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The heart of the matter 2: integration of ecosystemic family therapy practices with systems of care mental health services for children and families

Ellen Pulleyblank Coffey

Many children in this country do not receive the mental health care they need. At the same time, a nationwide movement known as systems of care is providing innovative services for families and children. This article links the ideas inherent in systems of care with ecosystemic family therapy principles and practices. Based on a study of nine innovative systems of care pilot projects in Massachusetts, it describes how these innovative programs, and others like them, have been most successful in increasing access to services and providing for coordinated services. They have been less successful in accomplishing positive clinical and functional outcomes. Change in these systems is often described in terms of how services are provided. Not enough attention is given to the conversations that take place between families and case coordinators and how these conversations lead to long-term change. This article contends that the ways in which services are delivered in these systems of care fit well with ecosystemic family therapy principles and practices. We, as family therapists, have an opportunity to link these two sets of ideas, which share common assumptions and values and increase the likelihood of positive clinical outcomes for children and families.

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This article is based on a study of nine innovative "systems of care" mental health programs for children and families in Massachusetts (Lightburn, Olson, Sessions, & Pulleyblank Coffey, 2002). With a broad pattern of innovation, these programs work to prevent out-of-home placement of children by emphasizing the coordination of resources for them and their families. This is accomplished through service delivery innovations based on the systems of care model recommended for children and families by the Surgeon General's Commission on Mental Health of Children (U.S. Public Heath Service, 2000). The systems of care model offers access to a wide range of services that fit family needs and build on family strengths. Decisions are made with families and are child centered, family focused, community based, and culturally responsive. Multisystemic integrated services are provided through collaborations between social agencies and community partners. In the best programs, funders offer flexible funding streams so that resources are accessed as needed (Stroul, 1996). This article acknowledges the innovations of the programs studied and suggests ways in which the integration of a systems of care service delivery model, with an ecosystemic family therapy model of clinical change, might enhance the innovations already in place.

The physicist Fritjof Capra (1996), in his description of the relationships among organisms, social systems, and ecosystems, outlines the historical roots of ecosystemic thinking about human systems. He describes how the word "system" was introduced by the biochemist Lawrence Henderson to denote both living organisms and social systems. Capra goes on to define a system as "an integrated whole whose essential properties arise from the relationships between its parts.... To understand things systemically literally means to put them into a context, to establish the nature of their relationship" (p. 27). Ecology is the study of these relationships. When applied to family therapy, an ecosystemic model includes the relationships within families, their immediate communities, and the wider culture. An assumption of this model is that by including these social networks as central to family therapy, families will have the greatest access to the resources that sustain them. Gregory Bateson (1979), examining this ecology, proposed a new language to describe the many interactive, spontaneous, and unpredictable outcomes that occur in these human systems. Rather than focus on particular outcomes, Bateson recommended that we look at how human systems "learn to learn." He included the therapist as part of the learning system. He described the important therapeutic conversation as a "meta-dialogue" in which the therapist and family comment on the interactions in the system. He posited that this commentary could radically alter the rules of interaction and its meanings.

In this article, ecosystemic family therapy includes therapeutic conversations that occur in the context of collaborative relationships among therapists, families, and communities; problem definitions that attend to relational and social contexts; and problem resolutions that emphasize possibilities, exceptions, resources, and strengths. This article explores how these practices are inferred in the systems of care model. It proposes that an emphasis on therapeutic conversations based on these principles strengthen the systems of care service delivery model and offer the possibility of improved clinical and functional outcomes.

This concern about a focus on service delivery rather than on clinical change in systems of care for children and families is shared by other researchers. Experimental systems of care that have tried various service delivery strategies have shown little difference in functional and emotional outcomes. A National Institute of Medicine research paper (1989) makes a clear statement of this concern:

   Less attention has been paid to the nature and effectiveness of
   specific mental health treatments delivered under the auspices

��of�the�emerging�"service�delivery�systems�or�systems�of�care.

