Medical family therapy

Research note (read first). The founders' books (McDaniel, Hepworth & Doherty 1992; McDaniel, Doherty & Hepworth 2014) are cited here from publisher descriptions, catalogue records and secondary sources; their chapter-level wording is not reproduced [uncertain]. The weak points were checked against legitimate secondary and author sources. The five levels of collaboration were checked against the SAMHSA-HRSA (2013) integrated-care framework, which summarises Doherty, McDaniel & Baird (1996). Doherty & Baird's levels of family involvement were checked against two Journal of Family Practice papers that report them (Meyer et al. 1989; Marvel et al. 1994). The dimensions of Rolland's illness typology were checked against Rolland (2020, Family Process), and the layout of his model against the contents of Rolland (2018, Guilford). The ten shared emotional themes of illness (4.22) come from the founders' own 2000 article abstract. Not confirmed against the founders' books: their own strategy list and wording, their definitions of agency and communion, any phase structure, "leave the door open", and the somatic-fixation procedures. These stay tagged [uncertain]. Section 5 is still synthesis. All example language is illustrative.

1. Introduction

Version followed: McDaniel, Doherty & Hepworth, Medical Family Therapy and Integrated Care, 2nd ed. (APA, 2014), the revision of the 1992 Medical Family Therapy: A Biopsychosocial Approach to Families with Health Problems. Collaboration levels follow Doherty, McDaniel & Baird (1996) as summarised in the SAMHSA-HRSA (2013) framework. Levels of family involvement follow Doherty & Baird (1986, Family Medicine 18:153–156) as reported in Meyer et al. (1989). Illness typology and time phases follow Rolland's Family Systems Illness (FSI) model (Rolland 1994; 2018; 2020).

Medical family therapy (MedFT) is not a separate school with its own manual. Its authors present it as an orientation, a way of practising, that combines a biopsychosocial perspective with systemic family therapy. The aim is to help patients and families living with illness, disability or health problems, working together with the medical team. [source: Doherty, McDaniel & Hepworth 2014, Family Process abstract; Tyndall 2012 Delphi study] It grew out of family therapists' work in primary care in the 1980s and 1990s. Today it is practised in specialty, hospital and integrated-care settings too. [source: Doherty, McDaniel & Hepworth 2014; Mendenhall et al. 2018]

How change happens. Illness strains two things: the patient's and family's sense of control over their lives and the illness, and the emotional bonds between family members and between family and carers. MedFT works on both. Its two overarching goals are agency (an active, self-directed stance toward the illness and the health system) and communion (emotional connection and support among family members and with professionals). [source: Tyndall 2012, which names agency and communion as MedFT's overarching goals; the definitions here are paraphrased, and the McDaniel et al. wording is not drawn on: uncertain] Change comes from:

making the biological, psychological and social dimensions of the problem jointly discussable;
giving illness a proportionate place in family life;
coordinating the family and professionals so that care is not split. [synthesis from the sources above]

2. Framework

MedFT has no fixed phase protocol or session count. Sources describe an episodic, collaborative course whose shape depends on the setting. [source: Tyndall 2012; Mendenhall et al. 2018 organise clinical methods by primary, secondary and tertiary care] The phase sequence below is a working structure taken from the books' usual chapter order (referral and collaboration; assessment; intervention; ending with an open door). [uncertain: the books' chapter-level structure is unconfirmed; sequencing partly synthesis]

Setting determines format. The two scaffolds below decide what the course looks like.

Levels of collaboration (Doherty, McDaniel & Baird 1996). The levels differ in where care happens and how much providers share systems. (1) Minimal collaboration: separate sites and systems; providers rarely talk about cases. (2) Basic collaboration at a distance: separate sites and systems; providers talk now and then about shared patients, mostly by phone and letter, and see each other as resources. (3) Basic collaboration onsite: same building, separate systems; contact is more regular and sometimes face to face. (4) Close collaboration in a partly integrated system: shared site and some shared systems (e.g. scheduling, charting); regular face-to-face contact; joint plans for difficult patients; each understands the other's role and culture. (5) Close collaboration in a fully integrated system: shared site, vision and systems; providers work as one team and know each other's roles in depth. [source: SAMHSA-HRSA 2013 Standard Framework for Levels of Integrated Healthcare, summarising Doherty, McDaniel & Baird 1996, Behavioral Healthcare Tomorrow, 25–28] The 2nd edition describes MedFT in outpatient therapy, co-located clinics, community health centres and fully integrated systems. [source: Bookshare synopsis; Lernmedien-shop description of the 2014 ed.] In practice: at referral, name the level you actually have with this clinician and plan your communication to fit it. [synthesis]
MedFT Healthcare Continuum (Hodgson, Lamson, Mendenhall & Crane 2014). Practitioners range from those who use MedFT ideas occasionally to those whose whole role is MedFT in a health setting, across knowledge and skill domains. Mendenhall et al. (2018) use a five-level table of MedFT integration in each clinical chapter, from a cursory role (level 1) to full integration into a medical department with policy and research duties (level 5). [source: Arthur 2019 review of Clinical Methods in Medical Family Therapy, Family Medicine] [uncertain: the continuum's own domain wording in Hodgson et al. 2014 is unconfirmed]

