Subclonal populations in an

MM patient, represented as

different colored cells

Credit: Lauren Solomon

Results of a new study suggest the genetic landscape of multiple myeloma (MM) may be more complex than we thought.

The research revealed “widespread” heterogeneity in samples from more than 200 MM patients.

In some cases, a single patient had multiple mutations in the same pathway. And most of the patients harbored at least 3 detectable subclonal mutations.

The researchers said these findings, published in Cancer Cell, might explain why targeted therapies are not always effective in MM and why some patients relapse after treatment.

“What this new work shows us is that when we treat an individual patient with multiple myeloma, it’s possible that we’re not just looking at one disease, but at many,” said study author Todd Golub, MD, of the Dana-Farber Cancer Institute in Cambridge, Massachusetts.

“In the same person, there could be cancer cells with different genetic make-ups. These findings indicate a need to identify the extent of genetic diversity within a tumor as we move toward precision cancer medicine and genome-based diagnostics.”

Dr Golub and his colleagues studied samples from 203 MM patients and identified frequent mutations in genes known to play an important role in MM, including KRAS, NRAS, and BRAF.

But many of these telltale mutations were not present in all MM cells. Instead, they were often observed only in a subclonal population.

This suggests targeted therapies may have limitations in patients whose tumors are made up of these subclonal populations, the researchers said.

To explore the therapeutic implications of this research, the team performed follow-up experiments looking specifically at BRAF, a gene for which several inhibitors exist.

Previous studies indicated that roughly 4% of MM patients may have mutations in this gene. And a recent report on a single MM patient treated with drugs targeting BRAF showed promising results.

However, Dr Golub and his colleagues found evidence that treating a tumor harboring subclonal BRAF mutations with one of these agents may, at best, kill a fraction of the cells and, at worst, stimulate another cancer cell subpopulation to grow.

“There’s clearly potential for these drugs in some patients with multiple myeloma, but we show that there are also potential problems for others,” said study author Jens Lohr, MD, PhD, also of Dana-Farber.

“If a patient has a BRAF mutation in less than 100% of his cells, or if he has mutations in KRAS or NRAS at the same time, [it] may influence the response to an inhibitor.”

This suggests subclonal populations could be one of the reasons many patients suffer relapse after treatment, the researchers said.

“Matching the right drug to the right patient may not be as easy as finding a mutation and having a drug that targets it,” Dr Lohr said. “We have to keep this additional parameter of heterogeneity in mind and keep exploring what it means for therapy.”

Subclonal populations in an

MM patient, represented as

different colored cells

Credit: Lauren Solomon

Results of a new study suggest the genetic landscape of multiple myeloma (MM) may be more complex than we thought.

The research revealed “widespread” heterogeneity in samples from more than 200 MM patients.

In some cases, a single patient had multiple mutations in the same pathway. And most of the patients harbored at least 3 detectable subclonal mutations.

The researchers said these findings, published in Cancer Cell, might explain why targeted therapies are not always effective in MM and why some patients relapse after treatment.

“What this new work shows us is that when we treat an individual patient with multiple myeloma, it’s possible that we’re not just looking at one disease, but at many,” said study author Todd Golub, MD, of the Dana-Farber Cancer Institute in Cambridge, Massachusetts.

“In the same person, there could be cancer cells with different genetic make-ups. These findings indicate a need to identify the extent of genetic diversity within a tumor as we move toward precision cancer medicine and genome-based diagnostics.”

Dr Golub and his colleagues studied samples from 203 MM patients and identified frequent mutations in genes known to play an important role in MM, including KRAS, NRAS, and BRAF.

But many of these telltale mutations were not present in all MM cells. Instead, they were often observed only in a subclonal population.

This suggests targeted therapies may have limitations in patients whose tumors are made up of these subclonal populations, the researchers said.

To explore the therapeutic implications of this research, the team performed follow-up experiments looking specifically at BRAF, a gene for which several inhibitors exist.

Previous studies indicated that roughly 4% of MM patients may have mutations in this gene. And a recent report on a single MM patient treated with drugs targeting BRAF showed promising results.

However, Dr Golub and his colleagues found evidence that treating a tumor harboring subclonal BRAF mutations with one of these agents may, at best, kill a fraction of the cells and, at worst, stimulate another cancer cell subpopulation to grow.

“There’s clearly potential for these drugs in some patients with multiple myeloma, but we show that there are also potential problems for others,” said study author Jens Lohr, MD, PhD, also of Dana-Farber.

“If a patient has a BRAF mutation in less than 100% of his cells, or if he has mutations in KRAS or NRAS at the same time, [it] may influence the response to an inhibitor.”

This suggests subclonal populations could be one of the reasons many patients suffer relapse after treatment, the researchers said.

“Matching the right drug to the right patient may not be as easy as finding a mutation and having a drug that targets it,” Dr Lohr said. “We have to keep this additional parameter of heterogeneity in mind and keep exploring what it means for therapy.”

Subclonal populations in an

MM patient, represented as

different colored cells

Credit: Lauren Solomon

Results of a new study suggest the genetic landscape of multiple myeloma (MM) may be more complex than we thought.

The research revealed “widespread” heterogeneity in samples from more than 200 MM patients.

In some cases, a single patient had multiple mutations in the same pathway. And most of the patients harbored at least 3 detectable subclonal mutations.

The researchers said these findings, published in Cancer Cell, might explain why targeted therapies are not always effective in MM and why some patients relapse after treatment.

“What this new work shows us is that when we treat an individual patient with multiple myeloma, it’s possible that we’re not just looking at one disease, but at many,” said study author Todd Golub, MD, of the Dana-Farber Cancer Institute in Cambridge, Massachusetts.

“In the same person, there could be cancer cells with different genetic make-ups. These findings indicate a need to identify the extent of genetic diversity within a tumor as we move toward precision cancer medicine and genome-based diagnostics.”

Dr Golub and his colleagues studied samples from 203 MM patients and identified frequent mutations in genes known to play an important role in MM, including KRAS, NRAS, and BRAF.

But many of these telltale mutations were not present in all MM cells. Instead, they were often observed only in a subclonal population.

This suggests targeted therapies may have limitations in patients whose tumors are made up of these subclonal populations, the researchers said.

To explore the therapeutic implications of this research, the team performed follow-up experiments looking specifically at BRAF, a gene for which several inhibitors exist.

Previous studies indicated that roughly 4% of MM patients may have mutations in this gene. And a recent report on a single MM patient treated with drugs targeting BRAF showed promising results.

However, Dr Golub and his colleagues found evidence that treating a tumor harboring subclonal BRAF mutations with one of these agents may, at best, kill a fraction of the cells and, at worst, stimulate another cancer cell subpopulation to grow.

“There’s clearly potential for these drugs in some patients with multiple myeloma, but we show that there are also potential problems for others,” said study author Jens Lohr, MD, PhD, also of Dana-Farber.

“If a patient has a BRAF mutation in less than 100% of his cells, or if he has mutations in KRAS or NRAS at the same time, [it] may influence the response to an inhibitor.”

This suggests subclonal populations could be one of the reasons many patients suffer relapse after treatment, the researchers said.

“Matching the right drug to the right patient may not be as easy as finding a mutation and having a drug that targets it,” Dr Lohr said. “We have to keep this additional parameter of heterogeneity in mind and keep exploring what it means for therapy.”

Abstract

• Objective: To review current criteria and rationale for Chlamydia trachomatis screening, testing methods, and treatment of infection.
• Methods: Review of the literature.
• Results: C. trachomatis urogenital infections are an important public health problem. Screening for C. trachomatis in women age 25 and younger and men and women of any age at increased risk allows for the early treatment of disease, avoiding morbidity such as pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain, and reducing health care costs.
• Conclusion: Current screening recommendations are not being implemented satisfactorily. Home-based methods of screening are acceptable and may improve universal screening rates.

