In the days of biological reductionism, with its brain disease metaphor and emphases on descriptive diagnoses and psychotropic medications, it is easy to forget that life is lived in relationships, and the quality of those relationships has much to do with how life turns out (1).
Although general residency training programs in psychiatry have rarely, if ever, wholeheartedly embraced couples and family therapy, the value of family training in the preparation of tomorrow’s psychiatrists has never been more important. The advent of first-line, empirically supported family interventions for many axis I disorders, such as bipolar disorder, major depression, and schizophrenia, has the potential to move the family perspective from the margin of academic psychiatry into its center. Just as psychopharmacology, neurosciences, and evidence-based individual treatments have increasingly occupied a greater share of residency training, systemic and behavioral treatments supporting the patient’s recovery through the mobilization of family and other social resources will stand by them as key cornerstones for psychiatric training in the next decade.
In recent reviews of treatment outcome (2–5), couples and family therapies have been found to be effective across a broad range of psychopathology, including many of the severe axis I disorders. Family treatments are relatively brief compared to other forms of intervention and can be more cost-effective (6). Although most psychiatry residents exposed to couples and family therapy training report a high rate of interest in this field, residency training programs typically offer only minimal training experiences. Pinsof (4) has observed that outside of the major academic medical centers, training grossly neglects work with the families of persons with serious mental illness—a durable state of affairs that remains largely unchanged.
Recent Trends Calling for the Reintegration of Family Training
Four significant trends have more recently pushed the reintegration of couple and family approaches back into the discussion within psychiatric training curricula. In early 2001, the Accreditation Council for Graduate Medical Education (ACGME) (7) initiated a major shift in objectives of residency training, requiring all residency programs to develop core competencies including the ability to communicate with patients and their families. The residency review committee (RRC) in psychiatry also proposed five competencies in “psychotherapy.” As a result, psychiatric residents would be required to show competency in a number of types of psychotherapy (cognitive behavior, psychodynamic, supportive, brief, and combined psychotherapy-psychopharmacology). In this context, the Group for the Advancement of Psychiatry (GAP) Committee on the Family (8) proposed a well-defined, expanded set of family skills as part of the ACGME core competencies that could be taught and implemented across all settings (e.g., inpatient, outpatient, consultation-liaison, child/adolescent). Berman and Heru (9) suggest that these recent changes in residency accreditation and the shift toward competency-based training offer a “window of time in which there is a renewed possibility for integrating family systems training into basic psychiatric training.”
The second broad trend can be traced to the growing evidence that family factors are implicated in the maintenance of psychiatric illness. Research on expressed emotion—which describes families with high levels of criticism, hostility, and over-involvement—has shown that high expressed emotion is a robust predictor of relapse in many psychiatric illnesses such as schizophrenia (10), depressive disorders (10, 11), bipolar disorder (12, 13), and alcoholism (14). Caregiver research has identified the high emotional and practical burdens of caring for relatives with psychiatric illnesses (15, 16). Because family psychoeducation has also been shown to be central to medication compliance (2, 5), family interventions are the ideal complimentary therapy to medication (13). Heru (2) points out that APA practice guidelines already recommend early couple and family involvement as well as family based interventions for axis I disorders, including, but not limited to, schizophrenia, bipolar disorder, major depression, panic disorder, and eating disorders.
Consistent with the burgeoning evidence for the value of family interventions, the President’s New Freedom Commission on Mental Health (17), which established new priorities in the delivery of mental health services, emphasizes family centered care. Current standards of treatment for the seriously mentally ill recognize the importance of family members’ roles in the promotion of long-term recovery. In response to the Commission’s findings, the Veterans Health Administration health care system, the largest health care system in the United States, developed an action agenda titled “VA’s Achieving the Promise: Transforming Mental Health Care in the VA” (18). One of the report’s strongest recommendations was to implement consumer and family centered care programs in all Veterans Affairs medical centers. This shift in focus represents the third trend supporting family training.
Finally, the trend toward couples and family centered, collaborative, biopsychosocial models of health care for patients with physical illness 19–24) provides further impetus for family training in psychiatry. Rolland and Walsh (25) noted that consumers have increasingly advocated for health care that attends to the physical and psychosocial challenges of major health conditions for all family members (not just the sickest person). Heru (2) suggests that, “improving the family environment has important health implications equivalent to the reduction of risk factors for chronic illness.” As consultants in medical settings, psychiatrists serve an important function in recognizing that chronic illness, disability, terminal illness, and loss represent changes that invariably affect every family member.
To summarize, these four related trends should renew our consideration of the present and future significance of training our residents today to ably practice in tomorrow’s evolving health care systems. Because trainees must master ever expanding areas of knowledge during what remains a fixed time period for residency training, difficult decisions must be made as to what is essential and what is not. We are well aware that we are arguing yet another competency domain to be reintegrated into the mainstream of psychiatric teaching and practice. This suggestion is made even in the context of present demands on curriculum and funding issues (6, 26). The reasons enumerated above highlight the importance of this change despite the anticipated hardships.
