Need Essay, Please

A NATIONAL SURVEY OF FAMILY PHYSICIANS: PERSPECTIVES ON COLLABORATION WITH

MARRIAGE AND FAMILY THERAPISTS

Rebecca E. Clark Lifespan Family Healthcare, Newcastle, Maine

Deanna Linville University of Oregon

Karen H. Rosen Virginia Polytechnic Institute and State University

Recognizing the fit between family medicine and marriage and family therapy (MFT), members of both fields have made significant advances in collaborative health research and practice. To add to this work, we surveyed a nationwide random sample of 240 family physicians (FPs) and asked about their perspectives and experiences of collaboration with MFTs. We found that FPs frequently perceive a need for their patients to receive MFT- related care, but their referral to and collaboration with MFTs were limited. Through responses to an open-ended question, we gained valuable information as to how MFTs could more effectively initiate collaboration with FPs.

Despite the success of medical family therapists in providing integrative, collaborative healthcare, we know little about how commonly family physicians (FPs) and marriage and fam- ily therapists (MFTs) collaborate in routine patient care. To our knowledge, there have been no studies published from the perspective of the FP that describe the extent to which FPs seek the collaboration of MFTs, the degree to which they are aware of MFT as a field, their per- ceived need for their patients to receive MFT, or their attitude toward MFT as a potential resource for patient treatment.

Leaders in family medicine and MFT recognize the common occurrence of mental health concerns arising in a medical visit. In fact, it has been estimated that more than 60% of patient visits to primary care physicians (PCPs) include mental health concerns (Moon, 1997), and many of these concerns may not be the presenting complaint (Jackson & Tisher, 1996; Schurman, Kramer, & Mitchell, 1985). Several MFT ⁄ FP teams have developed models for col- laboration (Doherty & Baird, 1983; Dym & Berman, 1986; Hepworth & Jackson, 1985; Sea- burn, Lorenz, Gunn, Gawinski, & Mauksch, 1996). Other researchers and practitioners have written books that serve as a guide to other mental health practitioners for how to be effective collaborators with other healthcare practitioners (e.g., Seaburn et al., 1996).

The specialty of family medicine, which arose in the 1960s, embraces a systemic, biopsy- chosocial perspective to illness that stresses the importance of caring for the whole person within his or her family, social context, and life cycle stage (Chung, 1996; Fischetti & McCutchan, 2002). It is not surprising that FPs regularly treat their patients’ mental health problems. By definition of their specialty, FPs are trained to integrate behavioral science con- cepts with their biomedical training (AAFP, 2000; Seaburn et al., 1996) as well as to manage

Rebecca E. Clark, MS, Lifespan Family Healthcare, Newcastle, Maine; Deanna Linville, PhD, Couples and

Family Therapy Program, Department of Counseling Psychology and Human Services, University of Oregon;

Karen H. Rosen, EdD, Marriage and Family Therapy Program, Department of Human Development, Virginia

Polytechnic Institute and State University, Northern Virginia Center.

Address correspondence to Rebecca Clark, Lifespan Family Healthcare, 80 River Road, Newcastle, Maine

04553; E-mail: [email protected]

Journal of Marital and Family Therapy April 2009, Vol. 35, No. 2, 220–230

220 JOURNAL OF MARITAL AND FAMILY THERAPY April 2009

psychotropic medication. The American Academy of Family Physicians (AAFP, 2000) recom- mended curriculum guidelines delineate how family medicine residents must understand the individual in the context of his or her family, as well as the emotional impact of illness, and be able to evaluate and diagnose mental health disorders from a biopsychosocial perspective. For decades, authors in family medicine and collaborative healthcare journals have published literature regarding the use of MFT techniques such as family systems thinking, the use of gen- ograms, meeting with the entire family, brief therapy techniques, and when to refer patients for family therapy (Bader, 1990; Bloom & Smith, 2001; Bullock & Thompson, 1979; Christie-Seely, 1981; Davis, 1988; Frank, 1985; Lang et al., 2002; Mayer et al., 1996; Tomson & Asen, 1987). Additionally, organizations such as the Collaborative Family Healthcare Association (CFHA; see http://www.cfha.net) and the Society for Teachers of Family Medicine (STFM; see http:// www.stfm.org) continue to promote research, education, and practice in collaborative health- care. Given family medicine’s emphasis on family systems, the family as the unit of care, and biopsychosocial perspective, it seems that MFTs would be a logical, and even sought-after, complement to FPs in providing comprehensive patient care.