Abstract

• Objective: To review current criteria and rationale for Chlamydia trachomatis screening, testing methods, and treatment of infection.
• Methods: Review of the literature.
• Results: C. trachomatis urogenital infections are an important public health problem. Screening for C. trachomatis in women age 25 and younger and men and women of any age at increased risk allows for the early treatment of disease, avoiding morbidity such as pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain, and reducing health care costs.
• Conclusion: Current screening recommendations are not being implemented satisfactorily. Home-based methods of screening are acceptable and may improve universal screening rates.

Abstract

• Objective: To review current criteria and rationale for Chlamydia trachomatis screening, testing methods, and treatment of infection.
• Methods: Review of the literature.
• Results: C. trachomatis urogenital infections are an important public health problem. Screening for C. trachomatis in women age 25 and younger and men and women of any age at increased risk allows for the early treatment of disease, avoiding morbidity such as pelvic inflammatory disease, ectopic pregnancy, and chronic pelvic pain, and reducing health care costs.
• Conclusion: Current screening recommendations are not being implemented satisfactorily. Home-based methods of screening are acceptable and may improve universal screening rates.

From Children’s Mercy Kansas City, Kansas City, MO.

Abstract

• Objective: To review functional gastrointestinal disorders (FGIDs) in children, with an emphasis on evidence-based diagnostic and treatment approaches.
• Methods: Review of the literature.
• Results: Chronic or recurrent abdominal pain is a common condition in children. No clinical practice guidelines currently exist for pediatric functional abdominal pain broadly or FGIDs more specifically. The Rome classification system includes several discrete diagnostic entities that are diagnosed based on symptom criteria in the absence of red flags. The prevailing biopsychosocial model of pediatric functional abdominal pain suggests that intervening to address biological factors, while providing coping skills and environmental supports to encourage functioning, offers the greatest likelihood of positive treatment outcomes and decreased disability.
• Conclusion: Simultaneously treating all contributors to pain maintenance in FGIDs offers the greatest promise in effectively breaking the pain cycle.

From Children’s Mercy Kansas City, Kansas City, MO.

Abstract

• Objective: To review functional gastrointestinal disorders (FGIDs) in children, with an emphasis on evidence-based diagnostic and treatment approaches.
• Methods: Review of the literature.
• Results: Chronic or recurrent abdominal pain is a common condition in children. No clinical practice guidelines currently exist for pediatric functional abdominal pain broadly or FGIDs more specifically. The Rome classification system includes several discrete diagnostic entities that are diagnosed based on symptom criteria in the absence of red flags. The prevailing biopsychosocial model of pediatric functional abdominal pain suggests that intervening to address biological factors, while providing coping skills and environmental supports to encourage functioning, offers the greatest likelihood of positive treatment outcomes and decreased disability.
• Conclusion: Simultaneously treating all contributors to pain maintenance in FGIDs offers the greatest promise in effectively breaking the pain cycle.

From Children’s Mercy Kansas City, Kansas City, MO.

Abstract

• Objective: To review functional gastrointestinal disorders (FGIDs) in children, with an emphasis on evidence-based diagnostic and treatment approaches.
• Methods: Review of the literature.
• Results: Chronic or recurrent abdominal pain is a common condition in children. No clinical practice guidelines currently exist for pediatric functional abdominal pain broadly or FGIDs more specifically. The Rome classification system includes several discrete diagnostic entities that are diagnosed based on symptom criteria in the absence of red flags. The prevailing biopsychosocial model of pediatric functional abdominal pain suggests that intervening to address biological factors, while providing coping skills and environmental supports to encourage functioning, offers the greatest likelihood of positive treatment outcomes and decreased disability.
• Conclusion: Simultaneously treating all contributors to pain maintenance in FGIDs offers the greatest promise in effectively breaking the pain cycle.

Stem cells in the

artificial bone marrow

Credit: C. Lee-Thedieck

Researchers say they have developed artificial bone marrow analogs that can be used to reproduce hematopoietic stem and progenitor cells (HSPCs).

The team created macroporous hydrogel scaffolds that mimic the stem cell niche of the bone marrow.

When they introduced mesenchymal stem cells (MSCs) from actual bone marrow into the analogs, the MSCs promoted HSPC proliferation.

In fact, the MSCs preserved HSPC stemness more effectively in the analogs than in standard 2-dimensional cell culture systems.

Annamarija Raic, of the Max Planck Institute for Intelligent Systems in Stuttgart, Germany, and her colleagues reported these results in Biomaterials.

The researchers noted that reproducing functional HSPCs in the lab has proven challenging. The cells cannot be cultured in vitro for a feasible period of time without differentiating.

So the team set out to create a culture system that mimics the important physical and biological parameters of the stem cell niche: the 3D architecture, the adhesive extracellular matrix, soluble factors, and the stromal cell compartment.

They used salt leaching technology to produce poly(ethylene glycol) diacrylate hydrogel scaffolds that could soak cells into their pores. To biofunctionalize the scaffolds, the investigators added an RGD peptide carrying an acrylate moiety.

They then introduced 3 different cell types into the scaffolds—the human osteosarcoma cell line CAL72, MSCs from bone marrow, and MSCs from umbilical cord blood—to see which best supported the proliferation of CD34+ HSPCs isolated from cord blood.

Each of the cell types supported HSPC proliferation, but bone marrow MSCs were the most effective. The researchers therefore decided to use bone marrow MSCs when they compared their 3D scaffolds to a 2D culture system.

The bone marrow MSCs had a beneficial effect on HSPC proliferation in the 2D cell cultures. Over 4 days, HSPCs divided 1 to 2 times more often when they were cultured with bone marrow MSCs than without the cells.

In the 3D scaffolds, HSPC proliferation was comparable or slightly lower than that observed in the 2D cultures. However, the scaffolds had a higher percentage of CD34+ HSPCs after 4 days.

The investigators therefore concluded that their hydrogel scaffolds meet the basic requirements for creating artificial stem cell niches.

Stem cells in the

artificial bone marrow

Credit: C. Lee-Thedieck

Researchers say they have developed artificial bone marrow analogs that can be used to reproduce hematopoietic stem and progenitor cells (HSPCs).

The team created macroporous hydrogel scaffolds that mimic the stem cell niche of the bone marrow.

When they introduced mesenchymal stem cells (MSCs) from actual bone marrow into the analogs, the MSCs promoted HSPC proliferation.

In fact, the MSCs preserved HSPC stemness more effectively in the analogs than in standard 2-dimensional cell culture systems.

Annamarija Raic, of the Max Planck Institute for Intelligent Systems in Stuttgart, Germany, and her colleagues reported these results in Biomaterials.

The researchers noted that reproducing functional HSPCs in the lab has proven challenging. The cells cannot be cultured in vitro for a feasible period of time without differentiating.

So the team set out to create a culture system that mimics the important physical and biological parameters of the stem cell niche: the 3D architecture, the adhesive extracellular matrix, soluble factors, and the stromal cell compartment.

They used salt leaching technology to produce poly(ethylene glycol) diacrylate hydrogel scaffolds that could soak cells into their pores. To biofunctionalize the scaffolds, the investigators added an RGD peptide carrying an acrylate moiety.

They then introduced 3 different cell types into the scaffolds—the human osteosarcoma cell line CAL72, MSCs from bone marrow, and MSCs from umbilical cord blood—to see which best supported the proliferation of CD34+ HSPCs isolated from cord blood.

Each of the cell types supported HSPC proliferation, but bone marrow MSCs were the most effective. The researchers therefore decided to use bone marrow MSCs when they compared their 3D scaffolds to a 2D culture system.

