An Integrated Approach to Family Therapy Training for Psychiatric Residents* HERTA GUTTMAN, M.D. I, RONALD FELDMAN, M.D. 2 AND SHIRLEY BRAVERMAN, M.S.W. 3
oriented, and cognitive therapies, as well as "hybrids such as cognitive-behavioural and interpersonal therapy" (1). The book contains no specific recommendations for training in systemic family therapy. This omission seems to indicate that it is not considered an essential component of residency training programs. On the contrary, we believe that there is a great deal of evidence for the relevance of family therapy training in general psychiatric residency programs. The specific contribution of family therapy to the management of major psychiatric and physical disorders has received considerable attention in recent years (2). Programs which include family therapy, together with the use of phenothiazines, social skills training, education, and social support reduce the relapse rate and morbidity of schizophrenic patients, at least in the short term (2-5). While the specific contribution of the family therapy component requires further investigation, Falloon et al (6) recently reported that the social morbidity of schizophrenic patients was reduced more effectively by family management than by individual management, and that these differences were apparent at two year follow-up. Anderson and her co-workers (7) have explored the benefits of family approaches in the management of depressive disorders. Family therapy has been recommended in the treatment of anorexia nervosa (8,9) and bulimia (10). The first controlled trial of family therapy in anorexia nervosa and bulimia (11) found that family therapy was more effective than individual therapy for young anorectics without chronic illness, while individual supportive therapy tended to be of greater value in older patients. The outcome for patients with bulimia nervosa was not significantly related to family or individual therapy. Family intervention is also finding a role in augmenting the coping abilities of patients and their families facing a variety of chronic medical illnesses (12). Aside from this specific evidence, there is increasing awareness of the need to inculcate in future psychiatrists a more global, systemic approach to patient care. Family therapy training is one way of fostering this perspective. In our view, there are two major requirements for the establishment of a family therapy training program for psychiatric residents: 1. the integration of family therapy teaching into a general psychiatric residency program in such a way as to accord to it equal status with other aspects of the curriculum; 2. the demonstration to psychiatric residents that knowledge of family theory and skill in family intervention are important components of psychiatric practice.
Unlike nonmedical family therapists, psychiatric family therapists are able to evaluate and treat both the biological and psychosocial components of a problem. They can integrate knowledge of biology, psychopharmacology and individual psychodynamics with family systems theory and family therapy skills. A family therapy training program is presented as a model which prepares psychiatric residentsfor this unique role. This model emphasizes the importance of having psychiatrists as family therapy teachers, the use of both systems and psychodynamic perspectives in teaching about families, and the principle ofpresenting concepts and interventive techniques at successively greater levels of difficulty. Illustrative examples are presented. A minimum of two years offamily therapy training and supervision is recommended during a four year residency program.
I
n recent decades, psychiatry has experienced the parallel growth of biological discoveries and new developments in psychotherapy, such as cognitive therapy, behaviour modification and family therapy. At this time there is an increasing recognition that not only psychopharmacology, but also psychosocial intervention is required to ameliorate the long term effects of a variety of physical and psychiatric illnesses. These developments point to the need for an integrative approach to the teaching and practice of psychiatry. The purpose of this paper is to indicate that family therapy forms part of such an integrative approach and that family therapy training should be included in residency training programs. Although this might seem self-evident, it is a view which does not seem to have been adopted by the mainstream. A summary of a conference on psychiatric education held in 1986, entitled Training Psychiatrists for the '90s: Issues and Recommendations, concludes that residents need exposure to various schools of psychotherapy, specifically mentioning behavioural, dynamic-psychoanalytically
*Manuscript received December 1988; revised March 1989. 'Professor of Psychiatry, McGill University, Montreal, Quebec. 2Associate Professor of Psychiatry, McGill University, Montreal, Quebec. 3Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec. Addressreprintrequests to: Dr. Herta A. Guttman, Allan Memorial Institute, 1025 Pine Avenue West, Montreal, Quebec H3A IAI.
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Our philosophy of training provides a frame for fulfilling these requirements.
practice are considered fundamental to the knowledge base of the psychiatrist.
PhiJosophy of Training Ideology Family therapists have traditionally considered the medical model to be antithetical to systems theory, describing it as being reductionistic and ignoring recursive feedback mechanisms (13). In contrast with these beliefs, it is our view that the medical model is fundamentally systemic in nature and that it provides a coherent model for integrating the many systems which make up the human body. Medical students are taught to be aware of the multiple recursive effects of a change in one organ system, whether this be induced by an illness or by a treatment, on the whole organism. A modern physician should think systemically about relationships between various organ systems, and also about the relationship between "mind" and body and between the person, the family and the social context. The psychiatrist, as a doctor with particular expertise in psychobiosocial interrelationships, should be able to use a multiplicity of pharmacological, intrapsychic and interpersonal interventions (14). It is the ability concurrently to evaluate and treat biological illness and psychosocial problems that distinguishes the psychiatrist from the nonmedical family therapist.
Goals Our training program has two primary goals: to teach psychiatric residents a systemic conceptualization of symptom formation and to provide them with basic executive skills for the practice of family and couple therapies. We do not expect all residents to become full-fledged family therapists. However, whatever their future practice, it is important for them to conceptualize the relationship of behaviour to the family context, and to be able to draw upon the resources and cooperation of the family in the management of acute and chronic problems.
Status Issues Although the ultimate fate of a new treatment modality depends on its efficacy, we have observed that its preliminary acceptance relates to the status of its practitioners and teachers. In psychiatric settings, trainees are likely to view as inferior those therapies which are consigned to psychiatric, medical or paramedical personnel who are on lower echelons, regardless of the beneficial effect of the treatment on the patients. If a new therapy paradigm receives the active support of the chief of a department, it will be more readily accepted (15). At the present time, the position of family therapy within our department of psychiatry is reflected in the fact that the Director of Family Therapy Training has equal status with other section heads within the department. He fully participates in departmental planning of therapeutic and training programs. This allows the residents to become actively involved in family therapy without compromising their vision of their future institutional or academic status. The majority of our family therapy supervisors of psychiatric residents are psychiatrists, some of them psychoanalysts and others more oriented toward organic psychiatry. The residents are therefore presented with members of their future profession as role models. Nevertheless, nonmedical clinicians and researchers also have an important role in the teaching program. The teaching seminars are under the joint direction of a psychiatrist (R. F.) and a senior social worker (S.B.), and other professionals who are psychologists or psychoanalysts participate by giving theoretical seminars or demonstration interviews. Thus the resident is exposed to a milieu enriched by the collaboration of different professions, in which family therapy training and
Training Program Context Twelve to 14 psychiatric residents are assigned to our department. They may be in any year of training. Whereas most of them are involved in some aspect of adult psychiatry (for example, inpatient or outpatient department, psychiatric consultation-liaison service, geriatrics), one or two are usually doing a child psychiatry rotation. All residents, whatever their level of experience, attend departmental teaching seminars together. Family therapy is part of this core teaching and is mandatory. The minimum time requirements of the family therapy program are six hours per week; one and one half hours at a weekly family therapy seminar, three hours treating families and couples, and one and one half hours of supervision. Some residents devote additional time to family therapy in their other service assignments. For example, residents in child psychiatry routinely assess and treat families, residents on the adult inpatient service are involved in assessments and crisis intervention, and residents in chronic care services participate in survival skills workshops. Content We have developed a sequence of teaching which takes into account the residents' need to become effective under pressured circumstances quickly, to integrate diverse biopsychosocial models and to prepare for academic examinations. Our teaching integrates systems theory and psychodynamic object relations theory, because to understand the family it is necessary to understand both the impact of groups processes and of the intrapsychic life of the individual on personality development. Training begins with family evaluations. We use a modified Beavers-Timberlawn Family Evaluation Scale (16) as an assessment guide. The fact that this scale contains categories related to family function and structure facilitates the learning of residents who are already familiar with a medical model which emphasizes categories, functions, cybernetics and systems. Thus, no major conceptual leap is required to extend their previous training to the psychosocial sphere.