As a specialty of MFT, medical family therapy (MedFT) has already made significant advances in this area. Particularly helpful for chronic illness, MedFT has enabled MFTs to skillfully integrate the biopsychosocial-spiritual perspective, a systemic integration of physical and emotional health, familial ⁄ social relationships, and spiritual belief systems, with a family systems framework (McDaniel, Hepworth, & Doherty, 1992a; Rolland, 1994; Weihs, Fisher, & Baird, 2002). Specifically trained medical MFTs have effectively collaborated with medical prac- titioners to provide care for families struggling with chronic medical illnesses such as infertility (Burns, 1999; McDaniel, Hepworth, & Doherty, 1992b), cancer (Yeager et al., 1999), childhood asthma and diabetes, cardiovascular and neurological disorders (Campbell & Patterson, 1995), obesity (Campbell & Patterson, 1995; Flodmark, Ohlsson, Ryden, & Sveger, 1993), somatoform disorder (McDaniel, Hepworth, & Doherty, 1995), dual diagnosis (Harkness & Nofziger, 1998), and anorexia nervosa (Dare & Eisier, 1995).

Roadblocks to Identifying and Managing Patient Psychosocial Concerns There is a range of limitations to the quantity and quality of psychosocial care FPs can

deliver to their patients. Researchers have identified lack of training (Christie-Seely, 1981; Fosson, Elam, & Broaddus, 1982), time (Glied, 1998; Rost, Humphrey, & Kelleher, 1994; Tomson & Asen, 1987), patient reluctance (Kainz, 2002; Williams et al., 1999), managed care (DeGruy, 1997; Fisher & Ransom, 1997), and lack of confidence (Gerdes, Yuen, & Frey, 2001; Williams et al., 1999) as roadblocks to FPs and other PCPs identifying and treating patient mental health needs.

Roadblocks to referral. Regardless of to whom they refer, physicians identify several road- blocks when referring patients to mental health professionals. These have included patient reluctance, the unavailability of appropriate mental health professionals in rural communities, lack of affordability of mental health, significant lag time between referral and appointment availability, lack of adequate feedback from mental health professionals, the stigma patients attach to mental healthcare, and poor communication from the mental health professional (Kainz, 2002; Kushner et al., 2001; McCulloch et al., 1998; Reust, Thomlinson, & Lattie, 1999; Rost et al., 1994; Williams et al., 1999).

The purpose of this exploratory study was to discover FPs’ views of MFTs as potential collaborators on the healthcare team. Specifically, this study seeks to answer three research questions:

(1) Do FPs view MFTs as a resource for patients with psychosocial needs? (2) Are FPs interested in collaborating with MFTs? (3) What would make MFTs more helpful collaborators?

April 2009 JOURNAL OF MARITAL AND FAMILY THERAPY 221

METHODS

This study was a national survey of 240 FPs. A questionnaire was mailed to 240 board cer- tified FPs who were randomly selected from the AAFP directory. The inclusion criteria were engagement in the practice of family medicine, graduation from a U.S. medical school, comple- tion of residency after 1969, and residence within a U.S. zip code.

Participants and Procedures After obtaining IRB approval, a randomly selected mailing list was obtained from the

AAFP. Questionnaires were mailed along with an introductory letter describing the study, a brightly colored sticky note with a brief hand-written note, and a self-addressed stamped envelope. Each questionnaire was numbered to enable a follow-up mailing to nonrespondents. During the first wave, 104 questionnaires were returned. After 4 weeks the same material was re-mailed to nonrespondents. After two mailings we received 153 responses, representing a 64% response rate. Of those responses, 16 questionnaires were excluded from analyses because respondents were no longer practicing family medicine full time. Consequently, there were a total of 137 usable questionnaires (57%). We received responses from FPs in 37 out of 42 states as well as an FP in Puerto Rico and a deployed military FP. Respondents had been in practice for an average of 12 years and were an average age of 46. Table 1 depicts demo- graphic data such as gender and geographical distribution of respondents. The four major census regions of the United States as well as U.S. territories and military were represented in the sample. Based on the AAFP 2002 census of their members (AAFP, 2003), the sample appears representative of both the gender and regional distribution of FPs throughout the United States.

