Australian and New Zealand Journal of Family Therapy 2016, 37, 7587

doi: 10.1002/anzf.1140

On Family Therapy Training in Psychiatric

Education: A Recent Trainees Perspective
Timothy R. Rice*
The Icahn School of Medicine at Mount Sinai, New York City, New York
Family therapy has been labelled a neglected core competency of psychiatric residency training programs. Several
models of effective integration into training in both general and child and adolescent psychiatry have been proposed, yet the restraint exhibited in educational guidelines to guide developed family therapy programming results
in varied trainee experiences. This perspective piece offers the narrative of a trainees progression through one
educational program that offered a generous elective engagement with family therapy. This piece intends to complement in an original manner the existing literature supporting family therapy training for psychiatric trainees that
are usually authored by senior clinicians and/or established proponents of family therapy. The program described
in this piece is an American model that entailed mandatory seminar didactics with elective active case involvement and clinical supervision. The authors three-year engagement with a family consisting of a young man diagnosed with schizophrenia and his mother, who comprised the active case component, is presented with a
description of how both the family and the clinician developed through the process. The conclusion comments
upon how this work facilitated ongoing work with severely disturbed children and their families upon the trainees
graduation to serve as a unit attending on a child and adolescent psychiatry acute inpatient service. This piece
illustrates in a personal narrative the importance of family therapy training to the contemporary graduate and recommends greater immersion for psychiatric trainees in this modality.
Keywords: family therapy, training, child and adolescent psychiatry, psychosis

Key Points
1 Family therapy training for adult and child and adolescent psychiatry trainees is considered important in
major educational consensus statements.
2 The optimal structure and intensity of this training is debated.
3 To inform this debate, this manuscript is written from the perspective of the trainee.
4 Longitudinal supervised work with a family with schizophrenia is presented to show the benefit of such
work on a trainees development.
5 When coupled with didactic seminars and peer support, this model of engagement was found to have benefits that may be generalisable to many psychiatric trainees.

Family therapy has been labelled a neglected core competency of psychiatric residency
training programs (Heru, Keitner, & Glick, 2012). While family therapy is a major
treatment modality in existing and approved requirements for American graduate
medical education in both general and child and adolescent psychiatry (Accreditation
Council for Graduate Medical Education, 2007, 2014), only minimal standard educational guidelines are available. Many authors worldwide favour in-depth family therapy training in general psychiatry residency training (e.g., Rait & Glick, 2008), and
in particular in child and adolescent psychiatry training (Josephson, 2008, 2013; Rait,
Address for correspondence: timothy.rice@mssm.edu
*I wish to thank Barbara Feld, Associate Clinical Professor of Psychiatry at the Icahn School of
Medicine at Mount Sinai, and Anne Ziff, Assistant Clinical Professor of Psychiatry at the Icahn
School of Medicine at Mount Sinai, for their supervision and contributions to this work.
2016 Australian Association of Family Therapy

75

Timothy Rice

2012). Yet, in the absence of standards for greater immersion, there remains great
variability in the intensity of family therapy educational immersion for trainees within
psychiatric training programs.
This paper intends to illustrate one feasible educational model and to illustrate this
models positive effect upon the authors development as an American psychiatric trainee.1 In this way this piece intends to complement the voice of those in favour of a
greater immersion in family therapy for psychiatry trainees in an original manner by
directly emphasising the perspective of the trainee. Following a review of the literature
concerning the role of family therapy in psychiatric education, this paper will present
a history of the authors three-year engagement in weekly hour-long encounters with
a family comprising a young man diagnosed with schizophrenia and his mother. The
emphasis will be upon the mutual developmental benefit of this experience for both
the family and the trainee.
This paper was developed during the authors training and was completed while
serving as an attending psychiatrist on an acute inpatient child and adolescent psychiatry unit. From this vantage point, this paper is suited to supporting family therapy
training as expressly important for child and adolescent psychiatrists development. It
suggests that in this trainees experience, the repeated and longitudinal exposure
through the family therapy training experience to a family with psychotic pathology
facilitated the development of capabilities to more effectively engage with families
with severe childhood pathology. The mode of this development is conveyed to be
the warmth and security of the supervisory process. In this process there was a focus
upon attachment models and processing of related affects. At times those affects experienced through engagement with the family and its psychotic process were intense.
Supervision was integral to processing and understanding the experience.
The limitation of this paper is that it represents a single subjective experience that
may not be generalisable to the trainees of America, Australia, and New Zealand, or
elsewhere. However, in the absence of writings on this topic from the perspective of
the psychiatric trainee, this writing is a unique contribution that complements the
existing literature and intends to stimulate its further development. It is difficult to
identify experientially the benefits of family therapy training in psychiatric residency
when observations are written from a perspective distant from training or by professionals of a different discipline. The aim of the paper is to strengthen the dimensions
of evidence in support for greater family therapy integration into psychiatric residency
programs.
Review of the Literature
Since the growth and diversification of family therapy and the systems perspective in
the 1960s and 1970s, there have been calls to ensure that both adult and child and
adolescent psychiatric trainees receive exposure to family therapy. These calls in the
early years of family therapy were likely related to the conflict between individual
therapy and the emerging systems perspectives: educators did not wish to see this conflict restrict trainees. Early calls for integration in adult (Harbin, 1980; Sugarman,
1984) and child and adolescent (Malone, 1974) psychiatric residency education were
protective of the trainee being hindered from conflict between the fields. Indeed, one
argument within the child and adolescent literature labelled the intensity of the conflict to be akin to an undeclared war (McDermott & Char, 1974, p. 422).

