Family Systems Training in Psychiatric Residencies ELLEN BERMAN, M.D.w ALISON M. HERU, M.D.z
Both extensive research and common sense dictate that attention to families is necessary for appropriate care of psychiatric patients. However, training in family skills has often been difficult to integrate into psychiatric residency programs because of conflicting paradigms, turf battles, constraints of time and money, and confusion over whether family-centered care or family therapy should be taught. Current changes in residency accreditation mandate that family skills (not necessarily family therapy in its sophisticated form) be part of all residency programs. This article reviews the history of systems training in residencies, current accreditation requirements, and the GAP proposal for family systems skills, knowledge, and attitudes that that are teachable within the limited time available to residents. The application of these core skills is described using a case example and formulation. Challenges in teaching and ways of overcoming programmatic constraints are outlined. Fam Proc 44:321–335, 2005
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or many years, family psychiatrists have been engaged in an effort to integrate family skills/family therapy training into general (adult) psychiatry residencies. The challenges in this process have their origins in the separate histories and cultures of medicine, psychiatry, and family therapy, and ultimately in the conflict between systemic thinking and the individualistic philosophy of Western thought. The difficulties faced by family psychiatrists have been compounded by turf battles between healthcare providers. Despite the paradigm conflict, there is general agreement, both from research and practice, that psychiatric illness is shaped by, and in turn shapes, the immediate family and social environment. The critical issue is how we can encourage an enlarged vision of psychological functioning that includes the person-in-the-system, and how to teach this vision within a formalized psychiatric training structure.
wClinical professor of psychiatry, University of Pennsylvania. zAssociate professor of psychiatry (clinical), Brown University School of Medicine.
Correspondence concerning this article should be addressed to Ellen Berman, M.D., Clinical Professor of Psychiatry, University of Pennsylvania, 321 Mallwyd Road, Merion Station, PA 19066, Tel: (610) 667-4617. E-mail:
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Recent changes in residency accreditation (ACGME, 2004) and the move to competency-based training offer a window of time in which there is a renewed possibility for integrating family systems training into basic psychiatric training. This article discusses current and possible future models of family systems training and focuses on how family therapists can have an impact. The authors begin with the premise that psychiatric illness exists, that it has a genetic and biological component, and that it is expressed most clearly under certain environmental conditions. This vulnerability/stress model has become increasingly accepted in all medical and therapy fields. It is important to be clear about our premise because some writers in both psychiatry and family therapy have argued against this concept. Family factors have been implicated in the development of almost all major psychiatric illnesses. Several critical research studies have clarified that although biology accounts for much of the vulnerability to major mental illness, family factors are critical to its expression (Tienari et al., 2004). The influence of genetics and family factors in the expression of illness and health illustrates the importance of maintaining a complex model for understanding human functioning (Reiss, Neiderhiser, Hetherington, & Plomin, 2000). Family factors are also implicated in the maintenance of psychiatric illness. Research on expressed emotion, which describes families with high levels of criticism, hostility, or emotional overinvolvement as ‘‘high EE’’ families, has found that high EE is a significant and robust predictor of relapse in many psychiatric illnesses (Butzlaff & Hooley, 1998) such as schizophrenia (Kavanaugh, 1992), depressive disorders (Hooley & Teasdale, 1989), acute mania (Micklowitz & Goldstein, 1997), and alcoholism (O’Farrell, Hooley, Fals-Stewart, & Cutter, 1998). High EE in families can also result from ongoing stressful interaction with a disturbed family member; this is a bidirectional process (Miklowitz, 2004). Family dysfunction, especially marital dysfunction, has been associated with a higher rate of depression, especially for women, and a slower rate of recovery from a major depressive episode (Keitner & Miller, 1990). Caregiver research has identified the high burden of caring for relatives with psychiatric illnesses (Chakrabarti, Kulhara, & Verma, 1992), and high levels of psychiatric morbidity, especially depressive symptoms, can be found when family members are screened (Ferro, Verdeli, Pierre, & Weissman, 2000). Considered from this vantage point, it seems obvious that knowledge of how to understand and assess a family, as well as how to provide education and treatment, should be part of psychiatric training. However, efforts to integrate the knowledge gained from many years of family research and clinical family therapy into psychiatric training have been only partially successful.