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The curriculum next addresses dyadic relationships based upon object relations theory (17-19). This permits the residents to link psychoanalytic theory, which they are concurrently studying, with interpersonal behaviour. Live family interviews and simulations are used to illustrate the relationship between individual psychodynamic processes, such as denial, splitting and projection, and processes of family interaction, such as reciprocal projective identification and collusion. Developmental Approach The program is grounded in a developmental approach. The couple and family are viewed as rooted in their history, while moving forward in time through developmental stages. Current couple and family functioning is related to repetitions of family-of-origin experiences and to attempts to master previous unfinished developmental tasks (20). The residents are taught the family life cycle (21) and the use of the genogram (22). The idea of a genogram is particularly well received by psychiatric residents, for whom it connects with human genetics. Triadic Conceptualization The next phase of the program introduces a conceptual and perceptual shift, taking the resident beyond the traditional dyadic models to theories of triadic functioning (23). These are illustrated in triadic exercies which allow each resident to experience both the impact of different triads on his/her own behaviour and the converse. The trainees are divided into threesomes and are given the task of discussing their learning objectives. Each triad then chooses a spokesperson who reports on the group discussion. When they have done so, the teacher explores with each triad the process through which the spokesperson was "chosen" or "volunteered". Negotiations and nonverbal cueing which seemed "irrelevant" or "unimportant" when they occurred are revealed as being very powerful. "Secret" affiliations and coalitions are uncovered. This exercise highlights the issue of power in groups, especially the power of the "weak", the "nonparticipant", the "inadequate" member. To make systems theory even more relevant, we simulate specific problematic family situations, as described by Imber-Coppersmith (24). The exercise in triadic decision-making illustrates two important systems concepts; circular versus linear causality, and the role of the interviewer as part of the system. Circular causality is demonstrated by the fact that the spokesperson is neither "selected" nor "self-selected". Rather, he or she is a participant in a process of selection, shaping and being shaped by the responses of the two other participants in the triad. The interviewer does not simply interview and elicit information. Rather, his or her questions are shaped by the responses of the interviewees, a process which is always clearer to the observer than to the interviewer or the interviewees. The concepts of triadic functioning, circular causality, the genogram and the family life cycle provide conceptual building blocks for introducing the structural model of family therapy (25). We have found this model to be most helpful
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to beginning students in organizing a family interview and formulating a therapeutic direction. The structural concepts of subsystems, boundaries and triangulation can be easily demonstrated in the here-and-now of family interviews and can be linked to strategies of intervention which can be clearly described. Link to Disease Entities We believe that family therapy training must be connected to the residents' activities within a clinical context (26) which includes families in which there are major psychiatric and physical illnesses. After having taught basic concepts and skills we focus on the family therapy of specific desease entities, particularly schizophrenia (27), borderline personality disorder (28), psychosomatic illness (29) and anorexia nervosa (8,9, II). We recognize that this approach is controversial in view of the ongoing dialogue between family therapists who eschew the medical model (13) and those who believe it is important (3). In our seminars, we address the implication of concurrently identifying one family member as being ill and working on a systems level. When we conceptualize the illness as being primarily of biological origin and when the objective is to maintain the patient on medication and to play a psychoeducational role with the family, it is consistent for the therapist to be responsible for medication as well as therapy. We agree with Wendorf and Wendorf (31) that medication is one of several relevant levels of intervention in a family system and that it is irresponsible to neglect chemotherapeutic agents which have been scientifically proven to be effective in controlling a disease. When the primary task is to define illness behaviour as originating in the interpersonal sphere (for instance, in anorexia nervosa), we recommend that the family therapist's activity be confined to psychotherapy, while another physician makes decisions concerning the physical management of the identified patient. Systemic Hypothesizing Hypothesizing about the function of symptoms within the family system is introduced early in training (32). Put simply, if a symptom has a function in maintaining the family's stability, then the symptom bearer has value to the family. The students learn to ask themselves questions such as, "Who would be most affected if the problem were to cease?"; "How does the symptom help the family to stay together?"; "Who is protected by the symptom?" While we recognize that this functionalist framework is open to criticism (33) and is inappropriate to illness with a predominantly biological component, it does encourage the trainee to attempt to conceptualize the family as a system. Furthermore, it helps to establish, an optimistic therapeutic attitude towards the identified patient and to the family and sensitizes the studenttherapist to the possibility of systemic resistance to change, while avoiding a confrontational therapeutic atmosphere. We consider strategic family therapy techniques, such as paradoxical tasks and reframing, distracting and difficult for junior residents who are learning basic skills. These
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techniques are introduced during the supervision of residents who are more experienced family therapists and who are treating cases which may profit from such interventions (34). We focus on the couple and on marital therapy within the context of family development and family therapy. The sexual component of the couple relationship is introduced via several seminars by the staff of the sexual dysfunction clinic. Residentsare thus sensitized to the importance of the sexual relationship, but the teaching in the family therapy seminars emphasizes assessment and referral rather than training in sex therapy. Similarly, the relevance and efficacy of other forms of behavioural intervention are acknowledged. Our program cannot teach all the skills which may be useful to the fully trained family therapist.
