of Bem’s
knowledge and experience in
the world of psychology, there is
nothing in the article to suggest
that she met with a therapist to
discuss her decision. If she had,
that therapist may have faced a
deep and diicult struggle: Is it a
therapist’s responsibility to try to
stop her?
In six states and the District
of Columbia, a doctor can
legally prescribe medication
to someone who is terminally
ill with the intention that the
person will use the medicine to
end his or her life.* Under the
current Code of Ethics for the
American Counseling Association,
a counselor whose client has
expressed such plans does not
necessarily need to intervene to
attempt to stop them:
Counselors who provide services to
terminally ill individuals who are
considering hastening their own
deaths have the option to maintain
condentiality, depending on applicable
laws and the specic circumstances of
the situation and aer seeking
consultation or supervision from
appropriate professional and legal parties
(ACA, 2014, p. 7).
However, the current AAMFT Code of
Ethics (2015) is silent on the issue. In
Bem’s case, she lived in a state without
such a law. And even if she had been in
such a state, she may not have met the
law’s requirements. Those laws typically
require that the person have a prognosis
that they will die within six months—a
prognosis that doctors may be reluctant
to give those with Alzheimer’s disease,
considering the unpredictable timeline
of the disease’s progression.
Legal standards determining a therapist’s
obligations to a suicidal client vary by
state or province. In most locations, the
law creates an exception to therapist-
client condentiality when a client
expresses intent to harm themselves.
The AAMFT Code, like many state and
provincial laws, requires MFTs to inform
clients of this and other applicable limits
of condentiality at the beginning of
services.
In a technical sense, however, an
exception to condentiality is not the
same thing as an obligation to share
information. In other words, the fact that
a therapist can legally share a certain
piece of information from therapy
does not necessarily mean they must.
And suicidality is one area where the
therapist’s obligations are oen muddy.
In a 1978 ruling, the California Court of
Appeals determined that a psychiatrist
must intervene to protect a client
who appears likely to commit suicide
(Bellah v. Greenson, 1978). That ruling
has widely been seen as applicable
to other mental health professionals,
including MFTs (Griin, 2011). But in
that case, which involved a 15-year-
old who had committed suicide while
under the psychiatrist’s care, that same
court stopped short of saying that the
psychiatrist had an obligation to share
information with the patient’s parents
about her risk level. Instead, the court
simply determined that the psychiatrist
had a duty to take “reasonable
preventive measures.”
Nearly 40 years later, California passed
its law allowing a terminally ill patient to
hasten death with medication prescribed
by a physician (California End of Life
Option Act, 2015). That law protects
physicians from liability if they are
involved in the process. But it does not
address the responsibilities or liabilities
of other healthcare providers who are
aware of the patient’s plans.
As MFTs, we generally support clients’
autonomy to make their own choices,
and do not impose upon their major
life decisions. On the other hand, the
principle of “Do No Harm” is equally as
foundational as that of Autonomy, and it
LEGAL+ETHICAL
The fact that a therapist can legally share a
certain piece of information from therapy does not
necessarily mean they must. And suicidality is one
area where the therapist’s obligations are often
muddy.
26 FAMILY THERAPY MAGAZINE
is debatable whether actively choosing
not to intervene constitutes harm when
a therapist knows that the client is
intending to kill themselves.
For many of us, that debate is deeply
personal. It touches on our own morals,
and oen on our own experiences with
loved ones. The discussion might also
call attention to your religious beliefs,
particularly if you have strong beliefs
about the sanctity of life, or about
possible eternal consequences for
someone who takes their own life.
The fundamental question boils down
to: When, if ever, might it be acceptable
for an MFT to choose to quietly stand
aside, knowing that a client plans to end
his or her life? If, for moral or religious
reasons, you do not believe it to ever
be acceptable for any person to stand
aside when they know another person
is planning to take his or her own life,
then the specic professional role may
be irrelevant to you. Even outside of
personal moral or religious beliefs, you
may believe that failing to intervene
with a client considering dying is
incompatible with your professional
role—a stance that runs parallel with the
American Medical Association’s formal
position on aid-in-dying laws (Bailey,
2018).
On the other hand, you may believe
that there are some circumstances
where standing aside would be a better
reection of your professional values.
Such a stance is more parallel with that
of several AMA chapters, which have
dropped their formal opposition to aid-
in-dying laws (Bailey, 2018).