The bone marrow MSCs had a beneficial effect on HSPC proliferation in the 2D cell cultures. Over 4 days, HSPCs divided 1 to 2 times more often when they were cultured with bone marrow MSCs than without the cells.

In the 3D scaffolds, HSPC proliferation was comparable or slightly lower than that observed in the 2D cultures. However, the scaffolds had a higher percentage of CD34+ HSPCs after 4 days.

The investigators therefore concluded that their hydrogel scaffolds meet the basic requirements for creating artificial stem cell niches.

Stem cells in the

artificial bone marrow

Credit: C. Lee-Thedieck

Researchers say they have developed artificial bone marrow analogs that can be used to reproduce hematopoietic stem and progenitor cells (HSPCs).

The team created macroporous hydrogel scaffolds that mimic the stem cell niche of the bone marrow.

When they introduced mesenchymal stem cells (MSCs) from actual bone marrow into the analogs, the MSCs promoted HSPC proliferation.

In fact, the MSCs preserved HSPC stemness more effectively in the analogs than in standard 2-dimensional cell culture systems.

Annamarija Raic, of the Max Planck Institute for Intelligent Systems in Stuttgart, Germany, and her colleagues reported these results in Biomaterials.

The researchers noted that reproducing functional HSPCs in the lab has proven challenging. The cells cannot be cultured in vitro for a feasible period of time without differentiating.

So the team set out to create a culture system that mimics the important physical and biological parameters of the stem cell niche: the 3D architecture, the adhesive extracellular matrix, soluble factors, and the stromal cell compartment.

They used salt leaching technology to produce poly(ethylene glycol) diacrylate hydrogel scaffolds that could soak cells into their pores. To biofunctionalize the scaffolds, the investigators added an RGD peptide carrying an acrylate moiety.

They then introduced 3 different cell types into the scaffolds—the human osteosarcoma cell line CAL72, MSCs from bone marrow, and MSCs from umbilical cord blood—to see which best supported the proliferation of CD34+ HSPCs isolated from cord blood.

Each of the cell types supported HSPC proliferation, but bone marrow MSCs were the most effective. The researchers therefore decided to use bone marrow MSCs when they compared their 3D scaffolds to a 2D culture system.

The bone marrow MSCs had a beneficial effect on HSPC proliferation in the 2D cell cultures. Over 4 days, HSPCs divided 1 to 2 times more often when they were cultured with bone marrow MSCs than without the cells.

In the 3D scaffolds, HSPC proliferation was comparable or slightly lower than that observed in the 2D cultures. However, the scaffolds had a higher percentage of CD34+ HSPCs after 4 days.

The investigators therefore concluded that their hydrogel scaffolds meet the basic requirements for creating artificial stem cell niches.

NK cell in action

Credit: Bjorn Onfelt/Dan Davis

The parasites that cause malaria are adapted to the hosts they infect, so studying the disease in mice doesn’t necessarily reveal information that translates to human disease.

But scientists believe they may have overcome this limitation. They’ve developed a strain of mice that mimics many features of the human immune system and can be infected with Plasmodium falciparum.

Using this strain, the researchers discovered that natural killer (NK) cells preferentially interact with and kill infected red blood cells (RBCs) in a contact-dependent manner.

The group recounted this discovery in PNAS.

“Human malaria studies have been hampered by a lack of animal models,” said study author Jianzhu Chen, PhD, of the Singapore-MIT Alliance for Research and Technology in Singapore.

“This [research] paves the way to start dissecting how the host human immune system interacts with the pathogen.”

Scientists studying malaria in mice previously generated mice with human RBCs. But these mice have compromised immune systems, so they can’t be used to study the immune response to malaria infection.

Over the past several years, Dr Chen and his colleagues have developed strains of mice that have the human cells necessary for a comprehensive immune response.

To generate these cells, the researchers deliver human hematopoietic stem cells, along with cytokines that help them mature into B and T cells, NK cells, and macrophages. These mice have already proven useful to study other diseases, such as dengue fever.

To adapt the mice for the study of malaria, the scientists injected them with human RBCs every day for a week, at which point 25% of their RBCs were human. And this was enough for the malaria parasite to cause an infection.

The researchers investigated the role of NK cells and macrophages during the first 2 days of malaria infection. And they found that eliminating macrophages had very little impact on the immune response during those early stages.

However, in mice lacking NK cells, parasite levels went up 7-fold, suggesting that NK cells are critical to controlling infection early on.

To further investigate the role of NK cells, the scientists placed human NK cells in a sample of infected and uninfected RBCs. The NK cells randomly interacted with both types of cells, but they latched onto infected cells much longer, eventually killing them.

The researchers also identified a cell adhesion protein called LFA-1 that helps NK cells bind to RBCs. They are now studying this process in more detail and trying to determine what other molecules, including those produced by the malaria parasite, might be involved.

Dr Chen and his colleagues also hope to use these mice to study experimental malaria vaccines or drugs. And in another future study, they plan to inject the mice with RBCs from patients with sickle cell anemia to investigate how the sickle-shaped cells help people survive malaria infection.

NK cell in action

Credit: Bjorn Onfelt/Dan Davis

The parasites that cause malaria are adapted to the hosts they infect, so studying the disease in mice doesn’t necessarily reveal information that translates to human disease.

But scientists believe they may have overcome this limitation. They’ve developed a strain of mice that mimics many features of the human immune system and can be infected with Plasmodium falciparum.

Using this strain, the researchers discovered that natural killer (NK) cells preferentially interact with and kill infected red blood cells (RBCs) in a contact-dependent manner.

The group recounted this discovery in PNAS.

“Human malaria studies have been hampered by a lack of animal models,” said study author Jianzhu Chen, PhD, of the Singapore-MIT Alliance for Research and Technology in Singapore.

“This [research] paves the way to start dissecting how the host human immune system interacts with the pathogen.”

Scientists studying malaria in mice previously generated mice with human RBCs. But these mice have compromised immune systems, so they can’t be used to study the immune response to malaria infection.

Over the past several years, Dr Chen and his colleagues have developed strains of mice that have the human cells necessary for a comprehensive immune response.

To generate these cells, the researchers deliver human hematopoietic stem cells, along with cytokines that help them mature into B and T cells, NK cells, and macrophages. These mice have already proven useful to study other diseases, such as dengue fever.

To adapt the mice for the study of malaria, the scientists injected them with human RBCs every day for a week, at which point 25% of their RBCs were human. And this was enough for the malaria parasite to cause an infection.

The researchers investigated the role of NK cells and macrophages during the first 2 days of malaria infection. And they found that eliminating macrophages had very little impact on the immune response during those early stages.

However, in mice lacking NK cells, parasite levels went up 7-fold, suggesting that NK cells are critical to controlling infection early on.

To further investigate the role of NK cells, the scientists placed human NK cells in a sample of infected and uninfected RBCs. The NK cells randomly interacted with both types of cells, but they latched onto infected cells much longer, eventually killing them.

The researchers also identified a cell adhesion protein called LFA-1 that helps NK cells bind to RBCs. They are now studying this process in more detail and trying to determine what other molecules, including those produced by the malaria parasite, might be involved.

Dr Chen and his colleagues also hope to use these mice to study experimental malaria vaccines or drugs. And in another future study, they plan to inject the mice with RBCs from patients with sickle cell anemia to investigate how the sickle-shaped cells help people survive malaria infection.

NK cell in action

Credit: Bjorn Onfelt/Dan Davis

The parasites that cause malaria are adapted to the hosts they infect, so studying the disease in mice doesn’t necessarily reveal information that translates to human disease.