Family therapy has been viewed as an integral part of psychiatric training for over 25 years. Early articles in the 1980s by Harbin (27) and Sugarman (28) described the implementation of the AMA residency requirements, looked at questions of whether family therapy was a modality or an overall orientation, and offered concrete educational guidelines. In a thoughtful review, Combrinck-Graham (29) proposed a “systemic residency,” emphasizing a sequence of family training experiences during each postgraduate year (PGY) that highlighted family strengths and the biopsychosocial model. Throughout the 1990s, advocates continued to extend family training in psychiatric residencies (30, 31). In one of the first evaluative reports of family therapy training in a residency setting, Slovik et al. (32) found that recent graduates suggested a restructuring of psychotherapy training, emphasizing the integration of family therapy with the “full range of psychiatric treatment modalities,” as opposed to seeing it as an isolated entity.
In many psychiatry training residencies, couples and family therapy training has been an integral part of the training program for many years. Recently, Glick et al. (6) championed a comprehensive family therapy training program that included courses in each residency year, and required couples, family, and child/adolescent cases for all trainees during the entire course of their training. Celano et al. (33) described their family evaluation clinic, emphasizing interdisciplinary collaboration, systemic thinking, and the benefits of live supervision of cases. Heru (34) reviewed a family systems training model for second-year residents in an acute inpatient setting, with the focus on achieving core competency requirements. Finally, Berman and Heru (9) renewed the call for repositioning family therapy training as an important basic competency to be expected of all graduating residents in psychiatry.
Couples and Family Training in Psychiatry Today
In the current context, Berman and Heru (9) and GAP Committee on the Family (8) have made a major contribution by highlighting the ACGME mandate for family training that exists—understanding, communicating with, allying with, and educating families. Berman and Heru (9) suggest that:
…residents should be able to ally with families of their patients, support them, assess them, and have some knowledge of how to treat them. They need to know about caregiver burden and about the specific needs of families when dealing with major mental illness. They need to be able to determine when a family therapy referral is necessary for their patients to succeed in treatment. They should also recognize problems where the issues are system specific and no identified patient exists. This is the basic family skill set. We believe that the concept of “family skills” rather than family therapy is useful.
We agree that family treatment skills comprise a heterogeneous collection of conceptual skills and technical competencies and concur that they are necessary skills for all residents. We also believe, however, that the authors chart an overly conservative course that offers broad appeal without compelling residents and their faculty members to aim high enough. Couples and family therapy should also be added to the five required psychotherapy competencies defined by the residency review committee, and we believe that there is both room and the opportunity in the curriculum for more than basic exposure.
In our view, Doherty and Baird’s (20) multitiered model of “family centered care” deserves closer examination in the development of competency-oriented training in couples and family therapy. This model, originally developed for teaching family skills in family practice residency programs, has obvious benefits when applied to psychiatry training programs. It proposes different levels of training for psychiatrists as they progress through their residency training: minimal emphasis on the family, ongoing medical information and advice, feelings and support, systematic assessment and planned intervention, and family therapy.
In this regard, faculty supervisors can identify context-specific skills, and couples and family therapy can be seen as an evolving set of competencies rather than an aggregate set of “minimal residency requirements.” Berman and Heru’s (9) “family skills” may therefore represent a starting point for some programs and an endpoint for others. While most residents can expect to progress from novices to proficient beginners or competent intermediate-level clinicians, the development of couples and family therapy skills representing mastery (during or postresidency) can only be accomplished with a systematic program of didactic instruction, clinical cases under expert supervision, and the time for systemic concepts to be internalized and integrated.
Residents in psychiatry are increasingly confronted with complex clinical problems that can be understood from a range of perspectives. Because biopsychosocial systemic thinking provides a powerful framework for looking at multiple levels of systems and their interrelationships, greater emphasis on developing a strong systemic perspective should be considered as a core competency in general psychiatry training. Slovik et al. (32) have recommended that residency programs establish competencies in the following areas: treating patients with major psychiatric disorders with couple- and family-centered therapies; treating medically ill patients with couple- and family-centered therapies; integrating psychopharmacology and family therapy; and solving interpersonal problems that arise administratively within hospitals, departments of psychiatry, and multidisciplinary treatment teams. At the same time, GAP Committee on the Family (8) has argued eloquently for a renewed emphasis on family skills to be part of every resident’s training. We support these goals as the starting place for broader, comprehensive training in couples and family therapy.
Contemporary psychiatry training can afford to be more than a middle-of-the-road compromise; it can and should push the margins and foster innovation and creativity. Fresh psychosocial ideas in psychiatry have often been carefully positioned to appear palatable, to avoid unsettling, to not disturb. If family training moves from the margin into the interior of residency training, initial resistance should be anticipated. Thoughtful program directors and faculty members can anticipate turf issues, competition over scarce residency training time, and the inevitable pushback that frequently accompanies systemic change. Nonetheless, with the changes in ACGME, growing research on the family’s role in maintaining severe psychopathology and the efficacy of couples and family interventions across a wide range of psychiatric disorders, the President’s Commission on Mental Health, and emerging models of collaborative biopsychosocial health care, it should no longer be “easy to forget that life is lived in relationships” (1).