Table 1 Demographics

Variable Percentage

of respondents

Percentage of random sample

Percentage of 2002 National AAFP Censusa

Region Northeast 15 13 15 South 35 33 33 Midwest 27 33 28 West 21 20 21 U.S. territory ⁄ Army Post Office 2 2 3

Gender Male 66 71b

Female 34 29b

Note. n = 137. aMembership (U.S., U.S. Territories, and Military; AAFP, 2003). bActive AAFP members (this percentage includes 138 Canadian members and 350 foreign members that were not part of the sampled population). AAFP = American Academy of Family Physicians.

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The questionnaire, which contained both closed and open-ended questions, was based on a review of literature and in consultation with MFTs and FPs. In the development phase, the questionnaire was administered to five FPs and revised based on their feedback.

Analysis Quantitative data analyses were completed using SPSS for Windows, v10.0 (Norusis, 2000).

Qualitative data were analyzed using a modified version of the constant comparative method described by Strauss and Corbin (1990). Each segment of the written responses to the open- ended questions was coded independently by both authors to identify and name major themes. Once a list of major themes was developed, content analysis (Patton, 2002) was used to deter- mine how frequently each theme was mentioned by respondents.

RESULTS

In this section, each research question is addressed in turn. When qualitative data gene- rated noteworthy themes, the themes are identified and quotes provided for illustration.

Do FPs View MFTs as a Resource for Patients With Psychosocial Needs? This research question was addressed by five questions on our questionnaire. Respondents

were asked to estimate the percentage of their patients with identified psychosocial concerns who they believed could benefit from marital and ⁄ or family therapy. Respondents were also asked to estimate their referral practices. On average, respondents estimated that 48% of their patients could benefit from marital and ⁄ or family therapy and that they referred 12% of their patients for mental health services. However, respondents estimated that they referred 5% of their patients specifically for marital and ⁄ or family therapy–related care. We specified marital and ⁄ or family therapy–related care rather than MFT because at that time several states did not license MFTs (three of the states represented in this survey did not).

Additionally, respondents were asked to check all that applied from a list of potential roadblocks encountered when referring patients for MFT-related care. As can be seen in Figure 1, ‘‘Patient reluctance’’ was checked by 85% of the respondents, ‘‘HMO ⁄ Insurance’’ by 65%, ‘‘unavailability of appropriate therapists’’ by 40%, ‘‘time’’ by 34%, ‘‘lack of awareness of appropriate therapists’’ by 33%, and ‘‘don’t feel this type of therapy is helpful’’ by 4%. Although 24 respondents provided written answers in response to ‘‘other please specify,’’ no new categories of roadblocks to referral emerged.

Figure 1. Roadblocks encountered by FPs when referring patients for marriage and family therapy–related care (n = 136).

April 2009 JOURNAL OF MARITAL AND FAMILY THERAPY 223

Finally, respondents were asked if they were aware that MFTs are licensed mental health professionals ‘‘trained in psychotherapy and family systems and licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples, and family systems.’’ While 83% of respondents checked ‘‘yes’’ to this question, 64% reported that prior to receiving our survey they did not recognize the initials ‘‘LMFT’’ as credentials for a Licensed Marriage and Family Therapist.

Are FPs Interested in Collaborating With MFTs? This research question was addressed by five questions on our questionnaire. Respondents

were asked, ‘‘Have you ever consulted with a mental health professional regarding a patient case?’’ All of the respondents checked ‘‘yes’’ to this question. When respondents were asked whether or not they had ever consulted with an LMFT regarding a patient or family, 47% of the respondents checked ‘‘yes,’’ while 53% of the respondents indicated they either had not or were not sure if they had consulted with an LMFT.

Additionally, respondents were given a list of collaborative modes and asked to check all that applied to their experience of collaborating with MFTs or comparable mental health pro- fessionals in their community. ‘‘Infrequently receive reports’’ was checked by 49% of the FPs, ‘‘phone call ⁄ email with a MFT’’ by 43%, ‘‘informal consultation with a MFT’’ by 40%, ‘‘no patient-care contact with MFTs’’ by 20%, ‘‘regularly receive reports’’ by 19%, and ‘‘regular meetings with MFTs’’ by 3%.

Respondents were asked to describe how helpful they found patient-care consults with MFTs. The collaborative interactions with MFTs were indicated by 82% of the respondents to be either ‘‘very helpful’’ or ‘‘somewhat helpful.’’ Five percent checked either ‘‘somewhat unhelpful’’ or ‘‘very unhelpful,’’ while 12% checked ‘‘not applicable.’’