   The dearth of clinical outcome data in the services research
   literature raises the frightening possibility that evidence of
   increased access and variety of services may be construed as a
   proxy for quality and effectiveness of clinical services rendered.
   (p. 230)

The Fort Bragg Study (Bickman, 1996; Bickman, Guthrie, & Foster, 1995) and the Stark County study (Bickman, Summerfelt, & Noser, 1997), which evaluated how system delivery innovations affected functional and clinical outcomes, supported this concern. These studies showed how changes in service delivery improved access to services and increased the range of services available in a continuum of care. They found no difference, however, between the experimental and control groups in clinical outcomes. The Fort Bragg Study warned that the current momentum for reform in children's mental health services might be severely compromised if widely adopted innovative models are shown to be clinically ineffective. In addition, other authors have pointed to the lack of congruence among values, program goals, objectives, and practice in systems of care projects (Berry & Cash, 2002; Davidson et al., 2001; Green, 1998; Johnson & Rogers, 1998).

In our study (Lightburn et al., 2002), we came to the following conclusion about therapeutic interventions in these programs:

   Most of the programs studied employed a loose synthesis of
   ecological practice based on systemic and structural models

��of�family�therapy�(Franklin�&�Jordan,�2002;�Minuchin�&�Fishman,

   1980), adapted to the particular needs of individual families.
   Although individual and family therapy were usually part of the

��overall�intervention,�some�clinicians'�actual�practice�lacked

   clear description. (p. 292)

THE WIDER CONTEXT: MENTAL HEALTH NEEDS OF CHILDREN AND FAMILIES

In an earlier article based on a pilot study of the effects of managed care on family therapy, the author and research group concluded that many writers in the field of family therapy have tried to fit contextual and relational family therapy models into current managed care formats. The effect of using the language of managed care, a language that is medically oriented and focused on costs rather than on standards of care, has led to loss of knowledge of systemic theories, reduced complexity in therapeutic family practice, and a focus on biological explanations and treatments that often occur out of context (Pulleyblank Coffey, Olson, & Sessions, 2001).

The implications of that pilot study led our team into the problems and scandals concerning public mental health treatment for children and families in the United States. Throughout this country, children are stuck in hospitals and residential facilities for lack of effective alternatives in their communities. In Massachusetts alone, according to Dr. Stephen Sharfstein, during a recent 6-month period, children "stuck" in institutions spent 15,796 days--or more than 43 years--of unnecessary time in hospitals. In addition, there had been an increase in the amount of this time over the previous 6 months (Goldberg, 2001). In addition, most children who need help do not get it. In 2000, the U.S. Surgeon General's Commission for the Mental Health of Children estimated that 80% of children and adolescents in need of mental health services do not receive them. Gaps in these services mean that children and their families with serious emotional and behavioral problems are in danger of being trapped by their conditions as others are overtreated and trapped in institutions. Many state departments of mental health are preoccupied with extending services to underserved children and freeing stuck children. Lawsuits attempting to remedy these situations are taking place in many states across the country.

In the spring of 2001, with these problems in mind, a research consortium was formed with a group of stakeholders who share concerns about public mental health services for children and families in Massachusetts. This consortium was made up of representatives from the State Department of Mental Health, the State Department of Social Services, Medicaid, managed care companies, regional and local nonprofit mental health providers, a parent advocacy group, and faculty members of the Smith School of Social Work. Initially, the research team proposed to the consortium the possibility of developing a demonstration project for children and families, using ecosystemic family therapy practices that would be cost effective and maintain a high quality of care.

With the research consortium and throughout the subsequent study of innovative programs, the research team adopted an interactional style that combined postmodern dialogue and reflection with standard qualitative methods of inquiry. At the first meeting, the group searched for the strengths of all of the participants and their desired outcomes of future mental health services. The resulting dialogue led consortium members to recommend that, rather than starting another pilot project, a study of existing innovative programs based on systems of care initiatives serving children and families well would benefit them more. The consortium members suggested the following research question: What is the state of the art in Massachusetts regarding best practices for children and adolescents with severe emotional and behavioral problems? They wanted to understand how these programs addressed the problems generated by more traditional service delivery models such as the fragmentation of services; the disconnection between policy and practice; parent alienation; culturally irrelevant services; high staff turnover; poorly trained staff; and poor integration of cost-effective, evidence-based treatment. The consortium guided the research study in all of its phases.

The nine sites represented a range of state agencies using family- and community-based programs to divert high-risk children and adolescents from long-term residential care. Some programs were located in existing community mental health agencies, while others were formed through new partnerships of funders, including managed care, community agencies, and universities. They differed in how they worked within a systems of care model and in how they integrated service delivery with therapeutic clinical practices.

