In clinical child and adolescent psychiatry, it is essential to effectively work with families. Yet, these are tough times for formal family therapy, necessitating a reevaluation of what and how family therapy is taught. The need for reevaluation can be summarized in three areas: pragmatic concerns, the contemporary psychiatric educational environment of psychiatry, and a review of the systems concept of family therapy.
It is a challenge to find the time needed to conduct adequate family therapy training, particularly to ensure that residents see families over an extended period of time, a critical component of learning. Shorter inpatient stays, briefer outpatient treatments, descriptive “checklist interviewing,” and inadequately elicited psychosocial data all lead to a decrease in developmental teaching and the in-depth patient understanding necessary for therapy. Perhaps the biggest challenge in teaching family therapy is that residents being trained in the current “biologic era” struggle with integrating psychosocial interventions, such as family therapy, into their psychiatric practice.
These practical challenges accompany dramatic developments in the neurosciences which have competed with teaching time for psychosocial therapies and unwittingly given rise to the notion that psychosocial therapies are not the province of psychiatrists (1). There is debate about how much psychotherapy technique and experience is needed in contemporary psychiatric training and this touches all the psychosocial therapies. The challenges in teaching family therapy are not unique in that all psychosocial therapies share the same core value: words and relationships are used in the service of fostering behavioral change.
What is there in family therapy which needs change? Family therapy has traditionally been synonymous with systems therapy. It began as a therapy competing with individual therapy, yet increasingly became seen as esoteric. The “schools” of family therapy were founded by charismatic clinicians who devised various strategies for change. Such techniques were often taught with an antimedical bias. Enough of these images remain to foster the marginalization of family therapy from psychiatry. As the influence of the progenitors of the various schools of family therapy wanes, the field seems to be searching for an identity (2). Family therapy is briefly mentioned in both the requirements of general and child and adolescent residencies (3). Yet, if one inspects the essentials more carefully, family factors are replete in the documents, which include family-related themes of development, epidemiology, domestic abuse, cultural issues, gender issues, religion, and spirituality. This suggests that it is time for a new look at family therapy.
This article presents a pedagogical model for family therapy in the new millennium which draws on the historical strength of “family systems therapy” but goes beyond it—suggesting a new paradigm, new terminology, and a new teaching perspective. It discusses the historical background of family therapy training, a scientific foundation for what residents should be taught, and an integrative clinical model which emphasizes the sequencing of family therapy. While there is some recent literature discussing the role of family therapy education in adult psychiatry residencies (4), there is little systematic data on child and adolescent residencies. This article is meant to address that gap. In the article, the term “resident” implies a child and adolescent psychiatry resident, although many of the issues discussed are relevant for general psychiatry residents and, indeed, other nonmedical mental health providers.
This article is a synthesis of perspectives developed through my experience as a child and adolescent psychiatrist/educator in a career which began at the end of the systemic revolution in psychiatry and continues through the developments of the neurobiological revolution. If this article generates a vigorous discussion in child and adolescent psychiatry regarding the need for innovation in family therapy training, it will have met its goal.
Historical Background to Contemporary Family Therapy
Arguably, family therapy began with the child guidance clinics of the early 1900s and continued throughout the early part of the last century when “pioneers” experimented with interviewing families. These clinicians became disenchanted with sole individual therapy as they noted many treatments were undermined by families who had difficulty adjusting to therapeutically induced changes in their children (5, 6).
However, in the 1950s and 1960s a set of new ideas ushered in a dramatic era of change in thinking about the family. Family systems therapy—the broad rubric for many of the “schools” of family therapy (e.g., strategic, structural, experiential, symbolic, contextual) which have been extensively reviewed elsewhere (7)—espoused a radical environmentalism approach which some thought would cure many mental illnesses. Founded in emerging systems thinking in biology, this was revolutionary in that the family system was seen as the unit of treatment and the primary symptom bearers. Systemic factors were seen as maintaining a child’s problem and the child’s problems were an expression of systemic dysfunction.