Phase	Goals	Typical format	Move on when
0. Referral and collaboration set-up	Agree the question with the referring clinician; agree on information sharing; frame the referral for the patient as part of routine care	Phone call, chart note, or a warm handoff in the exam room (integrated care)	Patient and family agree to meet; consent for two-way communication is in place
1. Engagement and biopsychosocial assessment	Hear the illness story from each member; map the family's illness history and beliefs; place the illness on Rolland's typology and time phase; identify strengths	1–3 sessions with patient plus whoever is involved; sometimes a joint session with the physician	A shared working formulation that names biological, psychological and relational targets, written up for the team
2. Intervention	Strengthen agency (self-management, voice with providers) and communion (support, less blame and isolation); give illness its place; deal with developmental and life-cycle tasks; coordinate care	Family, couple or individual sessions; family conferences with the team; psychoeducation	Agreed goals are met, or the illness enters a new phase that needs re-assessment
3. Ending with an open door	Consolidate; plan for later illness transitions; agree how to come back	Spaced sessions, then ending with an explicit invitation to return	Family can name warning signs and knows how to return through the medical team

[source for the table: synthesis organising Doherty, McDaniel & Hepworth 2014 and the sources listed under Sources. "Leave the door open" as an ending stance is widely attributed to the 1992 book: uncertain. Session numbers are synthesis: integrated primary care contacts are often brief (15–30 minutes, 1–6 visits); specialty and tertiary work can be long-term and episodic.]

Doherty & Baird's levels of family involvement (1986) were written for physicians. They work as a dial for how deep to go with a given family: (1) minimal emphasis on the family; (2) ongoing medical information and advice; (3) feelings and support; (4) systematic assessment and planned intervention to help the family cope; (5) brief family therapy aimed at family problems that were there before the illness. [source: level wording as reported in Meyer, Schneid & Craigie 1989, J Fam Pract 29:401–405, citing Doherty & Baird 1986] Marvel, Schilling, Doherty & Baird (1994) later extended the model to individual patients. They note that level 5 usually needs fellowship-level training and ongoing supervision, and that level 4–5 work was rare in routine family-practice visits. [source: Marvel et al. 1994, J Fam Pract 39:535–544] For MedFT: the therapist works mostly at levels 4–5 and coaches medical colleagues to work at levels 2–3. [synthesis]

Training and credentials. No licence or certification is needed to practise under the name. MedFT is taught in graduate programmes (e.g. East Carolina University's doctoral programme, where the Delphi study was done) and in continuing education. The University of Rochester Institute for the Family runs a week-long annual June intensive, co-directed by Susan McDaniel and Tziporah Rosenberg. It combines clinical presentations with daily small groups that look at how family and personal experience shape professional work, and that also serve as case and systems consultation. [source: URMC MFTI page; Tyndall 2012]

3. Guiding principles

[source: the biopsychosocial-systemic orientation, collaboration as foundational, agency and communion, the spiritual dimension, and support for medical staff are all from Tyndall 2012 and Doherty, McDaniel & Hepworth 2014. The individual principle wordings are paraphrase or synthesis, and the books' own list is unconfirmed: uncertain]

Biopsychosocial (and spiritual) by default. Never treat a symptom as "just psychological" or "just medical"; keep all levels on the table at once, and ask about meaning and faith where relevant.
Systemic lens. The unit of care is the patient in their family and care network. Ask who is affected, who decides, and who helps; invite them.
Collaboration is the treatment frame, not an add-on. Agree roles and information flow with the medical team at the start, and keep communicating throughout.
Agency. Every intervention should increase the patient's and family's active choice and voice. Do for them only what they cannot yet do.
Communion. Reduce isolation and blame, increase support and connection within the family and with the clinicians.
Respect for the medical reality. Know the disease, the treatment and its course well enough to talk about them; do not challenge medical findings or offer medical opinions outside your role.
Give illness its place. Help families keep the illness from taking over their identity, routines and development, without denying it.
Developmental and life-cycle lens. Ask what the illness interrupts (launching, a new couple, retirement), and help families protect or renegotiate those tasks.
Non-blaming stance. Families of ill people often feel judged; normalise, accept ambivalence and "unacceptable" feelings (resentment, wish for it to be over).
Self of the therapist. Your own illness and loss history shapes your reactions. Reflect on it (e.g. in supervision or the small groups of the Rochester format).
Support the care team. Help medical staff with difficult relationships, burnout and compassion fatigue as part of the role.
Fit the setting. Adapt length, pace and language to the context (exam room, inpatient unit, outpatient office); write in brief, jargon-free terms for colleagues.
Leave the door open. Illness changes phase; families return at transitions. Ending is a pause, not a close.

