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The Canadian Child and Adolescent Psychiatry Review logoLink to The Canadian Child and Adolescent Psychiatry Review
. 2004 Nov;13(4):114–118.

The Dalhousie Family Therapy Training Program: Our 6-Year Experience

Normand Carrey 1,✉, Lou Costanzo 1, Ann Sexton 1, John Aspin 1
PMCID: PMC2538708  PMID: 19030490

Abstract

Introduction

Training in family therapy for general psychiatry residents during their child rotation is either not taught or the objectives not well described in psychiatric curricula.

Method

Based on the combined experience of 4 family therapists over a 6 year period with 56 students (psychiatry, social work, psychology), we describe our experience with training general psychiatry residents in an introduction to an interdisciplinary family therapy, systemic-reflective course during their child psychiatry rotation. The model was based on experiential training, where both trainees and supervisors could build skills as they reflect on their process as learners and teachers.

Results

Residents’ ratings at the end of rotation indicated extremely high satisfaction with the course.

Conclusion

We advocate that an experiential interdisciplinary course serving as an introduction to family assessment and systemic/reflective principles are valuable skills that have lasting value to general psychiatry residents.

Keywords: psychiatry residents, family therapy, reflective, systemic

INTRODUCTION

As psychiatric residents are squeezed for time by competing demands in their program, training in a modality specific to child psychiatry such as family therapy may appear unnecessary. The explosion of knowledge in neurosciences, genetics, psychopharmacology and developmental psychology as applied to child psychiatry impose demands on training programs to keep residents up to date within the narrow time limits allocated to child training. Competing demands on the time of clinicians as teachers and supervisors is an added factor in deciding the potential cost/benefit of family therapy in terms of scarce teaching resources. Current Royal College guidelines in Canada (RCPSC) mandate that residents rotate through six months of child psychiatry but do not specify the content--especially in areas related to a specific psychotherapeutic skill such as family therapy.

It has been validated through research studies that family therapy as a therapeutic intervention is effective and has been applied to a variety of mental health disorders including schizophrenia, anxiety disorders, attachment difficulties, eating disorders, behavioral disorders, substance abuse and medical conditions with psychological factors (Diamond & Siqueland, 2001). However, even within larger programs that have the professional resources to teach family therapy (ie: programs with child fellows), educating students on competing models of family therapy schools would take an extended period of time to cover adequately. In addition for students to become competent in skill development, they need extended training in longitudinal follow-up and treatment of families.

While teaching in family therapy in psychiatric programs has received less emphasis in the last decades (Celano, Croft & Morrissey-Kane, 2002), the field of marriage and family therapy (MFT) is one of the fastest growing fields in mental health. It currently boasts over 50,000 practitioners in the US alone (see American Association of Marriage and Family Therapy or AAMFT, website www.AAMFT.org) who have an overlapping mandate to treat the same clinical populations as psychiatrists. Approximately 24,000 MFTs are certified with the AAMFT, a rigorous certification process that requires a minimum of 2 years after a Masters degree with 1000 hours of MFT clinical hours of which 200 must be under the supervision of an AAMFT approved supervisor. Therefore, psychiatrists not only have less training in family therapy and systemic principles but also need to familiarize themselves about collaboration with a parallel field of mental health practitioners who treat the same clinical population. Under current training schemes the potential for divergence already in existence between psychiatry and MFTs could become even greater.

In a literature search focusing on how family therapy is integrated in general psychiatry programs (Pubmed with key words family therapy training, psychiatric residents, child and adolescent residents), the extant literature was scant and over 20 to 25 years old except for one study (Celano, Croft & Morrissey-Kane, 2002). Harbin (1980) described the University of Maryland four year psychiatry residency program where residents received over 70 hours of family didactic seminars, 500 hours of family and marital therapy and 175 hours of one to one supervision by a family therapist. One of the family therapy supervisors in this program was Jay Haley. Sugarman (1980) reviewed some of the advantages and difficulties in integrating family therapy training in general psychiatry training, including controversies about the definition of the field, elective versus required teaching, curriculum content and who/when/where to teach family therapy. Feldman and Feldman (1982) identified programmatic resistances to family therapy teaching as due to identity problems (non-congruent with the medical model), competency problems (motivation to graduate, institutions geared towards individual treatment) and bureaucratic problems (economic and administrative). Celano, Croft and Morrissey-Kane (2002) integrated psychiatry residents and psychology interns within a family evaluation clinic. Most trainees found the experience valuable in their current practice whether working with individuals, families or systems.