THE HISTORICAL RELATIONSHIP BETWEEN FAMILY THERAPYAND PSYCHIATRY The medical establishment of the last century in the United States has been part of a culture of high individualism in which illness was seen as residing within the individual and doctors as individual heroes doing battle with disease. A history of hospitals over that period (Rosenberg, 1987) illustrates a system in which families were increasingly excluded, and even the person of the patient disappeared in dramatic technical feats of skill. This perhaps reached its peak during the 1960s, when even the patient’s name sometimes disappeared in medical rounds and the person became ‘‘the www.FamilyProcess.org
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liver in room 503.’’ Although a more humanistic model of care is currently taught, there still a sense that an appreciation of the mind or the family system as affecting the body is considered ‘‘soft.’’ Psychiatry has generally been viewed as a low-status specialty within medicine. Families, however, have always needed tending. Family social work began in the 1890s, and as described by Beels (2002), developed a strongly systemic understanding of how people functioned. Marital counseling began in the 1930s. Because the psychiatrists of those days refused to see family members, this field was developed primarily by social workers and ministers, to whom couples turned for family advice. Emily Mudd, a social worker, started the second marital clinic in the country, Marriage Council, in 1932, and became a member of the Department of Psychiatry at the University of Pennsylvania. She is widely credited with the first textbook in the field, The Practice of Marriage Counseling (1951). However, it was not until the 1950s and 1960s that family therapy came into its own as a discipline, when several individual therapists and working groups, including many psychiatristsFamong them, Nathan Ackerman, Murray Bowen, Eric Erickson, Sal Minuchin, Carl Whitaker, Ivan Boszormenyi-Nagy, Don Jackson, Chris Beels, Lyman Wynne, and Helm SteirlinFbegan to research family functioning and write about therapy models and techniques. As Chris Beels pointed out in his brilliant article in Family Process, systems theory was presented and framed as a new epistemology (although it had roots in a series of older traditions and philosophies). Systemically based family therapy was seen by its creators as a new model that would compete with, and eventually supersede, older (i.e., psychoanalytic) methods of therapy. Most of this new work was published in family therapy journals but not in psychiatric journals, and thus was not read by most psychiatrists. Many therapists in other disciplines became interested in family work at this time, and the developing field became truly interdisciplinary. These models, however, were not integrated into the mainstream of psychiatry because the systems paradigm was so different from standard methods of psychiatric treatment and such a direct challenge to prevailing psychoanalytic thought. In the 1960s and 1970s, charismatic clinical teachers and active teaching centers began to gather interested students, and specific schools of family therapy began to develop. Family therapy models tended to be more exclusive than integrative because of the excitement of the work and its experimental and developing nature. For many, it was a mark of research and developing clinical practice to see how much could be done using one particular ‘‘pure’’ model. At a personal level, deeply embedded in the memory of the first author were struggles at the University of Pennsylvania psychiatric residency in the late 1960s, when Child Guidance was the leading center for structural family therapy and part of the psychiatry department. Many faculty and residents believed that it was impossible to integrate structural family therapy with other models of treatment, and hours were spent arguing over their relative merits. At the practical level, away from the think tanks in which theory was developing, many people worked in an integrative way, but this work was largely ignored and did not gain much credence in a literature that was deeply divided. By the 1970s, there was a national movement to make marriage and family therapy (MFT) a fifth therapy profession, and indeed it has become so, with licensing in most states. Given that systems work is also done by other mental health professionals, this has also added to the complexition of integration. Fam. Proc., Vol. 44, September, 2005
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All these differing views and stances have made integration of systems thinking into psychiatric training programs difficult. In addition, psychiatry as a specialty is fighting to be seen as legitimate and as worthy as other medical specialties, such as surgery and medicine. Therefore, the main psychiatric training paradigm is more focused on individual diagnosis and biological treatment. Also, until the 1980s, psychodynamic therapy, with its emphasis on inner fantasy rather than lived experience, was the primary, if not the only, psychotherapy taught, and the one least compatible with understanding the real lived experience of other family members. Compounding these difficulties, the developing HMOs (which generally avoided paying for any psychiatric illness when possible) balked at paying for problems that could not be defined as ‘‘illness.’’ In recent years, particularly in the last 15 years, as both psychiatry and family therapy matured and changed, integration has become a goal. Recent research has consistently shown that both biological and systems issues are relevant to psychiatric illness. Family therapists, to a great extent, have accepted the fact that there are biologically based psychiatric illnesses, and psychiatry has begun to grapple with families, culture, and gender. The American Psychiatric Association Practice Guidelines for most illnesses now mandate attention to families (APA, 2004; APA, 2002; APA, 2000; APA, 2003). Both psychiatry and family therapy have moved from a position of ‘‘choose a model and stick to it’’ to ‘‘both / and’’ to ‘‘clinical multiplicity’’ (Goldner, 2004). However, despite the persistent efforts of several generations of psychiatrists committed to including systems training in psychiatry, the results have been mixed. Although most programs admit that families are important, there is remarkable variation in the level of integration, which is at the discretion of the chair and training director. The persistence of the vision that families are not in the purview of psychiatry was illustrated when the second author sent a book proposal aimed at teaching basic therapy family skills to first-year inpatient psychiatry residents to a well-known publishing house. One reviewer, identified as a psychiatrist, questioned the validity of teaching family therapy to psychiatrists, missing the point that the aim of the book is to teach family skills in the context of a biopsychosocial model. The reviewer was further concerned about psychiatrists ‘‘doing work that is traditionally identified as social work.’’ The second reviewer, a social worker, was enthusiastic about the idea of residents learning how to work with families.