At least two researchers visited each program. Administrators, supervisors, and clinicians participated in the interviews. A combination of asking questions and reflecting on answers was employed. This process allowed for the inclusion of multiple perspectives and had the unexpected effect of encouraging interviewees to reflect on and question their processes and those of the research team. Program descriptions, agency policies, annual reports, grant applications and reports, and evaluations were part of the data used in developing the analysis of themes and patterns of organization and practice.

Participants were asked to describe the services they provided and to give an example of a "best practice." In some instances, an array of integrated services offered by an agency was described. In addition, participants were asked to describe the following aspects of their programs: population served; access to services; length of waiting lists; length of treatment; use of a clinical model; use of diagnosis and medication; availability of training; and clinical examples of the program at its best. Each program differed as to whether it included a wide or narrow net of referrals, but at each site, all records and providers (medical, school, legal, and social service) were coordinated. These relationships were maintained in different ways by the different programs and agencies. Some programs provided a family assessment and recommended a service plan to be provided by another agency, while others provided a continuum of services for one population. Still other agencies offered a full range of services across populations. The extent to which a program or agency offered a fully integrated continuum of care was often related to its ability to purchase the needed services.

The following are some of the innovative service delivery methods described by these programs:

   We begin intervening from the moment we call a family.
   We collect all records, and do a strength-based family
   assessment and offer immediately needed services. We
   develop a plan with the family. Once the assessment is
   completed, we refer the family to another agency for it
   to provide needed services.

   Our program is integrated at every level, top to bottom.
   Each family has a care manager who gets to know the family
   and works with them to set up a care plan. We gather all
   records from all previous service providers and bring together
   everyone involved with the family, including family members
   and people from their community, to work together as a team.

   Focusing on one program in our agency (as the most innovative)
   misses how we have developed an intertwined continuum of care
   across all our programs. We offer an array of programs, building
   our own system of care. These services include assessment, outreach,
   outpatient services, and intensive family services. Clients move
   back and forth between different levels of care. There is
   communication and coordination between all service providers.

   The first thing we do is bring together all service providers,
   including social services, school systems, and health maintenance
   providers. These services develop contractual agreements that specify
   how they will work together and share responsibilities.

   Our program is not providing services, but accessing and developing
   community services in a coordinated way with families at the center
   of planning.

   We develop teams that continue to meet throughout service provision,
   though at lessening levels of frequency. In some instances, families
   take responsibility for convening and inviting team participants. In
   other instances, team meetings are convened by social workers or case
   coordinators. Teams often include family members, social worker,
   psychiatrist, parent partner, coordinator/case manager, and
   representatives from other agencies. All meet to review, advise,
   plan, and provide services.

Assessments of children and families included both medical diagnoses and strength-based assessments of needs and resources. Although medical diagnoses activated eligibility for treatment, strength-based models formed the basis of these assessments. Assessments began with an identification of family resources and strengths. An underlying assumption of these programs was that treatment would be time limited and that families would learn to use their own resources and the resources of the community without the need for intensive services in the long term (length of time of intensive services ranged from one month for assessment to an unspecified length of time for parent support). Medication was carefully assessed and coordinated with other aspects of the services. A number of programs reported that there was an indication that with careful assessment and increased coordination with other services, medication requirements decreased over time.

The programs described numerous family-based practices that included:

* Families as partners in developing a treatment plan and activating resources.

* Development of approach for crises that uses outreach workers, respite, and special program inputs to ensure least-restrictive options.

* Wraparound services and expansion of care to fit the needs of the child and the family rather than focusing on out-of-home placements.

* Wraparound services that include the purchase of social and material services by the mental health provider. These services may include the integration of school, medical, psychiatric, therapeutic, community outreach, and parent partnering resources.

* Focus on daily living tasks in families and in other settings.

* Focus on development of family capacities to plan and access future services.

* An agreement about the central need for family involvement (although programs differed as to how much families were central to the administration), development, and planning of services.

* Families, when necessary, moved in and out of levels of care provided by the treating system.

* Service provider teams were collaborative and nonhierarchical. These multiprovider and multidisciplinary teams (psychiatrists, psychologists, social workers, case coordinators, outreach workers, and parent partners) responded to need and designated who should be involved with various services and how they should be involved.

