醫療家族治療於臺灣之發展與應用：我的實踐

Development and Application of Medical Family Therapy in Taiwan: Personal Actualization

10.6251/BEP.202103_52(3).0008

熊秉荃(Ping-Chuan Hsiung)

以家庭為中心的健康照護 ； 臺灣醫療家族治療 ； 實踐 ； family-centered healthcare ； medical family therapy in Taiwan ； actualization

教育心理學報

52卷3期（2021 / 03 / 01）

665 - 683

繁體中文

臺灣許多助人專業人員從事不同形式之家庭服務，對崛起於1950年代的美國家族治療有相當的接觸與了解，然而對蓬勃發展於美國1990年代至今的「醫療家族治療」可能相對陌生，本文將介紹「臺灣醫療家族治療的軌跡」、「美國醫療家族治療的進程」及「實踐醫療家族治療」三個面向，提升臺灣助人專業人員認識在健康照護體系提供家族治療的專業脈絡。包括說明「醫療家族治療於美國的爭議與推崇」、「突破阻礙健康照護的藩籬與區隔」、「形成與執行醫療家族治療」、「醫療家族治療的目標」、「動態的醫療家族治療歷程」及「五個層級的系統性合作模式」的內涵。由於臺灣健康保險體系對心理社會及靈性照護的低給付點數及缺乏行政資源及專業架構，因此作者進而娓娓道來在目前的健康照護體系中「實踐醫療家族治療」的歷程，包括：「學習醫療家族治療」、「開拓與奠定專業教育」、「基礎與當代議題」、「家庭與特定疾病共舞：案例分享」、「專業間的競爭與合作」及「一次性邀請與永續合作的醫療家族治療。」作者期望醫療在現今追求高技術水準及高科技化的同時，也能夠提供更完善及整全的服務，並透過本文邀集更多對於以家庭為中心的健康照護系統有認識及有興趣的專業夥伴加入健康照護服務，同時拓展及建構絕佳的衛生和社會福利政策及制度，將健康照護、系統和病人及家屬之間做更好的銜接。

