(Revised 2013)
POST-GRADUATE TRAINING OBJECTIVES
IN COUPLE AND FAMILY PSYCHOTHERAPY
University of Toronto, Department of Psychiatry
Psychotherapy Stream, PHES Division
I. PREAMBLE
The teaching outlined in this document is designed to enable residents to integrate psychodynamic, systems,cognitivebehavioral and communication principles in dealing with couples or families.
Couple therapy refers to the conjoint process in which two persons in a close relationship (marital,common-law, prenuptial or other, homo or heterosexual, or two members of a family subsystem) meetwith the therapist to redefine the causes, the dynamics and the possible solutions to conflicts that haveobstructed their joint development and well-being.
The goal of this kind of treatment is not to keep two individuals together at all costs. At times, throughcouple therapy, the dyad discovers their relationship no longer has a basis to reconstruct it. The goalmay then be an amicable separation, or an arrangement, where the parties and the children are hurt as little as possible, or an business-like arrangement, where the participants stop expecting re-construction of the couple. Family therapy refers to the conjoint process in which all available/interested members of a "family" system meet with the therapist to redefine problems and solutions. "Family" refers to the many ways inwhich kith and kin systems are lived and constructed.
Why must residents have some knowledge about couple and family dynamics and therapy?
- Graduating residents increasingly work in under-serviced areas and may be responsible forthe integrated treatment of their patients, including couple and family problems, with lesspossibility of referring to a specialist.
- If they go into private practice, they will face an increasing demand for couples that seek helpunder OHIP. In Canada, one of three marriages ends in divorce; at the same time, manyindividuals remarry and seek help when they feel in danger of repeating mistakes. Blendedfamilies of two divorced individuals with children of previous marriages increasingly seek thepsychiatrist's help, as do gay, lesbian or transgender couples, with or without children, and couples where oneof the two are HIV positive or have AIDS.
- For a complete assessment of one individual's life situation.
- For an assessment of the impact of the physical or psychiatric illness of one individual on thepartner and the family system.
- To enlist the help of the partner and the family in the treatment of one individual; or
- To help the couple and family resolve relational crises, be they acute or chronic, developmentalor due to unexpected upheavals.
Whitaker et al (1981) distinguish three levels of training:
1) Learning about family therapy;
2) Learning to do family therapy, and
3) Becoming a family therapist.
The first level involves acquiring some theoretical knowledge about the methods.
The second involves a program where Residents learn to do couple/family therapy as part of theirtraining; ideally they will learn:
• How to assess couple/family structure and dynamics
• How to recognize couple/family processes which generate, use and promote individual or family
symptoms as defenses against anxiety.
• How to intervene in SOME couple/family crises.
• How to utilize consultation with an experienced couple/family therapist.
These objectives are achievable by giving Residents: theory seminars,the opportunity to observe a clinician doing the therapy, and the supervision of the treatment of two or three couples or families the resident treats during one year. Couple/Family Therapy Afternoon takes place once a year, in June, and any resident who wished to attend will receive protected time to do so, can attend.
For the third level (becoming a family therapist) the Psychiatrist has to undertake a two or three yearimmersion training program in the specialty. The time allotted for couple and family therapy in ourPsychiatric Residency precludes this, yet level two of training is achievable.
Ms. C. Chagoya and Dr. L. Chagoya, offer an elective for this residency training.
II. WORKING KNOWLEDGE TRAINING OBJECTIVES IN COUPLE OR FAMILY
PSYCHOTHERAPY
A. Knowledge
Residents should be familiar with:
1)The indications and contraindications of couple and family therapy (Frelick et al, 1987),
2)The basic principles of systems theory (Constadine, 1986).
3)The integration of systemic, developmental, communication, psychodynamic, cognitive behavioral and psycho-educational principles applied to understanding and assessing a couple ora family (Chagoya et al, 1983).
4)The role of the interviewer-therapist with each member of a couple or a family.
5)The objectives in a couple or family assessment and in the subsequent treatment.
6)The conceptual, perceptual and executive skills necessary to assess a couple or a family
(Cleghom et al, 1973), and the fact that a single assessment interview CAN be therapeutic.
B. Skills
Residents must be able to:
1)Negotiate a therapy contract with the couple or family,
2)Interview couples and families without taking sides, without becoming punitive orantagonistic and without seeking premature closure in relational issues.
3)Combine support and challenge about where problems come from and about how they may besolved.
4)In couple and family assessment interviews, manage and be aware of individualpsychopathology without getting sidetracked by it.