4. Intervention inventory

Scope note: MedFT authors present a set of strategies and stances, plus applications for particular health problems, not a numbered technique list. The available sources confirm the orientation (BPS + systems), collaboration, agency and communion, the topic areas of the 2nd edition (integrated care, fertility, genomic medicine) and the founders' ten shared emotional themes of illness (4.22). The strategy names below follow the strategies the 1992 and 2014 books are commonly cited for in the MedFT literature, and the step-by-step detail is synthesis. Each item is tagged. All example language is illustrative.

4.1 Collaborative referral and contracting with the medical team

Purpose / when: At every new referral. This sets the collaboration that the whole model depends on. [source: Tyndall 2012; Doherty, McDaniel & Hepworth 2014]
Steps: (1) Talk to the referring clinician directly: what worries them, what they have told the patient, what they want from you. (2) Decide which collaboration level is realistic (see Section 2). (3) Get the patient's consent for two-way information sharing and agree what will be shared. (4) Help the clinician frame the referral as routine team care ("we work as a team for people with X"), not as a sign that the problem is "in your head". (5) Where possible, do a warm handoff or a first joint meeting. (6) After session one, send a short jargon-free note with your formulation and plan. [synthesis]
Example language (illustrative): To the physician: "What would make this referral a success from your side, and what has Mrs. L already heard about why she's seeing me?" To the patient: "Dr. R and I work together with people managing diabetes; my part is how it's affecting life at home."
Watch for: Patients who feel dismissed ("sent to the shrink"); referrals you cannot act on ("fix her compliance"). It is working when the patient attends, the clinician reads and responds to your notes, and goals are shared.

4.2 Convening the family and the first session

Purpose / when: Early, to bring in the people who live with the illness, care for the patient, or affect treatment decisions. [uncertain: convening guidance is attributed to the books, wording unconfirmed; steps are synthesis]
Steps: (1) Ask the patient who is affected and who helps; invite them as "experts on what the illness is like at home". (2) If the patient declines, accept this and work individually with a systemic lens; revisit later. (3) Open with introductions and each person's view of why they are here. (4) Hear the medical facts first (4.4), then the illness story (4.3). (5) Close with a shared summary and one concrete next step.
Example language (illustrative): "Illness happens to families, not just to bodies. It would help me to hear from the people who see what this is like day to day."
Watch for: A member speaking for the patient; children used as interpreters; the patient feeling ganged up on. It is working when several voices are heard and the patient keeps their own voice.

4.3 Soliciting the illness story

Purpose / when: In the first sessions and again at transitions. It shows the meaning of the illness for each member and gives them the experience of being heard. [uncertain: "solicit the illness story" is a strategy attributed to McDaniel, Hepworth & Doherty 1992; wording unconfirmed]
Steps: (1) Ask each member, in turn, how the illness began for them, what they noticed, and what happened next. (2) Ask about the diagnosis moment and dealings with health professionals. (3) Explore explanations ("What do you think caused it?") and fears ("What worries you most about where this is going?"). (4) Reflect differences between members without ranking them. (5) Note strengths and earlier coping.
Example language (illustrative): "Each of you lived through the diagnosis from a different chair. Tell me how it was from yours."
Watch for: Stories of being dismissed by clinicians (handle these as data, not as complaints to defend against); secret theories of cause, such as guilt or heredity. It is working when members learn something new about each other's experience.

4.4 Recognising the biological dimension

Purpose / when: Throughout. You need enough medical understanding to hold the biological level and to avoid psychologising disease. [uncertain: attributed strategy; wording unconfirmed]
Steps: (1) Read the chart or ask the clinician about diagnosis, prognosis, treatment, side effects and what the patient was told. (2) Ask the family to explain the condition in their own words; note gaps and misunderstandings. (3) Learn the illness yourself (patient-education sources, the clinician). (4) Bring medically relevant observations back to the team, such as side effects affecting mood or non-use of medication. (5) Never give medical advice. Route medical questions to the clinician and help the family prepare them.
Example language (illustrative): "Help me understand what the doctors have told you about how this condition usually goes."
Watch for: Symptoms that may be medical (new neurological signs, medication effects). Refer back promptly.