CURRENT FAMILY THERAPY TRAINING IN GENERAL (ADULT) PSYCHIATRY RESIDENCIES Psychiatric training takes 4 years following medical school, 6 if a child fellowship is included. Like other medical training programs, it is an apprenticeship as much as an intellectual endeavor. Learning takes place primarily within the axis of resident, patient, and supervisor. The hours are long, the responsibility is high, and the amount of necessary learning has grown by quantum leaps as our understanding of brain chemistry has advanced. Residents are expected to understand and use a broad biopsychosocial model and to be able to provide medication and appropriate therapy for major mental illness, substance abuse, personality disorders, trauma, and posttraumatic stress disorder (PTSD), and to be familiar with several widely differing models of psychotherapy. Residents tend to be pragmatically focused and tired. www.FamilyProcess.org
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In most residencies, the amount of time available for learning ‘‘talk therapy’’ of any kind has sharply decreased. In psychiatric residencies after WWII, residents received approximately 3,000 hours of psychoanalytically oriented psychotherapy training and almost no hours for medication management, then in its infancy. In comparison, the Joint Task Force Report for the Association for Academic Psychiatry and AADPRT in 1990 recommended only an average of 200 to 600 hours of psychotherapy training (Wallerstein, 1991). Psychiatric residents spend thousands of hours seeing patients in inpatient units, consultation/liaison, medication clinics, and other assessment units, but the actual time using psychotherapy as a treatment method has dropped dramatically.
CURRENT TRAINING PROGRAM GOALS What should residents actually be able to do with families? They certainly do not have 1 or 2 years to concentrate on family therapy as do students in postdegree training institutes or in master’s or doctoral programs in MFT. We believe, however, as illustrated below, that residents should be able to ally with families of their patients, support them, assess them, and have some knowledge of how to treat them. They need to know about caregiver burden and about the specific needs of families when dealing with major mental illness. They need to be able to determine when a family therapy referral is necessary for their patients to succeed in treatment. They should also recognize problems where the issues are system specific and no identified patient exists. This is the basic family skill set. We believe that the concept of ‘‘family skills’’ rather than family therapy is useful. This model has also been referred to as ‘‘family-centered care’’ (Doherty & Baird, 1987). It is the opinion of the authors (and to some extent, the accrediting organizations) that it is critical for psychiatry residents to develop systems knowledge. Psychiatrists are the health professionals who see very ill patients and their caregivers. As team leaders, if psychiatrists do not understand how systems work, they are more likely to make leadership mistakes. In outpatients, marital distress has been correlated with increased psychiatric morbidity and poorer treatment outcome, requiring that treating doctors be able to assess marital quality and appropriately treat or refer (Whisman & Uebelacker, 2003). It is for this reason that the authors, who are both volunteer faculty, devote many hours to residency teaching in family systems. Young practicing psychiatrists, when polled, stated that family skills were the least taught during residency and among the skills most needed after graduation (Guttman, 1999; Slovik, Griffith, Forsythe, & Polles, 1997). These psychiatrists were, however, using the knowledge they had about systems with their individual patients and in their work with larger systems. Many were seeing some couples in couples therapy because of the frequency of marital issues encountered.