As these descriptions illustrate, interviewees tended to use the language of service delivery to describe how their systems of care models help children and families. As with the language of managed care, the language of system delivery obscures a focus on what conversations actually occur between families and service providers. Instead, service providers were disconnected from the knowledge of how they spoke with families and communities. As a result of this disconnection among theory, values, and practice, family meetings often were described with fuzzy, simple, and incomplete descriptions of therapeutic conversations. There was not clear differentiation among giving support, accessing resources, facilitating rehabilitation, educating clients, creating family networks, and promoting therapeutic change. The language of service delivery also obscured a process of reflection that might alert clinicians to re-examine their clinical practices. Instead, in a number of the programs, clinicians and clinical interventions were discounted. There was a widely held belief that clinical work focused mainly on pathology and individual intrapsychic change. There appeared to be little knowledge of a family therapy tradition that could have been integrated with the systems of care goals. In addition, innovative intensive services that were coordinated with more traditional fee-for-service delivery systems had difficulty coordinating their innovative systemic approaches with this traditional service delivery model.

These programs represent the work of what Lisbeth Schorr (1997) calls new professionals who "strengthen families by adopting an empowering and collaborative mode of professional practice" (p.15). She refers to the work of Donald Schon, an MIT organizational theorist, who describes these new practitioners as able to work collaboratively and allow themselves to be uncertain about what to do, often searching for moments in which they "act on their own sense of what needs to be done" (p. 13). However, Schorr goes on to say that these new professionals must possess "a rigorous understanding of the theory that underlies practice" (p.15). She cautions that the subtleties of effective interventions are often underestimated, and, as Donald Schon (1983) suggested, that practitioners operate on many levels that they often cannot describe.

In our study, practitioners did not articulate the theories on which their services were based. They did not clearly describe the nature of the different kinds of conversations needed within their service delivery models. If theory is unclear, and if there is no reflection leading to an understanding of how relationships are made and changes occur in families, it is not surprising that clinical outcomes are poor and replications are difficult. This article suggests that training for case coordinators and other mental health workers in a coherent ecosystemic clinical change model that can be integrated with the innovative systems delivery model might be the next step in the development of these systems of care for children and families.

THE ECOSYSTEMIC THEORETICAL UNDERPINNINGS OF SYSTEMS OF CARE

A long tradition in social work places families at the center of treatment. This is also a core value of systems of care for children and families. Taking these ideas further, Edgar Auerswald (1968) developed an ecosystemic model that relied heavily on developing the natural support systems of families. This idea of expanding the resources that support families is embedded in the systems of care model. In this model, it is assumed that families will become more active in all arenas of their lives as they are given support and responsibility for defining and accessing needed services. However, a "meta-dialogue" as described by Bateson (1979) that promotes changes in the underlying rules governing family beliefs and actions is not well defined. Instead, families often are connected to services and sometimes become dependent upon them without generating new strategies of personal authority or social action.

Although the work of many theorists built upon Bateson's ideas, particularly relevant to the systems of care model is the work of Anderson and Goolishan (1988; Anderson, 1997), who brought to family therapy theory a model of human systems as language systems. In their model, the therapist is both a participant observer along with the family and a participant manager of conversations that move in the direction of change, taking equally into account the voices of all participants. In this position, the therapist does not impose a desired outcome but works with the family to make meaning of their situation and search for their desired outcomes. Anderson and Goolishan redefined the expertise of the clinician from one who knows the right outcomes for a family to one who instead has expertise in creating and maintaining conversations that lead to new outcomes. Feminist theorists brought into focus concerns about gender and power, and challenged the position of the therapist as expert and the existing notions about what constitutes a family (Goldner 1988; Green 1996; Hare-Mustin 1994; Laird 1998). These ideas fit well with the team-building model of systems of care. In searching for new outcomes, the work of Tom Anderson's (1990) reflecting team demonstrated how many points of view and new alternatives become more evident as one group reflects on the dialogue of another and both conversations are equally valued. Michael White and David Epston (1990) expanded these ideas in their development of Narrative Therapy by using a reflecting dialogue to focus on the strengths and positive outcomes on the margins of people's awareness.

Finally, work on race and culture challenged the dominant culture's definitions of what is normal and what works for families (Boyd-Franklin 2000; Green, 1998; Sue & Sue, 1990). Papp and Imber-Black (1996) described how the use of identifying themes at different levels of experience depathologizes symptoms and offers new ways to understand and change problems. From this perspective, as with externalizing conversations as described by White (1989), there is a shift away from seeing pathology in families to seeing families in their wider contexts and acknowledging their strengths and their obstacles resulting from the effects of racism and classism. These theoretical ideas have been translated into postmodern, narrative, feminist, and culture-contextual models of practice and training. These clinical practices could be effectively linked to the systems of care service delivery model.