Our challenge as educators of family therapy was to decide what principles of family/systemic therapy were important to teach and then how to provide this teaching to general psychiatry residents with no previous experience in child psychiatry. The supervisors had extensive experience in teaching different schools of family therapy (strategic, structural, systemic). We decided to offer a 14 week half-day experientially based course focusing on systemic-reflective principles using the refiecting team as a core teaching element. The choice of this model reflected our underlying philosophy that students needed to: 1) focus on the broader interpersonal and social context of families, 2) experience themselves as part of the system, 3) use reflectivity as a basic tool for self-supervision and 4) be able to experience and reflect on the effect of multiple realities and perspectives in co-constructing their encounter with the family. Therefore our model borrowed elements from systemic, narrative and reflective principles but was congruent with the post-modern philosophy of social constructivism (Foucault, 1980; Gomez, 1996; Rober, 1999; Shapiro & Ross, 2002).

As a result of our group experience and based on questionnaire feedback received from residents over the last 6 years, we advocate that an experiential interdisciplinary course serving as an introduction to family assessment and systemic/reflective thinking, provides valuable skills that have lasting value to general psychiatry residents.

METHOD

Description of the Course

In terms of logistics, during their 6 month child rotation residents receive 14 half-days of the family course and 10 half-days of didactic seminars. Each resident is required to rotate 3 months on the inpatient unit and 3 months in the outpatient clinic. Residents receive additional supervision during their child inpatient and outpatient rotations from staff child psychiatrists.

There are four supervisors available (two child psychiatrists, two AAMFT accredited family therapists) in the program, and supervisors work in pairs. There are from four to eight learners for each six month period. Learners, in addition to psychiatry residents, include masters level students in social work and psychology. Child mental health staff (social work, psychology) also have the opportunity to join the training. Each pair of supervisors has three to four students. Each student interviews 2 new families in the 14 week program after they observe each supervisor demonstrate a live interview.

The emphasis in early sessions is to establish the rationale for a family approach and focus on the reason for referral in terms of who, what, when and why (Haley, 1976; Tomm & Wright, 1979). The family genogram as a technique for creating rapport with all family members and mapping intergenerational influences and psychopathology is introduced at this stage as well (McGoldrick & Gerson, 1995). Genograms help map out intergenerational patterns where family myths, beliefs and meanings can be generated and mapped out against trauma, loss or serious psychopathology. Genograms also help students think in terms of family patterns of functioning (boundaries, roles, emotional support, communication patterns).

Students are invited to shift their thinking from linear (intraindividual) to systemic (inter-relational), narrative (multiple perspectives, effect of pathologizing) and reflective (self in relation to system) styles. This may be a challenge for residents to shift from a linear perspective since most of their training to date has been in the individual assessment of symptoms and treatment in psychotherapy. All interviewers are taught how to assess for safety risk and crisis intervention when a situation requires it (such as in cases of suicidality, family violence, psychosis).

The Reflecting Team Process

The reflecting team is a relatively new therapeutic tool that embodies the technique and philosophy of a collaborative healing dialogue between therapist and family. Our teaching is embedded within the reflecting team experience. We adopted the guidelines provided by Andersen (1991; 1995) for the reflecting team interview but modified the last stage to emphasize the “self in relation”. The skills we mention above (ie: such as genogram interview) are embedded in the reflecting team interview.

The first stage of the reflecting team process is the student having a conversation with the family about their problem and the influence of the problem on the family’s life. The supervisor and the rest of the reflecting team are behind the one way mirror. The team observes the interview without any dialogue between members so that each team member can offer reflections from his perspective rather than a group consensus or the supervisor’s perspective.