5)Regulate the emotion and aggression level of the sessions, balancing them with support andpsycho-education, so the sessions will not be overwhelming experiences patients will want toavoid.
6)Regulate the go-between process in family triangles, given that the couple or family, morefrequently than not, will put the Resident in the role of a judge (Zuk, 1971).
7)Be aware of their countertransference and avoid acting it out.
8)Be aware that couple or family therapy, can be combined with other forms ofpsychotherapy or pharmacotherapy.
C. Attitudes
Residents must acquire:
1)Acceptance of and respect for the values in couples and families from different cultures,different socio-economic strata and in different life cycle stages.
2)Awareness of the personal prejudices we all have regarding couples and families; prejudicesunavoidably based on our sexual orientation, culture, family background, age, marital status,and having or not having children or adolescent progeny.
3)Awareness of how the couple or family perceives the therapist.
4)Willingness to collaborate with social agencies, for instance when protection is neededfor abused children or adults.
5)Sensitivity to the fact that the therapist can create resistance by advocating only for onepartner or one family member, neglecting the needs of the other or others.
6)Adherence to the ethics of couple and family therapy, which excludes exploitation of patients(sexual, financial or otherwise) or omnipotent deciding for them what their destiny should be;this includes accepting and respecting the couple's or family's goals and constructive methodsof problem solving.
D. Commitments
1)Theory seminars.
2)Six sessions of supervised couple or family therapy (1 case)
3)Attendance to observe couple/family sessions (20)
III.PROFICIENCY TRAINING OBJECTIVES IN COUPLE OR FAMILYPSYCHOTHERAPY
A. Knowledge
The items enumerated in the Introductory Training Objectives, plus
1)The history and evolution of couple or family therapy.
2)An integration of theories, applied to the couple and the family, such as:
- Systems theory (Constadine, 1986)
- Communication theory (Watzlawick et al, 1967)
- Developmental life cycle theory (Carter et al, 1980)
- Psychodynamic theory, both classical and object relations (Scharff et al, 1987)
- Cognitive/Behavioral theory (Jacobson et al, 1995)
- Sex therapy (Singer, 1987)
- Psychoeducation (Falloon et al, 1981)
- Divorce therapy (websites)
- Research of evidence-based interventions with couples and families (Gottman, 1999)
B. Skills
The ones delineated in the Introductory Training Objectives, plus:
1)The ability to establish a therapeutic alliance with each member of the therapeutic system
2)The ability to keep redefining goals during therapy, according to its evolution, the obstaclesfound and the willingness of the couple or family to continue treatment.
3)The ability to handle confidentiality issues without breaking the therapeutic alliance with eachsystem member.
4)The ability to use him/her self as a therapeutic tool, aware of how to usehis/her verbal and non-verbal communication, to support or try to modify couple or family stances asthe treatment proceeds
5)The ability to use supervision to create his/her own therapeutic style.
6)The ability to perceive when counter-transference is an obstacle to the appropriate technique orto the therapeutic alliance.
7)The ability to maintain ethical boundaries between the therapist and the couple or family, inspite of patients' attempts to blur them.
C. Attitudes
The ones delineated in the Introductory Training Objectives, plus:
1)Realism about what couple or family therapy can and can not achieve, depending on thepatients' motivation, intelligence, patience, culture, socio-economic situation and pathology.
2)Patience to allow the time required for the process of working-through, thus avoidingpremature closure of therapeutic challenges.
3)Openness to recognize when the therapeutic relationship becomes dysfunctional, and it isbetter for all concerned to refer the couple or family to another therapist, or for the therapist toseek a consultation with a colleague.
D. Commitments
1)Minimum of 2 supervised family or couple cases – each case a minimum of 6 sessions
RECOMMENDED READING
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Tomm K_ Interventive interviewing. Part III: Intending to ask lineal, circular, strategic or reflective
questions? Family Process 27: 1-15,1988.
Watzlawick P, Beavin JH, Jackson DD: Pragmatics of Human Communication. A Study of InteractionalPatterns, Pathologies and Paradoxes. New York. Norton. 1967
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Websites
addiction mental health/couple therapy.html
articles. flndarticles.com/p/articles/mi_mOAZV/is_2_41
Click on Manuals: SFT&TAP
This document was prepared by:
Charlotte Chagoya, RN, PsychNrs.Fam Ther
Leopoldo Chagoya MD, FRCPC, Couple/Family Therapy Modality Lead
Richard Sugarman MSW
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