But scientists believe they may have overcome this limitation. They’ve developed a strain of mice that mimics many features of the human immune system and can be infected with Plasmodium falciparum.

Using this strain, the researchers discovered that natural killer (NK) cells preferentially interact with and kill infected red blood cells (RBCs) in a contact-dependent manner.

The group recounted this discovery in PNAS.

“Human malaria studies have been hampered by a lack of animal models,” said study author Jianzhu Chen, PhD, of the Singapore-MIT Alliance for Research and Technology in Singapore.

“This [research] paves the way to start dissecting how the host human immune system interacts with the pathogen.”

Scientists studying malaria in mice previously generated mice with human RBCs. But these mice have compromised immune systems, so they can’t be used to study the immune response to malaria infection.

Over the past several years, Dr Chen and his colleagues have developed strains of mice that have the human cells necessary for a comprehensive immune response.

To generate these cells, the researchers deliver human hematopoietic stem cells, along with cytokines that help them mature into B and T cells, NK cells, and macrophages. These mice have already proven useful to study other diseases, such as dengue fever.

To adapt the mice for the study of malaria, the scientists injected them with human RBCs every day for a week, at which point 25% of their RBCs were human. And this was enough for the malaria parasite to cause an infection.

The researchers investigated the role of NK cells and macrophages during the first 2 days of malaria infection. And they found that eliminating macrophages had very little impact on the immune response during those early stages.

However, in mice lacking NK cells, parasite levels went up 7-fold, suggesting that NK cells are critical to controlling infection early on.

To further investigate the role of NK cells, the scientists placed human NK cells in a sample of infected and uninfected RBCs. The NK cells randomly interacted with both types of cells, but they latched onto infected cells much longer, eventually killing them.

The researchers also identified a cell adhesion protein called LFA-1 that helps NK cells bind to RBCs. They are now studying this process in more detail and trying to determine what other molecules, including those produced by the malaria parasite, might be involved.

Dr Chen and his colleagues also hope to use these mice to study experimental malaria vaccines or drugs. And in another future study, they plan to inject the mice with RBCs from patients with sickle cell anemia to investigate how the sickle-shaped cells help people survive malaria infection.

Doctor consults with a family

Credit: Rhoda Baer

As implementation of the Affordable Care Act (ACA) continues, a new report indicates that most community health centers across the US are attempting to help uninsured individuals obtain health insurance.

But health centers in certain states are hampered in their outreach and enrollment efforts and are significantly less optimistic about the impact of health reform in their communities.

“These findings show the effects of state policies that are designed to stand in the way of health reform,” said study author Sara Rosenbaum, of the George Washington University School of Public Health and Health Services in Washington, DC.

“These restrictive policies are measurably impairing community-level efforts to cover the uninsured. Without the Medicaid expansion or comprehensive enrollment assistance, millions of people in medically underserved communities could go without the benefits provided under the Affordable Care Act.”

Using data from a nationwide survey, Rosenbaum and her colleagues examined the early outreach and enrollment efforts of 606 community health centers across the US.

The data showed that, by early October 2013, virtually all of the responding health centers had received enhanced outreach funding.

And three quarters of them had already instituted expanded outreach and enrollment assistance efforts, such as one-on-one assistance with online and paper applications for health insurance, and enrollment help in multiple languages.

The researchers also compared health center outreach and enrollment in the 21 states (and Washington DC) that have embraced health reform to health centers in 9 states that have resisted or rejected key parts of the ACA.

The 9 “restrictive” states were those that had rejected an expansion of Medicaid and adopted policies or Navigator laws that make it harder to provide assistance to the uninsured.

The comparison showed that community health centers in the restrictive states had significantly more limited outreach and enrollment resources and had significantly fewer enrollment staff. Restrictive states had an average of 3 full-time enrollment staff members, compared to 6 staff members in full-implementation states.

Furthermore, health centers in restrictive states were significantly less likely than those in full-implementation states to be assessing patient eligibility for insurance coverage—59% and 79%, respectively.

And health centers in the 9 restrictive states were significantly less optimistic about the potential impact of the ACA on their patients.

In restrictive states, nearly 1 in 6 health center leaders expected at least half of their patients to remain uninsured. In full-implementation states, only 2% of leaders said the same.

For more details, see the full report, “Assessing the Potential Impact of State Policies on Community Health Centers’ Outreach and Enrollment Activities.”

Doctor consults with a family

Credit: Rhoda Baer

As implementation of the Affordable Care Act (ACA) continues, a new report indicates that most community health centers across the US are attempting to help uninsured individuals obtain health insurance.

But health centers in certain states are hampered in their outreach and enrollment efforts and are significantly less optimistic about the impact of health reform in their communities.

“These findings show the effects of state policies that are designed to stand in the way of health reform,” said study author Sara Rosenbaum, of the George Washington University School of Public Health and Health Services in Washington, DC.

“These restrictive policies are measurably impairing community-level efforts to cover the uninsured. Without the Medicaid expansion or comprehensive enrollment assistance, millions of people in medically underserved communities could go without the benefits provided under the Affordable Care Act.”

Using data from a nationwide survey, Rosenbaum and her colleagues examined the early outreach and enrollment efforts of 606 community health centers across the US.

The data showed that, by early October 2013, virtually all of the responding health centers had received enhanced outreach funding.

And three quarters of them had already instituted expanded outreach and enrollment assistance efforts, such as one-on-one assistance with online and paper applications for health insurance, and enrollment help in multiple languages.

The researchers also compared health center outreach and enrollment in the 21 states (and Washington DC) that have embraced health reform to health centers in 9 states that have resisted or rejected key parts of the ACA.

The 9 “restrictive” states were those that had rejected an expansion of Medicaid and adopted policies or Navigator laws that make it harder to provide assistance to the uninsured.

The comparison showed that community health centers in the restrictive states had significantly more limited outreach and enrollment resources and had significantly fewer enrollment staff. Restrictive states had an average of 3 full-time enrollment staff members, compared to 6 staff members in full-implementation states.

Furthermore, health centers in restrictive states were significantly less likely than those in full-implementation states to be assessing patient eligibility for insurance coverage—59% and 79%, respectively.

And health centers in the 9 restrictive states were significantly less optimistic about the potential impact of the ACA on their patients.

In restrictive states, nearly 1 in 6 health center leaders expected at least half of their patients to remain uninsured. In full-implementation states, only 2% of leaders said the same.

For more details, see the full report, “Assessing the Potential Impact of State Policies on Community Health Centers’ Outreach and Enrollment Activities.”

Doctor consults with a family

Credit: Rhoda Baer

As implementation of the Affordable Care Act (ACA) continues, a new report indicates that most community health centers across the US are attempting to help uninsured individuals obtain health insurance.

But health centers in certain states are hampered in their outreach and enrollment efforts and are significantly less optimistic about the impact of health reform in their communities.

“These findings show the effects of state policies that are designed to stand in the way of health reform,” said study author Sara Rosenbaum, of the George Washington University School of Public Health and Health Services in Washington, DC.

“These restrictive policies are measurably impairing community-level efforts to cover the uninsured. Without the Medicaid expansion or comprehensive enrollment assistance, millions of people in medically underserved communities could go without the benefits provided under the Affordable Care Act.”

Using data from a nationwide survey, Rosenbaum and her colleagues examined the early outreach and enrollment efforts of 606 community health centers across the US.

The data showed that, by early October 2013, virtually all of the responding health centers had received enhanced outreach funding.

And three quarters of them had already instituted expanded outreach and enrollment assistance efforts, such as one-on-one assistance with online and paper applications for health insurance, and enrollment help in multiple languages.

The researchers also compared health center outreach and enrollment in the 21 states (and Washington DC) that have embraced health reform to health centers in 9 states that have resisted or rejected key parts of the ACA.