Finally, respondents were asked to describe their interests in collaborating with LMFTs or comparable mental health professionals when identifying patients’ psychosocial needs by check- ing all that applied from a list of collaborative approaches. The mode of collaboration pre- ferred by most of the respondents was ‘‘referral out with continuing collaborative communication’’ (84%). Some respondents also indicated that they would be interested in ‘‘inviting a family therapy provider to a patient’s appointment’’ (15%) or ‘‘meeting regularly with a MFT regarding complex patients’’ (11%). Only 7% of the respondents indicated they were ‘‘not interested’’ in collaborating with MFTs.

What Would Make MFTs More Helpful Collaborators? This research question was addressed by an open-ended question. Respondents were asked

to ‘‘briefly describe what would make MFT providers a more helpful resource when treating patients with psychosocial issues, OR if you don’t consult with an MFT, why not?’’ Eighty-nine respondents (65% of sample) answered this question, offering a total of 141 coded responses. A content analysis produced six primary themes: (a) ideal collaborative practices, (b) barriers to referral, (c) MFT specialty awareness, (d) let us know who you are, (e) barriers to collaboration, and (f) attitudes toward MFTs. Quotes are included to better illustrate the themes and subthemes.

Ideal collaborative practices. Fifty-four responses were coded as relating to collaborative practices that would make MFTs more helpful resources. These included proximity (‘‘I wish I had a family therapist in my office’’), ease of referral (‘‘Be available to my patients within 2 weeks of the request’’), collaborative communication (‘‘More communication after [patient] evaluation,’’ ‘‘Regular feedback’’), topical ⁄ specialty information (‘‘Suggestions on what I can do to help further the therapeutic goals,’’ ‘‘A specialist who could incorporate issues related to aging’’), and religious ⁄ faith-based (‘‘Faith-based, a plus!’’ ‘‘I would like to work with a Christian marriage and family therapist’’).

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Barriers to referral. We coded 33 comments as barriers respondents face when making referrals to MFTs, including patient reluctance (‘‘Difficulty convincing patients that therapy can help them and sometimes even that there is a problem’’), managed care (‘‘Many patients don’t have mental health coverage,’’ ‘‘I do use other therapists when driven by insurance’’), do not know the therapist (‘‘hard to refer when don’t know therapist’’), and lack of availability (‘‘Ther- apists not available in my rural area,’’ ‘‘If one were more readily available, this would be an excellent resource’’). Only one of the responses indicated that the respondent encountered no barriers to referral.

MFT specialty awareness. We coded 15 responses as relating to respondents’ awareness of MFT as a specialty. Many of these respondents indicated they were either completely unaware of MFT as a distinct field or were unclear about the professional role of an MFT (‘‘I didn’t know there was a family ⁄ marriage therapy specialist’’). Other respondents asked for more infor- mation about MFTs and the types of services they provide. Some indicated that they had not differentiated between the various mental health professionals with whom they worked (whether they be MFTs, social workers, or psychologists).

Let us know who you are. We coded 14 responses as indicating respondents wanted to be able to identify the MFTs in their communities. Responses placed in this category suggested that respondents were either unaware of MFTs, had no professional contact with MFTs in their communities, or were less likely to work with therapists they had not met (‘‘Probably meeting face to face [would be helpful]’’).

Barriers to collaboration. We coded 13 responses as describing barriers to collaboration. Subcategories of this theme are the following: time (‘‘Unfortunately we seem to have less time to [collaborate]’’), managed care (‘‘HMO . . . typically listed an 800# to call . . . made commu- nication very difficult between the anonymous therapist and I’’), lack of therapist feedback (‘‘Helpful to get reports back from therapists, but it often doesn’t happen’’), and interest (‘‘I like to refer but don’t necessarily feel I need to receive reports’’).

Attitudes toward MFTs. We coded 12 responses as relating to FPs’ attitudes regarding MFTs. Seven responses had positive overtones (‘‘They are already a helpful resource for me—I can’t think of any way to improve this presently’’). Two responses suggested an uncertain or even negative mind-set toward MFTs (‘‘most of the MFT people only have a Master’s . . . for more complex cases, I might choose psychiatry or doctoral psychology background’’). Three responses made reference to the importance of a philosophical fit.