WRAPAROUND PROCESSES: PRINCIPLES AND DILEMMAS

To examine this link further, I have selected one of the central processes of the systems of care model, providing wraparound services, as an example of the ways in which ecosystemic postmodern clinical practices might enhance a systems of care service delivery system. The wraparound notion of providing services comes in many forms; the basic assumption, however, is that family members are better served when they participate in developing resources that best fit them rather than fitting into existing service systems. Assessment and intervention are based on the needs and resources of a family. A team of helpers, with the family at the center, serves as advocates for the family and defines with the family what they need and how they might access required resources. A care plan is developed to attend to many aspects of family life, including family relationships; safety; crisis intervention; legal, medical, psychological, and educational/vocational issues; and housing, transportation, recreational, and spiritual needs (Goldman & Faw, 1998). When needed services are not available, the team works with community groups to develop them.

Lightburn et al. (2002) describe clinical dilemmas found in wraparound processes. These include an inability to engage and sustain relationships with families who are extremely isolated; sustain ongoing collaborative relationships with multiple service providers; clarify the nature of therapeutic conversations; provide resources and support independence in families; and terminate families from intensive services.

Wraparound philosophy assumes that the ways in which services are assessed, accessed, and developed lead to ongoing change in families. The case coordinators, however, do not distinguish clearly between changes that occur through finding particular solutions for particular problems and changes that require new ways for families to organize themselves and operate in the world over time. This lack of clarity between different kinds of change leads to a significant tension between how case coordinators provide information and look to the family as resources and agents on their own behalf. Another difficulty in these programs is the relationship between the wraparound process and more traditional mental health services. In some programs, family teams include a therapist who is often selected from the wider community of mental health providers and does not necessarily share the language or the specific wraparound training provided for other service team members. Some service team members express a strong prejudice against clinical work in that they believe that most clinicians are poorly trained in acknowledging strengths. For this group of providers, the consensus is that the more clinical training a person has, the less likely it is that the person fits with their wraparound family team approach. In these instances, providers are referring often to psychotherapy that is individually based and not connected to ecosystemic family ideas and practices.

POSTMODERN ECOSYSTEMIC PRACTICE LINKS TO WRAPAROUND SERVICE DELIVERY

By focusing on some of what is known in the family therapy literature about building resilience, engaging and sustaining therapeutic relationships, and creating therapeutic conversations, this article attempts to address some of the dilemmas of the wraparound process.

A Strength-Based Perspective: From Pathology to Resilience

As described previously, the wraparound process focuses primarily on building family resources by coordinating activities for families and the communities that serve them. This approach to families coincides with a growing focus in the field of family therapy on a strengths-based family resilience model. Madsen (1999) describes how a shift in attitude on the part of the therapist--from a focus on deficits to a focus on strengths--radically alters therapeutic conversations. Walsh (1998) tracks the development of a family therapy resilience model. An important aspect of this model includes not only building on the strengths of families but also empowering them to address the contextual obstacles that often stand in their way. Walsh examines in depth what is involved in building family resources to support and develop resilience and capacities for social action. She includes the following therapeutic goals:

* Overcoming a cycle of suspicion, rejection, failure, and withdrawal

* Forging a trusting relationship through honest and respectful communication

* Encouraging families to prioritize their many needs and aims

* Believing in family members' potential and giving them hope and confidence

* Increasing family members' ability to solve problems, avert crises, and advocate on their own behalf (p. 265)

She describes therapeutic processes that accomplish these goals, including changes in family belief systems, organizational patterns, and communication processes. These changes imply a certain set of assumptions and skills on the part of the therapist that go beyond giving support, information, and case management. Walsh adds that there are particular difficulties for the clinician in creating and continuing to maintain the necessary empathetic relationship with families who are slow to change. This creates unique challenges for the clinician and requires ongoing supervision and training.