The 9 “restrictive” states were those that had rejected an expansion of Medicaid and adopted policies or Navigator laws that make it harder to provide assistance to the uninsured.

The comparison showed that community health centers in the restrictive states had significantly more limited outreach and enrollment resources and had significantly fewer enrollment staff. Restrictive states had an average of 3 full-time enrollment staff members, compared to 6 staff members in full-implementation states.

Furthermore, health centers in restrictive states were significantly less likely than those in full-implementation states to be assessing patient eligibility for insurance coverage—59% and 79%, respectively.

And health centers in the 9 restrictive states were significantly less optimistic about the potential impact of the ACA on their patients.

In restrictive states, nearly 1 in 6 health center leaders expected at least half of their patients to remain uninsured. In full-implementation states, only 2% of leaders said the same.

For more details, see the full report, “Assessing the Potential Impact of State Policies on Community Health Centers’ Outreach and Enrollment Activities.”

An earlier column reviewed the institution of marriage up to the middle of the last century. Since the 1950s, postmodernism has been gathering momentum, beginning as a critique of art, architecture, philosophy, and how we think about society and culture. Views on many aspects of our lives, as we live it, began to change.

Postmodernism stands in contrast to the "modern’ " or scientific view that touts a singularity of truth and a singular view of the world. Social construction is a type of postmodern theory that states that truth, reality, and knowledge are based in the social context of that particular person. This aspect of postmodernism is most applicable to mental health professionals assessing and treating patients, and to families in specific social and cultural contexts.

A postmodern view of the family considers the traditional view of the family, the "nuclear family," as only one view. Other forms of family and other views of marriage that had been marginalized, considered deviant and nonconforming, are now brought forward and considered as viable alternatives. Postmodernism discards many assumptions that we have been taught. One assumption that is being reexamined, for example, is that sexual nonexclusivity or extra-relationship sex, or romantic involvements are symptoms of troubled relationships or forms of sexual acting out.

Another assumption that needs to be reexamined is the notion that family structures found in other cultures are "abnormal" or dysfunctional. These assumptions are not necessarily true or false but require assessment in context of the relationship at hand. Postmodernism challenges us to assess each family variation on its own merit.

Beginnings

In the 20th century, Monica McGoldrick, Ph.D., one of the strong voices in family therapy, advocated for increased sensitivity to cultural variation. Her book, "Ethnicity and Family Therapy" (New York: The Guilford Press, 2005), describes characteristics of common ethnicities in American society.

Family therapists have attempted to address "nontraditional" families with articles, for example, about raising a biracial child, what to do if your child identifies as gay, etc. Most older articles focused on helping families "cope" with the nontraditional. Family therapists are now more willing to acknowledge "difference" as a normal rather than a pathological variant, and to recognize strengths inherent in diversity.

Acknowledging diversity

Marlene F. Watson, Ph.D., brings a nuanced understanding of the African American family, detailing the effect of slavery on the individuals in the family, and how internalized racism can be recognized and managed in family therapy (e-book, "Facing the Black Shadow," 2013). This is an important book for therapists, especially those who come from traditional families, as it articulates the reality of African American lives in a way that therapists can apply to clinical practice.

Dr. Watson illustrates through case examples how internalized racism affects marriages, and offers effective ways to help couples negotiate and overcome the negative aspects of their heritage. A postmodern stance also will help the couple recognize the resilience and strengths that are inherent in overcoming adversity.

Linda M. Burton, Ph.D., and Cecily R. Hardaway, Ph.D., highlight the role of "othermothers" in raising children in low-income families, be they white, Latino, or African American. They define "othermothering" as a form of coparenting, distinct from stepparenting. Women othermother children who are their romantic partners’ children from previous and concurrent relationships. Compared to stepfamilies, these multiple partner fertility relationships are more prevalent among young couples with limited financial resources, contentious relationships, and serial childbearing through serial repartnering.

In general, low-income women and women of color take on this style of coparenting to help the biological parents of relatives and friends who have limited social and psychological capital to protect and raise "good children"(Fam. Process. 2012;51:343-59). Family therapists will become much more effective if they understand and recognize that the motivation behind this form of mothering fosters resilience in the mothers. The more we know and understand alternate family structures, the more we can work toward building and sustaining resilience.

Assimilation has for many decades been the main focus of political and therapeutic endeavors. In postmodern times, transnationalism described a new way of thinking about relationships that extend across national boundaries and cultures (Fam. Process. 2007;46:157-71).

Immigrants maintain connections with their countries of origin with children who are parented by grandparents, or other relatives, perhaps in several countries at the same time. Family members use Skype, often daily, to connect with the matriarch or patriarch "back home."

Postmodern theories of social justice and cultural diversity work well with immigrants, bringing multiple perspectives into the treatment room. Immigrants bring many complex and diverse values in relation to marriage, gender, parenting, and religious practices. A social justice approach focuses on the racism and discrimination that is common in the lives of immigrants. Marriage might take place across nations, be arranged, or might be mixed race or mixed nationalities. Therapy that acknowledges these complexities will be most helpful. We still need to think further about global family life, how relationships evolve over long distances, and how to develop systemic and transnational interventions for separations and reunifications.

Sex and marriage

Nelson Mandela’s father had four wives, and he reported in an interview that he considered all of them his mothers and gained support from them all.

Polygamy has flourished in Africa and Asia for centuries, and more than 40 countries recognize polygamous marriages. In the former Soviet republic of Kazakhstan, rich Kazakhs used to buy second wives from parents, often in exchange for livestock. Since Kazakhstan’s independence in 1991, polygamy, although illegal, has again become common practice and is a status symbol for rich Kazakhs. Polygamy reportedly also is a way out of poverty for young women who save money and support their relatives back home

In the United Kingdom, polygamy has become more common in Muslim communities. Successful British Muslim women, who have delayed marriage to build careers, may choose to become a co-wife. They choose to share a husband in a relationship that they see as sanctioned by Islam. These women retain an independent lifestyle. "I didn’t want a full-time husband," one Muslim woman noted in an interview.

In the United States, the practice of polygamy was officially ended in the Mormon church in 1890. Nevertheless, several small "fundamentalist" groups continue the practice. One family of 14 wives and 17 children, the Browns of Nevada, are stars of a reality show that they reportedly hope educates the public about the choice.

Polyandry, a woman with multiple husbands, is described in many cultures. This practice frequently involves the marriage of all brothers in a family to the same wife, which allows family-owned land to remain undivided. In some cultures, such as the Inuit, a man might arrange a second husband (frequently his brother) for his wife because he knows that, when he is absent, the second husband will protect his wife. Should she become pregnant while he is gone, it would be by someone he had approved in advance.

Penn State’s Stephen Beckerman, Ph.D., and his colleagues, in their study of the Bari people of Venezuela, found that children understood to have two fathers are significantly more likely to survive to age 15 than are children with only one. This is called "informal polyandry," because while the two fathers might not be formally married to and living with the mother in all cases, the society around them officially recognizes both men as legitimate mates to the mother, and father to her child.

Polyamory, the practice of open, multiple-partner relationships, is a structure that is increasingly common in Western countries, according to sociologist Elisabeth Sheff, Ph.D. Dr. Sheff’s 15 years of research leads her to believe that polyamory is a "legitimate relationship style that can be tremendously rewarding for adults and provide excellent nurturing for children."

She said she has found that children aged 5-8 do not seem to care about how the adults relate to one another, as long as they are taken care of. Overall, such children seem to fare well as long as they live in stable, loving homes.

Making this practice work, she acknowledges, is "time consuming and potentially fraught with emotional booby traps." People in polyamorous relationships emphasize that their relationships are about emotional connections with others, as opposed to primarily physical relationships.

