Family therapy is a neglected core competency in psychiatric residency training programs. Recent attempts to remedy this omission include a redefinition of family therapy as “family skills,” which is the basic requirement for all residents to be able to ally with and communicate with families and provide psychoeducation (1) or “family interventions,” which, for the child psychiatrist, refer to “a coordinated set of clinical practices that attempts to alter family interaction, family environment, and parental executive function (p 407)” (2). Competence in working with families is important because family interventions are effective interventions for many adults (3) and children (4) with psychiatric illnesses. Working with families also has a sustained, albeit poorly recognized, benefit for other family members. What can be done to help residency programs incorporate training in family skills and family interventions into the curriculum? This editorial outlines the rationale for including families, and delineates teaching goals and resident competencies that can reasonably be expected. Key components of making this change happen are the identification of role models, mainly psychiatrists who work with families, and support from the Chairs and Residency Directors in each Department of Psychiatry.
Psychiatrists provide an individual assessment that synthesizes biological, psychological, and social factors. We educate patients and their families about how brain functioning, psychological development, and social systems interact for that particular person in his or her particular circumstances, to produce their symptoms. Psychiatrists explain how treatment modalities work, what outcomes can be expected from different modalities and help patients and families choose modalities that are likely to be effective for them. Virtually all psychiatric illnesses occur in a family or interpersonal context. Quality care requires an integrated individual, family, and medical approach. Psychiatrists need to be trained to assess family functioning, include families in medical decision-making about treatment options, and, when indicated, include families in the treatment process.
Family interventions improve patient outcome for many illnesses, including schizophrenia, bipolar disorder, depression, and eating disorders (3). For schizophrenia, one site for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Study found that having a supportive, involved family member was a strong predictor of medication compliance and good outcome (5). The APA Practice Guidelines for many DSM-IV Axis I disorders, for example, major depression, bipolar disorder, and schizophrenia (6–8) include the expectation that patients’ family members will be involved in the assessment and treatment of patients. Child and adolescent psychiatrists are also expected to include families in the assessment and treatment of childhood disorders such as oppositional defiant disorder and other Axis I disorders (4). Family interventions are promoted by the Institute of Medicine as an effective way to prevent psychopathology (9).
Like individual therapies, family therapies have many theoretical and practical models. As currently defined in residency programs, competency as a psychiatrist includes the ability to be proficient in one form of individual therapy. Competency should also include proficiency in one form of family intervention.
As in individual therapies, common factors are found in the broad range of family therapy models. These common factors include conceptualizing problems in relational terms, disrupting dysfunctional relationship patterns, and expanding direct treatment and the therapeutic alliance to include family members of the index patient (10). Competency should include an understanding of and an ability to utilize these common factors.
Also, psychiatric residents should have competency in completing a family assessment in the context of the patient’s presenting problem, explaining to the patient's and family what is occurring in the family, and be able to discuss evidence-based family treatments. The psychiatrist must be able to integrate biological, psychological, and social issues into a comprehensive formulation that helps the patient and family members understand the illness and the ways in which they may be helpful or detrimental to its management. Psychiatry residents and fellows need skills in integrating medication management with individual and family therapeutic interventions.
According to the Residency Review Committee for Psychiatry (http://www.acgme.org), residents are required to learn how to ally with/communicate with families, provide psychoeducation, and have exposure to family therapy as part of the core competencies. The Group for Advancement of Psychiatry (GAP) has developed a set of attitudes, knowledge, and skills that constitute best practice for residency programs to teach family skills and interventions (1, 11). An application of this model by the University of Pennsylvania was chosen in 2010 as the American Association of Directors of Psychiatric Residency Training (AADPRT) model curriculum for teaching family skills in the adult residency program. The University of Pennsylvania’s curriculum is posted on the AADPRT website and on the University of Pennsylvania’s Couples and Family Therapy Clinic website (http://www.med.upenn.edu/ccaf/curriculum.html). The GAP curriculum gives latitude to residency programs to develop their own curriculum according to the availability of teaching faculty.
Teaching skills should occur across the 4 years of residency training. Five levels of family involvement have been differentiated (12). For practical use, these can be collapsed into three levels: family inclusion, family psychoeducation, and family therapy. Each level of intervention has an associated knowledge-base and skill-set. The GAP and the University of Pennsylvania’s curricula delineate how to set learning objectives and goals for each rotation and year.
According to the GAP curriculum, family skills required in all clinical settings include an attitude of interest, empathy, and appreciation of multiple points of view, the ability to think systemically, family-interviewing skills, collaborative treatment-planning, and managing high levels of emotion. Residency programs need to identify core teaching staff, especially psychiatrists, who can be role-models.
The Stanford’s Department of Psychiatry and Behavioral Sciences also has a model for integrating couples and family therapy training into residency training (13). Conceptual and practical skills are taught developmentally and focus on joining with the couple or family; seeing systemic patterns; recognizing the family’s developmental stage, history, and culture; identifying family structure; and intervening systemically. This family systems training model can also serve as a training resource for residency programs.
These psychiatry core competencies are somewhat different than the core competencies that have been developed by psychologists (14) and the Association of Marriage and Family Therapists (AAMFT) (15). The psychiatry competencies are more specific to the clinical rotations of the resident; for example, substance abuse, emergency psychiatry. The psychiatry competencies are also focused on the provision of integrated care; psychopharmacology with individual and family interventions. The goal is to ensure that psychiatrists are competent to include family members in the assessment and treatment process, and not to train all psychiatrists as “family therapists.”
Department Chairs who support the teaching of family assessment and treatment (Hales R, (personal communication, 2011), can encourage their Residency Directors to adopt the AADPRT model curriculum. Enlisting the help of psychiatric leaders in our field can promote an integrated model of care (16, 17). There have been family courses and family texts used at various institutions over the years (18), but there has been a general, overall lack of commitment from Department Chairs and Residency Program Directors to promote family systems training. This is, in part, due to a lack of psychiatrists who teach an integrated model that includes family intervention.
Without change, an integrated form of psychiatric care will become difficult to practice, and psychiatry risks becoming relegated to a very narrow scope of practice. Currently, in many communities, primary-care providers prescribe medications and refer their patients and families to psychologists, social workers, and marriage family therapists for treatment. Psychiatrists are seen as “expensive” psychopharmacologists and thought not to provide any “added value” over clinicians who are well-trained in evidence-based individual or family psychotherapies.
Family-systems training can be incorporated into residency training. The research evidence for the efficacy of combining psychotherapy and medications is compelling (19). There is now a recognized AADPRT model curriculum and a core family-therapy textbook specific for psychiatrists: the Clinical Manual of Couples and Family Therapy (20). Also, the American Society of Clinical Psychopharmacology (ASCP) model psychopharmacology curriculum strongly recommends combining medications with family intervention for most Axis I and Axis II disorders (21). The expectation must be that competency as a psychiatrist means being able to understand, assess, and include families in treatment. This means including family skills as a core competency in psychiatric residency programs.