Developing Collaborative Relationships--From Experts to Partners

The family service team in the wraparound process is based on the belief that families know best about what they need. Service providers join with them to access resources to meet these needs. What is left unexplored is the role strain for service providers as they give needed information and work to maintain family autonomy. Families also come to these programs with a set of expectations about what service providers will do for them and expect of them. The skill set needed to deconstruct these expectations is often not articulated. The ability to create a collaborative relationship and facilitate dialogue in a situation often fraught with crises requires supervision and training of a particular kind. The structure of the family team in a wraparound process is extremely well suited to supporting a collaborative relationship between service providers and clients, but this structure alone does not provide conversations that establish collaborative relationships. The practice of specific questioning, reflecting on these questions, and dialogic skills are all necessary if the goal of shared responsibility is to be established and maintained in these complex relationships.

The Nature of Therapeutic Conversations--What Creates Change?

The wraparound process implies that through team development, assessment of strengths, and accessing of needed services, problems in families will be solved. As stated earlier, the nature of conversations that lead to change is left unclear. Sluzki (1992) describes how different models of change in family therapy lead to different therapeutic conversations. He points out that the overarching theme of these different models is that each of them leads to alternative family stories:

   An encounter can be defined as therapeutic when in its course a

��transformation�has�taken�place�in�the�family's�set�of�dominant

   stories to include new experiences meanings and interactions with
   the effect of a loosening of the thematic grip of the set of
   stories about symptomatic-problematic behaviors. (p. 219)

The wraparound process lacks what Pakman (2000) calls the "poetics" of therapeutic conversations, or "a specific way of generating openings and creating alternatives in very specific types of situations" (p. 123).

Monk and Gehart (2003) point out subtle yet important differences in therapeutic conversations that are collaborative and focused on multiple perspectives, and those that use externalizing narrative methods to activate clients to act against oppression. This is only one set of distinctions in a field that has been developing for over four decades. The dilemma is, how does one bring this set of ideas to wraparound practitioners?

CONCLUSION

A growing number of demonstration projects based on the systems of care model in offering innovative service delivery have been resoundingly successful (Fallon, 2003). There is also strong agreement that this model, although providing coordinated care that addresses many of the problems of traditional models of service delivery, has not developed a clinical theory and model that leads to better clinical and functional outcomes. As public policy has moved in this direction of systems of care that place families at the center of these services, there is a growing sense that family therapy and the systemic practices in which it is embedded have been losing ground (Johnson 1998; Pulleyblank Coffey et al., 2001; Shields, Wynne, McDaniel, & Gawinski, 1994). One exception is psychoeducation with multiple family groups, which is becoming a significant treatment approach with the seriously mentally ill (McFarlane, 2002). As family therapists, we have an opportunity to link with the systems of care service delivery model and continue to move out of our offices, bringing our skills into the public domain. There is a long tradition in family therapy of going beyond the treatment room and applying systemic ideas to larger systems (Doherty & Carroll, 2003; Imber-Black, 1988; Rojano, 2004; Romney, 2000; Olson, 2000; Hoffman, 1998). An integration of a systems of care service delivery model with ecosystemic postmodern family clinical practice could significantly address the problems facing children and families in our mental health system. This integration has the potential to reach beyond the healthcare needs of children and families; it could also affect wider systemic change in what Pakman (2000) calls the "micro-politics" of practice (i.e., the political/social/institutional situations in which we work) by addressing the institutionalized problems of traditional fee-for-service delivery models that make it difficult for clinicians, families, and communities to access needed services effectively.

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ELLEN PULLEYBLANK COFFEY, PH.D., Clinical Psychologist, Berkeley, CA.

Correspondence concerning this article should be addressed to Dr. E. Pulleyblank Coffey, 1628 Euclid Avenue, Berkeley, CA 94709. E-mail: ellen@berkeleyfamilytherapy.com

The original study on which this essay is based was supported by the Massachusetts Department of Mental Health, the Davis Foundation, the Brown Clinical Research Institute, and the Center for Innovative Practice at Smith School for Social Work. I wish to thank my research colleagues Mary Olson, Ph.D., Anita Lightburn, Ed.D., and Phebe Sessions, Ph.D., at the Center for Innovative Practice. Though the ideas and conclusions in this essay are mine, many were developed during conversations with them. I would also like to thank the following colleagues, friends, and family members for reading and editing this manuscript: Patrick Coffey, Ph.D., Sarah Pulleyblank, M.S., Paul McCormick, M.S., Carlos Sluzki, M.D., and Jane Ariel, Ph.D.