If you do believe it is acceptable in at
least some circumstances for an MFT
to not intervene in a client’s decision to
die, where do you draw the line? State
legislation on the issue typically requires
a prognosis of less than six months to
live, but that leaves out many people
who would like to control their own
death. For Bem, though her cognitive
abilities had deteriorated signicantly,
it was not clear how much longer she
might have lived. Would you be willing to
stand aside, if she had been your client,
even if you believed she could have lived
another three years? What if there were
a chance, no matter how slim, that some
quality of life could be restored in that
time?
Would you be willing to stand aside if
a person who was otherwise of sound
mind, but headed into the throes of an
incredibly diicult and painful, but not
terminal, illness chose to take his or
her own life? Are there other kinds of
suering where you would understand a
client’s decision to die to the point of not
interfering?
In the Bellah v Greenson ruling, the
psychiatrist was called upon to act
within the profession’s standard of care.
In other words, he should have done
at least what the average psychiatrist
would do to protect the patient. Today’s
movement toward allowing terminally ill
individuals to hasten their death—which
is currently supported by roughly 70%
of U.S. residents (Tinker, 2017), begs
the question of whether such a singular
standard could even be identied in
family therapy.
Most terminally ill patients who consider
assisted suicide do so out of concerns
with control, rather than pain, as they
approach the end of life (Szabo, 2016).
If a terminally ill client came to an MFT
and said she was considering hastening
her death, could she trust that the MFT
would not immediately take that control
away?
*These bills are generally referred to
as Right to Die, Death with Dignity, or
Assisted Suicide laws, though there is
some debate about whether the term
“suicide” is actually appropriate because
of its connotations (Tinker, 2017). I use
the term here in its broadest and most
literal sense of ending one’s own life, and
without intending to imply impulsivity or
irrationality.
Benjamin E.
Caldwell, PsyD,
is a Clinical Fellow
of AAMFT based
in Los Angeles.
He writes for the
Psychotherapy
Notes blog.
References
AAMFT. (2015). AAMFT code of ethics. Retrieved from www.
aam.org/code-of-ethics.
ACA. (2014). ACA code of ethics. Retrieved from https://www.
counseling.org/Resources/aca-code-of-ethics.pdf.
Bailey, M. (2018, January 26). As doctors drop opposition,
aid-in-dying advocates target next battleground states.
Kaiser Health News. Retrieved from https://khn.org/news/
as-doctors-drop-opposition-aid-in-dying-advocates-target-
next-battleground-states.
Bellah v. Greenson (1978). 81 Cal. App. 3d 614.
California End of Life Option Act, Cal. Stat. Health and Safety
Code § 443 (2015).
Griin, M. (2011). Working with suicidal clients. The Therapist,
23(4), 20-25.
Marantz Henig, S. (2015 May 14). The last day of her life. The
New York Times Magazine. Available online at https://www.
nytimes.com/2015/05/17/magazine/the-last-day-of-her-life.
html.
Szabo, L. (2016, October 24). ‘Death with dignity’ laws and
the desire to control how one’s life ends. Washington Post.
Retrieved from https://www.washingtonpost.com/national/
health-science/death-with-dignity-laws-and-the-desire-to-
control-how-ones-life-ends/2016/10/24/6882d1e6-9629-11e6-
bc79-af1cd3d2984b_story.htm.
Tinker, B. (2017, June 29). 111 people died under California’s
new right-to-die law. CNN. Retrieved from https://www.cnn.
com/2017/06/28/health/california-end-of-life-2016-bn/index.
html.
LEGAL+ETHICAL
Would you be willing to stand aside if a person who was otherwise of sound
mind, but headed into the throes of an incredibly difficult and painful, but not
terminal, illness chose to take his or her own life?
MARCH / APRIL 20 1 8 27
PERSPECTIVES
Lisa Rene Reynolds, PhD
In our program, the clinical director and I have repeatedly pondered
the subject of assigning clients to therapists of a similar background. At
rst glance, it may seem like a simple matter. However, when I decided
to hold a focus group (with current masters level marriage and family
therapy students in our program) about their thoughts and experiences
with this, I found a rich, layered, complex body of feedback.
Our program is nestled just outside the proverbial “melting pot” of
New York City. This location aords us a wealth of diversity in our
client populations, as well as in the makeup of our graduate students.