4.5 Family illness genogram (health genogram)

Purpose / when: Assessment phase. It maps the illness, death, disability and coping history across generations, and the beliefs and legacies attached to them. [source for the principle: Rolland's FSI model recommends asking about earlier illness and adversity in the family, to find both vulnerabilities and resilience (Rolland 2020; Rolland 2018 ch. 6, "Understanding Multigenerational Experiences"). Uncertain: the illness-genogram format as used in MedFT and family-oriented primary care (McDaniel, Campbell, Hepworth & Lorenz 2005; McGoldrick, Gerson & Petry); steps are synthesis]
Steps: (1) Draw three generations. (2) For each person, note significant illnesses, causes of death, disabilities, addictions and mental health problems. (3) Ask how each illness was handled: who cared, what was said or not said, how the family changed. (4) Ask about beliefs ("In our family, illness means...") and current health anxieties, such as reaching the age a parent died. (5) Mark caregiving roles and gender patterns. (6) Link legacies to how the family is responding now.
Example language (illustrative): "When someone got sick in your family growing up, what happened? Who took over? What did people say, or not say?"
Watch for: Anniversary reactions; a family member repeating a role from a previous illness; unspoken genetic fears. It is working when the family recognises patterns and chooses rather than repeats them.

4.6 Illness typology and time-phase assessment (Rolland)

Purpose / when: To predict the psychosocial demands of a particular condition and match the plan to them. Rolland's 2018 book organises the Family Systems Illness (FSI) model around a psychosocial typology of illness, the time phases of illness, and key family processes: organisation and communication, multigenerational experience, life cycle, and belief systems. [source: chapter structure on the Guilford contents page for Rolland 2018; Rolland 2020]
Steps: (1) Classify the condition on five dimensions: onset (acute or gradual); course (resolving, progressive, constant, or relapsing/episodic); outcome (anywhere from nonfatal to fatal); incapacitation (the type and degree of disability or complications); and how uncertain its course is. [source: Rolland 2020] (2) Place the family in the illness time phase: crisis (around diagnosis and first adjustment), chronic (the long haul) or terminal. [source: time phases are the subject of Rolland 2018 chs 3 and 10; phase definitions as in Rolland 1994: uncertain] (3) Name the typical tasks of that phase. In the crisis phase: reorganise roles and routines, and acknowledge risk while keeping hope. In the long term: pace yourselves to avoid burnout, balance relationships, and protect each member's autonomy and developmental goals. [source: Rolland 2020, which illustrates these tasks with COVID-19 phases] (4) Ask who is included in, and who is left out of, conversations about health; about earlier illness and crisis experiences in the family; and about beliefs on what causes or prevents the illness. [source: Rolland 2020] (5) Review again when the phase changes, for example at a relapse. [synthesis]
Example language (illustrative): "With a condition that flares and settles, families often swing between crisis mode and normal life. How has that rhythm been for you?"
Watch for: A family stuck in crisis mode long after diagnosis, or preparing for death when the prognosis is good, or the reverse. [synthesis]

4.7 Psychoeducation and support

Purpose / when: Whenever the family lacks information about the illness, its emotional effects or common family reactions. [uncertain: "provide psychoeducation and support" is an attributed strategy; wording unconfirmed]
Steps: (1) Find out what they know and want to know. (2) Give information in small pieces, coordinated with the medical team; correct misunderstandings and check what they have taken in. (3) Normalise common reactions: exhaustion, irritability, grief, protective silence. (4) Point to reputable patient-education resources and condition-specific support groups. (5) Revisit as the illness changes.
Example language (illustrative): "Many families find the person who's ill and the person caring both end up feeling alone. Does that fit?"
Watch for: Overloading families in crisis; information that contradicts the team (check first). It is working when misunderstandings drop and families use the information.

4.8 Respecting defences, removing blame, accepting unacceptable feelings

Purpose / when: When denial, guilt, blame or forbidden feelings block coping. [uncertain: attributed strategy; wording unconfirmed]
Steps: (1) Treat denial or minimising as protective; do not force confrontation unless safety or a key decision is at stake. (2) Ask about and gently dismantle blame (self-blame for causing the illness, blaming the patient's lifestyle). (3) Name and normalise ambivalent feelings such as resentment, wishing it were over, or relief. (4) Give each person a turn without the others' judgement; use individual time if needed.
Example language (illustrative): "Caring for someone you love for this long, it's very common to feel resentful sometimes and then guilty for feeling it. Is any of that true for you?"
Watch for: Denial that endangers treatment decisions (involve the medical team); blame that turns into contempt. It is working when emotional tone softens and members talk more openly.