Illustrative Example I The following example illustrates the use of a combination of biological, family and individual intervention by one therapist. The therapist was Dr. L, a psychiatric resident who had chosen concurrent half time electives in child psychiatry and family therapy for his fourth and final year of training. The family was self-referred. The mother had phoned the family service because of her concerns about her 28 year old son Ian, who lived at home. She said that he was very unhappy and did not work or study. When unhappy, he would often drink too much alcohol and might become violent. On her initial telephone call she mentioned that Ian had seen one psychiatrist twice, that he had attended our Psychiatric Day Treatment Hospital, and had been seen by a social worker on two occasions five years ago. She did not report that Ian had also had two previous hospitalizations six and five years previously, for suicidal attempts and psychotic symptoms. The diagnosis at that time had been atypical psychosis, which was treated with phenothiazines and supportive therapy. Ian was seen together with his parents for an initial evaluation. An older married sister lived outside the home and did not participate in the family interview. Ian was a university graduate, who had once been a good student with considerable academic ambitions, which he had never relinquished. He was painfully aware of the gap between his aspirations and his inability to work, study, focus and concentrate. He attributed his failures to family pressures and strains, and he felt that if only he could find a job and could move away from his family, he would be successful and happy. His habitual blaming was predictably followed by recurrent arguments with his parents during which he occasionally became somewhat physically aggressive towards his father. His father's general attitude was quietly critical while his mother was caring and overinvolved. During the first meeting with the family, the resident learned that Ian's symptoms and substance abuse were quite pronounced. Ian experienced constant anxiety, a sense of depersonalization and unreality, recurrent depression, dizziness, and frequent "migraine" headaches, for which he treated himself with over the counter drugs taken indiscriminately in large quantities. The drugs most commonly used were aspirin, actifed, alcohol, and especially fiorinal with codeine, which he obtained from sources which
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he would not identify. The resident recognized that these symptoms were part of a psychotic decompensation which Ian was attempting to fight with self-medication. The therapist helped Ian and his parents to recognize that Ian's behaviour and feelings were related to his illness. Phenothiazines were prescribed but the medication was taken irregularly. It became apparent that neither Ian nor his parents had accepted the fact of his schizophrenic illness. The mother, in particular, attempted to deny it and resisted the use of medication by constant questioning about side effects, by attributing Ian's negative symptoms to the medication, and by encouraging Ian to explore alternative therapies. Weekly family therapy was undertaken with the following aims: to decrease the intensity of family involvement; to help the family to accept and to understand the nature ofIan's illness and limitations; to reduce critical remarks; to reduce blame and guilt; and to help Ian find alternatives to using alcohol to allay his anxiety. During the following sessions the resident gently helped the family to come to terms with the reality of their son's illness and with their sadness and mourning for the loss of the idealized Ian. Dr. L's comfort and familiarity with individual psychotherapy and with the mourning process enabled him to understand and to support the family through this difficult period. Family therapy continued for six months. During that time there were many crises, with recurrent episodes of despair and suicidal ideation in Ian. The resident offered support, availability and genuine psychiatric expertise. Eventually Ian was helped to establish contact with community agencies and obtained financial and other support. He found a part time job which was suitable for him and he moved into an apartment. This was the family status when Dr. L left the rotation. Arrangements were made for Ian to continue with individual therapy and supervision of medication while the family continued in monthly follow-up therapy with the resident's supervisor.
Illustrative Example II The following example illustrates the generalizability of family systems training on a service other than the family therapy setting. Dr. S, a consultation-liaison resident who had had previous family therapy training, was called to see a 78 year old widow. She had been hospitalized for six weeks, following a stroke complicated by pneumonia for which she required a tracheostomy. She had recovered fairly well until the previous weekend, when she reported having seen in her room her daughter, who actually lives in Vancouver. The resident was asked his opinion concerning hallucinations and a possible manic episode. Dr. S first established that the lady had in the past been treated for depressive episodes. He then spontaneously interviewed the following people: the patient's two sons; her primary nurse; the head nurse; members of the Stroke Team; her general practitioner. At the end of this investigation, he concluded that the patient might be becoming depressed again, in reaction to her draining hospital experience and the recent move of one son to a suburb, making him less available
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to her. These events precipitated in the patient a sense of despair. The quasi-hallucinatory experience of her daughter could be understood in the context of the patient's sense of loss and abandonment. After having formulated the patient's response as consisting of these several interrelated problems, the resident spoke with the doctor, proposing a lithium workup and the possible use of antidepressants. With the nurses, he discussed the patient's loneliness and stressed the need for frequent talks with the patient as well as possible occupational therapy. He also met with the sons and encouraged more predictable family visiting. While reporting this case, the resident spontaneously said to the supervisor, "You really have to consider a lot of systems in this kind of work. " Family therapy training seems to have helped this resident immediately consider many interlocking systems, ranging from the patient's physical and mental condition to her family and social situation, as well as her relationship with ward personnel. Although this type of training can, and often is, given on consultation-liaison services (35), previous contact with systems theory and intervention as they are taught and practiced by family therapists inculcates a systems perspective that can be useful in many aspects of psychiatric care. Discussion In 1984, Sugerman (36) reviewed the current status of family therapy training in psychiatric residency programs. He makes the point that those psychiatric educators who believe that family therapy training of psychiatric residents should be isomorphic with the medical model favour teaching a sequence of structural and strategic models. He also reports that many educators are concerned about the paucity of psychiatrists who teach family therapy, since this has an impact on its status within a department. He considers whether family therapy should be taught as a technique or a concept; whether it should be required or elective learning; whether one should teach a specific, an eclectic or an integrated approach. We have described one model which offers satisfactory solutions to many of the teaching problems enumerated by Sugarman. However, it is important to emphasize that this has resulted from 25 years of trying different approaches to teaching family therapy to psychiatric residents. During this time, the field has developed a great deal. It now has more solid theoretical foundations and there is more consensus as to the usefulness of family intervention. It should now be possible for institutions to develop an effective training program without as much trial and error. It is our view that all psychiatric residents should have some family therapy training. Otherwise, they will be unable to avail themselves of the family as a valuable diagnostic and treatment resource. Psychiatrists who are well trained in systems thinking will be less likely to rely excessively on one modality - be it biological or psychological - in the management of patients. We suggest that family therapy training should be a required and not an elective part of the
curriculum and that it should be a component of two years of a four year residency program. It is our impression that relatively few of the psychiatric residents who come through our program end up devoting a large amount of time to practicing family therapy. Most of them use family systems concepts to understand the context in which the patient lives and as a basis for short term intervention in crisis situations. Carter (37) has documented the enduring impact of residency training in marital and family therapy on post-graduate psychiatric practice. Replication of such studies by other training programs is required to explore the ramifications of this training upon future practice. Conclusion Family therapy training for psychiatric residents must take into account contextual, content and pedagogical issues. Firstly, it is important for residents to be exposed to a training setting in which family therapy teachers and practitioners are psychiatrists who occupy positions of high status within a department. The content of the teaching should build upon and expand the systemic medical model with which the resident is already familiar from his or her training in the biological systems of the body. Although technique should not be neglected, the main focus in training is to ensure that the residents acquire a good grasp of the concepts underlying family therapy. From a pedagogical point of view, concepts and interventive techniques in family therapy should be presented at successively greater levels of complexity, so as to provide the beginning therapist with essential skills. This process requires a minimum of two years of seminars and supervision in family therapy, within a four year psychiatric residency program. References 1 . Nadelson CC, Rabinowitz CB, eds. Training psychiatrists for the '90s. Issues and recommendations. Washington, D.C.: American Psychiatric Press, 1987. 2 . Lansky MR, ed. Family approaches to major psychiatric disorders. Washington, D.C.: American Psychiatric Press, 1985. 3. Goldstein MJ, Rodnick EH, Evans JR, et al. Drug and family therapy in the aftercare treatment of acute schizophrenics. Arch Gen Psychiatry 1978; 35: 1169-1177. 4. Leff JP, Kuipers L, Berkowitz R. Intervention in families of schizophrenics and its effect on relapse rate. In: McFarlane WR, ed. Family therapy in schizophrenia. New York: Guilford Press, 1983. 5. Falloon IRH, Lieberman RP. Behavioral family intervention in the management of chronic schizophrenics. In: McFarlane WR, ed. Family therapy in schizophrenia. New York: Guilford Press, 1983. 6. Falloon IRH, McGill CW, Boyd JL, et al. Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study. Psychol Med 1987; 17: 59-66. 7. Anderson CM, Griffin S, Rossi A, et al. A comparative study of the impact of education vs. process groups for families of patients with affective disorders. Fam Proc 1986; 25: 185-205.
