Recent reports by the American Academy of Child and Adolescent Psychiatry (AACAP) have highlighted the importance of family assessment and family interventions in psychiatric practice with children and adolescents (1, 2). Assessing the family helps the clinician understand the child or adolescent’s situation in the developing context of the family system, gather information about the family’s resources and challenges from multiple perspectives, appreciate the patterns of interaction that maintain psychopathology, and identify family strengths. Family interventions have been shown to produce positive outcomes for children and adolescents diagnosed with depression, conduct disorder, substance abuse, eating disorders, and bipolar disorder (2, 3).
In reaching out to prospective trainees, the AACAP encourages residents to consider the multiplicity of roles available to them, some of which involve offering consultation and treatment to families. To the question, “What does a child and adolescent psychiatrist actually do?” Fox (4) responds:
My patients range in age from infancy through their 80s. Many of my patients first come to me with a problem concerning their child. To address the problem, I may work with the child individually, or with his or her family . . . Child and adolescent psychiatrists are well-versed in individual, family, couples, and group psychotherapy.
If child and adolescent psychiatrists should expect to see families in their clinical practices, how well trained are they to do so?
Both the AACAP and Accreditation Council for Graduate Medical Education (ACGME) indicate that child psychiatry fellows will learn to conduct family therapy, yet we presently know very little about the state of family therapy training in child and adolescent psychiatry training programs (4–6). Stubbe (7) found that early-career graduates of child fellowships judged their family therapy training to be of lower quality than their inpatient experiences, psychopharmacology, and outpatient individual psychotherapy experiences. Respondents also perceived their training in family therapy to be insufficient for what was required in their current clinical practice. Despite showing interest in couples and family therapy, both child and adult psychiatrists often report feeling unprepared to provide family therapy on an outpatient basis (6–9).
The current study looked at the specific family therapy training experiences of fellows in a sample of child and adolescent psychiatry (CAP) fellowship programs. The overall aim was to construct a picture of the family therapy training that child psychiatry fellows actually receive. It was expected that fellows would express support for the family-systems perspective and interest in developing family assessment and treatment skills. It was also anticipated that while child fellows would report more substantial family therapy training experiences in their fellowships than in their general psychiatry residencies, they would describe their fellowship training in family therapy as limited.
Directors of training from nine CAP training programs were contacted to participate in the study toward the end of the training year in 2008. The sample was selected for diversity; public and private, as well as geographically distributed, programs were selected. Seven training directors (University of Washington, Stanford, UCLA, Baylor, Emory, Brown, and Cambridge Health Alliance; 77.8%) agreed, and fellows in their programs were invited to participate in a study of family therapy training. Fellows completed a questionnaire that assessed basic demographics, family therapy training experiences during residency and fellowship, common models of treatment and supervision, attitudes about family therapy, and perspectives on clinical training and clinical skill. All study participants gave informed consent.
Descriptive statistics were carefully reviewed for all study variables. After checking the distributions for normality, paired t-tests were conducted to test hypotheses. Exploratory analyses included paired t-tests and one-way ANOVAs. Confirmatory nonparametric analyses were also performed when distributions were not normally distributed.
A total of 66 child psychiatry fellows completed the questionnaire, representing 90.4% of the total sample of fellows (N=73) in the seven programs. The fellows had previously trained in 34 different general psychiatry residency programs. The sample was nearly equally divided between first-year fellows (N=34) and second-year fellows (N=31); their mean age was 34.19 years (SD: 4.24), and there were more women (N=40) than men (N=26). In terms of ethnic background, 48.5% were White (N=32), 31.8% Asian (N=15), 15.2% Black (N=10), 3% Latino (N=2), and 1.6% Mixed (N=1). More than half of the fellows were married (57.6%; N=38).
Fellows’ Experiences With Couples and Family Therapy
The fellows generally reported a high degree of interest in family therapy and regarded the family-systems perspective as important for child psychiatrists. They also indicated that having strong family therapy skills would benefit their patients. Table 1 shows their ratings on 7-point Likert scales.
TABLE 1.Fellows’ Attitudes About Family Therapy
| Add to My POL
|Not at all (important/interested/skilled/satisfied)||Extremely (important/interested/skilled/satisfied)|
|Definitely not (benefit/required)||Definitely (benefit/required)|
|Importance of family-systems perspective and family therapy skills for child and adolescent psychiatrists?||6.51||0.73||4–7|
|Patients benefit if you had strong skills/ competency in family therapy?||6.47||0.80||3–7|
|Level of interest in family therapy?||5.84||1.14||1–7|
|Family assessment should be a required competency for child psychiatrists?||6.03||1.15||2–7|
|Family therapy should be a required competency for child psychiatrists?||5.89||1.34||2–7|
|Quality of overall clinical training?||5.83||0.80||4–7|
|Quality of family therapy training?||4.67||1.19||2–7|
|Level of skill/competency in child/adolescent treatment?||4.74||1.12||1–7|
|Level of skill/competency in family therapy?||3.86||0.86||2–5|
Most fellows agreed that family assessment and treatment skills should be required competencies for child psychiatrists. However, fellows viewed the quality of their family therapy training to be lower than that of their overall clinical training, t=6.97; p=0.000, two-tailed. They saw their skills in family therapy to be weaker than their skills in child and adolescent treatment, t=5.76; p=0.000, two-tailed. These results were confirmed with nonparametric analyses.