Systemic concepts led to the clinical application of the entire family attending a therapeutic session. Individual diagnosis was minimized and, remarkably, there were provocative statements by some leaders in the field that individuals did not exist (8)! Many of the leaders of this movement perceived medical thinking to be linear and antisystemic, involving simple cause and effect relationships. Impatient with reflective methods, family therapy emphasized intervention techniques with little attention to history, formulation of cases, individual difference, or diagnostic classification. As a consequence, for a generation the field of family therapy had an ambivalent relationship with child and adolescent psychiatry, profoundly affecting the training of child and adolescent psychiatrists (9).
The current era of family therapy is one of rapprochement and integration of individual and systemic approaches (4, 10). It emphasizes a return to life experience and individual narrative without sacrificing strengths of the system concept. This integration sees individual problems and family conflict as interrelated and treats subgroups of a family when clinically indicated. The integration movement asks not which intervention is better but when each intervention is best used, in what sequence, and for which disorders (11).
In sum, contemporary teaching in family therapy occurs at a time of convergence of systemic and individual approaches (12, 13). As Malone has stated (12), child and adolescent psychiatrists increasingly note that the “internal and external are seen as inseparable and intrapsychic and interactional forces and the interventions related to them are viewed as interrelated and interdependent” (p 398). Contemporary family therapy teaching must be integrative teaching. It is best taught not as “schools” of family systems therapy but with the emphasis that there is a “self in the system” (14). The clinical and educational view proposed in this article argues strongly for a new model beyond the family as a system.
Reinventing Family Therapy: Teaching an Integrative Model of Family Intervention
The term “family therapy” is a misnomer. This article proposes a change of terms from family therapy to family intervention, which will be used subsequently in the article. The field has been gradually moving in this direction over the last several decades (15). Terms increasingly seen in the literature include family intervention science (16), family treatment (17), family-based treatments (18), family-centered treatment (4), relational processes and disorders (19, 20), family psychiatry (21), and family skills (22). The increasing multiplicity of terms indicates the clinical reality of different ways that work with families proceeds. The notion conjured by the term family therapy is a session with all family members present, an important practice of the family systems era. The term family intervention is more conducive to a clinician asking in each clinical encounter: How and in what way will I involve the family? The clinician decides not merely whether to do family therapy or not, but in each case decides how family factors will be addressed. Formal family systems therapy may be one intervention, but one size does not fit all.
The following definition is proposed: family intervention is a coordinated set of clinical practices which attempts to alter family interaction, family environment, and parental executive function. Its goals include optimizing the development of all family members and mitigating the risks associated with the onset of child and adolescent mental disorders. The intervention maximizes existing family strengths (i.e., protective factors) and is implemented collaboratively with parents. Family intervention mitigates risk by addressing any family factors which impede development (e.g., attachment problems) (23); are associated with disorders (e.g., neglect, over-involvement); and alter family context and environment (e.g., custody conflicts).
Any family intervention in contemporary psychiatry raises the question, “What is a family?” In this discussion, the term family refers to those who have daily interaction with its children and assume the responsibility of meeting their emotional and developmental needs. It implies biological, affective, and legal bonds, occurring in concert or separately. The term parent refers to those who make decision on behalf of children. Full discussion of the many changes in family structure in contemporary society is beyond the scope of this article. The topic is the subject of several thoughtful reviews (24).
Scientific Foundations of Family Intervention
Family intervention must be evidence-based whenever possible. This includes the epidemiology of family risk factors for disorder (e.g., divorce, adoption, abuse) and the science of demonstrated intervention effectiveness (18). Is there an evidence-based approach to unify family intervention strategies?
The emerging field of developmental psychopathology appears to offer a perspective from which to develop, and teach, rational family interventions (25). Developmental psychopathology is not a theory but an overarching perspective which includes multiple theories and levels of analysis from the molecular to the cultural. In this view, mental disorders are not traits or states that reside within individuals but rather the result of a “dynamic interplay between intra-individual and extra-individual contexts” (26). It allows the incorporation of family systems, psychodynamic, and biological contributions to disorder.
It will be necessary to make a deliberate effort to utilize the perspective of developmental psychopathology. The resident will need to make a conceptual “leap” to this new perspective, as it differs from the traditional disease orientation of general psychiatry training. Two components of the leap are the need to see family interaction as a risk or protective factor and the importance of understanding the family’s role in shaping and influencing individual mental functioning.