DISCUSSION

The primary theme emerging from this study is that FPs are interested in referral and col- laboration, in some form, but face barriers. This theme is illustrated by the quantitative and qualitative data. The data suggest that there is a considerable gap between the percent of patients FPs identified as potentially needing MFT (48%) and the percent of patients actually referred for MFT (5%). This may, in part, be understood by the roadblocks to referral (e.g., patient reluctance, HMO restrictions, unavailability of appropriate therapist, and time) faced by FPs in this study as well as in previous research studies (Kainz, 2002; Orleans, George, Houpt, & Brodie, 1985; Rosenthal, Shiffner, & Panebianco, 1990; Rost et al., 1994; Williams et al., 1999).

Secondly, FP respondents in this study reported that they are often unaware of MFTs in their community or unfamiliar with the discipline of MFT. Likewise, Kainz (2002) found that physicians would be more likely to refer to the mental health providers with whom they had met and developed a good relationship or of whom they had heard a good report from either colleagues or patients. It may be that FPs are also uncertain of the scope of MFTs’ training and practice.

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Thirdly, the FPs in this study appeared receptive to referring to and collaborating with MFTs, but collaboration is limited in its occurrence. In this study, HMOs, time limitations, and lack of therapist-initiated communication have been identified as significant barriers to col- laboration. These barriers that were identified by FPs are similar to the collaboration barriers identified by MFTs. Research articles and books written on collaboration give considerable attention to the issues around HMO-related barriers (e.g., DeGruy, 1997; McCulloch et al., 1998; Seaburn et al., 1996). Other potential barriers to collaboration may be attributed to patient reluctance to accepting a mental health referral. Reust et al. (1999) found that patient- identified barriers to following through with a physician-initiated mental health referral are comparable to the barriers identified by FPs in this study.

Finally, FP respondents reported that they want feedback from MFTs to whom they refer a patient. This finding is consistent with the findings of other studies on collaboration (Kainz, 2002; Rosenthal et al., 1990; Rosenthal, Shiffner, Lucas, & DeMaggio, 1991) which have identi- fied regular feedback to be essential, with the majority describing this feedback ideally to be a brief intake report or progress note. With these themes in mind, we make suggestions for enhancing collaboration between FPs and MFTs.

Suggestions for MFTs Specific training in MedFT will facilitate MFTs’ ability to collaborate and provide compre-

hensive, biopsychosocial care in conjunction with a client’s FP or other medical practitioner (McDaniel et al., 1992a). As with any relationship, it is important to take a learning stance in order to begin forging collaborative relationships with FPs. Researchers and practitioners in healthcare collaboration underscore the importance of understanding how the cultural and structural differences between the two professions present unique challenges for collaboration (McDaniel et al., 1992a; Patterson, Peek, Heinrich, Bischoff, & Scherger, 2002). Knowledge of the culture of family medicine or other medical specialties will add to MFTs’ abilities to approach collaboration with sensitivity and confidence. To build mutual respect, MFTs should communicate a desire to understand the needs of FPs and their patients. Overall, constant investments of time, communication, respect, and goal clarification are important for develop- ing successful collaborative relationships (McDaniel et al., 1992a; Seaburn et al., 1996).

We found that some FPs are either unaware of MFT as a unique discipline within the mental health field or unaware of MFTs’ availability in their community. In response to this finding, MFTs might introduce themselves to local FPs, especially those whose patients they are already counseling. Recognizing that it may be intimidating to make the initial contacts, McDaniel et al. (1992a) suggested finding venues for introduction such as through another medical colleague or inviting the medical practitioner to lunch. At this time it may be helpful to offer a business card, rolodex insert, and brochure describing areas of specialty in order to facilitate future contact or referral from the FP.

As MFTs learn about the types of patient psychosocial concerns that FPs commonly encounter, it may be helpful to create fact sheets addressing these concerns, offer brief work- shops, or even participate on grand rounds in local hospitals. FPs in this study suggested that information on specific psychosocial issues would be helpful. They most commonly requested suggestions for reducing patient reluctance to MFT care. MFTs might consider American Asso- ciation for Marriage and Family Therapy (AAMFT) brochures addressing specific mental health issues as a resource to offer FPs or referred patients. These brochures have a space for professional contact information and are available for purchase from AAMFT (see http:// www.aamft.org/store/shop/category.asp?catid=9). Also, MFTs can regularly participate on healthcare teams by obtaining releases from clients to exchange information with the referring physician. If a client declines to release his or her information, the MFT may want to send a brief note acknowledging and thanking the FP for the referral and discuss with the client the goals and potential benefits of a team approach.