The term polyfidelity, a subset of polyamory, was coined in the 1970s by members of the Kerista commune, which started in New York City in 1956. Polyfidelity is a concept in which clusters of friends form nonmonogamous sexual relationships. Under this family structure, group members do not relate sexually to anyone outside of the family group.

Although mainstream Judaism does not accept polyamory, some people do consider themselves Jewish and polyamorous. Sharon Kleinbaum, the senior rabbi at Congregation Beit Simchat Torah in New York, has said that polyamory is a choice that does not preclude a Jewishly observant, socially conscious life. Some polyamorous Jews also point to biblical patriarchs having multiple wives and concubines as evidence that polyamorous relationships can be sacred in Judaism.

Jim Fleckenstein, director of the Institute for 21st-Century Relationships, has said that the polyamory movement has been driven by science fiction and feminism. He states that disillusionment with monogamy occurs "because of widespread cheating and divorce."

One fact going for the polys (as they are often known), is the belief that polyamory is more honest and less hypocritical than monogamy with secret affairs. A manual, "What Psychology Professionals Should Know About Polyamory," for psychotherapists who deal with polyamorous clients, was published in September 2009 by the National Coalition for Sexual Freedom.

The late Michael Shernoff, who was an openly gay psychotherapist, wrote that nonmonogamy is "a well-accepted part of gay subculture," and that somewhere between 30% and 67% of men in male couples reported being in a sexually nonmonogamous relationship. A majority of male couples are not sexually exclusive, but describe themselves as emotionally monogamous.

Mr. Shernoff stated: One of the biggest differences between male couples and mixed-sex couples is that many, but by no means all, within the gay community have an easier acceptance of sexual nonexclusivity than does heterosexual society in general. Research confirms that nonmonogamy in and of itself does not create a problem for male couples when it has been openly negotiated (Fam. Process. 2006;45:407-18).

The role of affairs in marriage can now be subjected to a more nuanced discussion, after digesting the above views and practice of marriage. What is the meaning of an affair? What is an open relationship? What are the models of intimacy? Is an affair a breach in the couple’s definition of intimacy? What are the rules? How does a couple define an affair within the context of their own relationship?

Conclusion

Postmodernism provides family therapists a new set of theories and a new language for describing the variety of families. As Jacqueline Hudak, Ph.D., and Shawn V. Giammattei, Ph.D., have written: "As family therapists, we are uniquely poised to transform the meanings attached to ‘marriage’ and ‘family,’ to focus on the quality of relationships rather than on the gender of a partner or the assumption of particular roles" ("Expanding Our Social Justice Practices: Advances in Theory and Practice," Washington: American Family Therapy Academy, Winter 2010).

The traditional view of marriage is referred to as "heteronormativity" and is defined by the belief that a viable family consists of "a heterosexual mother and a father raising heterosexual children together" ("Handbook of Qualitative Research," Thousand Oaks, Calif.:Sage, 2000). Despite the above expansion of views on marriage and families, heteronormativity remains the current organizing principle of family theory, practice, research, and training. It will take many decades to shift the dominant paradigm. Developing awareness, and listening to families and couples is the first step.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

An earlier column reviewed the institution of marriage up to the middle of the last century. Since the 1950s, postmodernism has been gathering momentum, beginning as a critique of art, architecture, philosophy, and how we think about society and culture. Views on many aspects of our lives, as we live it, began to change.

Postmodernism stands in contrast to the "modern’ " or scientific view that touts a singularity of truth and a singular view of the world. Social construction is a type of postmodern theory that states that truth, reality, and knowledge are based in the social context of that particular person. This aspect of postmodernism is most applicable to mental health professionals assessing and treating patients, and to families in specific social and cultural contexts.

A postmodern view of the family considers the traditional view of the family, the "nuclear family," as only one view. Other forms of family and other views of marriage that had been marginalized, considered deviant and nonconforming, are now brought forward and considered as viable alternatives. Postmodernism discards many assumptions that we have been taught. One assumption that is being reexamined, for example, is that sexual nonexclusivity or extra-relationship sex, or romantic involvements are symptoms of troubled relationships or forms of sexual acting out.

Another assumption that needs to be reexamined is the notion that family structures found in other cultures are "abnormal" or dysfunctional. These assumptions are not necessarily true or false but require assessment in context of the relationship at hand. Postmodernism challenges us to assess each family variation on its own merit.

Beginnings

In the 20th century, Monica McGoldrick, Ph.D., one of the strong voices in family therapy, advocated for increased sensitivity to cultural variation. Her book, "Ethnicity and Family Therapy" (New York: The Guilford Press, 2005), describes characteristics of common ethnicities in American society.

Family therapists have attempted to address "nontraditional" families with articles, for example, about raising a biracial child, what to do if your child identifies as gay, etc. Most older articles focused on helping families "cope" with the nontraditional. Family therapists are now more willing to acknowledge "difference" as a normal rather than a pathological variant, and to recognize strengths inherent in diversity.

Acknowledging diversity

Marlene F. Watson, Ph.D., brings a nuanced understanding of the African American family, detailing the effect of slavery on the individuals in the family, and how internalized racism can be recognized and managed in family therapy (e-book, "Facing the Black Shadow," 2013). This is an important book for therapists, especially those who come from traditional families, as it articulates the reality of African American lives in a way that therapists can apply to clinical practice.

Dr. Watson illustrates through case examples how internalized racism affects marriages, and offers effective ways to help couples negotiate and overcome the negative aspects of their heritage. A postmodern stance also will help the couple recognize the resilience and strengths that are inherent in overcoming adversity.

Linda M. Burton, Ph.D., and Cecily R. Hardaway, Ph.D., highlight the role of "othermothers" in raising children in low-income families, be they white, Latino, or African American. They define "othermothering" as a form of coparenting, distinct from stepparenting. Women othermother children who are their romantic partners’ children from previous and concurrent relationships. Compared to stepfamilies, these multiple partner fertility relationships are more prevalent among young couples with limited financial resources, contentious relationships, and serial childbearing through serial repartnering.

In general, low-income women and women of color take on this style of coparenting to help the biological parents of relatives and friends who have limited social and psychological capital to protect and raise "good children"(Fam. Process. 2012;51:343-59). Family therapists will become much more effective if they understand and recognize that the motivation behind this form of mothering fosters resilience in the mothers. The more we know and understand alternate family structures, the more we can work toward building and sustaining resilience.

Assimilation has for many decades been the main focus of political and therapeutic endeavors. In postmodern times, transnationalism described a new way of thinking about relationships that extend across national boundaries and cultures (Fam. Process. 2007;46:157-71).

Immigrants maintain connections with their countries of origin with children who are parented by grandparents, or other relatives, perhaps in several countries at the same time. Family members use Skype, often daily, to connect with the matriarch or patriarch "back home."

Postmodern theories of social justice and cultural diversity work well with immigrants, bringing multiple perspectives into the treatment room. Immigrants bring many complex and diverse values in relation to marriage, gender, parenting, and religious practices. A social justice approach focuses on the racism and discrimination that is common in the lives of immigrants. Marriage might take place across nations, be arranged, or might be mixed race or mixed nationalities. Therapy that acknowledges these complexities will be most helpful. We still need to think further about global family life, how relationships evolve over long distances, and how to develop systemic and transnational interventions for separations and reunifications.

Sex and marriage

Nelson Mandela’s father had four wives, and he reported in an interview that he considered all of them his mothers and gained support from them all.