The therapist and family then reverse positions (second stage) as they now observe the reflecting team in dialogue about how the family is burdened by, but in other instances, has escaped the influence of the problem. The team members situate and contextualize their comments in their own experience. This “near experience” level of discussion helps the family to reflect on strengths and possibilities to engage in new patterns of change and defeat old patterns. The students are asked to emphasize change (growth) rather than symptom decrease. Therapists are also asked to state their comments from a position of “not knowing” (Anderson & Goolishian, 1986, 1988) which simply means being aware of the influence of ones biases on the therapeutic process (biases in privileging certain stories, points of views or information) and offering reflections as possibilities rather than defined truths.

The therapist and the family switch positions again with the reflecting team and the therapist asks the family if any of the comments by the team were helpful, upsetting, or were sources of disagreement (third stage). This idea of watching and being watched serves to remind therapists and trainees to couch their comments in simpler language and more personal ways that eliminate hiding behind professional distance and power relationships (Friedman, 1995). For some families this is the first time they have heard themselves talked about in such intimate and familiar way. Over 95 percent of our families find the reflecting team experience helpful as they are asked this question at the end of their interview. The family, if they need to be seen again, are given another appointment with the supervisor.

The family then leaves. In the fourth stage, which we have modified to enhance reflectivity and “self in relation to the system”, the therapist is asked by the reflecting team why he/she chose to ask certain questions because during the interview there can be “branch points” where the therapist chooses to go in one direction or another. This can lead to “reflection-in-action” (Schon, 1987) where the interviewer leaves him/herself open to surprises or unexpected outcomes but also decides on a course of action or a line of questioning to pursue based on his/her professional and personal experience. The supervisors deliberately chose the “self in relation” stage as a reflective skill to focus on in this course.

During this group discussion, emphasis is placed as well on narrative principles of the effect of gender, race, sexual preference and pathologizing or language of deficiency (Gergen, 1990a; 1990b) as the therapist is asked to reflect on the relative influences of these factors on the interview he/she just conducted. For most residents this is their first experience in reflective group supervision and interaction with another discipline. This invites discussions about hierarchies and the power differential between professions as well as differing professional beliefs about client realities.

When families cancel appointments, this time is used to review tapes from previous sessions, or students can present the genograms of their own families. Tape reviews as homework are encouraged but not enforced. The students are given articles throughout the course to illustrate theory and technique in relation to setting up the context of the interview (Haley, 1976), the genogram (McGoldrick & Gerson, 1995), interventive questioning (Tomm, 1987a; 1987b; 1988) the narrative approach (Rober, 1999; White & Epston, 1990) and post-modern philosophy (Foucault, 1980). These articles are discussed in varying detail before and after the families are seen depending on the time available.

RESULTS

A questionnaire was distributed at the end of the 14 weeks to ask if the goals set out at the beginning were accomplished. In addition, focus groups were held to elicit feedback not covered by the questionnaire. Fifty-six students completed an anonymous questionnaire (34 psychiatry residents, 20 social work and 2 psychology students; not all figures add up to 100 per cent as there was overlap in the questions).

Results from the questionnaire were divided into four domains of Cognitive (knowledge), Skills, Affective and Reflective Learning, and a sample question from each domain is given below.

  1. Reflective Domain: Did the course achieve its goal of inviting you to be a reflective practitioner?

    - 98 percent said yes

  2. Affective Domain: Has the experience in family therapy met your learning needs (interviewing more than one person, being comfortable with families etc)?

    - 94.5 percent said yes

  3. Skills Domain: Has the experience in family therapy increased your skills (genograms, rapport with several family members) for family therapy?

    - 86 percent said yes whereas 30 percent said no (total exceeds 100%) since some students said they acquired skills in assessment but wanted more long term experience with families.

  4. Cognitive Knowledge Domain: Certain concepts were emphasized such as systemic thinking, narrative stories by the articles and discussion. Were we successful in teaching these?

    - 84 percent said yes and 14 percent said no.

All students agreed (100 percent) that the three key practices of the reflecting team, group interdisciplinary experience and observing supervisors doing interviews were very useful.

The most frequent negative comment (30 percent) was that students did not see therapeutic intervention or follow-up. A few students requested more specific feedback on skills.

Here are some unsolicited comments from the questionnaires:

  • - “I have never had so much opportunity to observe and be observed in my whole training.”

  • - “best learning experience of my residency.”

  • - “one of the highlights of my psychotherapy training.”

  • - “a wonderful and useful course that I hope to make use of throughout my career.”