While biopsychosocial psychiatry is ostensibly taught in most programs, it is all too common to hear residents discussing cases—“This patient has depression”; “This child has got ODD”—belying the view that symptoms reside within the individual. In the language of developmental psychopathology, being exposed to a risk factor increases a child’s chances of developing a psychiatric disorder and protective factors mitigate the impact of these risk factors, termed resilience by some (27). The conceptual leap is to see family as one of these risk factors—not an epiphenomenon to disorder, but influencing its onset through permissive or protective means
In teaching family intervention, the first “battle to be won” is the scientific, evidence-based one—that residents learn that family intervention is rational and makes a difference. Numerous studies of developmental psychopathology address risk and protective factors by highlighting the importance of parenting quality on children’s adaptations (28) and the importance of family coherence and stability (29). The evidence base in family intervention outcome research is growing and impressive (18).
A second conceptual leap is required of the resident in understanding the relationship of the life experience of family interaction to the formation of mind. Residents typically see environmental and family events (e.g., trauma, divorce, geographic moves) as psychosocial stressors. As important as such stressors may be, the reality of family influence is more nuanced and requires a second leap. This leap is an extraordinary help in teaching family intervention as the resident comes to see the intervention not as a technique but as a way of influencing individual mental processes. Family interactions shape individual identity, develop internalized object relations, influence attachment, direct the regulation of impulses, and are the basis for negative cognitions.
One way to operationalize this concept is for the educator to ask a resident during a formulation presentation to describe a patient’s current mental set by proposing how the child would complete the statement “I am in the kind of world where _________.” The exercise helps the resident identify that an abused child believes that “I am in the kind of world where I might get hurt, people are mean,” and an indulged child understands that “I am in the kind of world where I am special; I will always get what I want.” It is a short step for the resident to see that these cognitions, frequently maladaptive, are powerfully influenced and shaped by family interaction.
The leap to identify how interaction becomes part of the self is aided by a diverse research and clinical literature.
Cognitive therapy: dysfunctional cognitions have developmental origins.
Infant research: infants structure their world (i.e., mental representations, social referencing) directly from environmental inputs (30–33).
Family therapy: family members form mental representations of family relationships (34).
Cognitive research: cognitive vulnerabilities (e.g., low self-worth) are affected by quality of relationships with parents (35).
Psychoanalysis: object relations approaches are relationship based (36).
Social experience becomes phenotype/part of the organism (37).
Thus, family intervention is not merely a therapeutic choice, or option, open to those who might be inclined to practice it. It is an intervention which addresses risk factors for illness and must be considered in each clinical encounter, just as biological and psychological factors. As a diagnostician, the child and adolescent psychiatrist should be trained to assess how families pose risk, how families protect, and how families shape the mind. As a clinician, the child and adolescent psychiatrist should be trained to make enough therapeutic interventions to understand their impact.
Preparing for Family Intervention: Teaching a Developmentally Based Family Formulation
Once residents have made the two leaps, how is the scientific basis for family invention taught? Rather than merely listing various factors, as residents often do on board examinations, we should ideally teach residents to think interactively using the processes of developmental psychopathology in developing case formulations.
In some ways, the interactive concepts of developmental psychopathology as a formulation map for clinical family intervention are not new, even if the research base to support them are more recent. Used appropriately, the biopsychosocial model of Engel (38) is consistent with developmental psychopathology, as are the constructs of other developmentalists (39, 40).
This article offers a teaching tool as an aid to developing case formulations which prepare for family intervention (see Table 1
). It uses a definition capturing the dynamic interplay of child and family, one which residents can easily remember and utilize: “Goodness of fit results when the properties of the environment and its expectations and demands are in accord with the organism’s own capacities, motivations and style of behaving” (39). In teaching, “capacities” refers to biological givens and/or vulnerabilities and “style” refers to biologically based temperament.
Several points from Table 1
1. There is an interactional basis (organism-environment) to child psychopathology (41).
2. The processes of psychological development are regulated by families (42). In health, family regulation is attuned to the developmental needs of the child; in psychopathology, various types of dysregulation are associated with clinical problems (e.g., underregulation of the need for attention; overregulating autonomous strivings).
