A model for reintegrating couples and family therapy training in psychiatric residency programs

A model for reintegrating couples and family therapy training in psychiatric residency programs
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  See discussions, stats, and author profiles for this publication at: A Model for Reintegrating Couples and Family Therapy Training in Psychiatric Residency Programs  Article   in  Academic Psychiatry · April 2008 DOI: 10.1176/appi.ap.32.2.81 · Source: PubMed CITATIONS 4 READS 39 2 authors: Douglas RaitStanford University 15   PUBLICATIONS   281   CITATIONS   SEE PROFILE Ira D GlickStanford University 181   PUBLICATIONS   4,519   CITATIONS   SEE PROFILE All content following this page was uploaded by Douglas Rait on 01 January 2015. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  Original Article  Academic Psychiatry, 32:2, March-April 2008  81  A Model for Reintegrating Couples and Family Therapy  Training in Psychiatric Residency Programs Douglas Rait, Ph.D., Ira Glick, M.D. Received April 3, 2006; revised July 17, 2006; accepted August 11,2006. Drs. Rait and Glick are affiliated with the Department of Psy-chiatry and Behavioral Sciences at Stanford University School of Medicine in Stanford, California. Address correspondence to Doug-las Rait, Ph.D., Department of Psychiatry and Behavioral Sciences,Stanford University School of Medicine, 401 Quarry Road, Stanford,CA 94305-5722; (e-mail).Copyright  2008 Academic Psychiatry Objective: The authors propose a family-systems trainingmodel for general residency training programs in psychiatry based onthe couples and family therapy training program in Stanford’s Department of Psychiatry and Behavioral Sciences. Methods:  The authors review key elements in couples and fam-ily therapy training. Examples are drawn from the family therapytraining curriculum in a general psychiatric residency program. Results:  Conceptual and practical skills taught over the span of  a psychiatric residency training program are described, focusing  on: joining with the couple or family; seeing systemic patterns, recognizing the family’s developmental stage, history, and cul-ture; identifying family structure; and intervening systemically. Conclusion:  This family-systems training model can serve as a resource for residency programs interested in integrating the cou- ples and family therapy model more fully into their curricula.  Academic Psychiatry 2008; 32:81–86 D espite support for family skills by the ACGME, ex-panding research on the efficacy of couples andfam-ily interventions for many psychiatric disorders, recom-mendations for family centered care by the President’sCommission on Mental Health, and emerging models of biopsychosocial health care, many psychiatric residencytraining programs do not offer thorough, family systemsoriented educational experiences (1–3). In this article, wedetail the couples and family therapy training program atStanford’s Department of Psychiatry and Behavioral Sci-ences in order to show how one generalresidencyprogramprovides a 3-year sequence of training experiences in cou-ples and family work. In many ways, our department istypical in that trainees are expected to masteracontinuallygrowing array of content areas and competencies in thecontext of steady educational, clinical, and administrativedemands.  Training Goals and Basic Concepts In training residents to work with couples and families, we emphasize five important conceptual and practical fea-turesof couplesandfamilytherapy:joiningwiththecoupleor family; seeing systemic patterns that maintainmaladap-tive behaviors, thoughts, and feelings; recognizing the im-portance of family developmental stage, history, and cul-ture; identifying the family structure; and understandingand using a systemic model of change. These skills aretaught in the broader context of the biopsychosocialmodelembedded in most psychiatric residency programs, as op-posed to the more specialized models of many couplesandfamily therapy institutes.  Joining With the Couple or Family  One of the earliest and most difficult challenges thatresidents face is learning how to manage therapeutic re-lationships with couples or multiple family members in anenvironment characterized by conflict, emotionality, vul-nerability, and threat (4). To new and experienced clini-cians alike, there appear to be so many ways to fail: by  COUPLES AND FAMILY THERAPY TRAINING 82 AcademicPsychiatry, 32:2, March-April 2008  TABLE 1. Family Life Cycle Centripetal stages Centrifugal stages MarriageBirth of first childFamily with young childrenChild enters elementary schoolSchool-aged childrenEntry into adolescenceLeaving homeBirth of grandchildrenRetirement and older ageDying and death overidentifying with one family member, overprotectinganother, or sharing in the family’s experience of helpless-ness. Not surprisingly, the drop-out rate in couples andfamily therapy is higher than in individual treatment (5).It is easy to take a wrong step, inadvertentlytakesides,andbecome a disappointment to a patient whose relationshipis foundering. The family oriented trainee must activelyunderstand the family’s predicament, appreciate expecta-tions that he or she will be able to repair even the mostproblematic relationships, and instill hope that their cir-cumstances can change.Minuchin and Fishman (6) view the family and clinicianas forming a time-limited partnership that will supporttheprocess of exploration and transformation.Fromthestruc-tural family therapy perspective, “joining” is consideredtobe the glue that holds together thetherapeuticsystem.Vir-tually every model of family therapy highlights the impor-tance of developing a strong initial bond with the coupleor family and its members, as the therapeutic work re-quires alliances sturdy enough and flexible enough to sup-port challenges to the couple’s or family’s