In Taiwan, numerous helping professionals provide family services in various formats and settings; although they are relatively familiar with the development of American family therapy in the 1950s, they might not know about the flourishing development of medical family therapy since the 1990s. Medical family therapy is a professional practice that applies the biopsychosocial-spiritual model and systemic family therapy principles in collaborative treatment for individuals and families with medical problems. This article has three sections illustrating the development and application of medical family therapy in Taiwan: ＂Trends of medical family therapy in Taiwan,＂ ＂The progress of medical family therapy in the United States,＂ and ＂The actualization of medical family therapy in Taiwan.＂ The aim of the article is to enhance helping professionals' understanding of their profession's developmental context of providing family therapy in healthcare systems. The author used the keywords ＂medical family therapy,＂ ＂medical counseling,＂ and ＂health counseling＂ to conduct a literature search from 1980 to 2019 in Taiwan and found 53 articles and theses. The majority of articles (88.5%) were published in the last 20 years, indicating that the field of medical family therapy has yet to fully develop in Taiwan. The section titled ＂The progress of medical family therapy in America＂ incorporates specific aspects such as controversy and support in medical family therapy, overcoming of barriers to high-quality healthcare, the formation and implementation of medical family therapy, the goals of such therapy, dynamic processes in such therapy, and the five levels of primary care and behavioral healthcare collaboration. The fundamental assumption of medical family therapy is that all health and relationship problems are biological, psychological, social, and spiritual in nature. Medical family therapy intends to address five ecosystemic splits that hinder health care: (a) splits between the mind and body; (b) splits between the individual and family; (c) splits among the individual, family, and institutional settings; d) splits among the clinical, financial, and operational worlds of health care; and e) the fault line between the often insular world of clinical health care and the larger community. Helping professionals must acquire interdisciplinary knowledge and clinical strategies to overcome the aforementioned splits and achieve the overarching goals of medical family therapy, namely the promotion of agency and communion. In this context, agency refers to empowering patients and families in making decisions regarding their health care, whereas communion refers to helping patients and families feel supported rather than isolated while coping with illness. By assessing individuals and their families' needs and addressing their reliance, medical family therapists plan and implement five levels of systemic collaboration with individuals and their families: (a) minimal provision of medical information and advice, (b) provision of support, (c) undertaking of a systemic assessment, (d) undertaking of planned interventions, and (e) family therapy. This five-level systemic collaboration between biomedical-focused and psychosocial-focused professionals provides a holistic health care framework to develop services that fit the needs of individuals and their families in navigating health challenges. In the article, the author illustrates the essence of cultivating medical family therapy in current health care systems in Taiwan, with minimal reimbursements from the current National Health Insurance program to psychosocial-spiritual care and a lack of institutional structures providing family-centered healthcare. In addition to the institutional shortcomings, the general public is familiar only with advanced, high-technology medical treatments but not integrated, holistic, and family-oriented psychosocial-spiritual care. The author begins by describing her personal experiences in learning medical family therapy in the United States, where she completed an internship at the Family Medicine Center of Highland Hospital and the Department of Psychiatry at Strong Memorial Hospital at the University of Rochester, New York, from 1997 to 1998. Subsequently, the author spent a year at the Chicago Center for Family Health as a Fulbright Senior Scholar during 2018-2019, where her clinical sites included the Advocate Medical Group Family Health Center-Ravenswood and the Ann & Robert H. Lurie Children's Hospital of Chicago at Northwestern University. The process of actualizing medical family therapy in Taiwan includes developing curricula and professional training, moving from basic issues to contemporary issues, working with individuals with cancer, genetic disorders, and social withdrawal and their family members (cases examples), interprofessional competition and collaboration, and beginning from one invitation to sustaining collaboration with family therapists in Asian regions. The author designed and taught four courses at the undergraduate and graduate levels. Three courses were designed to provide students with basic and advanced understandings of the complex relationships among health, illness, and families: ＂Family, Health, and Illness,＂ ＂Family and Cancer,＂ and ＂Family Therapy and Health.＂ They offer students a family systems framework for working with the impact of health problems on patients and families and are especially focused on understanding that all health and relationship problems have biological, psychological, and social natures. Students are encouraged to examine their family-of-origin experiences relating to health and illness. The fourth course is ＂Self-Development for Helping Professionals,＂ which is designed to prepare helping professionals make active and purposeful use of their whole selves in their encounters with clients, with a focus on concepts of self-awareness, access of self, use of self, and self-care. Students are encouraged to develop insight into their personal life experiences, realize the implications of these experiences, and develop skills to intentionally use their own life experiences in facilitating therapeutic change. Students also examine their self-care strategies and attitudes. For more than 20 years, the author has provided clinical training in multiple settings to generate interest in medical family therapy and promote the application of the biopsychosocial-spiritual framework to work with problems related to basic difficulties (i.e., individuals with physical and mental disorders) and contemporary challenges (e.g., individuals with substance use and individuals with gaming disorders). The author facilitated the Chinese translation of The Shared Experience of Illness: Stories of Patients, Families, and their Therapists published in 2003 and the second edition of Medical Family Therapy and Integrated Care published in 2020. These two books are effective tools and foundations for local readers in understanding medical family therapy and its practice. Case examples describe working with individuals with cancer, genetic disorders, and social withdrawal and their family members. The following five strategies were applied to build a locally grounded and globally informed family-centered psychosocial oncology in Taiwan: (a) Forming multidisciplinary teams to enhance professional competence in conducting research and providing services; (b) applying a family-oriented systemic approach and working with healthcare professionals to strengthen biopsychosocial-spiritual holistic care; (c) collaborating with nonprofit organizations to establish evidence-based effectiveness research; (d) raising public awareness of the biomedical and psychosocial dual emphasis regarding comprehensive care; and (e) developing international collaboration in locally grounded and globally informed family-centered healthcare services. Collaboration is an essential aspect of medical family therapy as well as possible tension, and interprofessional competition might be inevitable. ＂Power and status in medical settings,＂ ＂role clarity and scope of practice,＂ and ＂teamwork and patient-centered practice＂ are areas that medical family therapists must address in themselves to prepare students and helping professionals proactively and constructively transform interprofessional competition into collaboration. Recently, more exchanges and collaboration have occurred among therapists in East Asia. The author spent a fruitful week (February 1-8, 2009) in Tokyo with an international expert team, including Dr. Khawla Abu-Baker of Israel, Dr. Young Ju Chun of Korea, Dr. David McGill of the United States, and Dr. Takeshi Tamura of Japan. The intensive exchanges included family-of-origin work and cross-cultural case consultations. The discussants kept in mind that awareness and continuous work on one's self-of-the-therapist issues are crucial for the development of mature family therapists. The team members spent the first 2 days presenting and commenting on each other's family genograms, during which insightful questions were asked and in-depth processing occurred. The examination and reexamination of family themes and interaction patterns led to further understanding of one's family resources and challenges. Five cases were presented over the subsequent 2 days, where issues related to hikikomori were addressed in two families. Hikikomori literally means ＂social withdrawal＂ and has become a major social issue among young people in Japan. An estimated 3%-5% of the population between 18 and 25 years old suffers from hikikomori, and it affects more men than women. Those affected avoid and fear contact with people outside of the family. They do not attend school or hold jobs, and they stay home for months or years doing nothing; sometimes they are violent toward their parents or suicidal. Stimulating conversations surrounding the theme of the conference, ＂Culture, Gender, and Generation,＂ generated interesting viewpoints regarding intracultural as well as intercultural issues. Valuable exchanges continue in the Asian Academy of Family Therapy (AAFT) in the form of annual conferences and case consultations, which enrich training, research, and practice in East Asia. In 2021, The author will be a keynote speaker at the 7th Annual Conference of the AAFT in Seoul, South Korea, where she will address attendees on a topic related to medical family therapy. The author hopes that healthcare systems in Taiwan can achieve the dual aims of pursing advanced biomedical treatments and providing comprehensive family-centered healthcare. The ultimate goal of this article is to invite more helping professionals to provide services in healthcare systems and develop well-rounded social welfare and healthcare policies, thus bridging healthcare systems, patients, and their families.

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