Exploratory one-way ANOVA analyses showed no gender difference in family therapy skills F=0.217; NS, two-tailed. However, women fellows were more likely to see the family-systems perspective and family therapy skills as important for child and adolescent psychiatrists, F=9.07; p=0.008, two-tailed. Also, women in the sample were more interested in family therapy than were men: F=6.43; p=0.014, two-tailed. These results were confirmed with nonparametric analyses.
In reviewing their residency training, all of the fellows reported that their general psychiatry training programs offered a course in couples and family therapy, yet only half (N=32; 49.2%) indicated that the course was required. Most (N=41; 60.3%) reported that they did not see any couples or families in treatment during their residency training. In general, the fellows described more substantial training experiences in family therapy during their child fellowships. Nearly all (N=61; 93.8%) reported having taken a family therapy course, and most (N=48; 73.8%) indicated that the course was required. Roughly one-third of the fellows (N=19; 32.8%) described the course as “quarter-length,” and nearly one-third (N=17; 29.3%) noted that they had taken a year-long class. Most of the fellows (N=45; 66.2%) reported that they received specialized clinical training in family therapy. A paired t-test confirmed that these specialized clinical experiences in family therapy were more common in their fellowships than in their residency programs, t=4.112; p=0.000, two-tailed.
A majority of the fellows reported that they received family therapy supervision on outpatients (N=46; 70.8%) and inpatients (N=35; 55.6%). At the same time, the number of family therapy cases that child fellows saw in outpatient treatment was low (Median: 1). Most fellows (N=34; 52.3%) had seen no more than one supervised outpatient family case, and a significant number had seen none (N=19; 29.2%). In order to determine whether the low number of cases was attributable to the mix of first- and second-year fellows in the sample, cross-tabulations were performed, showing that 13 of those who had seen no outpatient families were first-year fellows. However, the number of fellows who had treated one or no outpatient cases did not vary with fellowship year (N=18; 52.9%, first-year; N=16, 51.6%, second-year).
The fellows were also asked about the major orientations in their training programs. They endorsed structural family therapy as the most common approach (N=36; 56.3%). Family psychoeducation (N=29; 45.3%) was the next most common model, followed by strategic (N=23; 35.9%), psychodynamic (N=19; 29.7%), cognitive-behavioral (N=14; 20.6%), integrative-eclectic (N=10; 15.6%), experiential (N=9; 14.1%), emotionally focused (N=8; 12.5%), narrative (N=6; 9.4%), and intergenerational (N=4; 6.3%) approaches.
Finally, the fellows were asked how they would enhance family therapy training in their programs by indicating their preferences from a list of options. They preferred “hands-on” clinical work, with the majority recommending live observation of cases (N=45; 70.3%), required family therapy supervision, (N=39; 60.9%), and establishing a family therapy clinic (N=36; 56.3%). Just under half of the fellows (N=28; 43.8%) favored adding a family-systems perspective to all specialty clinics. In contrast, only one-quarter of the fellows (N=16) recommended strengthening the didactic components of their training by lengthening their family therapy course or adding additional lectures.
These results offer a preliminary picture of the current state of family therapy training in CAP fellowship programs. As expected, the fellows expressed strong support for the family-systems perspective and recognized that having strong family therapy skills would benefit their patients. They reported that specialized family therapy training experiences were more common in their fellowship programs than in their residency programs, and required courses in family therapy were the norm. However, they viewed the quality of their family therapy training in their fellowships to be lower than that of their overall clinical training experiences.
Notably, most fellows had treated no more than one outpatient family case with family therapy supervision during their training. Over one-quarter of the fellows reported never having seen a family in family treatment, and half of the second-year fellows had not treated more than one outpatient family case by the end of their fellowship training. The fellows also saw their family therapy skills as weaker than their skills in child and adolescent treatment. These findings suggest that CAP training programs may offer exposure to family therapy without sufficient opportunities to develop proficiency. It would be unreasonable to expect fellows to achieve even beginning-level competency in family therapy, or any clinical modality, for that matter, with such a limited number of supervised outpatient cases.
Given the small sample of programs surveyed in this study, caution must be exercised in interpreting these findings. Although efforts were made to identify a heterogeneous group of fellowships, the participating training programs were not randomly selected. Also, the survey instrument itself could have benefited from more clarity in some instances. For example, fellows might not have known how to represent their participation in family meetings or consultations as co-therapists or team members. Further refinement of the questionnaire will continue, as will efforts to collect a broader sample.
The results of this study highlight an important area of need in contemporary child and adolescent psychiatric education (6). The CAP fellows regarded family therapy skills as a valuable component of CAP training, yet most had limited supervised clinical experiences with families. These data suggest that there is indeed room for improvement. If we hope to educate child psychiatrists who are more fully prepared to care for children, adolescents, and their families, expanding family therapy training in CAP fellowship programs represents a step in the right direction.
The author reports no financial relationships with commercial interests.