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8. Minuchin S, Rosman BL, Baker L. Psychosomatic families. Anorexia nervosa in context. Cambridge, MA: Harvard University Press, 1978. 9. Selvini-Palazzoli M. Self-starvation: from the individual to family therapy in the treatment of anorexia nervosa. New York: Jason Aronson Inc., 1978. 10. Schwartz RC, Barrett MJ, Saba G. Family therapy for bulimia. In: Garfinkel PE, Garner OM, eds. Anorexia nervosa: a multidimensional perspective. New York: Brunner/Mazel, 1982. I I. Russell GFM, Szmukler GI, Dare C, et aI. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44: 1047-1056. 12. Roback HW. Helping patients and their families cope with medical problems. San Francisco: Jossey-Bay, 1984. 13. Haley J. Family therapy. Int J Psychiatry 1970; 9: 233-242. 14. Marmor J. Systems thinking in psychiatry: some theoretical and clinical implications. Am J Psychiatry 1983; 140: 833-838. 15. Epstein NB. History of family therapy in Canada. Syst Humains 1985; I: 11-14. 16. Lewis JM, Beavers WR, Gossett JT, et aI. No single thread: psychological health in family systems. New York: Brunner/Mazel, 1976.· 17. Dicks H. Object relations theory and marital studies. Br J Med Psychol 1963; 36: 125-129. 18. Willi J. The concept of collusion: a combined systemic - psychodynamic approach to marital therapy. Fam Proc 1984; 23: 177-185. 19. Zinner J. The implications of projective identification for marital interaction. In: Grunebaum H, Christ J, eds. Contemporary marriage: structure, dynamics and therapy. Boston: Little, Brown and Company, 1976. 20. Braverman S. Family of origin as a training resource for family therapists. Can J Psychiatry 1982; 27(8): 629-633. 21. McGoldrick M, Carter EA. The family cycle. In: Walsh F, ed. Normal family processes. New York: Guilford Press, 1982. 22. McGoldrick M, Gerson R. Genograms in family assessment. New York: W.W. Norton and Company, 1985. 23. Hoffman L. Foundations offamily therapy. New York: Basic Books, 1981. 24. Coppersmith EI. Teaching trainees to think in triads. J Mar Fam Ther 1985; II: 61-66. 25. Minuchin S, Fishman HC. Family therapy techniques. Cambridge, MA: Harvard University Press, 1981. 26. Feldman RB, Feldman S. Resident training systems and family systems training: limits of compatibility. Can J Psychiatry 1982; 27(7): 559-560. 27. Anderson CM, Hogarty GE, Reiss OJ. Family treatment of adult schizophrenic patients: a psycho-educational approach. Schizophr Bull 1980; 6: 490-505.
28. Feldman RB, Guttman HA. Families of borderline patientsliteral-minded parents, borderline parents and parental protectiveness. Am J Psychiatry 1984; 141: 1392-1396. 29. White M. Structural and strategic approaches to psychosomatic families. Fam Proc 1979; 18: 303-314. 30. Weitzman J. Engaging the severely dysfunctional family in treatment: basic considerations. Fam Proc 1986; 24: 473-485. 31. Wendorf OJ, Wendorf RJ. Rejoinder to commentary by I Boszormenyi-Nagy on Wendorf OJ, WendorfRJ. A systemic view of family therapy ethics. Fam Proc 1986; 24: 457-460. 32. Selvini - Palazzoli M, Boscolo L, Cecchin G, etaI. Hypothesizing - circularity - neutrality: guidelines for the conductor of the session. Fam Proc 1980; 19: 3-12. 33. Bogdan J. Do families really need problems? The Family Therapy Networker 1986; 10: 30-35, 67-69. 34. Stanton MD. An integrated structural/strategic approach to family therapy. J Mar Fam Ther 1981; 7: 427-439. 35. Miller WB. Psychiatric consultation: I. a general systems approach. Psychiatry Med 1973; 4: 135-145. 36. Sugarman S. Integrating family therapy training into psychiatry residency programs: policy issues and alternatives. Fam Proc 1984; 23: 23-32. 37. Carter RJ. An evaluation of a partial training program in psychiatric residency on the later practise of marital.and family therapy. Am J Fam Therapy 1986; 14: 145-153.