3. Formulation prepares for effective treatment. Simply, any intervention must consider decreasing environmental stress (e.g., tutoring for a learning disordered child) and increasing organism resilience (e.g., through pharmacological intervention or psychotherapeutic intervention). As indicated by the earlier discussion, psychotherapy addressing cognitive schema (e.g., low self-esteem), without concomitantly addressing family interaction giving rise to maladaptive cognitive schema, will have less chance for success.
4. Developing a formulation suggests weighting clinical variables under consideration, emphasizing those with the most impact on the child’s or adolescent’s disorder. While family factors must be considered in every case, the sound formulation may weight them as less influential in some cases.
When family factors are influential, at one level the family acts as a stressor and at the second the family shapes the mind and maintains mental structures and behavioral patterns. Family stressors, like geographic moves, violence, and divorce can acutely precipitate problems. Family interaction can predispose to problems through negative family experience that is internalized (represented) and becomes part of the self. If it is ongoing, this chronic family interaction will perpetuate problems, a classic tenet of family systems therapy. Often family interactions are maintained and resist therapeutic intervention, due to the internalized world of parents and relationship problems of the parents. Family strengths protect children from succumbing to other vulnerabilities.
Implementing Family Intervention: Teaching the Sequencing of Treatments
Once residents are taught to formulate a case (What is wrong? How did it get that way?), they can be taught how to intervene in family function (What do we do to fix it?) (43). Given some instruction in technique, residents can be encouraged to use their own abilities to help the family “fix” problems.
As a result of the multiple ways families influence health and illness, family intervention should not be seen as an either/or intervention, or one that is better than another, but one that must be sequenced and coordinated with other interventions (4, 11, 13). The following coordinated intervention sequence is offered as one way to conceptualize how integration with other modalities might take place. It does not always unfold in the order listed, nor are all components always needed, although they should all be considered. Embedded in this sequence of interventions are the techniques classically thought of as family systems therapy. This proposed sequence broadens psychiatric education in this area, shifting from teaching “family therapy” to teaching “family interventions” or, simply, working with families. See Table 2
for guidance on how this clinical model is supplemented by didactic curriculum.
1. Stabilize a Crisis and Getting Going
When a clinical disorder first presents, the clinician addresses the immediate problem. This may involve a direct family intervention, such as removing a child from the home, most commonly by hospitalization. At times an acute psychopharmacological intervention may be indicated, accompanied by parent psychoeducation regarding the usage of medications (11). In less acute situations, feedback is given and a treatment plan is described regarding the role of family in the next steps of treatment.
2. Parent Education and Parent Management Training
This area is a key component of all family interventions and one with a growing evidence base (44). Not traditionally seen as a family therapy, it occurs concomitantly with a first clinical contact and acknowledges that parents perform the key executive functions for families. In this phase of family intervention, parents are informed of factors supporting the diagnosis, treatment interventions, course of disorder, and what families can do to support the child. This is critical in disorders with significant biological components, such as learning disorders and disorders of attention. Parent education regarding behavioral management principles is always important in the behavioral problems of children and conduct problems of adolescents.
At times parent education may be all that is indicated when families are stable. When history and clinical observation indicate significant problems in family interaction or specific parental vulnerabilities, more specific intervention is indicated. In this important phase of intervention, the clinician determines if family function is a response to illness, requiring parent education and support, or if family functioning predisposes to disorder, requiring the exploration of avenues to family behavioral change (6). Most families can accept the exploring of family interaction when a clinician sensitively proceeds with an approach of empathic accountability, expecting family change yet appreciating its difficulty. This approach and the guidelines for its utilization have been reviewed elsewhere (6). When it is determined that problems in family interaction require more than education, the next stage becomes relevant.