Current Training Program Content Knowledge. There is currently little consistency from program to program in the organization and content of family systems teaching. Informal discussions with training faculty members who belong to the American Family Therapy Academy (AFTA), the Group for the Advancement of Psychiatry, and the Association of Family Psychiatrists of the American Psychiatric Association have indicated that trends are toward teaching assessment and basic family skills, although almost all programs Fam. Proc., Vol. 44, September, 2005
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expect the residents to see several couple or family therapy cases. Some training is also given in thinking about systems with individuals and using systems thinking in larger social systems and groups. Programs vary depending on the availability and interests of faculty. In some institutions, a specific school of family therapy is taught, and in others, generic family interviewing, basic communication skills, assessment, and support are taught. Findings in family research are seldom mentioned, nor are skills for running multifamily groups, despite their obvious use in psychiatric settings. Attention to cultural and gender issues varies depending on the setting, the director of training, and the particular faculty. Resident attitudes. Residents usually enter training in their late 20s. The majority are single or in new marriages and have either no children or young children. In our experience, they tend to be curious, empathic, and flexible about gender orientation and to some extent gender roles. Given their life stage, they are frequently more sympathetic toward their adolescent and young adult patients than those patients’ parents, as one would expect. They have little personal sense of the difficulties of midlife and old age. Those who have been born in the United States into White majority culture often have little sense of issues of immigration, culture, and racism, and how these issues impact clinical practice. This is compounded by the fact that medical school trains students to action and decisiveness, rather than listening and the careful accretion of knowledge needed to understand a family. Residents in general, however, are open to faculty influence. If the faculty is interested in families, they will be also. If their supervisors see families primarily as obstacles to treatment, residents will also have this attitude. Resident Skill Levels. This is a complex area to consider. Although residents have had years of training, even fourth-year residents are only beginning therapists. If they have seen fewer than 100 hours of family assessment and treatment and done two to five complete ‘‘family therapy cases’’ (a common requirement), they have not had the experience to be competent family therapists as family therapy training programs would understand the term. However, this exposure usually makes it possible for residents to grasp the concept of a system adequately to support families and refer appropriately. Many programs settle for an absolute minimum: for the resident to have the ability to be in a room with a family without being anxious, to have some knowledge of common family systems issues, and to have some idea of what a functional family under stress is like. However, many programs expect more. The following case, supervised by the second author, represents a reasonable level of competence for a firstyear resident.
Case Dr. Scott, a first-year inpatient resident, was treating a 28-year-old woman admitted to the general inpatient treatment unit with a diagnosis of psychosis NOS. She presented with thought broadcasting, thought insertion, and delusional ideas about her parents playing games with her. Dr. Scott found the patient suspicious and guarded, and he found it difficult to establish a rapport with her. www.FamilyProcess.org
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Dr. Scott discussed with his supervisor how best to proceed, and a family meeting was suggested. At that time, he had observed several family meetings and attended an orientation session on working with families. He was excited and somewhat anxious about convening such a meeting. After supervision, he discussed the idea with the patient and made several phone calls to the family, finally arranging a meeting for patient and family on the unit in a private office. From the beginning of the meeting, the parents, especially the father, were hostile and aggressive, stating that they would not discuss their daughter’s problems in front of her. Dr. Scott described how a discussion of behavior would be beneficial to everyone in order to clarify symptoms and diagnosis. The family insisted that they did not want to discuss their daughter’s behavior in front of her. Dr. Scott stated that meeting together would be helpful in getting everyone on the same page and that we could discuss other things apart from the patient’s symptoms. Dr. Scott told the family that he would meet with them after the meeting if the patient gave permission, but for now, they would meet together and review some basic facts, such as who lived in the house, financial support, and so on. The father became very agitated and stood up and left the room. The mother stayed and the meeting proceeded. After a brief discussion about the patient’s presentation to the hospital, Dr. Scott described the assessment process, current treatment, and tentative plans for discharge. The mother and patient worked well together describing how the patient would live independently, financed by her parents. The amount of contact that she would have with her parents was discussed, and the mother’s role in ensuring treatment compliance was agreed upon. Informed consent was given regarding the medication and potential side effects. Follow-up appointments were discussed. After the formal meeting was over, the patient returned to the unit, the father returned to the office, and the parents met alone with Dr. Scott. The father continued to talk in an angry tone, mostly standing up with much gesturing regarding the patient’s unpredictable and aggressive behavior. The mother sat quietly. Dr. Scott listened to the parents and explained the diagnosis and treatment plan. It was clear to Dr. Scott that the patient had been ill for many years and that the family had denied the illness and saw their daughter’s behavior as bad behavior in need of punishment. The resident said in supervision later, ‘‘It was as though the father thought that he could punish the illness right out of her.’’ Dr. Scott stated that the meeting had been very helpful for him. He described an improved alliance with the patient, stating that the patient trusted him more and expressed less bizarre delusional ideas about her parents. Dr. Scott felt that it had been helpful for the patient to see him set limits with her father and observe her father’s agitated behavior. The patient felt validated by his agreement that her father was agitated. Dr. Scott was able to discuss her diagnosis with her and the treatment that would provide the best prognosis. He felt that he could not have done this without having met with her family. He also felt that supervisor support and clear discussion of what was and was not possible in a one-session meeting allowed him to keep his goals and expectations clear and his anxiety under control.