Polygamy has flourished in Africa and Asia for centuries, and more than 40 countries recognize polygamous marriages. In the former Soviet republic of Kazakhstan, rich Kazakhs used to buy second wives from parents, often in exchange for livestock. Since Kazakhstan’s independence in 1991, polygamy, although illegal, has again become common practice and is a status symbol for rich Kazakhs. Polygamy reportedly also is a way out of poverty for young women who save money and support their relatives back home

In the United Kingdom, polygamy has become more common in Muslim communities. Successful British Muslim women, who have delayed marriage to build careers, may choose to become a co-wife. They choose to share a husband in a relationship that they see as sanctioned by Islam. These women retain an independent lifestyle. "I didn’t want a full-time husband," one Muslim woman noted in an interview.

In the United States, the practice of polygamy was officially ended in the Mormon church in 1890. Nevertheless, several small "fundamentalist" groups continue the practice. One family of 14 wives and 17 children, the Browns of Nevada, are stars of a reality show that they reportedly hope educates the public about the choice.

Polyandry, a woman with multiple husbands, is described in many cultures. This practice frequently involves the marriage of all brothers in a family to the same wife, which allows family-owned land to remain undivided. In some cultures, such as the Inuit, a man might arrange a second husband (frequently his brother) for his wife because he knows that, when he is absent, the second husband will protect his wife. Should she become pregnant while he is gone, it would be by someone he had approved in advance.

Penn State’s Stephen Beckerman, Ph.D., and his colleagues, in their study of the Bari people of Venezuela, found that children understood to have two fathers are significantly more likely to survive to age 15 than are children with only one. This is called "informal polyandry," because while the two fathers might not be formally married to and living with the mother in all cases, the society around them officially recognizes both men as legitimate mates to the mother, and father to her child.

Polyamory, the practice of open, multiple-partner relationships, is a structure that is increasingly common in Western countries, according to sociologist Elisabeth Sheff, Ph.D. Dr. Sheff’s 15 years of research leads her to believe that polyamory is a "legitimate relationship style that can be tremendously rewarding for adults and provide excellent nurturing for children."

She said she has found that children aged 5-8 do not seem to care about how the adults relate to one another, as long as they are taken care of. Overall, such children seem to fare well as long as they live in stable, loving homes.

Making this practice work, she acknowledges, is "time consuming and potentially fraught with emotional booby traps." People in polyamorous relationships emphasize that their relationships are about emotional connections with others, as opposed to primarily physical relationships.

The term polyfidelity, a subset of polyamory, was coined in the 1970s by members of the Kerista commune, which started in New York City in 1956. Polyfidelity is a concept in which clusters of friends form nonmonogamous sexual relationships. Under this family structure, group members do not relate sexually to anyone outside of the family group.

Although mainstream Judaism does not accept polyamory, some people do consider themselves Jewish and polyamorous. Sharon Kleinbaum, the senior rabbi at Congregation Beit Simchat Torah in New York, has said that polyamory is a choice that does not preclude a Jewishly observant, socially conscious life. Some polyamorous Jews also point to biblical patriarchs having multiple wives and concubines as evidence that polyamorous relationships can be sacred in Judaism.

Jim Fleckenstein, director of the Institute for 21st-Century Relationships, has said that the polyamory movement has been driven by science fiction and feminism. He states that disillusionment with monogamy occurs "because of widespread cheating and divorce."

One fact going for the polys (as they are often known), is the belief that polyamory is more honest and less hypocritical than monogamy with secret affairs. A manual, "What Psychology Professionals Should Know About Polyamory," for psychotherapists who deal with polyamorous clients, was published in September 2009 by the National Coalition for Sexual Freedom.

The late Michael Shernoff, who was an openly gay psychotherapist, wrote that nonmonogamy is "a well-accepted part of gay subculture," and that somewhere between 30% and 67% of men in male couples reported being in a sexually nonmonogamous relationship. A majority of male couples are not sexually exclusive, but describe themselves as emotionally monogamous.

Mr. Shernoff stated: One of the biggest differences between male couples and mixed-sex couples is that many, but by no means all, within the gay community have an easier acceptance of sexual nonexclusivity than does heterosexual society in general. Research confirms that nonmonogamy in and of itself does not create a problem for male couples when it has been openly negotiated (Fam. Process. 2006;45:407-18).

The role of affairs in marriage can now be subjected to a more nuanced discussion, after digesting the above views and practice of marriage. What is the meaning of an affair? What is an open relationship? What are the models of intimacy? Is an affair a breach in the couple’s definition of intimacy? What are the rules? How does a couple define an affair within the context of their own relationship?

Conclusion

Postmodernism provides family therapists a new set of theories and a new language for describing the variety of families. As Jacqueline Hudak, Ph.D., and Shawn V. Giammattei, Ph.D., have written: "As family therapists, we are uniquely poised to transform the meanings attached to ‘marriage’ and ‘family,’ to focus on the quality of relationships rather than on the gender of a partner or the assumption of particular roles" ("Expanding Our Social Justice Practices: Advances in Theory and Practice," Washington: American Family Therapy Academy, Winter 2010).

The traditional view of marriage is referred to as "heteronormativity" and is defined by the belief that a viable family consists of "a heterosexual mother and a father raising heterosexual children together" ("Handbook of Qualitative Research," Thousand Oaks, Calif.:Sage, 2000). Despite the above expansion of views on marriage and families, heteronormativity remains the current organizing principle of family theory, practice, research, and training. It will take many decades to shift the dominant paradigm. Developing awareness, and listening to families and couples is the first step.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).

An earlier column reviewed the institution of marriage up to the middle of the last century. Since the 1950s, postmodernism has been gathering momentum, beginning as a critique of art, architecture, philosophy, and how we think about society and culture. Views on many aspects of our lives, as we live it, began to change.

Postmodernism stands in contrast to the "modern’ " or scientific view that touts a singularity of truth and a singular view of the world. Social construction is a type of postmodern theory that states that truth, reality, and knowledge are based in the social context of that particular person. This aspect of postmodernism is most applicable to mental health professionals assessing and treating patients, and to families in specific social and cultural contexts.

A postmodern view of the family considers the traditional view of the family, the "nuclear family," as only one view. Other forms of family and other views of marriage that had been marginalized, considered deviant and nonconforming, are now brought forward and considered as viable alternatives. Postmodernism discards many assumptions that we have been taught. One assumption that is being reexamined, for example, is that sexual nonexclusivity or extra-relationship sex, or romantic involvements are symptoms of troubled relationships or forms of sexual acting out.

Another assumption that needs to be reexamined is the notion that family structures found in other cultures are "abnormal" or dysfunctional. These assumptions are not necessarily true or false but require assessment in context of the relationship at hand. Postmodernism challenges us to assess each family variation on its own merit.

Beginnings

In the 20th century, Monica McGoldrick, Ph.D., one of the strong voices in family therapy, advocated for increased sensitivity to cultural variation. Her book, "Ethnicity and Family Therapy" (New York: The Guilford Press, 2005), describes characteristics of common ethnicities in American society.

Family therapists have attempted to address "nontraditional" families with articles, for example, about raising a biracial child, what to do if your child identifies as gay, etc. Most older articles focused on helping families "cope" with the nontraditional. Family therapists are now more willing to acknowledge "difference" as a normal rather than a pathological variant, and to recognize strengths inherent in diversity.

Acknowledging diversity

Marlene F. Watson, Ph.D., brings a nuanced understanding of the African American family, detailing the effect of slavery on the individuals in the family, and how internalized racism can be recognized and managed in family therapy (e-book, "Facing the Black Shadow," 2013). This is an important book for therapists, especially those who come from traditional families, as it articulates the reality of African American lives in a way that therapists can apply to clinical practice.

Dr. Watson illustrates through case examples how internalized racism affects marriages, and offers effective ways to help couples negotiate and overcome the negative aspects of their heritage. A postmodern stance also will help the couple recognize the resilience and strengths that are inherent in overcoming adversity.

