Despite support for family skills by the ACGME, expanding research on the efficacy of couples and family interventions for many psychiatric disorders, recommendations for family centered care by the President’s Commission on Mental Health, and emerging models of biopsychosocial health care, many psychiatric residency training programs do not offer thorough, family systems oriented educational experiences (1–3). In this article, we detail the couples and family therapy training program at Stanford’s Department of Psychiatry and Behavioral Sciences in order to show how one general residency program provides a 3-year sequence of training experiences in couples and family work. In many ways, our department is typical in that trainees are expected to master a continually growing array of content areas and competencies in the context of steady educational, clinical, and administrative demands.
Training Goals and Basic Concepts
In training residents to work with couples and families, we emphasize five important conceptual and practical features of couples and family therapy: joining with the couple or family; seeing systemic patterns that maintain maladaptive behaviors, thoughts, and feelings; recognizing the importance of family developmental stage, history, and culture; identifying the family structure; and understanding and using a systemic model of change. These skills are taught in the broader context of the biopsychosocial model embedded in most psychiatric residency programs, as opposed to the more specialized models of many couples and family therapy institutes.
Joining With the Couple or Family
One of the earliest and most difficult challenges that residents face is learning how to manage therapeutic relationships with couples or multiple family members in an environment characterized by conflict, emotionality, vulnerability, and threat (4). To new and experienced clinicians alike, there appear to be so many ways to fail: by overidentifying with one family member, overprotecting another, or sharing in the family’s experience of helplessness. Not surprisingly, the drop-out rate in couples and family therapy is higher than in individual treatment (5). It is easy to take a wrong step, inadvertently take sides, and become a disappointment to a patient whose relationship is foundering. The family oriented trainee must actively understand the family’s predicament, appreciate expectations that he or she will be able to repair even the most problematic relationships, and instill hope that their circumstances can change.
Minuchin and Fishman (6) view the family and clinician as forming a time-limited partnership that will support the process of exploration and transformation. From the structural family therapy perspective, “joining” is considered to be the glue that holds together the therapeutic system. Virtually every model of family therapy highlights the importance of developing a strong initial bond with the couple or family and its members, as the therapeutic work requires alliances sturdy enough and flexible enough to support challenges to the couple’s or family’s preferred patterns of interaction. As any clinician walking the tightrope between battling family members or competing coalitions knows, the most formidable clinical task involves not simply building these alliances, but sustaining them over the course of therapy.
Residents are first exposed to thinking systemically by watching videotaped clips from familiar movies and TV programs. Basic ideas regarding reciprocal, complementary patterns in family functioning are identified. For example, in “Who’s Afraid of Virginia Woolf,” the husband’s resigned, passive, and hostile stance is maintained by his wife’s histrionic, critical, and belittling behavior. Residents subsequently consider how various forms of individual psychopathology elicit recognizable interpersonal patterns that reinforce signs and symptoms of the disorders. In particular, the regularities that link the biological, intergenerational, and sociocultural contexts of family life are explored.
Because problems from a systemic perspective are situated in their interpersonal contexts, a new vocabulary is needed to characterize them. Residents come to appreciate how complementarity functions as a defining principle in every relationship. The importance of this conceptual shift cannot be underestimated. As Minuchin and Nichols (7) observe, “In any couple, one person’s behavior is yoked to the other’s … it means that a couple’s actions are not independent but codetermined, reciprocal forces” (p. 63). Consequently, the family systems oriented psychiatrist begins with a microscopic focus on the individual, his or her illness, and its treatment and then adds a wide-angle lens to better perceive the powerful social factors that influence, and are affected by, the sick person’s experience. Seeing these complementary relationships between self and system, between the individual’s behaviors and the system’s responses that maintain them, stands as the linchpin of systemic thinking.
Recognizing Family Developmental Stage, History, and Culture
It is difficult to overestimate the importance of identifying the family’s developmental stage. Just as in individual treatment, residents must recognize the normal developmental tasks and transitions, beginning with couple formation and ending with death, that couples and families routinely encounter. Residents soon appreciate that both centripetal (couple formation, marriage, birth of a child, birth of grandchildren, death) and centrifugal stages (going to school, adolescence, leaving home) occur and recur throughout the family life cycle, presenting new challenges that require reorganization at each step (Table 1).
