Justice in the Exam Room

The entire issue of Family Therapy News was interesting. Though it has never been a top of the charts specialty for me, I’ve collaborated on the development of a MedFT focus in graduate education, presented at various conferences on the topic, taught a course at African Christian College on the theory and practice of MedFT, published a thing or two, and helped to develop the emphasis with an AI tribe. All of those things are laid alongside my personal narrative of being in and out of hospitals when I was a kid with a dying father and a mother with numerous ailments and surgeries.

There is one thing that I think was missed in all of those articles, and maybe I just overlooked it.  That “one thing” is the cultural expression and values of the patient. Back in the previous chapter of my professional life, I was hired out of the MFT/ACU program to develop “family-oriented and culturally engaged” programming. That meant more than one person in the room and that also meant respecting, listening for, and engaging with the native culture of the patient/client in the therapy room or the exam room. I have no clue as to where these programs are these days. My sense was that those who followed me were less committed to these notions in principle and practice than we were when I joined up ten years ago.

In essence, a “family-oriented, culturally-engaged” approach to therapy and the Medical Family Therapy is radically different than the traditional approach. Family literally means more than one person in the room and culturally-engaged means connecting with and utilizing the family’s cultural strengths toward positive outcomes.

I believe that the literature speaks to the validity of both. Some conditions are especially amenable to a systemic engagement. Check out the names of Susan McDaniel, Jennifer Hodgsosn, Angela Lamson, Adam Moore, Tai Mendenhall, Russ Crane, and Jacob Christianson for examples. I also have come to believe that the healthiest of persons are those who can walk in two cultures, the one in which one is born, i.e., American Indian, Hispanic, Muslim, etc., and the one in which one lives, i.e., the “dominant culture,” or the white world.  This obviously goes against the grain of much of the rhetoric in public places and spaces these days.

My work in the MedFT world for the AI tribe was that of “consultant” to the physicians in family practice or internal medicine, amongst others. I recall the day in which I was called in to consult with an older AI woman who was not compliant in taking her medications. Though it took a while to figure out what she was thinking and feeling and doing, it became clear that we had missed her worldview. She was “going across the river” and consulting a medicine man from another tribe and getting treatment through those means.

To back up a step or two, I had been observing for about seven years the underlying messages of Indian people. The categories get very complicated, but here are a few. A phenotypically white person with AI status who identifies as AI with a low level of cultural engagement, and a low desire to become more engaged. Or, there was the phenotypically brown skin AI with a high identity, a low level of cultural engagement, and a high desire to be more engaged. Or, there could be a phenotypically white person with a high degree of cultural engagement and a high desire to be more engaged. Imagine those categories, with highs and lows in each and you begin to see complexities. Then, multiple that times the number of AI tribes, and you get even more complexity.

We then designed a 39-item enculturation scale which could be pared down and used in all settings as a “screening inventory.” Why? By doing so, we would then know things related to identity and cultural engagement and respond medically and therapeutically in appropriate ways.

I remember the day when a young clinician was troubled with how to treat a case of an acting out adolescent. We discussed who else lived in the house or was part of the family.  The clinician invited in grandmother who simply had to say something like “straighten up and fly right,” and the kid starting behaving.

So, I think there is a gross injustice when we fail to think family-orientation with problems. I think there is a gross miscarriage of justice when we fail to consider the cultural themes of the person and her or his family coming in to see us.

I think that justice means get the training in both. Engage both. In those ways, we bring about a correction to the injustice that dominates peoples’ lives. The break in shalom is corrected by hearing well and treating well.