POSSIBILITIES FOR CHANGE: THE RESIDENCY REVIEW COMMITTEE MANDATE At this time, changes are being introduced by the Accreditation Council for Graduate Medical Education (ACGME), which may significantly alter some aspects Fam. Proc., Vol. 44, September, 2005
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of psychiatric training and allow for a more logical integration of family skills and knowledge. In the last few years, there has been a major effort on the part of the ACGME to move from curriculum-based to competency-based education for all medical and surgical specialties. This means that instead of proving that a certain curriculum is taught, programs must demonstrate that residents have developed appropriate knowledge, skills, and attitudes to treatFthat is, true, behaviorally assessed competency. The impetus behind the introduction of the core competencies by the ACGME is to ensure that residents of all medical and surgical specialties are taught a general set of knowledge, attitudes, and skills in addition to the specific tasks of their specialty. Residency Review Committees (RRC) for each specialty, subcommittees of the ACGME, lay out the requirements for each specialty. The ACGME is phasing in their new standards for the accreditation of programs over several years to allow programs time to determine how to teach and assess the core competencies. Currently, in all specialties, the RRCs are developing, using, and revising both the specifics of competency requirements and assessment tools; they believe that within the next 5 years, this process will be completed. All residency programs are expected to teach and evaluate competency in six core areas: patient care, medical knowledge, interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice. Each specialty then determines the skills required for practice in that area. In psychiatry, these specialized competencies include both biological and psychosocial interventions. The Residency Review Committee for psychiatry (Accreditation Council for Graduate Medical Education [ACGME] 2004) describes the core competencies on its Web site as a ‘‘living document,’’ thus anticipating that changes to the core competencies will continue to be made. These competencies are extensive and complex, and the reader is advised to access the ACGME Web site (see ACGME, 2004) to understand their scope. As currently written, the core competencies for psychiatry are quite specific about the need to involve families in treatment. Embedded within the core competencies are multiple references to families that are often ignored but clearly substantiate our position. Table 1 separates and lists those sections of the core competencies that specifically mention families. These direct quotes can be used in demonstrating to residency directors that the RRC core competencies do in fact mandate family skills of understanding, communicating with, allying with, and educating families. In addition, they call for knowledge of a variety of therapies, including family therapy. Although similar language has been in various RRC documents for many years, the question at the moment is whether the training programs and accrediting reviewers will take the mandate seriously. The RRC, at present, also mandates five psychotherapy competencies: cognitivebehavioral, psychodynamic, supportive, brief, and combined psychotherapy-psychopharmacology. This list of psychotherapies is controversial and may be subject to change. Current political wisdom suggests that the list may be shortened rather than expanded. No one with whom the authors spoke off the record thought that there was a possibility that family therapy would become a nationally mandated therapy competency in adult programs in the next few years. Individual programs may add whatever additional competencies they wish, and many programs have included family skills/therapy as a required competence in their program. Although we strongly www.FamilyProcess.org
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TABLE 1 RRC Core Competencies Specific to Family and Systems Issues
Patient Care Based on a relevant psychiatric assessment, physicians shall demonstrate the following abilities: To develop and document: An appropriate DSM-IV multi-axial differential diagnosis. An integrative case formulation that includes neurobiological, phenomenological, psychological, and sociocultural issues involved in diagnosis and management. A comprehensive treatment plan addressing biological, psychological, and sociocultural domains. To conduct a range of individual, group, and family therapies using standard, accepted models and to integrate these psychotherapies in multimodal treatment, including biological and sociocultural interventions. Medical Knowledge Knowledge of major disorders, including considerations relating to age, gender, race, and ethnicity, based on the literature and standards of practice. This knowledge shall include: The etiology of the disorder, including medical, genetic, and sociocultural factors. The experience, meaning, and explanation of the illness for the patient and family, including the influence of cultural factors and culture-bound syndromes. Interpersonal and Communication Skills Physicians shall demonstrate the following abilities: To educate patients, their families, and professionals about medical, psychosocial, and behavioral issues. This shall include: Discussing the consultation findings with the patient and family. Physicians shall demonstrate the ability to communicate effectively with patients and their families by: – Gearing all communication to the educational and intellectual levels of patients and their families. – Demonstrating sociocultural sensitivity to patients and their families. – Providing explanations of psychiatric and neurological disorders and treatment that are jargon-free and geared to the educational/intellectual levels of patients and their families. – Providing preventive education that is understandable and practical developing and enhancing rapport and a working alliance with patients and their families. – Ensuring that the patient and/or family have understood the communication. Physicians shall demonstrate the ability to obtain, interpret, and evaluate consultations from other medical specialties. Professionalism Physicians shall demonstrate respect for patients and their families, and their colleagues as persons, including their ages, cultures, disabilities, ethnicities, genders, socioeconomic backgrounds, religious beliefs, political leanings, and sexual orientations. Systems-Based Practice Physicians should have a working knowledge of the diverse systems involved in treating patients of all ages and understand how to use the systems as part of a comprehensive system of care in general and as part of a comprehensive, individualized treatment plan.