At the same time, members of a couple bring with them idiosyncratic histories that serve as blueprints against which current situations are appraised. Residents learn to construct three-generational genograms, or family trees, that identify family patterns and themes as well as highlight connections between present family events and prior experience. The genogram is a useful tool because “a picture is worth a thousand words,” and residents soon recognize its value in efficiently gathering family historical information visually rather than in the traditional narrative form. Most couples and families enjoy the process of generating a genogram, as they see patterns emerge in their family histories in a way that is accessible and clarifying (Figure 1).
Finally, residents must develop cultural competence in their work with couples and families. By recognizing how each family member’s distinctive sociocultural background provides context and meaning for a family’s traditions, choices, and preferences, trainees can tailor both clinical formulations and strategies for change. Residents frequently comment that they receive far too little training in appreciating the strengths and differences among patients and families from different cultural and ethnic groups. In all cases, identifying critical influences such as gender, culture, class, race, religion, disability, and sexual orientation contributes to the development of culturally sensitive practices that address the distinctive aspects of each family’s idiosyncratic culture.
Identifying Family Structure
If genograms map the family’s history over time, the structural map represents the family’s present organization with special attention paid to proximity and affiliation, hierarchy and power, and boundaries and subsystems. Family structure, most notably associated with Minuchin (6–8), represents an inference drawn from redundant pieces of family process that identify preferred patterns and available alternatives: residents learn to see the couple or family in terms of its structure—instead of seeing only individuals, they begin to notice hierarchical imbalances in couples, coalitions and alliances, and relationship triangles (Figure 2).
Over time, residents begin to understand the couple or family’s preferred patterns and available alternatives. They practice diagramming couples and families, looking at patterns of closeness and distance, power, boundaries, coalitions, and alliances.
A family map is an organizational scheme. It does not represent the richness of family transactions any more than any map represents the richness of a territory. It is static, whereas the family is constantly in motion. But the family map is a powerful simplification device, which allows the therapist to organize the diverse material that he is getting (8, p. 90).
These structural maps serve as the basis for family assessment, goal-setting, and the determination of therapeutic progress.
Working with a Systemic Model of Change
Residents learning about systemic change can initially find it disorienting to learn that the shortest distance between the point of assessment and intervention is not necessarily a straight line. Rather than targeting problematic individual behaviors, the wider systemic view recognizes that intervening in relationships that support these behaviors can be quite powerful. In this regard, residents must experience a figure-ground shift, in that the individual “problem” can best be understood and treated by bringing these contextual factors into the foreground. The aim of systemic therapy is to disrupt dysfunctional patterns, to introduce alternative rules, and in doing so, to provoke systemic change. In this regard, the trainees begin to recognize the significant difference between “first-order” or technical change (such as improving communication skills) and “second-order” or systemic change (whereby the “rules of the game” are modified).
The Stanford model builds on broad, family systems principles based on both structural and intergenerational ideas. This integrative perspective allows for both an active here-and-now focus that residents appreciate with the added richness of a family-of-origin historical approach to data-gathering. Specifically, residents learn the premises for a treatment model in which the therapeutic task is to help the family move from one stage of development to a new stage where members’ developmental needs are better met; the therapist joins with the family by entering into their reality and becoming involved in the repeated interactions that form the family’s structure; the therapist expands the family’s range by challenging family rules, fostering boundary reorganization, promoting communication and conflict-resolution, and supporting greater individuation of family members; and the therapist monitors change process by helping family members integrate emerging patterns into a new level of functioning. These steps, originally proposed at the Philadelphia Child Guidance 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 area of specialty would assume priority in the competitive environment of residency training, so too do teachers of couples and family therapy imagine every resident developing solid competencies in this approach. In our program, residents begin their internship/PGY-II training with lectures on elements of systemic theory and practice relevant to working in inpatient psychiatry, emergency room, and consultation-liaison settings (3, 9). Residents participate in family sessions and provide family psychoeducation with the support of social workers and psychiatry faculty. In some regards, these early training sites require the greatest clinical skill due to the acuity, the time constraints, and the strong emotionality that often surrounds the presenting situation (Table 3).