preferred pat-terns of interaction. As any clinician walking the tightropebetween battling family members or competing coalitionsknows, the most formidable clinical task involves not sim-ply building these alliances, but sustaining them over thecourse of therapy. Seeing Systemic Patterns Residents are first exposed to thinking systemically by watching videotaped clips from familiar movies and TVprograms. Basic ideas regarding reciprocal, complemen-tary patterns in family functioning are identified. For ex-ample, in “Who’s Afraid of Virginia Woolf,” thehusband’sresigned, passive, and hostile stance is maintained by his wife’s histrionic, critical, and belittlingbehavior.Residentssubsequently consider how various formsofindividualpsy-chopathology elicit recognizable interpersonal patternsthat reinforce signs and symptoms of the disorders. Inpar-ticular, the regularities that link the biological, intergen-erational, and sociocultural contexts of family life are ex-plored.Because problems from a systemic perspective are sit-uated in their interpersonal contexts, a new vocabulary isneeded to characterize them. Residents come to appreci-ate how complementarity functions as a defining principlein every relationship. The importance of this conceptualshift cannot be underestimated. As Minuchin and Nichols(7) observe, “In any couple, oneperson’sbehaviorisyokedto the other’s . . . it means that a couple’s actions are notindependent but codetermined, reciprocal forces” (p. 63).Consequently, the family systems oriented psychiatrist be-gins with a microscopic focus on the individual, his or herillness, and its treatment and then adds a wide-angle lensto better perceive the powerful social factors that influ-ence, and are affected by, the sick person’s experience.Seeing these complementary relationships between self and system, between theindividual’sbehaviorsandthesys-tem’s responses that maintain them, stands as the linchpinof systemic thinking. Recognizing Family Developmental Stage,History, and Culture It is difficult to overestimate the importance of identi-fying the family’s developmentalstage.Justasinindividualtreatment, residents must recognize the normal develop-mental tasks and transitions, beginning with couple for-mation and ending with death, that couples and familiesroutinely encounter. Residents soon appreciate that bothcentripetal (couple formation, marriage, birth of a child,birth of grandchildren, death) and centrifugal stages (go-ing to school, adolescence, leaving home) occur and recurthroughout the family life cycle, presentingnew challengesthat require reorganization at each step (Table 1). At the same time, members of a couple bring with themidiosyncratic histories that serve as blueprints against which current situations are appraised. Residents learn toconstruct three-generational genograms, or family trees,thatidentify familypatternsandthemesaswellashighlightconnections between present family events and prior ex-perience. The genogram is a useful tool because “a pic-ture is worth a thousand words,” and residents soon rec-ognize its value in efficiently gathering family historicalinformation visually rather than in the traditional narra-tive form. Most couples and families enjoy the process of generating a genogram, as they see patterns emerge in  RAIT AND GLICK  Academic Psychiatry, 32:2, March-April 2008  83 FIGURE 1. Genogram Showing Family with aSymptomatic Daughter  CancersurvivorRetiredphysicianDied at 50(metastaticbreast cancer)RetiredteacherwithbreastcancerLawyer,mountaineerCollegefreshmanPanic attacks/school failureDiedat 52(suicide) 34785218 167248 FIGURE 2. Structural Map Showing Same Family in Therapy  FatherDaughterMother Husband and wife in conflict; mother overinvolved with symptomaticdaughter; father and daughter in conflict  their family histories in a way that is accessible and clar-ifying (Figure 1).Finally, residents must develop cultural competence intheir work with couples and families. By recognizing howeach family member’s distinctive socioculturalbackgroundprovides context and meaning for a family’s traditions,choices, and preferences, trainees can tailor both clinicalformulations and strategies for change. Residents fre-quently comment that they receive far too little training inappreciating the strengths and differences among patientsand families from different cultural and ethnic groups. Inall cases, identifying critical influences such as gender,cul-ture, class, race, religion, disability, and sexual orientationcontributes to the developmentofculturallysensitiveprac-tices that address the distinctive aspects of each family’sidiosyncratic culture. Identifying Family Structure If genograms map the family’s history over time, thestructuralmap representsthefamily’spresentorganization with special attention paid to proximity and affiliation, hi-erarchy and power, and boundaries and subsystems. Fam-ily structure, most notably associated with Minuchin (6–8), represents an inference drawn from redundant piecesof family process that identify preferredpatternsandavail-able alternatives: residents learn to see the couple or fam-ily in terms of its structure—instead of seeing only individ-uals, they begin to notice hierarchical imbalances incouples, coalitions and alliances, and relationshiptriangles(Figure 2).Over time, residents begin to understand the couple orfamily’s preferred patternsandavailablealternatives.Theypractice diagramming couples and families, looking atpat-terns of closeness and distance, power, boundaries, coali-tions, and alliances.  A family map is an organizational scheme. It does not rep-resent the richness of family transactions any more thananymap represents the richness of a territory. It is static, whereas the family is constantly in motion. But the familymap is a powerful simplification device, which allows thetherapist to organize the diverse material that he is getting(8, p. 90). These structural maps serve as the basis for family as-sessment, goal-setting, and the determination oftherapeu-tic progress.  