4.9 Increasing agency

Purpose / when: Throughout. Agency is one of the two overarching goals. [source: Tyndall 2012; steps are synthesis]
Steps: (1) Find the areas where the patient feels helpless: symptoms, treatment, dealings with providers, family life. (2) Separate what can be controlled from what cannot. (3) Set small self-management goals that the patient chooses. (4) Rehearse speaking with providers: write down questions, practise asking for clarification, bring a family member. (5) Help family members stop over-functioning, so that they support the patient's choices rather than take them over. (6) Credit the patient's and family's own successes.
Example language (illustrative): "What is one part of this you'd like more say over, even a small one?" / "Let's write the three questions you most want answered at Thursday's appointment."
Watch for: Agency goals that require control the patient does not have (e.g. curing a progressive disease); risk of self-blame when the illness worsens. It is working when the patient starts conversations with clinicians and makes decisions.

4.10 Enhancing communion

Purpose / when: When illness has isolated the patient or set members apart, or the family is disconnected from the care team. [source: Tyndall 2012; steps are synthesis]
Steps: (1) Track who talks to whom about the illness, and who is left out (often children, distant siblings, the patient). (2) Hold structured conversations where each person says what they need and what they can offer. (3) Help protective silences end where both sides want it, such as "I didn't want to worry you". (4) Spread caregiving tasks more widely. (5) Strengthen ties to friends, community, faith groups and peer support. (6) Repair strained family–clinician relationships, with a joint meeting if needed.
Example language (illustrative): "It sounds like you've each been carrying this alone to protect the other. What would it be like to carry some of it together?"
Watch for: Enmeshment presented as closeness; a sole carer heading for burnout.

4.11 Putting the illness in its place / reinforcing family identity

Purpose / when: In the chronic phase, when the illness dominates routines, rituals and conversation. [uncertain: "reinforce the family's identity" is attributed to McDaniel et al. 1992; the "illness in its place" idea draws on Gonzalez, Steinglass & Reiss's multiple-family work; neither confirmed in full text]
Steps: (1) Ask how much of family life now revolves around the illness, for example with a rough proportion. (2) Identify routines, rituals and roles lost to the illness, such as holidays, couple time, or a child's activities. (3) Choose one to restore, with practical adaptations. (4) Set "illness-free" times or topics if the family wants them. (5) Ask about values and stories that define the family apart from the illness.
Example language (illustrative): "If the illness were a member of the family, how much room is it taking up at the dinner table now? How much room would you like it to have?"
Watch for: Denial dressed up as "normal life" when medical tasks are being neglected.

4.12 Attending to developmental and life-cycle issues

Purpose / when: When illness interrupts or clashes with individual or family developmental tasks. [uncertain: attributed strategy; steps synthesis]
Steps: (1) Place each member on the life cycle. (2) Ask what the illness has postponed or forced early, such as a young adult not leaving home, a teen's independence with self-care, or a couple's early retirement. (3) Negotiate developmentally appropriate roles, for example a gradual handover of diabetes self-management to an adolescent. (4) Anticipate the next transition.
Example language (illustrative): "Before the diagnosis, what were the plans for this stage of your lives? Which of them can we still protect?"
Watch for: Parentified children; adolescents whose health behaviour becomes the battleground for autonomy.

4.13 Maintaining communication (family and team)

Purpose / when: Throughout. This keeps family members and providers aligned and prevents split messages. [uncertain: attributed strategy; steps synthesis]
Steps: (1) Agree within the family who receives and passes on medical information. (2) Help families tell children and relatives, in words suited to their age. (3) Keep a regular feedback loop with the medical team: brief notes, brief huddles. (4) If messages conflict, set up a joint conversation rather than going between the parties.
Example language (illustrative): "Who in the family hears the news first, and how does it travel to everyone else?"
Watch for: Triangulation (the therapist as go-between, or the family playing providers against each other).