In the PGY-III year, residents take a required, intensive seminar introducing them to structural family therapy concepts, couples and family assessment, the leading models and schools of family treatment, and applications across clinical settings. The focus of this course is on developing observational and conceptual skills by examining taped interviews, role playing initial interviews, generating hypotheses, and devising thoughtful and powerful clinical interventions. Residents review evidence-based approaches to working with couples and families, wrestle with the assumptions of the systemic model, and learn about combining psychopharmacological and family interventions. Although case material comes mostly from outpatient settings, residents also consider how the family systems approach can be applied in inpatient, consultation-liaison, and child/adolescent sites. In addition, residents each construct their own personal genogram, helping them to identify their own strengths and clinical “blind-spots.” The PGY-III seminar is fast-paced, provides a learnable model based on structural and intergenerational perspectives, and focuses on the concepts and skills needed to conduct couples and family treatment.
Finally, in the PGY-IV year, residents typically participate in a supervised, outpatient training experience in the Stanford Couples and Family Therapy Clinic. They meet weekly in small groups and present cases, most often by showing clips from videotaped sessions. Supervision focuses on case formulation and hypothesizing, supporting the development of creative interventions, and broadening the resident’s style. The atmosphere of the group tends to be lively, and residents value the opportunity to observe each other and the opportunity to learn from their peers’ experiences. Both generic (e.g., handling “resistance”) and specific (e.g., special questions with mood disorders) issues are highlighted.
Fourth year residents carry two outpatient cases through to completion. Through live and videotaped supervision, residents learn how family members play a critical role in both the maintenance of and recovery from acute and chronic psychiatric conditions. They become more skilled at tracking family process and dysfunctional patterns, evaluating psychiatric disorders in the context of couple or family relationships, intervening systemically, supporting the family’s strengths, and combining couples/family treatments with individual and psychopharmacological interventions. Trainees with a special interest in family work may pursue additional training in the Family Therapy Program at Palo Alto VA Health Care System.
Whether all residents should be able to competently conduct a couple/family evaluation and treatment is currently under discussion in many residency programs. In our training program, most residents elect to complete the full sequence in couples and family therapy, elevating this psychosocial model to a comparable position with other psychotherapeutic treatments. By the end of this program, these residents report that they feel prepared to begin to see couples and families independently, and some continue to seek couples and family supervision postresidency. Appendix 1 presents further suggested readings.
It has been said that the only way to learn to ride a bicycle is to climb on a bicycle and ride. In some regards, this analogy applies to learning psychotherapy as well, and there is no substitute for actually working with a couple or family. We agree with GAP Committee (3, 9) that residents should “be competent to form an alliance with, assess, educate and support families.” In addition, they “should be able to see a presenting problem through a systemic or an individual basis.” While adopting a systemic perspective can be challenging, learning how to intervene systemically requires practice, reflection, and careful attention.
Because couples are treated more commonly than families with children in general residency programs, caseloads tend to focus on skills in couples treatment. As noted above, supervision is primarily conducted through videotape review and live supervision. Treatment rooms are equipped with a one-way mirror, cameras, observation rooms, monitors, and a telephone hook-up so that the supervisor and observing team can communicate directly with the therapist in the treatment room. Couples and families sign informed consent, and they typically report appreciating the fact that a team is devoted to their care.
Although initially anxious, residents find observing themselves on videotape, supervisory feedback, and the experience of live supervision to be direct, genuine, constructive, and fun. Pedagogically, residents recognize that these forms of teaching, including “real-time” feedback, represent invaluable contributions to their overall clinical education. As Lieberman and Wolin (10) observe:
Training in family therapy is still the exception rather than the rule in psychiatry residency programs. Such training may seem to impose on already overscheduled programs, but developing specific skills to work with families makes clinical work more interesting and rewarding. Most residents and medical students like this training, which is experiential and includes “live” supervision. Family inclusive psychiatry adds to the attractiveness of our specialty in an era when technological approaches threaten to overwhelm its humanistic side.
In addition, because residents observe each other, they learn about the struggles of learning through their colleagues’ experiences as well. Finally, residents observing sessions with a supervisor behind the mirror or watching videotape can hear the supervisor “think out loud” about case formulation, therapeutic choice points, generating and executing interventions, and the development of a treatment strategy.
The final product of the training is the demonstrated skill of the resident in the conduct of couples and family treatment across a range of cases. Competencies are defined at the outset of each rotation, and trainees receive specific feedback on their progress in the areas of conceptual skills and systemic thinking, assessment and engagement, planning and conducting interventions, and professional conduct (11). The role of the teacher and supervisor is to create a setting in which these skills can be defined, described, demonstrated, and delivered effectively with couples and families.