3. Intervention in Family Process
This intervention most closely resembles family systems therapy. Here, the clinician attempts to help the family alter interactions between family members that have been observed to be problematic. Common examples requiring intervention include parents ineffectively setting limits by asking a child to stop negative behavior using a deferential, nonauthoritative manner, and parents speaking for an adolescent when the clinician has asked the question of the adolescent. Empathically intervening in such processes and recommending alternative approaches can have significant family impact. Although it is no longer true that the entire family needs to be present for every session, a tenet of a number of early family systems approaches, it is important that enough family interactions are observed to accurately determine which interactions are problematic. As the generation of family systems influence emphasized techniques, it is not surprising that a significant literature exists offering ideas of what to do in sessions (4, 17, 45, 46). Ideas such as reframing problems, circular questioning, and paradoxical intervention continue to be useful. After reading the literature, residents often learn best by observing faculty interventions as well as, in supervision, being directed as to how they can intervene themselves.
4. Individual Intervention
It is not uncommon for parent education or intervention in family processes to be unsuccessful. Typically, change in family interaction is resisted due to the cognitive perspective of parents, a cognitive set which would have to be altered if interactions were changed (e.g., a parent allowing a child’s increasing independence, unmasking parental insecurities). The parent may have a formal psychiatric disorder and there is an emerging evidence base which indicates that as parents’ psychiatric symptoms are ameliorated, child behavior improves (47). Focused individual work with a parent can be seen as a family intervention when parental issues (e.g., depression) are clearly related to child problems. The shoring up of parental self-esteem, coupled with parent education and altering family relationships, is an example of a coordinated family intervention. In such individual parent psychotherapy, the clinician is ever mindful of how the issues being dealt with ultimately affect the family generally and the parenting of children specifically (e.g., exploring how a sense of personal ineffectiveness is related to problems in limit setting).
5. Marital/Couple Intervention
At times problematic marital/caregiver interactions (e.g., one parent undermining the other) may outweigh individual factors. As the parents have the crucial role of “family executives,” it is often productive to recommend that couples/caregivers be seen alone to explore differences in parenting. This usually occurs after parent management education has been offered, intervention in family processes has been suggested and tried, but problems in the family continue.
In the process of focusing on an individual child it is not uncommon to identify the problems of other children in the family. Their issues can be addressed by including a discussion of their problems in parent education sessions or including them in the interventions in family interaction. In some instances, a formal individual evaluation of the sibling should take place.
In contemporary child and adolescent psychiatry, family intervention is a coordinated, sequenced process which occurs at multiple levels. There are other elements of clinical work that could rightly be viewed as a family work, if not formal intervention: helping parents negotiate community support systems such as in-home care, supporting parents’ efforts in procuring appropriate educational services, and communicating relevant information to the legal system when indicated. Some of these family-related interventions outside the clinic may have more impact on a child’s well being than any activity in the consulting room (48).
Challenges for the Future
Adopting a model of sequenced family interventions based on developmental psychopathology will not be easy, yet it has a better chance of being integrated into an evidence-based curriculum with a strong neuroscience emphasis than a sole family systems model of therapy. Utilizing only systems models to teach family therapy does not address the clinical reality of the need for interventions at several levels (e.g., individual parent).
Pragmatic concerns remain regarding finding time to keep residents abreast of recent development in psychopathology literature and curricular time for supervised, long-term case experience. Educational research will need to be conducted on the clinical effects of family intervention. In more broadly defining family intervention, clinical effectiveness may be enhanced, but measuring this may be difficult.
By reframing family therapy as a family intervention based on developmental psychopathology, the Residency Review Committee requirements become more family friendly. While the requirement for family therapy is muted in the document, it is replete with references which are relevant to family as a risk/protective factor and family as influencing mind. These include the child psychiatry competencies of patient care (e.g., treating families of diverse cultures and managing forensic issues such as custody evaluations psychotherapy); medical knowledge (e.g., developmental and sociocultural contributions to psychopathology, domestic/child abuse); and practice-based learning (e.g., education of families) (3).
Finally, it must be acknowledged that certain perspectives and practices of modern psychiatry make the teaching of family interventions difficult.
In a previous generation, psychiatrists were seen as “blaming” families for major mental illness. How much that occurred is debatable but it is not the field’s problem now. It is increasingly common to hear child psychiatrists concerned about the reductionistic medicalizing of some problems and excessive usages of medication in others (49). The contemporary resident must be trained to educate a family regarding child problems that are beyond its control and hold a family empathically accountable for child problems which are within its control. Teachers and programs must be equipped to help residents meet that high challenge, one which merges the art and science of practice.