4.14 Family conference with the medical team

Purpose / when: At diagnosis, decision points, discharge planning, conflict, or end-of-life planning. In family practice, a family conference is a short, problem-focused meeting of the clinician, the patient and one or more significant others, held to mobilise family resources. It is not family therapy and may or may not lead to further meetings. In one study most conferences had one other family member present and the median length was 15 minutes. A conference can run at any of the Doherty & Baird levels: medical information, emotional support, or assessment of coping with a plan. [source: Meyer, Schneid & Craigie 1989] [uncertain: structured conference protocols in family-oriented primary care texts (McDaniel, Campbell, Hepworth & Lorenz 2005); steps are synthesis]
Steps: (1) Prepare: agree the goals with the clinician and with the patient, and decide who attends. (2) Open with introductions and the purpose. (3) Ask what the family understands before giving information. (4) The clinician gives medical information; you help family members ask their questions and say what worries them. (5) Explore options and preferences; summarise decisions and who does what. (6) Debrief with the team and document.
Example language (illustrative): "Before Dr. S shares the results, could each of you say what you've understood so far and what you most want to know today?"
Watch for: Professionals dominating; the patient being talked about rather than to.

4.15 Health behaviour change with the family

Purpose / when: Smoking, diet, activity, substance use, treatment adherence, self-management of chronic disease. [synthesis: the 2nd edition covers health behaviour topics per its synopsis and subject headings; specific procedures unconfirmed]
Steps: (1) Map how family routines support or undermine the behaviour. (2) Find each member's stake and readiness. (3) Agree on supportive rather than policing roles: what help the patient wants, and what to stop doing (nagging, monitoring). (4) Change the shared environment (food in the house, smoke-free spaces). (5) Coordinate goals with the medical team. Avoid giving specific diet or weight targets yourself; leave those to the medical team.
Example language (illustrative): "What would helpful support from your wife look like, and what would feel like being watched?"
Watch for: Fights over control; shame. It is working when there is less conflict around the behaviour and steadier self-management.

4.16 Working with somatic symptoms and somatic fixation

Purpose / when: Patients whose symptoms are not explained by medical findings, or where patient and clinician have become stuck on a purely somatic approach. [uncertain: McDaniel, Campbell & Seaburn 1989 on "somatic fixation" and McDaniel, Hepworth & Doherty 1995 on co-creating therapeutic stories; their procedures are unconfirmed; steps synthesis]
Steps: (1) Collaborate closely with the primary clinician on a shared, both-medical-and-psychosocial plan. (2) Encourage regularly scheduled medical visits rather than symptom-driven ones, so care is not earned by symptoms. (3) Accept the symptom as real; start from the body (symptom diaries, effects on functioning) and only gradually connect it to stress and relationships. (4) Build an alternative explanation together that the patient can accept, rather than imposing a psychological one. (5) Work on function and relationships alongside the symptoms.
Example language (illustrative): "I'm not here because anyone thinks the pain isn't real. I'm here because pain this long affects everything, and we want to help with all of it."
Watch for: Any implication that it is "all in your head" (this ruptures engagement); real medical illness emerging. Keep medical review going.

4.17 Reproductive, genetic and genomic issues

Purpose / when: Infertility, assisted reproduction, pregnancy loss, genetic testing and family disclosure. These are named in the 2nd edition's synopsis as areas where families face conflicts. [source: Bookshare synopsis; procedures synthesis]
Steps: (1) Explore what each partner and family member means by and hopes for in parenthood, and their losses. (2) Help couples pace decisions about treatment and testing, and recognise when they differ. (3) For genetic results, help families plan who to tell, when and how, and work through guilt about passing on risk. (4) Coordinate with genetic counsellors and fertility teams. (5) Grieve pregnancy loss openly, including with relatives who may minimise it.
Example language (illustrative): "You're each carrying a different version of this decision. Could you tell each other what's at stake for you?"
Watch for: Pressure from relatives; secrecy that conflicts with relatives' health interests (discuss with the genetics team).

4.18 End of life, grief and caregiver support

Purpose / when: Terminal phase, bereavement, long-term caregiving. [synthesis drawing on the time-phase model in 4.6]
Steps: (1) Find out each member's understanding of the prognosis. (2) Help families talk about goals, wishes and goodbyes at a pace they can manage. (3) Support advance-care conversations alongside the team. (4) Plan caregiver respite and spread the load. (5) After the death, offer a follow-up session.
Example language (illustrative): "Some families find it helps to talk about what matters most in the time ahead. Would that be useful for you?"
Watch for: Mismatch between family members about prognosis; complicated grief; exhaustion in the carer.