wish the situation otherwise, the fact is that many programs do not have the time, faculty, or inclination to teach sophisticated family therapy. We believe, however, that using our model of core competency skills, residents can become competent to ally with families and to assess, educate, and refer. Interested residents will always seek out additional training, and if family skills become embedded in residency training, we believe that far more residents will become interested in family therapy. Fam. Proc., Vol. 44, September, 2005
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THE GAP COMMITTEE PROPOSAL FOR SPECIFIC FAMILY SKILLS COMPETENCY The GAP Committee on the Family is a standing committee of the Group for the Advancement of Psychiatry. Its current mandate is to operationalize the RRC requirements and to encourage the RRC and training programs to include more family skills training. The GAP Committee is proposing specific family competencies that consist of the knowledge, attitudes, and skills required for a resident to be competent in working with families, based on the RRC core competencies (Table 2). We are particularly concerned that the knowledge base include family research, evidence-based treatments, and information about family developmental stages, and focus on common family challenges and family dynamics. The development of these competencies should support the RRC’s goal of producing a set of assessable and consistent family skills that can be presented for accreditation. It is hoped that this will become a part of the teaching model. The knowledge section is proposed as the basis for a core curriculum and is based on a cross section of available curricula from around the country. This proposal essentially takes the resident to level 4 on the family skills level proposed for family medicine (Doherty & Baird, 1987). It is hoped, however, that many programs will be able to develop residents to level 5.
ASSESSMENT OF RESIDENTS Although assessment is critical to competency-based education, it is beyond the scope of this article. Previous attempts at competency-based education have faltered on the difficulties of true evaluation of competency (as opposed to the often nonspecific evaluations of supervisors and teaching faculty). The ACGME Web site (http:// www.acgme.org) has an excellent set of assessment tools. The GAP proposal is written to a level of specificity that should allow systems faculty to develop their own rating scales. An example of such rating scales can be obtained by e-mailing the first author.
TRAINING PROGRAM DEVELOPMENT Training programs vary greatly in size, faculty availability, and focus. Some programs see families as a matter of course, while others may have only one or two faculty members with family skills or interests. New family systems programs tend to develop from personal connections between the director of training and interested family therapists and usually begin with a single didactic course or weekly one-way-mirror case observation. Further supervision or coursework may develop on the inpatient or outpatient unit. The variety of methods with which family systems are taught is very wide. For example, the University of Pennsylvania program requires about 40 hours of formal class time spaced throughout the 4 years, and has couple/family observation and intervention primarily during the outpatient years and an elective in couples therapy in PG4. Brown has almost no didactic coursework but has several inpatient faculty members who do family skills supervision in various treatment settings. North General Hospital in Harlem has one faculty member (Peggy Papp) who does almost all the family therapy training. Her 4-hour-a-week class and observation course presented during the entire third year covers as much territory as many other more complex programs. Besides the formal training in family skills, finding ways to integrate family therapy skills into the residency program means encouraging all supervisors and facultyFnot www.FamilyProcess.org
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TABLE 2 GAP Proposal for Specific Family Systems Competencies
KNOWLEDGE The resident is expected to demonstrate knowledge of family factors as they relate to psychiatric and medical disorders, based on scientific literature and standards of practice. The resident is expected to demonstrate knowledge of the following: 1. Basic concepts of systems, applicable to families, multidisciplinary teams in clinical settings, and medical/government organizations impacting the patient and doctor. 2. Couple and family development over the life cycle and the importance of multigenerational patterns. 3. Principles of adaptive and maladaptive relational functioning in family life; family organization, communication, problem-solving, and emotional regulation. 4. Family strengths, resilience, and vulnerability. 5. How age, gender, class, culture, and spirituality affect family life. 6. The variety of family forms (single parent, stepfamily, same-sex parents, and so on). 7. How the family affects and is affected by psychiatric and nonpsychiatric disorders. 8. Special issues in family life, including sexuality, loss, divorce and remarriage, immigration, illness, secrets, affairs, violence, and alcohol and substance abuse. 9. Relationship of families to larger systems (e.g., schools, work, healthcare systems, government agencies). SKILLS The resident should demonstrate reasonable ability to conduct a family interview and complete an assessment and formulation that includes family factors. Operational skills include: 1. Identify family members and other relevant persons in larger systems who are involved with the patient’s current functioning. In adult residency programs, this might include parents, spouses, partners, adult or minor children, extended family, and staff in healthcare and other larger systems. 2. Meet with significant family members of the majority of patients and be able to deal with reluctance on the part of patient or family to meet. 3. Foster a therapeutic alliance with all family members by instilling feelings of trust, openness, and rapport. 