Some students have internship sites that handle clients distressed by
immigration issues, language barriers, various religions, illiteracy, and
Matching Clients with Student Clinicians
of Similar Backgrounds
28 FAMILY THERAPY MAGAZINE
others who may be otherwise at risk
for marginalization. We strive to ll
a void in oering free/sliding scale
services to those in need, and at
the same time, giving our students
the most diverse clinical experience
possible. Still, what is the best matching
technique that provides an optimal
working relationship for both therapist
and client?
AAMFT’s Code of Ethics (2015) gives
us some general templates that help
inform the decision of matching clients
and therapists, however, it leaves much
“gray area” to navigate.
Standard I – Responsibility to Clients
1.8 Client Autonomy in Decision Making.
Marriage and family therapists respect
the rights of clients to make decisions
and help them to understand the
consequences of these decisions.
In our clinic, if a new intake requests
a particular type of therapist, the st
step is for the director to explore the
reasoning behind the request. For
example, if a young woman asks for
a female therapist because she is
experiencing distress over a recent
date rape, and is feeling uncomfortable
with men, her desire will be granted
(respecting the rights of clients to make
decisions).
In a focus group, some students
challenged the notion that only a
female therapist could adequately help
the aforementioned client. Perhaps a
“safe” experience with a male therapist
would help the client develop a
healthy, boundaried relationship with
a male who could help her overcome
her fear of men. This may be a valid
point, but does not adhere to the rule
of respecting clients’ rights. This is
where 1.8, and help them to understand
the consequences of these decisions,
comes into play. Our director has
encountered intakes that initially asked
for a particular type of therapist, but
aer a discussion that dispelled their
myths, or alleviated their concerns,
were comfortable with any therapist
assigned.
Common factors research (Lambert,
1992) highlights the importance of the
therapeutic relationship in accounting
for change and positive outcome
in therapy. A good t is vital to a
productive and favorable therapeutic
result. For this reason, perhaps the
client is giving a “gi” in presenting us
with things that would enhance their
comfort in the clinical setting?
So, how oen do incoming clients
ask for specics in their provider? Our
director nds it “not uncommon” for
incoming clients to say, “I’m fairly
religious, and was hoping there
would be a clinician who shares and
understands those views,” or, “I’d
prefer an older clinician who has life
experience under her belt, since I’m not
comfortable with someone who can’t
relate to what it’s like to be at this point
in my life.”
Of course, we know that just because
a younger clinician may not personally
understand the middle age experience,
this does not preclude the clinician
from being able to be eective with
the client. Nevertheless, if the client is
strongly wedded to that belief, should
we honor the appeal?
Our director responds airmatively.
She cites a couple of important reasons
for her stance. First, client retention is
imperative for training clinics. Without
steady clients who stay, therapists
cannot hone their skills. Additionally,
having the experience of seeing the
therapeutic process evolve over time,
rather than only doing a few initial
sessions, is important to both the
therapist’s growth, and the client’s
successful change.
Next, early rejections can be diicult for
beginning therapists. If it is possible to
avoid unnecessary challenges from the
onset, this is preferable for students’
condence. However, that said, the
director is careful not to commit to
anything prematurely. She might say, “I
will consider your request, but I cannot
promise we’ll be able to accommodate
that for you. I’ll do the best I can. I
assure you, all of our therapists are
trained thoroughly and are supervised
by licensed professionals with many
years of practice. If you have any
concerns, you can either discuss with
your therapist or call me at any time.”
There are also times as a supervisor
where, if it will in no way compromise
the comfort of the client, I have chosen
to place a particular therapist with
a client with an issue/personality/
presentation that challenges the
student. The desensitization process of
students becoming more familiar with
cases they report as “scaring” them is an
integral part of the therapists’ growth.
A good fit is vital to a productive and favorable therapeutic
result. For this reason, perhaps the client is giving a “gift” in
presenting us with things that would enhance their comfort in
the clinical setting?
MARCH / APRIL 2018 29
What if aer the therapy begins, a
diiculty in “match” becomes apparent?
The following AAMFT Code of Ethics
guidelines can help inform this: 1.9
Relationship Benecial to Client.
Marriage and family therapists continue
therapeutic relationships only so long
as it is reasonably clear that clients are
beneting from the relationship.
If a client reports concerns regarding the
therapist “t,” it should be addressed
immediately. If a therapist has concerns,
the clinical director and supervisor
should work with the student to
understand the situation, in order to
determine the next course of action. It is
also highly recommended that graduate
programs and clinics develop an internal
policy on conscience-based referrals,
as Dr. Ben Caldwell (2013) describes.