4.19 Self-of-therapist work: personal illness and health genogram

Purpose / when: In training and ongoing practice, to recognise how your own health, illness and loss history colours your work. [source: the Rochester small groups focus on how family and personal experience shape professional work (URMC MFTI page); the founders note that a therapist's own experience of illness can help or hinder the work (McDaniel, Hepworth & Doherty 2000 abstract); the personal-genogram exercise is attributed to the books and to The Shared Experience of Illness, 1997: uncertain]
Steps: (1) Draw your own illness genogram (as in 4.5). (2) Note the illnesses or deaths that still affect you, and the case types that trigger you. (3) Discuss them in supervision or peer consultation. (4) After hard cases, debrief.
Watch for: Over-identification, avoidance of end-of-life topics, rescuing.

4.20 Consultation and support to medical colleagues

Purpose / when: Difficult patient–clinician relationships, team conflict, clinician distress or burnout. [source: Tyndall 2012 lists psychosocial support to medical staff against burnout and compassion fatigue; steps synthesis]
Steps: (1) Offer hallway or huddle consultation on "difficult" patients, reframing the relationship pattern. (2) Coach clinicians on family-involvement skills (Doherty & Baird levels 2–3). (3) Offer debriefs after deaths or crises. (4) Help teams agree consistent messages to the patient.
Example language (illustrative): "It sounds like the harder you push, the more he pulls away. What happens if we try the opposite next visit?"

4.21 Ending with an open door

Purpose / when: When goals are met. Chronic illness means families may need help again at future transitions. [uncertain: "leave the door open" attributed to the 1992 book; steps synthesis]
Steps: (1) Review gains in agency and communion. (2) Predict upcoming transitions (new treatment, adolescence, relapse). (3) Agree on signals for returning and a route back (through the medical team). (4) Tell the referring clinician about the ending and the plan.
Example language (illustrative): "We'll stop here for now. Illnesses change, and many families check back in at the next turning point; you can come back through Dr. R anytime."

4.22 Working with the shared emotional themes of illness

Purpose / when: Throughout, especially when a family seems stuck. McDaniel, Hepworth and Doherty describe ten emotional themes that recur when a family meets illness, each a pair of poles: denial and acceptance, despair and hope, secrecy and sharing, guilt and forgiveness, burden and relief, isolation and connection, passivity and taking charge, fear and courage, loss and renewal, senselessness and meaning. They propose that the therapist work with one or more themes as they arise, and note that the therapist's own illness experience can help or hinder this. [source: McDaniel, Hepworth & Doherty 2000, Journal of Family Psychotherapy abstract (UMN Experts)]
Steps: No published step-by-step procedure was found; the steps below are the writer's synthesis [synthesis]. (1) Listen for which theme is live for each member; members are often at opposite poles (one taking charge, another passive). (2) Name the pair and treat both poles as understandable responses. (3) Explore what a small move toward the other pole would look like for this family now. (4) Link the theme to the matching strategy: secrecy and sharing to 4.13, guilt and forgiveness to 4.8, passivity and taking charge to 4.9, isolation and connection to 4.10, senselessness and meaning to 4.3. (5) Notice your own pull on the theme and take it to supervision (4.19).
Example language (illustrative): "Part of the family wants to keep the diagnosis private and part of you wants everyone to know. Both make sense. What would it be like to tell one more person?"
Watch for: Pushing a family toward the "positive" pole (acceptance, hope, meaning) before they are ready; members at opposite poles blaming each other; your own preference for one pole.

5. Handling problems

No published MedFT problem-handling protocol was found. Everything in this section is [synthesis] built on the principles in Section 3, except where noted.