4. In an assessment interview, the resident should: a. Elicit each family member’s perspective of the presenting problem. b. Obtain a family history, including strengths, stressors, and repeating intergenerational patterns of behavior or illness. The ability to construct a genogram and a timeline are helpful in this process. c. Elicit the family’s cultural, class, and gender orientation and describe how these impact their response to the patient and his or her illness and treatment. d. Identify and assess the emotional climate, family organization, and interactional problemsolving as described by the Global Assessment of Relational Functioning (GARF). Include the GARF score in assessment. e. Be aware of personal feelings in relation to family members and be able to tolerate intense affects, especially when directed at the resident. f. Elicit strengths, competencies, and resources of couples and families so that they become useful and effective allies in treatment. 5. Following the interview, the resident should be able to: a. Integrate the impact of current relational functioning into the case formulation. b. Provide feedback, and if appropriate, psychoeducation, to the family. c. Involve the family members in collaborative treatment planning for the identified patient if appropriate. d. Make appropriate decisions regarding the future, including interventions that may include other family members. (Continued)
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TABLE 2 (Contd.) ATTITUDES The attitudes demonstrated by the competent resident are empathy, curiosity, and respect for all family members. The resident must accept differences in perspectives on the problem and solution and understand that in families, truth is a relative thing. This is demonstrated by: 1. 2. 3. 4. 5.
Allowing each family member to describe the presenting problem. Identifying and acknowledging strengths and prior problem-solving affects. Acknowledging realistic limitations while maintaining an attitude of hopefulness. Showing balanced concern for each member of the family and his or her point of view. Working collaboratively with families and seeing them as allies.
only those trained in systems therapyFto consider family processes in individual patients. One way to do this is to insist that the residents see partners and families of their individual inpatients and outpatients rather than seeing families only in a ‘‘family clinic.’’ In this way, residents must look at all their cases as potential family cases. Encouraging residents to meet with family members bringing patients to the medications clinic or on the consultation liaison service is one way of beginning this process.
CONSTRAINTS AND POSSIBILITES IN THE TEACHING OF SYSTEMS Whether the family systems model becomes a normative part of the culture of training will depend on several changes occurring. First, the culture of a residency program usually contains preferred or dominant discourses regarding the central curative factors for patients. As we have suggested, most psychiatric residencies, whether they are biologically or analytically based, embrace an individual rather than a systemic paradigm. A culture receptive to systems theory requires the belief that involving families improves the assessment and treatment outcome in most cases. In many programs, faculty members are unfamiliar with, and occasionally strongly disagree with, some aspects of standard family systems practice, such as routinely seeing family members early in treatment. It may be easy to provide a volunteer faculty member to do a series of lectures on families, but it is harder to change the department culture so that supervisors and administrators are continually receptive to the needs and issues involved in bringing in family members. This is the job of the director of training, but it can be improved by bringing to the attention of everyone the currently emerging evidence-based research demonstrating the links between family stresses, physiological stress responses, and psychiatric illness, and reduction of illness with family support, education, and treatment. Second, residents must grapple with the conflicts between paradigms embodied by their supervisors as they try to develop their own blend of skills. Although residents will always have to contend with supervisor differences (indeed, the hallmark of an excellent program is resident exposure to a wide variety of models and styles), it is still difficult for residents to be faced with supervisors whose advice is directly contradictory. This is true with many models, such as psychoanalytic psychotherapy and cognitive therapy. But family work, with its emphasis on ethical responsibility to all family members and its focus on the here and now, as opposed to past and individual memory, seems to produce a particular dissonance in some programs. In such situations, it is necessary for the faculty to develop an overarching philosophical position in the residency program that many truths are possible, that many methods should be www.FamilyProcess.org
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sampled, and that complexity is a good thing. The integration of systems thinking into a program is a top-down phenomenon. A director of residency training must take seriously the idea that family and cultural systems must be part of the understanding of any patient. It is hoped that the RRC requirements and evidence-based research will spur further attempts on the part of programs to find ways to continue to integrate multiple system levels. Third, many family systems therapists are not physicians, and their integration into the higher levels of an academic medical hierarchy is often difficult in terms of salary, appropriate respect for their work, and concern about their suitability as role models for residents. Psychiatry faculty who are able to teach the assessment and treatment of families and couples work appropriate to a general psychiatry residency are often difficult to find. However, most areas in which