Skills
- Family-interviewing skills, especially managing high levels of emotion and making room for multiple points of view.
- Promoting resilience, hope, and strength.
- Basic psychoeducation techniques, which includes providing a therapeutic space for emotional processing, providing information about the illness, skills such as better communication, problem-solving, and relapse drill and support.
- Collaborative treatment planning with family members and other helping professionals. Treatment planning should include all members of the system: patient, family members, and members of the treatment team. Good planning establishes a role for family members, helps define criteria for managing emergencies, looks for areas of strength and resilience and provides clear and realistic goals for treatment.
- Knowledge of, and referral to, local and national resources, both in the community and online.
Attitudes
- Appreciate the multiple points of view in a family.
- Interest in family members as people with their own needs and history.
- Including family members as a resource in recovery.
- Understand caregiver burden and rewards and that stress extends to all family members.
Training techniques
Most learning takes place at the level of patient, supervisor, and resident. It is critical that the resident sees faculty members dealing with patients in observed or shared family sessions, and /or sees videos made by faculty or professionally made videos. Attitudes are best learned by modeling.
Areas of focus can include time management, addressing the fear that family sessions may get out of control, and the influence of the residents’ own life experiences and background including potential generational or cultural differences on their assessment and interactions with patient family dynamics. In skill development, our goal is efficient interviewing, history taking, and support in controlling sessions.
It is difficult to specify which techniques are most useful in didactic sessions as each presenter will have a different skill set for engaging the class. The techniques that work best are the ones most comfortable to the presenter. Any technique that gets emotions involved, such as role play, sculpting, discussing movie clips, bringing in family members to discuss their experiences, or self-exploration, will generate the most powerful learning. If time permits, exploration of the resident’s own family, including a genogram, is an exceptionally helpful technique, especially if accompanied by asking the residents to interview their own families.
Adult didactic curriculum
The curriculum represents basic concepts. We have vignettes by the authors, if needed, but it is best if the class, including the supervisor, uses vignettes from their own experiences. Material for use in class is in references, but the class is urged to draw on their own experiences as this supports strength-based teaching. The following are key topics and concepts for each of the training years.
Basic concepts for PGY1 and PGY2
1. Where are you in the family and individual life cycles? What are your experiences with psychiatric illness in family/friends? Open discussion about how individual and family life cycles interact. Draw genograms of s/o in the class or with the supervisor.
2. Healthy family functioning and family resilience. Recommend asking residents to talk to their parents/elders about their lives and family life cycle when they were your age. Open discussion about what makes a healthy resilient family.
3. How do I connect with the family rather than just one person? How do you learn to hold multiple perspectives? How do I try not to take sides/multidirectional partiality? How do I see each person in a positive way? How do I focus on family strengths, rather than focusing on someone behaving badly (which is really hard because it is overlearned in individual therapy).
4. What are the common factors used across all therapies, both individual and family? When is it best to use an individual relational approach versus a family systemic approach?
5. How do I decide if a family needs support or education or family therapy?
6. Psychoeducation: Research, current use and cultural adaptations.
7. Attachment styles and couples therapy.
8. What is the evidence base behind our work?
System practice for PGY 3 and 4
These seminars follow the basic seminars. The focus is on clarification of what systems thinking means. Systems thinking or relational thinking is to be differentiated from systems-based practice. These lectures require knowledge of systemic practice. If there are no local experts, residency programs can reach out to national experts at the Association of Family Psychiatrists, for help with virtual/remote or in-person teaching.
Here is a list of other topics that should be covered:
- Relational formulation, nested subsystems, boundaries, history of these concepts, contributions to the development of family therapy.
- How to define and identify common systems concepts, such as circular patterns, feedback loops, and triangulation. Teach circular questioning. Framing. This concept is the family systems equivalent of insight. How to intervene to effect communication change and behavior change?
- Working at interfaces: community, legal, government, agencies, and so on, and other treaters, consultation. Include systemic and individual racism.
- Understanding the complexity of intimacy.
- Emergency situations. When to report regarding abuse. Dealing with family trauma.
- Varieties of family therapy; assumptions and major concepts.
*The new curriculum was written by The GAP Committee on the Family: Ellen Berman, MD; John Rolland, MD, MPH; John Sargent, MD; and me, and with guests Chayanin Foongsathaporn, MD; Sarah Nguyen, MD, MPH; Neha Sharma, DO; and Jodi Zik, MD. For the full curriculum, which includes residency milestones, site-specific training goals, references, and case studies, please access the Association of Family Psychiatry’s website: www.familypsychiatrists.org.Dr. Heru is professor of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals” (New York: Routledge, 2013). She has no conflicts of interest to disclose. Contact Dr. Heru at alison.heru@ucdenver.edu.