Resume Contrairement aux therapeutes familiaux non diplomes en medicine, les psychiatres specialises en therapie familiale sont a meme d'evaluer et de traiter les composantes tant biologiques que psychologiques d 'un probleme. Ils peuvent combiner Ii fa theorie des systemes familiaux et Ii leurs competences en matiere de therapie familiale leur connaissance de fa biologie, de fa psychopharmacologie et de la psychodynamique. On propose Ii titre de modele un programme de formation en therapie familiale visant a preparer les residents en psychiatrie ce role particulier. On insiste sur I'importance de choisir des psychiatres comme professeurs de therapie familiale, d'enseigner fa therapie familiale Ii lafois dans le contexte des systemes et de la psychodynamique, et de presenter les concepts et les techniques d'intervention selon un ordre de difficulte croissante. Dans un programme de residence de quatre ans, on recommande que fa formation et la supervision en therapie familiale dure au moins deux ans.
a
oriented, and cognitive therapies, as well as "hybrids such as cognitive-behavioural and interpersonal therapy" (1). The book contains no specific recommendations for training in systemic family therapy. This omission seems to indicate that it is not considered an essential component of residency training programs. On the contrary, we believe that there is a great deal of evidence for the relevance of family therapy training in general psychiatric residency programs. The specific contribution of family therapy to the management of major psychiatric and physical disorders has received considerable attention in recent years (2). Programs which include family therapy, together with the use of phenothiazines, social skills training, education, and social support reduce the relapse rate and morbidity of schizophrenic patients, at least in the short term (2-5). While the specific contribution of the family therapy component requires further investigation, Falloon et al (6) recently reported that the social morbidity of schizophrenic patients was reduced more effectively by family management than by individual management, and that these differences were apparent at two year follow-up. Anderson and her co-workers (7) have explored the benefits of family approaches in the management of depressive disorders. Family therapy has been recommended in the treatment of anorexia nervosa (8,9) and bulimia (10). The first controlled trial of family therapy in anorexia nervosa and bulimia (11) found that family therapy was more effective than individual therapy for young anorectics without chronic illness, while individual supportive therapy tended to be of greater value in older patients. The outcome for patients with bulimia nervosa was not significantly related to family or individual therapy. Family intervention is also finding a role in augmenting the coping abilities of patients and their families facing a variety of chronic medical illnesses (12). Aside from this specific evidence, there is increasing awareness of the need to inculcate in future psychiatrists a more global, systemic approach to patient care. Family therapy training is one way of fostering this perspective. In our view, there are two major requirements for the establishment of a family therapy training program for psychiatric residents: 1. the integration of family therapy teaching into a general psychiatric residency program in such a way as to accord to it equal status with other aspects of the curriculum; 2. the demonstration to psychiatric residents that knowledge of family theory and skill in family intervention are important components of psychiatric practice.
Unlike nonmedical family therapists, psychiatric family therapists are able to evaluate and treat both the biological and psychosocial components of a problem. They can integrate knowledge of biology, psychopharmacology and individual psychodynamics with family systems theory and family therapy skills. A family therapy training program is presented as a model which prepares psychiatric residentsfor this unique role. This model emphasizes the importance of having psychiatrists as family therapy teachers, the use of both systems and psychodynamic perspectives in teaching about families, and the principle ofpresenting concepts and interventive techniques at successively greater levels of difficulty. Illustrative examples are presented. A minimum of two years offamily therapy training and supervision is recommended during a four year residency program.
I
n recent decades, psychiatry has experienced the parallel growth of biological discoveries and new developments in psychotherapy, such as cognitive therapy, behaviour modification and family therapy. At this time there is an increasing recognition that not only psychopharmacology, but also psychosocial intervention is required to ameliorate the long term effects of a variety of physical and psychiatric illnesses. These developments point to the need for an integrative approach to the teaching and practice of psychiatry. The purpose of this paper is to indicate that family therapy forms part of such an integrative approach and that family therapy training should be included in residency training programs. Although this might seem self-evident, it is a view which does not seem to have been adopted by the mainstream. A summary of a conference on psychiatric education held in 1986, entitled Training Psychiatrists for the '90s: Issues and Recommendations, concludes that residents need exposure to various schools of psychotherapy, specifically mentioning behavioural, dynamic-psychoanalytically
*Manuscript received December 1988; revised March 1989. 'Professor of Psychiatry, McGill University, Montreal, Quebec. 2Associate Professor of Psychiatry, McGill University, Montreal, Quebec. 3Associate Professor, Department of Psychiatry, McGill University, Montreal, Quebec. Addressreprintrequests to: Dr. Herta A. Guttman, Allan Memorial Institute, 1025 Pine Avenue West, Montreal, Quebec H3A IAI.
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Our philosophy of training provides a frame for fulfilling these requirements.
practice are considered fundamental to the knowledge base of the psychiatrist.
PhiJosophy of Training Ideology Family therapists have traditionally considered the medical model to be antithetical to systems theory, describing it as being reductionistic and ignoring recursive feedback mechanisms (13). In contrast with these beliefs, it is our view that the medical model is fundamentally systemic in nature and that it provides a coherent model for integrating the many systems which make up the human body. Medical students are taught to be aware of the multiple recursive effects of a change in one organ system, whether this be induced by an illness or by a treatment, on the whole organism. A modern physician should think systemically about relationships between various organ systems, and also about the relationship between "mind" and body and between the person, the family and the social context. The psychiatrist, as a doctor with particular expertise in psychobiosocial interrelationships, should be able to use a multiplicity of pharmacological, intrapsychic and interpersonal interventions (14). It is the ability concurrently to evaluate and treat biological illness and psychosocial problems that distinguishes the psychiatrist from the nonmedical family therapist.
Goals Our training program has two primary goals: to teach psychiatric residents a systemic conceptualization of symptom formation and to provide them with basic executive skills for the practice of family and couple therapies. We do not expect all residents to become full-fledged family therapists. However, whatever their future practice, it is important for them to conceptualize the relationship of behaviour to the family context, and to be able to draw upon the resources and cooperation of the family in the management of acute and chronic problems.
Status Issues Although the ultimate fate of a new treatment modality depends on its efficacy, we have observed that its preliminary acceptance relates to the status of its practitioners and teachers. In psychiatric settings, trainees are likely to view as inferior those therapies which are consigned to psychiatric, medical or paramedical personnel who are on lower echelons, regardless of the beneficial effect of the treatment on the patients. If a new therapy paradigm receives the active support of the chief of a department, it will be more readily accepted (15). At the present time, the position of family therapy within our department of psychiatry is reflected in the fact that the Director of Family Therapy Training has equal status with other section heads within the department. He fully participates in departmental planning of therapeutic and training programs. This allows the residents to become actively involved in family therapy without compromising their vision of their future institutional or academic status. The majority of our family therapy supervisors of psychiatric residents are psychiatrists, some of them psychoanalysts and others more oriented toward organic psychiatry. The residents are therefore presented with members of their future profession as role models. Nevertheless, nonmedical clinicians and researchers also have an important role in the teaching program. The teaching seminars are under the joint direction of a psychiatrist (R. F.) and a senior social worker (S.B.), and other professionals who are psychologists or psychoanalysts participate by giving theoretical seminars or demonstration interviews. Thus the resident is exposed to a milieu enriched by the collaboration of different professions, in which family therapy training and
Training Program Context Twelve to 14 psychiatric residents are assigned to our department. They may be in any year of training. Whereas most of them are involved in some aspect of adult psychiatry (for example, inpatient or outpatient department, psychiatric consultation-liaison service, geriatrics), one or two are usually doing a child psychiatry rotation. All residents, whatever their level of experience, attend departmental teaching seminars together. Family therapy is part of this core teaching and is mandatory. The minimum time requirements of the family therapy program are six hours per week; one and one half hours at a weekly family therapy seminar, three hours treating families and couples, and one and one half hours of supervision. Some residents devote additional time to family therapy in their other service assignments. For example, residents in child psychiatry routinely assess and treat families, residents on the adult inpatient service are involved in assessments and crisis intervention, and residents in chronic care services participate in survival skills workshops. Content We have developed a sequence of teaching which takes into account the residents' need to become effective under pressured circumstances quickly, to integrate diverse biopsychosocial models and to prepare for academic examinations. Our teaching integrates systems theory and psychodynamic object relations theory, because to understand the family it is necessary to understand both the impact of groups processes and of the intrapsychic life of the individual on personality development. Training begins with family evaluations. We use a modified Beavers-Timberlawn Family Evaluation Scale (16) as an assessment guide. The fact that this scale contains categories related to family function and structure facilitates the learning of residents who are already familiar with a medical model which emphasizes categories, functions, cybernetics and systems. Thus, no major conceptual leap is required to extend their previous training to the psychosocial sphere.