Working with a Systemic Model of Change Residents learning about systemic change can initiallyfind it disorienting to learn that the shortest distance be-tween the point of assessment and intervention is not nec-essarily a straight line. Rather than targeting problematicindividual behaviors, the wider systemic view recognizesthat intervening in relationships that support these behav-iors can be quite powerful. In this regard, residents mustexperience a figure-ground shift, in that the individual“problem” can best be understood and treated by bringingthese contextual factors into the foreground. The aim of systemic therapy is to disrupt dysfunctional patterns, to in-  COUPLES AND FAMILY THERAPY TRAINING 84 AcademicPsychiatry, 32:2, March-April 2008  TABLE 2. ‘‘Thinking Family’’ and Working Systemically   Join with the family Focus on patterns and process rather than content Consider family developmental stage, history, and cultureIdentify family structureDevise systemic interventions that encourage systemic/structural changeSupport the couple/family and highlight their strengths  TABLE 3. Structure of Stanford Couples and Family  Therapy Training Program • PGY-I/II Lectures on couples and family assessment, in-patient family sessions• PGY-III Core seminar in couples and family therapy • PGY-IV Couples and family therapy rotation (out-patient) troduce alternative rules, and in doing so, to provoke sys-temic change. In this regard, the trainees begin to recog-nize the significant difference between “first-order” ortechnical change (such as improvingcommunicationskills)and “second-order” or systemic change (whereby the“rules of the game” are modified).The Stanford model builds on broad, family systemsprinciples based on both structural and intergenerationalideas. This integrative perspectiveallowsfor bothanactivehere-and-now focus that residents appreciate with theadded richness of a family-of-srcin historical approach todata-gathering. Specifically, residents learn the premisesfor a treatment model in which the therapeutic task is tohelp the family move from one stage of development to anew stagewheremembers’developmentalneedsarebettermet; the therapist joins with the family by entering intotheir reality and becoming involved in the repeated inter-actions that form the family’s structure; the therapistexpands the family’s range by challenging family rules,fos-tering boundary reorganization, promoting communica-tion and conflict-resolution, and supporting greater indi- viduation of family members; and the therapist monitorschange process by helping family members integrateemerging patterns into a new level of functioning. Thesesteps, srcinally proposed at the Philadelphia Child Guid-ance Clinic, serve as a guide for a flexible approach to working with couples and families (Table 2). Organization of the Training Program Just as every faculty member wishes that his or her areaof specialty would assume priority in the competitive en- vironment of residency training, so too do teachers of cou-ples and family therapy imagine every resident developingsolid competencies in this approach. In our program, res-idents begin their internship/PGY-II training with lectureson elements of systemic theory and practice relevant to working in inpatient psychiatry, emergencyroom,andcon-sultation-liaison settings (3, 9). Residents participate infamily sessions and provide family psychoeducation withthe support of social workers and psychiatry faculty. Insome regards, these early trainingsitesrequirethegreatestclinical skill due to the acuity, the time constraints,andthestrong emotionality that often surrounds the presentingsituation (Table 3).In the PGY-III year, residents take a required,intensiveseminar introducing them to structural familytherapycon-cepts, couples and family assessment, the leading modelsand schools of family treatment, and applications acrossclinical settings. The focus of this course is on developingobservational and conceptual skills by examining tapedinterviews, role playing initial interviews, generating hy-potheses, and devising thoughtful and powerful clinical in-terventions. Residents review evidence-based approachesto working with couples and families, wrestle with theassumptions of the systemic model, and learn about com-bining psychopharmacological and family interventions. Although case material comes mostly from outpatient set-tings, residents also consider how the family systems ap-proach can be applied in inpatient, consultation-liaison,and child/adolescent sites. In addition, residents each con-struct their own personal genogram, helping them to iden-tify their own strengths and clinical “blind-spots.” ThePGY-III seminar is fast-paced, provides a learnablemodelbased on structural and intergenerational perspectives,and focuses on the concepts and skills needed to conductcouples and family treatment.Finally, in the PGY-IV year, residents typically partici-pate in a supervised, outpatient training experience in theStanford Couples and Family Therapy Clinic. They meet weekly in small groups and present cases, most often byshowing clips from videotaped sessions. Supervision fo-cuses on case formulation and hypothesizing, supportingthe development of creative interventions,andbroadeningthe resident’s style. The atmosphere of the group tends tobe lively, and residents value the opportunity to observeeach other and the opportunity to learn from their peers’experiences. Both generic (e.g., handling“resistance”)andspecific (e.g., special questions withmooddisorders)issuesare highlighted.Fourth yearresidentscarrytwooutpatientcasesthroughto completion. Through live and videotaped supervision,
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