At what point do a therapist’s moral
values outweigh a client’s request for
help? Having such guidelines will assist
in making informed decisions that are
ethically based. In the case that the
therapeutic relationship is deemed
counterproductive, the following ethical
principle must be followed:
1.10 Referrals.
Marriage and family therapists
respectfully assist persons in obtaining
appropriate therapeutic services if the
therapist is unable or unwilling to provide
professional help.
So, what are the student therapists’
thoughts on their exposure to dierent
client “matches”? The following is an
overview of some of the most signicant
points they cite.
Pros: One student believed that, except
in cases of extreme rationale, clients and
therapists should not be matched at all.
She made the point that not personally
identifying with a client’s circumstances
forces the therapist to “stay curious,”
and better adhere to the postmodern
view of client as expert on his or her own
experiences/perceptions.
Another student mentioned that in
order for students to grow clinically, they
must be exposed to as great a variety as
possible of clients. An example of this
was shared by two students who were
given almost exclusively Latino clients
because they were bilingual. They both
found that, although they understood
the need for this due to the language
barrier, they felt it stunted their growth
as clinicians. Additionally, both reported
that there were things they understood
culturally on a personal basis, yet there
were unique nuances including dierent
dialects and word meaning.
Yet another stated, “No matter how
well matched we are to a client by
our personal experience, can we
ever really understand any other
person’s cultural, family of origin, or
parenting experience?” Also related
was the comment, “If a therapist is too
comfortable and tting with a client’s
experience, the client might end up
feeling like the therapist is more of
a friend, and this might impede the
process of eective therapy or contribute
to boundary issues.”
Additionally, a few students admitted
that by knowing too much about a
client’s experience, they felt a little “lazy”
at times in session, making too many
assumptions. One interesting comment
was oered, citing boundaries and
the rights of therapists. “If a client asks
for a religious therapist, by agreeing
to accommodate this request, we are
thus disclosing the clinician’s religious
ailiation.” Aer some discussion,
it was agreed that the therapist
should be consulted on all matters
regarding similarity matching prior to
any disclosure of any information on
therapists to client. One more point was
made, “Are we perpetuating the belief/
stereotype that a clinician needs to be of
a similar race, age, gender, in order to be
an eective clinician?”
Cons: The majority of favorable
comments were concerned with
increasing the client’s comfort. One
student said, “Going to therapy can
be a big step for people, and why not
help them from the get-go to feel more
comfortable if they request a certain type
of therapist?” Many students described
the importance of t in the therapeutic
relationship. “If a kid, who is struggling
with a lacking father gure in his life has
a mom who requests a male therapist,
how couldn’t that be the right thing to
do?” Others said that if a certain type of
therapist were available, it made sense
to allow the request. Others echoed that
it was a bonus to have such requests
from clients in knowing what makes
them comfortable. Furthermore, there is
the “placebo eect” to consider, in that
clients who believe a certain therapist
will relate better and be more eective,
might aid in helping the joining process,
and subsequent progress and success of
therapy.
These are great viewpoints to prompt a
continued dialogue on this important
topic. This dialogue is an integral part of
delivering best practices in the clinical
encounter for both client and student.
In closing, it would seem that the most
important pieces to the decisions made
regarding good client-therapist matches
are:
1. Thorough coursework in MFT
programs that gives students a strong
understanding of a multitude of issues
in order to best prepare them for the
many issues clients may present
2. Excellent supervision, with an ongoing
focus of client-therapist “t,” soliciting
client feedback, and monitoring
progress towards treatment goals
3. Good (and frequent) communication
between clinical directors, students,
clients, and supervisors about the
therapeutic experience.
Lisa Rene
Reynolds, LMFT,
PhD, is assistant
professor/program
director of the
Marriage and Family
Therapy Program at
Iona College in New Rochelle, New York.
Reynolds is an AAMFT Clinical Fellow.
References
AAMFT. (2015) Code of ethics. Retrieved from www.aam.org/
code-of-ethics.
Caldwell, B. (2013, September/October). Whose conscience
matters? Family Therapy Magazine, 20-27.
Lambert, M. J. (1992). Psychotherapy outcome research:
Implications for integrative and eclectic therapists. In J. C.
Norcross, & M. R. Goldfried (Eds.), Handbook of psychotherapy
integration (1st ed.). New York: Basic Books (pp. 94–129).
30 FAMILY THERAPY MAGAZINE
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