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The curriculum next addresses dyadic relationships based upon object relations theory (17-19). This permits the residents to link psychoanalytic theory, which they are concurrently studying, with interpersonal behaviour. Live family interviews and simulations are used to illustrate the relationship between individual psychodynamic processes, such as denial, splitting and projection, and processes of family interaction, such as reciprocal projective identification and collusion. Developmental Approach The program is grounded in a developmental approach. The couple and family are viewed as rooted in their history, while moving forward in time through developmental stages. Current couple and family functioning is related to repetitions of family-of-origin experiences and to attempts to master previous unfinished developmental tasks (20). The residents are taught the family life cycle (21) and the use of the genogram (22). The idea of a genogram is particularly well received by psychiatric residents, for whom it connects with human genetics. Triadic Conceptualization The next phase of the program introduces a conceptual and perceptual shift, taking the resident beyond the traditional dyadic models to theories of triadic functioning (23). These are illustrated in triadic exercies which allow each resident to experience both the impact of different triads on his/her own behaviour and the converse. The trainees are divided into threesomes and are given the task of discussing their learning objectives. Each triad then chooses a spokesperson who reports on the group discussion. When they have done so, the teacher explores with each triad the process through which the spokesperson was "chosen" or "volunteered". Negotiations and nonverbal cueing which seemed "irrelevant" or "unimportant" when they occurred are revealed as being very powerful. "Secret" affiliations and coalitions are uncovered. This exercise highlights the issue of power in groups, especially the power of the "weak", the "nonparticipant", the "inadequate" member. To make systems theory even more relevant, we simulate specific problematic family situations, as described by Imber-Coppersmith (24). The exercise in triadic decision-making illustrates two important systems concepts; circular versus linear causality, and the role of the interviewer as part of the system. Circular causality is demonstrated by the fact that the spokesperson is neither "selected" nor "self-selected". Rather, he or she is a participant in a process of selection, shaping and being shaped by the responses of the two other participants in the triad. The interviewer does not simply interview and elicit information. Rather, his or her questions are shaped by the responses of the interviewees, a process which is always clearer to the observer than to the interviewer or the interviewees. The concepts of triadic functioning, circular causality, the genogram and the family life cycle provide conceptual building blocks for introducing the structural model of family therapy (25). We have found this model to be most helpful
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to beginning students in organizing a family interview and formulating a therapeutic direction. The structural concepts of subsystems, boundaries and triangulation can be easily demonstrated in the here-and-now of family interviews and can be linked to strategies of intervention which can be clearly described. Link to Disease Entities We believe that family therapy training must be connected to the residents' activities within a clinical context (26) which includes families in which there are major psychiatric and physical illnesses. After having taught basic concepts and skills we focus on the family therapy of specific desease entities, particularly schizophrenia (27), borderline personality disorder (28), psychosomatic illness (29) and anorexia nervosa (8,9, II). We recognize that this approach is controversial in view of the ongoing dialogue between family therapists who eschew the medical model (13) and those who believe it is important (3). In our seminars, we address the implication of concurrently identifying one family member as being ill and working on a systems level. When we conceptualize the illness as being primarily of biological origin and when the objective is to maintain the patient on medication and to play a psychoeducational role with the family, it is consistent for the therapist to be responsible for medication as well as therapy. We agree with Wendorf and Wendorf (31) that medication is one of several relevant levels of intervention in a family system and that it is irresponsible to neglect chemotherapeutic agents which have been scientifically proven to be effective in controlling a disease. When the primary task is to define illness behaviour as originating in the interpersonal sphere (for instance, in anorexia nervosa), we recommend that the family therapist's activity be confined to psychotherapy, while another physician makes decisions concerning the physical management of the identified patient. Systemic Hypothesizing Hypothesizing about the function of symptoms within the family system is introduced early in training (32). Put simply, if a symptom has a function in maintaining the family's stability, then the symptom bearer has value to the family. The students learn to ask themselves questions such as, "Who would be most affected if the problem were to cease?"; "How does the symptom help the family to stay together?"; "Who is protected by the symptom?" While we recognize that this functionalist framework is open to criticism (33) and is inappropriate to illness with a predominantly biological component, it does encourage the trainee to attempt to conceptualize the family as a system. Furthermore, it helps to establish, an optimistic therapeutic attitude towards the identified patient and to the family and sensitizes the studenttherapist to the possibility of systemic resistance to change, while avoiding a confrontational therapeutic atmosphere. We consider strategic family therapy techniques, such as paradoxical tasks and reframing, distracting and difficult for junior residents who are learning basic skills. These
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techniques are introduced during the supervision of residents who are more experienced family therapists and who are treating cases which may profit from such interventions (34). We focus on the couple and on marital therapy within the context of family development and family therapy. The sexual component of the couple relationship is introduced via several seminars by the staff of the sexual dysfunction clinic. Residentsare thus sensitized to the importance of the sexual relationship, but the teaching in the family therapy seminars emphasizes assessment and referral rather than training in sex therapy. Similarly, the relevance and efficacy of other forms of behavioural intervention are acknowledged. Our program cannot teach all the skills which may be useful to the fully trained family therapist.