major hospital and teaching programs are located contain a variety of professionals well trained in family work. By working in teams, interested psychiatry faculty can improve their own family skills. Fourth, the need for videotape or live family observation has in the past necessitated at least one or two large rooms with a one-way mirror or audiovisual equipment. Although cell phones and TV monitors are replacing one-way mirrors and are making observed interviews easier, convincing residents and supervisors to make use of them takes a certain level of persistence. Luckily, supervisors of other psychotherapies are becoming more comfortable with this supervisory model. It is sometimes a useful tactic to demonstrate that assessing competence is easier when you can observe the resident working. Using videos made by residents or faculty when teaching or presenting at case conferences also normalizes this method of working. Fifth, the chair and director of training need to insist on respect for families and for nonpsychiatrists as faculty. Family systems faculty, in turn, must not only be available to residents, but also to the general faculty, and be willing to present at grand rounds, circulate relevant research, and see families wherever they areFin the inpatient unit, the consultation floor, or the outpatient medications clinic. The most effective way to teach family skills is to find a way to integrate into existing treatment programsFwhether inpatient, consultation liaison, or medications clinicsFrather than create a separate program for ‘‘couples cases.’’ If our goal is to convince all residents, interested or not, that all cases have systemic implications, it is critical not to play into the traditional dichotomy of ‘‘family cases’’ vs. ‘‘individual cases.’’ However, for those interested in elective or advanced training in PG4, a small ‘‘couples and adult families’’ clinic can be useful, particularly with referrals from the PG2s and PG3s, and standard referral sources. In some residencies, interested residents take part in private practice sessions held in faculty members’ offices.
WHAT CAN BE DONE BY INTERESTED FAMILY THERAPISTS? Increased pressure to follow the RRC guidelines for core competencies should encourage programs to teach family skills as part of everyday psychiatric training. Residents can be encouraged to see families of all their patients, as opposed to the old model of finding ‘‘family cases’’ for family therapy. Although the level of interventional skill that residents acquire may not be what training faculty are used to seeing in postdegree family therapy training programs, the need to involve families as allies in treatment and the ability to understand both family and larger social systems are critical skills for residents and practicing psychiatrists. Fam. Proc., Vol. 44, September, 2005
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Interested family therapists can use the GAP proposal in Table 2 as a core curriculum that meets all the requirements mandated by the RRC. Systems-oriented therapists must proactively approach those in charge of training, armed with the RRC accreditation guidelines and a variety of teaching strategies that can be used depending on the program. Curricula, bibliographies, and teaching tapes have been developed so that no one has to reinvent the wheel. For many psychiatric programs, the most problematic area is the tension between systems and individual models. The developing biopsychosocial model, in which the brain itself is conceptualized as developing and changing in response to social interaction, should allow a way to integrate systems thinking into psychiatry. For their part, family therapists interested in working in a residency program must be comfortable as part of a multidisciplinary team and accept the validity of a biological component to much psychiatric distress and the potential usefulness of medication as one part of a treatment plan.
CONCLUSION Extensive research points conclusively to the need for including families in understanding health and illness. We hope that the new RRC requirements mandating family skills and the APA Practice Guidelines that include attention to families as part of treatment of psychiatric illness will allow family therapy to become a more integrated part of residency training. The most appropriate goal for residents is the development of family skills, with the option of specialty training in family therapy. The development of teaching tools and assessment tools should make the goal of having every resident proficient in family skills more attainable. Although the biological and medical models hold precedence in many residencies, the pendulum is beginning to swing toward a more integrative model of human functioning. It is important for the field and for our clients, both individual and families, that we work toward making this integration part of residency training. REFERENCES Accreditation Council for Graduate Medical Education (ACGME). (2004). Retrieved May 13, 2004, from http://www.acgme.org American Board of Psychiatry and Neurology (ABPN). (2004). Psychiatry, neurology and subspecialties core competencies. Retrieved May 13, 2004 from http://www.abpn.com/geninfo/ competencies American Psychiatric Association. (2000). Work group on depression: Practice guidelines for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157(April Suppl.) 8,17, 34. American Psychiatric Association. (2002). Work group on bipolar disorder: Practice guidelines for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry, 159(April Suppl.),7, 32–33. American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with suicidal behaviors. American Journal of Psychiatry, 160(Nov. Suppl.), 7, 35. American Psychiatric Association. (2004). Work group on schizophrenia: Practice guidelines for the treatment of patients with schizophrenia (2nd ed.). American Journal of Psychiatry, 161(Feb. Suppl.), 10–11, 21–22. Beels, C. (2002). Notes for a cultural history of family therapy. Family Process, 41, 7–82.
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