"I'm not crazy, it's physical" / refusal of referral. Frame yourself as part of the medical team and the work as coping with a real illness. Start with the body and functioning (4.4, 4.16). Offer a joint visit with the physician. Never argue about cause.
Family won't come in. Work individually with a systemic lens (genogram, mapping relationships). Invite one key member for a single "consultation" session to help the patient. Use the physician's authority ("Dr. R asked that the family be part of the plan").
Stuck in crisis mode or illness taking over. Re-assess the illness type and time phase (4.6). Introduce putting the illness in its place (4.11). Check with the team whether the medical picture really is stable.
Denial affecting safety or key decisions. Respect it as protection (4.8), but arrange a family conference (4.14) so the medical facts are heard directly from the clinician. Record that the information was given. Respect the patient's right to decide.
Non-adherence. Explore meaning, side effects, cost, beliefs and family dynamics before assuming the patient is unmotivated. Reduce policing by family members (4.15). Report barriers to the team (with consent) so the regimen can be simplified.
Overwhelm (patient or carer). Slow the pace and narrow to one concrete next step. Mobilise practical support and respite (4.10, 4.18). Screen for depression, anxiety and carer burnout, and for suicide risk using your service's standard risk-assessment procedure. Liaise with the team about medical contributors (pain, medication effects).
Conflict between family and medical team. Avoid taking sides or carrying messages between them. Convene a joint meeting with clear goals (4.13, 4.14). Privately validate both sides' frustrations.
Rupture with the therapist (feeling blamed, psychologised, or reported on to the doctor). Name it and apologise for any part you had in it. Re-clarify what is shared with the team. Return to the patient's priorities.
Confidentiality tensions in integrated care. Agree at the start what goes in the shared record and what stays in therapy notes. Tell the family. Follow local law and organisational policy on record access. [synthesis: integrated-care record arrangements vary by system]
Secrets (e.g. genetic risk relatives don't know about, affairs during illness). Clarify your stance on secrets early. Explore the reasons for and costs of disclosure. Consult the genetics team or an ethics advisor where relatives' health interests are involved.
Children excluded or parentified. Bring children in for age-appropriate explanations. Protect their developmental tasks (4.12). Coordinate with school where relevant.
Therapist over-identification or burnout. Use self-of-therapist work (4.19), supervision, and peer groups (the Rochester intensive's small groups are built for this purpose). [source: URMC MFTI page for the small-group format]
Collaboration breaks down (clinician doesn't respond, or works at level 1–2). Adjust to the level actually available. Send brief, useful notes, ask one clear question per contact, and show your value on a shared case.
Domestic violence or neglect surfacing in caregiving. Assess safety separately for each person. Follow mandatory reporting and adult or child protection procedures. Joint sessions may not be safe.
Medical deterioration during therapy. Treat it as a phase change. Re-assess, involve the team, and shift goals toward the new phase (4.6, 4.18).

Sources

Web pages consulted:

Further web pages consulted:

Books and papers cited (claims resting only on these are tagged [uncertain]):

McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1992). Medical Family Therapy: A Biopsychosocial Approach to Families with Health Problems. Basic Books.
McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2014). Medical Family Therapy and Integrated Care (2nd ed.). American Psychological Association.
McDaniel, S. H., Hepworth, J., & Doherty, W. J. (Eds.) (1997). The Shared Experience of Illness: Stories of Patients, Families, and Their Therapists. Basic Books.
McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1995). Medical family therapy with somatizing patients: The co-creation of therapeutic stories. Family Process.
McDaniel, S. H., Campbell, T. L., & Seaburn, D. B. (1989). Somatic fixation in patients and physicians: A biopsychosocial approach. Family Systems Medicine.
McDaniel, S. H., Campbell, T. L., Hepworth, J., & Lorenz, A. (2005). Family-Oriented Primary Care (2nd ed.). Springer.
Doherty, W. J., & Baird, M. A. (1986). Developmental levels in family-centered medical care. Family Medicine.
Doherty, W. J., McDaniel, S. H., & Baird, M. A. (1996). Five levels of primary care/behavioral healthcare collaboration. Behavioral Healthcare Tomorrow.
Hodgson, J., Lamson, A., Mendenhall, T., & Crane, D. R. (Eds.) (2014). Medical Family Therapy: Advanced Applications. Springer.
Rolland, J. S. (1994). Families, Illness, and Disability: An Integrative Treatment Model. Basic Books.
Gonzalez, S., Steinglass, P., & Reiss, D. (1989). Putting the illness in its place: Discussion groups for families with chronic medical illnesses. Family Process.
Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science.

Also cited (titles from Doherty's CV): Doherty, W. J., & Lamson, A. (2015). The Levels of Family Involvement model: 20 years later. Doherty, W. J. (1995). The why's and levels of collaboration. Doherty, W. J., McDaniel, S. H., & Hepworth, J. (1994). Medical family therapy: An emerging arena for family therapy. Doherty, W. J., & Mendenhall, T. (2019). Medical family therapy. In APA Handbook of Contemporary Family Psychology. Rolland (2018) is cited from its table of contents.

[uncertain] summary. Confirmed by legitimate secondary or author sources: the names and features of the five collaboration levels; the five Doherty & Baird levels; the five dimensions of Rolland's typology and how his FSI model is organised; the ten shared emotional themes of illness (McDaniel, Hepworth & Doherty 2000 abstract); the five-level MedFT integration table in Mendenhall et al. 2018 (Arthur 2019 review). Not confirmed against the founders' books: their own list of MedFT strategies and its wording; their definitions of agency and communion (only Tyndall 2012 names these as overarching goals); any phase structure; "leave the door open"; the crisis, chronic and terminal phase definitions as Rolland gives them; and the somatic-fixation procedures (McDaniel, Campbell & Seaburn 1989; McDaniel, Hepworth & Doherty 1995). Session counts and Section 5 are synthesis.

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