  • - “I was left feeling vulnerable-the lone wolf out there.” (three students),

  • - “they are nice people after all!” (Referring to myths between psychiatry/social work).

Since many of the residents tend to stay within our geographical area, we were able to solicit informally the following feedback about the training over the years. Two years later two students, now adult psychiatrists who supervise residents, stated they now realized what we were talking about. (ie: the systemic perspective). One student (now the director of postgraduate education) suggested the program be extended over the residency. Five students became child fellows.

DISCUSSION

The majority of students benefited from the training and our goals as teachers matched our intentions at the beginning of the course of increasing awareness of reflective/systemic principles. For most students it was their first interdisciplinary experience and appeared beneficial for psychiatry residents with an orientation to adult or child psychiatry and social work students planning to do family work. This interdisciplinary perspective led to increased awareness of socio-cultural issues in psychiatry residents and increased awareness of individual-biological factors for social work students. Psychiatry residents previously exposed to individual and group psychodynamic approaches welcomed the addition of the family/systemic perspective as complimentary rather than conflicting.

While rewarding, the group experience is not a benign technique. Students may feel vulnerable since the family therapy context may elicit some of their own family of origin issues. Supervisors needed to be vigilant to help them work through this. The major criticism of the course was the lack of opportunity to witness therapeutic intervention and follow-up of families. The course should be modified to provide this experience or students should be given this opportunity outside of the course. For supervisors, taking the time to reflect is necessary and provides a forum to grow in their own reflective skills so that the learning experience is a two way street.

There are other models of teaching family therapy but we chose reflectivity as a basic tool to self supervision and clinical practice since it can be applied to professional learning and teaching regardless of theoretical orientation and stage of learning (Schon, 1987). In the reflective model, students are met at their own level of motivation and anxiety for learning these principles. Teaching and learning are fostered in an environment of mutual safety and risk-taking where the student reflects on the self in relation to surrounding systems (the therapist, his/her family of origin, the supervisory relationship, the residency, the culture). Once the appetite is whetted, if students want a more in depth experience then electives in family therapy are available.

Some evidence exists that family and systemic training has lasting value for psychiatric practitioners after they graduate. Celano et al. (2002) collected survey data for general psychiatry residents rotating through a family evaluation training program. The trainees indicated that the program was helpful and valuable to them in their current practice. Guttman, Feldman and Engelsmann (1999) indicated in a survey of 291 psychiatrists who had completed couple and family training in their residency, that the training had beneficial effects on their roles as therapists and teachers, supervisors and program directors. Carter (1989) reporting on a follow-up survey of 87 psychiatrists who had training during their residency in marital and family therapy found similar effects.

Since our questionnaire falls more in the category of “consumer satisfaction”, this survey does not claim to be measuring core competency skills as required in psychotherapy training. Weerasekera et al. (2003) outlined their program’s approach to evaluating competency assessment in the McMaster Psychotherapy Program. For subspecialty training, Sexson et al. (2001) and Sargent et al. (2004) as part of the Work Group on Training and Education of the American Academy of Child and Adolescent Psychiatry have developed sample core competencies in six areas for training the child and adolescent psychiatrist but the guidelines are vague about incorporating systemic teaching.

The lack of literature discussing either content or process of family/systemic therapy teaching in psychiatry programs is concerning. First year trainees are taught the biopsychosocial model (Engel, 1979; Marmor, 1983) but practical ways to model skills, attitudes or core knowledge through systemic training are not readily available or widely discussed. There will never be enough child psychiatrists to meet service demands (Leverette & Massabki, 1995) so many children, adolescents and families will be seen by generalists. With trends toward growth in mental health fields such as Marriage and Family Counseling, psychiatrists are called upon to do more collaborative work with other professionals and systems of care but are receiving less training in systemic issues. In addition, psychiatrists often are called upon to be clinical leaders or consultants but have little experience in systems theory or lack the necessary reflective skills.

Our enthusiasm and advocacy for this type of teaching should in no way indicate that this brief training is a substitute for either a full child psychiatric training program or an intensive family therapy training program. The program we propose is a beginning to help residents think systemically in a biopsychosocial model incorporating interdisciplinarity and reflective skills.

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