Family-Centered Integrated Care

This is is part of the Pecha Kucha: A Special Families and Health Blog Series.

Family systems theory is the foundation upon which family-centered care is built. The following patient story illustrates two aspects of this theory. Although Erica is not her real name, her story is real, and she has given permission to share it to help demonstrate the value of family-centered integrated care.

Dan Felix, PhD, LMFT

Erica’s type 1 diabetes had been managed pretty well since she was diagnosed at age 6, but now at 19 she was being admitted to the hospital four or five times a month in diabetic ketoacidosis. Although Erica is not her real name, her story is real, and her story demonstrates the value of integrated care. More importantly, it demonstrates the value of family-centered integrated care.

Erica’s physicians—the family medicine residents who I teach—provided appropriate medical treatment each time she was hospitalized. They then sent her home only to see her back the following week with higher levels of blood sugar. “Why don’t you just take your medication?” was answered only by a gentle shrug of her hospital gown-covered shoulders. I was invited into the case with “Dr Felix, fix her. She’s not right in the head. She claims she doesn’t want to die but she sure is acting like it.” So I chatted with her at the bedside a couple of times, which was enough to convince her to come to see me in the clinic between her hospitalizations.    

At first, we didn’t discuss her diabetes. Instead, I found out that she has been with her boyfriend for several months, which was a big deal to her. Relationships, I discovered, had never come easy for her, especially since childhood during which she endured abuses and betrayals.

During the next appointment, with her boyfriend in the room, we explored what keeps them together and what pushes them apart. With amazing courage, she vulnerably declared her belief that she couldn’t stop being hospitalized because if she did he might leave her. We drew out their cycle. This is the actual paper we used:

Some people have been known to say things like, “I’ll kill myself if you break up with me” as an attempt to keep their relationship intact. She didn’t have to kill herself. Her uncontrolled diabetes was doing that for her. She simply needed to allow herself to be sick and he would rush in like Superman to save the day. He would manage her meds on her behalf to rescue her from this villainous disease that she appeared to have no control over. I remember when he first grasped what was going on. He turned to her and asked, “Is this true?” She sheepishly nodded that it was, to which he responded by abruptly leaving the room unable to look her in the eye. Thankfully he was willing to reenter, re-engage, forgive, and begin to work through it with her.

This cycle had been reiterating for many months. I went back through her medical records at both of the hospitals where my residents had treated her and mapped out a timeline of her hospitalizations.

Notice the drastic stop in blue and green lines (admissions to both hospitals). Why did they so drastically stop? Had we finally found the correct medication and dosage for her? The red lines are the family therapy appointments I had with her, and the purple ones are the outpatient follow-ups she had with our residents. She had traditionally no-showed most of her outpatient appointments because, I suppose, they weren’t medical crises where she was getting her emotional attachment needs met.

Erica’s story is a good illustration of two family systems principles, specifically family system homeostasis and circular causality, which can play a huge role in the reasons why some patients struggle to become and remain healthy. Embracing these principles can improve a health care provider’s ability to offer family-centered care.

System Homeostasis

Homeostasis is a natural process of attaining and maintaining stability, or equilibrium, in a system. Systems must balance in order to persist. Solar systems, for example, maintain homeostatic orbits by balancing the inward pull of gravity and the outward pull of planets in motion. Ecosystems balance the populations of prey and predator. For example, as the number of rabbits in an area increases or decreases, the population of coyotes in that area homeostatically responds with a matching increase or decrease of its own. This is true of solar systems and ecosystems, but also renal, respiratory, and reproductive systems; and it’s definitely true of family systems.

Erica was using her health problems, perhaps unknowingly, to bring her relational and emotional attachment needs into balance. Her behavior was homeostatic although she would never have used such a word to describe it. As health care providers we need to be aware of the homeostatic pressures that some patients’ family members place on our patients, even subconsciously, to not stop smoking, to stay disabled, or any number of other seemingly counterintuitive health behaviors. One man I know responded to his wife’s bariatric surgery and new exercise habit by cooking her old favorite “creamy bacon pasta casserole” for dinner more often. He was trying to keep his family roles and home life the same. He was trying to maintain homeostasis in his family system.  

Circular Causality

In Erica’s story, we see another important systems concept: circular causality. This is the notion that things can be both a cause and an effect of each other, especially when they codevelop over time. A personal example is my basketball skills. I am definitely not good at the sport and I almost never play it. Do I not play basketball because I’m bad at it? Or am I bad at it because I don’t play it? The answer is both. These effects have become causes of each other gradually over time. The same type of thing was happening in Erica’s system. Was her boyfriend rescuing her because she was getting sick, or was she getting sick because he was rescuing her? The answer again is both.

We sometimes assume that we can change the outcome by changing the cause. But what if the outcome is the cause? With Erica, we needed to not only change how her boyfriend was rescuing her but also how she was needing to be rescued, and we needed to change these the same way they had developed—gradually over time. So we set up a new pattern in their relationship such that he no longer came to see her when she was hospitalized but was present at all her outpatient visits. We helped her learn to ask for love and control her attachment anxiety through less life-threatening means. I collaborated closely with her new outpatient primary care doctor who was one of the residents I teach. We did not try to address the circular causality linearly; instead, we counseled her on ways to manage her blood sugar, as well as ways to appropriately ask for emotional security from her boyfriend.

We integrated not just behavioral services into her care, but also integrated her family system (in this case her boyfriend) as a member of her health care team. Not only did she benefit, but so did the resident physician who I was training and collaborating with. Her case is one of many experiences he has had that are shaping him to be not just a family doctor, but truly a doctor of the family, skilled at practicing family-centered, integrated care. I like to believe that our integrated family-centered approach may have saved this young woman’s life.