Illustrative Example I The following example illustrates the use of a combination of biological, family and individual intervention by one therapist. The therapist was Dr. L, a psychiatric resident who had chosen concurrent half time electives in child psychiatry and family therapy for his fourth and final year of training. The family was self-referred. The mother had phoned the family service because of her concerns about her 28 year old son Ian, who lived at home. She said that he was very unhappy and did not work or study. When unhappy, he would often drink too much alcohol and might become violent. On her initial telephone call she mentioned that Ian had seen one psychiatrist twice, that he had attended our Psychiatric Day Treatment Hospital, and had been seen by a social worker on two occasions five years ago. She did not report that Ian had also had two previous hospitalizations six and five years previously, for suicidal attempts and psychotic symptoms. The diagnosis at that time had been atypical psychosis, which was treated with phenothiazines and supportive therapy. Ian was seen together with his parents for an initial evaluation. An older married sister lived outside the home and did not participate in the family interview. Ian was a university graduate, who had once been a good student with considerable academic ambitions, which he had never relinquished. He was painfully aware of the gap between his aspirations and his inability to work, study, focus and concentrate. He attributed his failures to family pressures and strains, and he felt that if only he could find a job and could move away from his family, he would be successful and happy. His habitual blaming was predictably followed by recurrent arguments with his parents during which he occasionally became somewhat physically aggressive towards his father. His father's general attitude was quietly critical while his mother was caring and overinvolved. During the first meeting with the family, the resident learned that Ian's symptoms and substance abuse were quite pronounced. Ian experienced constant anxiety, a sense of depersonalization and unreality, recurrent depression, dizziness, and frequent "migraine" headaches, for which he treated himself with over the counter drugs taken indiscriminately in large quantities. The drugs most commonly used were aspirin, actifed, alcohol, and especially fiorinal with codeine, which he obtained from sources which
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he would not identify. The resident recognized that these symptoms were part of a psychotic decompensation which Ian was attempting to fight with self-medication. The therapist helped Ian and his parents to recognize that Ian's behaviour and feelings were related to his illness. Phenothiazines were prescribed but the medication was taken irregularly. It became apparent that neither Ian nor his parents had accepted the fact of his schizophrenic illness. The mother, in particular, attempted to deny it and resisted the use of medication by constant questioning about side effects, by attributing Ian's negative symptoms to the medication, and by encouraging Ian to explore alternative therapies. Weekly family therapy was undertaken with the following aims: to decrease the intensity of family involvement; to help the family to accept and to understand the nature ofIan's illness and limitations; to reduce critical remarks; to reduce blame and guilt; and to help Ian find alternatives to using alcohol to allay his anxiety. During the following sessions the resident gently helped the family to come to terms with the reality of their son's illness and with their sadness and mourning for the loss of the idealized Ian. Dr. L's comfort and familiarity with individual psychotherapy and with the mourning process enabled him to understand and to support the family through this difficult period. Family therapy continued for six months. During that time there were many crises, with recurrent episodes of despair and suicidal ideation in Ian. The resident offered support, availability and genuine psychiatric expertise. Eventually Ian was helped to establish contact with community agencies and obtained financial and other support. He found a part time job which was suitable for him and he moved into an apartment. This was the family status when Dr. L left the rotation. Arrangements were made for Ian to continue with individual therapy and supervision of medication while the family continued in monthly follow-up therapy with the resident's supervisor.
Illustrative Example II The following example illustrates the generalizability of family systems training on a service other than the family therapy setting. Dr. S, a consultation-liaison resident who had had previous family therapy training, was called to see a 78 year old widow. She had been hospitalized for six weeks, following a stroke complicated by pneumonia for which she required a tracheostomy. She had recovered fairly well until the previous weekend, when she reported having seen in her room her daughter, who actually lives in Vancouver. The resident was asked his opinion concerning hallucinations and a possible manic episode. Dr. S first established that the lady had in the past been treated for depressive episodes. He then spontaneously interviewed the following people: the patient's two sons; her primary nurse; the head nurse; members of the Stroke Team; her general practitioner. At the end of this investigation, he concluded that the patient might be becoming depressed again, in reaction to her draining hospital experience and the recent move of one son to a suburb, making him less available
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to her. These events precipitated in the patient a sense of despair. The quasi-hallucinatory experience of her daughter could be understood in the context of the patient's sense of loss and abandonment. After having formulated the patient's response as consisting of these several interrelated problems, the resident spoke with the doctor, proposing a lithium workup and the possible use of antidepressants. With the nurses, he discussed the patient's loneliness and stressed the need for frequent talks with the patient as well as possible occupational therapy. He also met with the sons and encouraged more predictable family visiting. While reporting this case, the resident spontaneously said to the supervisor, "You really have to consider a lot of systems in this kind of work. " Family therapy training seems to have helped this resident immediately consider many interlocking systems, ranging from the patient's physical and mental condition to her family and social situation, as well as her relationship with ward personnel. Although this type of training can, and often is, given on consultation-liaison services (35), previous contact with systems theory and intervention as they are taught and practiced by family therapists inculcates a systems perspective that can be useful in many aspects of psychiatric care. Discussion In 1984, Sugerman (36) reviewed the current status of family therapy training in psychiatric residency programs. He makes the point that those psychiatric educators who believe that family therapy training of psychiatric residents should be isomorphic with the medical model favour teaching a sequence of structural and strategic models. He also reports that many educators are concerned about the paucity of psychiatrists who teach family therapy, since this has an impact on its status within a department. He considers whether family therapy should be taught as a technique or a concept; whether it should be required or elective learning; whether one should teach a specific, an eclectic or an integrated approach. We have described one model which offers satisfactory solutions to many of the teaching problems enumerated by Sugarman. However, it is important to emphasize that this has resulted from 25 years of trying different approaches to teaching family therapy to psychiatric residents. During this time, the field has developed a great deal. It now has more solid theoretical foundations and there is more consensus as to the usefulness of family intervention. It should now be possible for institutions to develop an effective training program without as much trial and error. It is our view that all psychiatric residents should have some family therapy training. Otherwise, they will be unable to avail themselves of the family as a valuable diagnostic and treatment resource. Psychiatrists who are well trained in systems thinking will be less likely to rely excessively on one modality - be it biological or psychological - in the management of patients. We suggest that family therapy training should be a required and not an elective part of the
curriculum and that it should be a component of two years of a four year residency program. It is our impression that relatively few of the psychiatric residents who come through our program end up devoting a large amount of time to practicing family therapy. Most of them use family systems concepts to understand the context in which the patient lives and as a basis for short term intervention in crisis situations. Carter (37) has documented the enduring impact of residency training in marital and family therapy on post-graduate psychiatric practice. Replication of such studies by other training programs is required to explore the ramifications of this training upon future practice. Conclusion Family therapy training for psychiatric residents must take into account contextual, content and pedagogical issues. Firstly, it is important for residents to be exposed to a training setting in which family therapy teachers and practitioners are psychiatrists who occupy positions of high status within a department. The content of the teaching should build upon and expand the systemic medical model with which the resident is already familiar from his or her training in the biological systems of the body. Although technique should not be neglected, the main focus in training is to ensure that the residents acquire a good grasp of the concepts underlying family therapy. From a pedagogical point of view, concepts and interventive techniques in family therapy should be presented at successively greater levels of complexity, so as to provide the beginning therapist with essential skills. This process requires a minimum of two years of seminars and supervision in family therapy, within a four year psychiatric residency program. References 1 . Nadelson CC, Rabinowitz CB, eds. Training psychiatrists for the '90s. Issues and recommendations. Washington, D.C.: American Psychiatric Press, 1987. 2 . Lansky MR, ed. Family approaches to major psychiatric disorders. Washington, D.C.: American Psychiatric Press, 1985. 3. Goldstein MJ, Rodnick EH, Evans JR, et al. Drug and family therapy in the aftercare treatment of acute schizophrenics. Arch Gen Psychiatry 1978; 35: 1169-1177. 4. Leff JP, Kuipers L, Berkowitz R. Intervention in families of schizophrenics and its effect on relapse rate. In: McFarlane WR, ed. Family therapy in schizophrenia. New York: Guilford Press, 1983. 5. Falloon IRH, Lieberman RP. Behavioral family intervention in the management of chronic schizophrenics. In: McFarlane WR, ed. Family therapy in schizophrenia. New York: Guilford Press, 1983. 6. Falloon IRH, McGill CW, Boyd JL, et al. Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study. Psychol Med 1987; 17: 59-66. 7. Anderson CM, Griffin S, Rossi A, et al. A comparative study of the impact of education vs. process groups for families of patients with affective disorders. Fam Proc 1986; 25: 185-205.