Linda M. Burton, Ph.D., and Cecily R. Hardaway, Ph.D., highlight the role of "othermothers" in raising children in low-income families, be they white, Latino, or African American. They define "othermothering" as a form of coparenting, distinct from stepparenting. Women othermother children who are their romantic partners’ children from previous and concurrent relationships. Compared to stepfamilies, these multiple partner fertility relationships are more prevalent among young couples with limited financial resources, contentious relationships, and serial childbearing through serial repartnering.

In general, low-income women and women of color take on this style of coparenting to help the biological parents of relatives and friends who have limited social and psychological capital to protect and raise "good children"(Fam. Process. 2012;51:343-59). Family therapists will become much more effective if they understand and recognize that the motivation behind this form of mothering fosters resilience in the mothers. The more we know and understand alternate family structures, the more we can work toward building and sustaining resilience.

Assimilation has for many decades been the main focus of political and therapeutic endeavors. In postmodern times, transnationalism described a new way of thinking about relationships that extend across national boundaries and cultures (Fam. Process. 2007;46:157-71).

Immigrants maintain connections with their countries of origin with children who are parented by grandparents, or other relatives, perhaps in several countries at the same time. Family members use Skype, often daily, to connect with the matriarch or patriarch "back home."

Postmodern theories of social justice and cultural diversity work well with immigrants, bringing multiple perspectives into the treatment room. Immigrants bring many complex and diverse values in relation to marriage, gender, parenting, and religious practices. A social justice approach focuses on the racism and discrimination that is common in the lives of immigrants. Marriage might take place across nations, be arranged, or might be mixed race or mixed nationalities. Therapy that acknowledges these complexities will be most helpful. We still need to think further about global family life, how relationships evolve over long distances, and how to develop systemic and transnational interventions for separations and reunifications.

Sex and marriage

Nelson Mandela’s father had four wives, and he reported in an interview that he considered all of them his mothers and gained support from them all.

Polygamy has flourished in Africa and Asia for centuries, and more than 40 countries recognize polygamous marriages. In the former Soviet republic of Kazakhstan, rich Kazakhs used to buy second wives from parents, often in exchange for livestock. Since Kazakhstan’s independence in 1991, polygamy, although illegal, has again become common practice and is a status symbol for rich Kazakhs. Polygamy reportedly also is a way out of poverty for young women who save money and support their relatives back home

In the United Kingdom, polygamy has become more common in Muslim communities. Successful British Muslim women, who have delayed marriage to build careers, may choose to become a co-wife. They choose to share a husband in a relationship that they see as sanctioned by Islam. These women retain an independent lifestyle. "I didn’t want a full-time husband," one Muslim woman noted in an interview.

In the United States, the practice of polygamy was officially ended in the Mormon church in 1890. Nevertheless, several small "fundamentalist" groups continue the practice. One family of 14 wives and 17 children, the Browns of Nevada, are stars of a reality show that they reportedly hope educates the public about the choice.

Polyandry, a woman with multiple husbands, is described in many cultures. This practice frequently involves the marriage of all brothers in a family to the same wife, which allows family-owned land to remain undivided. In some cultures, such as the Inuit, a man might arrange a second husband (frequently his brother) for his wife because he knows that, when he is absent, the second husband will protect his wife. Should she become pregnant while he is gone, it would be by someone he had approved in advance.

Penn State’s Stephen Beckerman, Ph.D., and his colleagues, in their study of the Bari people of Venezuela, found that children understood to have two fathers are significantly more likely to survive to age 15 than are children with only one. This is called "informal polyandry," because while the two fathers might not be formally married to and living with the mother in all cases, the society around them officially recognizes both men as legitimate mates to the mother, and father to her child.

Polyamory, the practice of open, multiple-partner relationships, is a structure that is increasingly common in Western countries, according to sociologist Elisabeth Sheff, Ph.D. Dr. Sheff’s 15 years of research leads her to believe that polyamory is a "legitimate relationship style that can be tremendously rewarding for adults and provide excellent nurturing for children."

She said she has found that children aged 5-8 do not seem to care about how the adults relate to one another, as long as they are taken care of. Overall, such children seem to fare well as long as they live in stable, loving homes.

Making this practice work, she acknowledges, is "time consuming and potentially fraught with emotional booby traps." People in polyamorous relationships emphasize that their relationships are about emotional connections with others, as opposed to primarily physical relationships.

The term polyfidelity, a subset of polyamory, was coined in the 1970s by members of the Kerista commune, which started in New York City in 1956. Polyfidelity is a concept in which clusters of friends form nonmonogamous sexual relationships. Under this family structure, group members do not relate sexually to anyone outside of the family group.

Although mainstream Judaism does not accept polyamory, some people do consider themselves Jewish and polyamorous. Sharon Kleinbaum, the senior rabbi at Congregation Beit Simchat Torah in New York, has said that polyamory is a choice that does not preclude a Jewishly observant, socially conscious life. Some polyamorous Jews also point to biblical patriarchs having multiple wives and concubines as evidence that polyamorous relationships can be sacred in Judaism.

Jim Fleckenstein, director of the Institute for 21st-Century Relationships, has said that the polyamory movement has been driven by science fiction and feminism. He states that disillusionment with monogamy occurs "because of widespread cheating and divorce."

One fact going for the polys (as they are often known), is the belief that polyamory is more honest and less hypocritical than monogamy with secret affairs. A manual, "What Psychology Professionals Should Know About Polyamory," for psychotherapists who deal with polyamorous clients, was published in September 2009 by the National Coalition for Sexual Freedom.

The late Michael Shernoff, who was an openly gay psychotherapist, wrote that nonmonogamy is "a well-accepted part of gay subculture," and that somewhere between 30% and 67% of men in male couples reported being in a sexually nonmonogamous relationship. A majority of male couples are not sexually exclusive, but describe themselves as emotionally monogamous.

Mr. Shernoff stated: One of the biggest differences between male couples and mixed-sex couples is that many, but by no means all, within the gay community have an easier acceptance of sexual nonexclusivity than does heterosexual society in general. Research confirms that nonmonogamy in and of itself does not create a problem for male couples when it has been openly negotiated (Fam. Process. 2006;45:407-18).

The role of affairs in marriage can now be subjected to a more nuanced discussion, after digesting the above views and practice of marriage. What is the meaning of an affair? What is an open relationship? What are the models of intimacy? Is an affair a breach in the couple’s definition of intimacy? What are the rules? How does a couple define an affair within the context of their own relationship?

Conclusion

Postmodernism provides family therapists a new set of theories and a new language for describing the variety of families. As Jacqueline Hudak, Ph.D., and Shawn V. Giammattei, Ph.D., have written: "As family therapists, we are uniquely poised to transform the meanings attached to ‘marriage’ and ‘family,’ to focus on the quality of relationships rather than on the gender of a partner or the assumption of particular roles" ("Expanding Our Social Justice Practices: Advances in Theory and Practice," Washington: American Family Therapy Academy, Winter 2010).

The traditional view of marriage is referred to as "heteronormativity" and is defined by the belief that a viable family consists of "a heterosexual mother and a father raising heterosexual children together" ("Handbook of Qualitative Research," Thousand Oaks, Calif.:Sage, 2000). Despite the above expansion of views on marriage and families, heteronormativity remains the current organizing principle of family theory, practice, research, and training. It will take many decades to shift the dominant paradigm. Developing awareness, and listening to families and couples is the first step.

Dr. Heru is with the department of psychiatry at the University of Colorado at Denver, Aurora. She is editor of the recently published book, "Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals" (New York: Routledge, 2013).