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Beyond the routine collaborative communication, MFTs can look for ways to maintain con- tact and develop the relationship. For instance, MFTs might locate current journal articles or other brief materials for FPs that may pertain to collaboration, mental health issues, or behavioral health techniques. Due to the demands of patient care, FPs have limited time for researching issues in mental health and may appreciate this collaborative gesture (E. Ng, MD, personal communication, December 3, 2003). Experienced collaborators underscore the importance of the long-term efforts necessary to maintain collaborative relationships. MFTs may also be interested in joining a collaborative healthcare organization such as the CFHA (which includes a subscrip- tion to the journal Families, Systems, and Health) or participating in other like-minded events such as the Conference on Families and Health sponsored by the STFM and CFHA.

Implications for Clinical Training and the MFT Field Professionals in the field of MFT must continue to look for ways to bridge the gap

between these two compatible fields. Based on our findings, it seems that MedFT and collabo- rative training programs offer skills necessary to collaborate with FPs in comprehensive, systemic care. These trainings are offered in academic settings, in fellowship training programs, professional associations, professional journals, and community interactions (for information on training programs, see www.cfhcc.org/pages/education-and-training/; see also a list of pro- grams in Seaburn et al., 1996, pp. 270–272). It may be necessary for MFT training programs to add collaboration training or MedFT to their curriculum. William Doherty (personal communi- cation, March 22, 2003) stated that professionals most often collaborate with whom they train or know personally. Since most MFTs do not have the opportunity to know FPs personally, a collaborative component early in MFT training would offer an opportunity for students to interact with health professionals from other disciplines and for medical health professionals in the community to learn about MFT and meet future MFTs. Students could be encouraged to seek internships in medical settings or to conduct research relevant to both fields and to publish in family medicine journals.

Numerous associations (such as the AAFP, AAMFT, Health Psychology Division of the American Psychology Association, CFHA, and STFM) offering workshops and conferences provide additional opportunities for MFTs and FPs to interact and increase their collaboration skills. As MFTs learn to connect with FPs, it is possible that MFTs and FPs will find ways to work together to promote marketing and to advocate for managed care policy change. Man- aged care corporations may respond to pressure placed on them by organized, collaborating FPs and MFTs to ensure reimbursement for mental healthcare.

Limitations When interpreting the results of the study, it is important to be mindful of the following

limitations. First, the questionnaire has not been tested for reliability or validity. While the sur- vey method is an efficient mode for data collection, questionnaires are self-administered tools in uncontrolled settings. Thus, it is possible for the participants to misinterpret questions. To address these limitations, this survey was scrutinized by several FPs, and qualitative questions were included to add depth and clarity to the findings.

Secondly, although the size of our sample is sufficient to produce a confidence interval of about ±6% (Rea & Parker, 1997), it is still a relatively small sample compared to a population of over 53,000 FPs. Readers are encouraged to consider the margin of error when interpreting results. However, this study’s response rate (64%) is remarkable when compared with physician response rates to other surveys with and without incentives (VanGeest, Wynia, Cummins, & Wilson, 2001).

Suggestions for Future Research More research is needed to enhance our understanding of what increases the likelihood of

successful collaboration between FPs and MFTs. One approach to this may be for researchers

April 2009 JOURNAL OF MARITAL AND FAMILY THERAPY 227

to examine collaborative relationships that are working. What types of training in an MFT program or FP residency are linked to increased collaboration? What current practices of col- laboration are most effective and why? Additionally, another member of the collaborative triad, the patient, could be a valuable source of information about the helpfulness of FP ⁄ MFT col- laboration. The patient’s perspective of the risks ⁄ benefits of his or her FP and MFT working together may be useful in establishing a link between psychosocial care and cost-effective healthcare that would interest managed care companies.

Despite the barriers and limitations to FP ⁄ MFT collaboration identified in this study, our findings suggest that FPs think many of their patients could benefit from MFT and are inter- ested in collaborating with MFTs. It is our hope that this study will encourage interdisciplinary discussion that continues to bridge the gap between FPs and MFTs and ultimately promote more effective care for the patient ⁄ client.

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