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8. Minuchin S, Rosman BL, Baker L. Psychosomatic families. Anorexia nervosa in context. Cambridge, MA: Harvard University Press, 1978. 9. Selvini-Palazzoli M. Self-starvation: from the individual to family therapy in the treatment of anorexia nervosa. New York: Jason Aronson Inc., 1978. 10. Schwartz RC, Barrett MJ, Saba G. Family therapy for bulimia. In: Garfinkel PE, Garner OM, eds. Anorexia nervosa: a multidimensional perspective. New York: Brunner/Mazel, 1982. I I. Russell GFM, Szmukler GI, Dare C, et aI. An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44: 1047-1056. 12. Roback HW. Helping patients and their families cope with medical problems. San Francisco: Jossey-Bay, 1984. 13. Haley J. Family therapy. Int J Psychiatry 1970; 9: 233-242. 14. Marmor J. Systems thinking in psychiatry: some theoretical and clinical implications. Am J Psychiatry 1983; 140: 833-838. 15. Epstein NB. History of family therapy in Canada. Syst Humains 1985; I: 11-14. 16. Lewis JM, Beavers WR, Gossett JT, et aI. No single thread: psychological health in family systems. New York: Brunner/Mazel, 1976.· 17. Dicks H. Object relations theory and marital studies. Br J Med Psychol 1963; 36: 125-129. 18. Willi J. The concept of collusion: a combined systemic - psychodynamic approach to marital therapy. Fam Proc 1984; 23: 177-185. 19. Zinner J. The implications of projective identification for marital interaction. In: Grunebaum H, Christ J, eds. Contemporary marriage: structure, dynamics and therapy. Boston: Little, Brown and Company, 1976. 20. Braverman S. Family of origin as a training resource for family therapists. Can J Psychiatry 1982; 27(8): 629-633. 21. McGoldrick M, Carter EA. The family cycle. In: Walsh F, ed. Normal family processes. New York: Guilford Press, 1982. 22. McGoldrick M, Gerson R. Genograms in family assessment. New York: W.W. Norton and Company, 1985. 23. Hoffman L. Foundations offamily therapy. New York: Basic Books, 1981. 24. Coppersmith EI. Teaching trainees to think in triads. J Mar Fam Ther 1985; II: 61-66. 25. Minuchin S, Fishman HC. Family therapy techniques. Cambridge, MA: Harvard University Press, 1981. 26. Feldman RB, Feldman S. Resident training systems and family systems training: limits of compatibility. Can J Psychiatry 1982; 27(7): 559-560. 27. Anderson CM, Hogarty GE, Reiss OJ. Family treatment of adult schizophrenic patients: a psycho-educational approach. Schizophr Bull 1980; 6: 490-505.
28. Feldman RB, Guttman HA. Families of borderline patientsliteral-minded parents, borderline parents and parental protectiveness. Am J Psychiatry 1984; 141: 1392-1396. 29. White M. Structural and strategic approaches to psychosomatic families. Fam Proc 1979; 18: 303-314. 30. Weitzman J. Engaging the severely dysfunctional family in treatment: basic considerations. Fam Proc 1986; 24: 473-485. 31. Wendorf OJ, Wendorf RJ. Rejoinder to commentary by I Boszormenyi-Nagy on Wendorf OJ, WendorfRJ. A systemic view of family therapy ethics. Fam Proc 1986; 24: 457-460. 32. Selvini - Palazzoli M, Boscolo L, Cecchin G, etaI. Hypothesizing - circularity - neutrality: guidelines for the conductor of the session. Fam Proc 1980; 19: 3-12. 33. Bogdan J. Do families really need problems? The Family Therapy Networker 1986; 10: 30-35, 67-69. 34. Stanton MD. An integrated structural/strategic approach to family therapy. J Mar Fam Ther 1981; 7: 427-439. 35. Miller WB. Psychiatric consultation: I. a general systems approach. Psychiatry Med 1973; 4: 135-145. 36. Sugarman S. Integrating family therapy training into psychiatry residency programs: policy issues and alternatives. Fam Proc 1984; 23: 23-32. 37. Carter RJ. An evaluation of a partial training program in psychiatric residency on the later practise of marital.and family therapy. Am J Fam Therapy 1986; 14: 145-153.
Resume Contrairement aux therapeutes familiaux non diplomes en medicine, les psychiatres specialises en therapie familiale sont a meme d'evaluer et de traiter les composantes tant biologiques que psychologiques d 'un probleme. Ils peuvent combiner Ii fa theorie des systemes familiaux et Ii leurs competences en matiere de therapie familiale leur connaissance de fa biologie, de fa psychopharmacologie et de la psychodynamique. On propose Ii titre de modele un programme de formation en therapie familiale visant a preparer les residents en psychiatrie ce role particulier. On insiste sur I'importance de choisir des psychiatres comme professeurs de therapie familiale, d'enseigner fa therapie familiale Ii lafois dans le contexte des systemes et de la psychodynamique, et de presenter les concepts et les techniques d'intervention selon un ordre de difficulte croissante. Dans un programme de residence de quatre ans, on recommande que fa formation et la supervision en therapie familiale dure au moins deux ans.
a