76

2016 Australian Association of Family Therapy

Family Therapy Training in Psychiatric Education

Tensions calmed between the two perspectives in the 1980s. The charismatic ageing leaders of family therapy passed on leadership to more integrationist and moderate innovators, and psychiatrists became more sensitive to the value of the systemic
perspective. Articles on the role of family therapy training in psychiatric residency
education continued to be published (Celano, Croft, & Morrissey-Kane, 2002; Combrinck-Graham, 1988; Guttman, Feldman, Engelsmann, Spector, & Buonvino, 1999;
Resnikoff & Lapidus, 1990; Slovik, Griffith, Forsythe, & Polles, 1997), but the friction of the earlier papers appeared to have been smoothed.
Recent developments in mental health have again flared tensions and concerns
regarding the role of family therapy within psychiatric education. Josephson (2008)
identifies the increasing pull towards biological models of mental health in psychiatric
residency education as problematic and suggests that psychosocial interventions are
outside the province of psychiatrists. Additionally, with the transition from the categorical diagnostic system model (American Psychiatric Association, 2013) to the
brain-based dimensional Research Domain Criteria model (Insel, 2014), there is again
the opportunity for the systems perspective to be further marginalised.
These debates concerning the role of family therapy in residency education often
reference the dialectic between what has come to be termed family skills training and
family therapy training. The family skills training model (Berman & Heru, 2005) recommends that psychiatric training in family therapy should focus on integrating system competencies into the dominant perspective of the psychiatric provision of care.
In contrast, the family therapy training model recommends making family therapy
one of several major competencies in psychotherapy, equal among cognitive behavioural psychotherapy, psychodynamic psychotherapy, supportive psychotherapy, brief
psychotherapy, and combined psychotherapy-psychopharmacology, and mandates that
residents carry family and couples cases (Rait & Glick, 2008). This debate also
extends into the child and adolescent training literature (Josephson, 2008, 2013; Rait,
2012), where its satisfactory resolution has been identified as a particular challenge
(Beresin, Balon, Coverdale, & Roberts, 2012).
Educational Program Setting

The narrative that follows was initially developed during the authors training in, first,
an American general adult psychiatric residency program (three years), and then in an
American child and adolescent psychiatric residency program (two years). The family
therapy educational model of both programs included a mandatory didactic seminar
(one hour approximately once a week for three months in the adult program, one
hour once a week for a year in the child and adolescent program), and an elective
opportunity to carry a family therapy case with group clinical supervision. The universal seminar for all residents regardless of their elective choice ensured that accreditation requirements were met (Accreditation Council for Graduate Medical
Education, 2007, 2014).
In the child and adolescent psychiatry program, the seminar provided both trainee-led didactic teaching under supervisor oversight as well as group and peer supervision of family interactions in active individual child and adolescent therapy cases. In
the didactic component each resident was assigned a major family therapy theoretician
on which to read the primary literature, review their life biography, and present to
the class their theory in the light of their personal background. Trainees were
2016 Australian Association of Family Therapy

77

Family Therapy Training in Psychiatric Education

James and Junes first session when James was at the age of 25 was emotionally
distant and rote with introductions made and treatment goals discussed. James understood the treatment goals as to continue my recovery from schizophrenia, and June,
to better support James. James presented as accepting the role of identified patient
of the family, and June generally wished to retain the therapeutic focus upon James.
Conflict between neuropsychiatric and family system models

As a new trainee, I recall feeling conflicted between understanding James disability as

a neuropsychiatric disorder and as a function of the family system. I had little cognitive or emotional flexibility at that time to see the determinants of his condition as
multifactorial and laid out on a spectrum between those two extremes; the intensity
of James presentation made it easier for me to see it as all one or the other. The
emphasis in medical education upon biology initially served only to foreclose on
opportunities to understand James condition as an attempt to convey family disequilibrium (Bateson, 1972; Bowen, 1978; Watzlawick, Weakland, & Fisch, 1974), pain
(Satir, 1964), structural inflexibility (Minuchin, 1974), or a pluralistic mix of these
perspectives in interaction with psychodynamic or behavioural models. As an early
trainee I shared the feeling of being handicapped in working with the individual
with schizophrenia (Haley, 1979). The traditional medical perspective dictated primarily educational interventions (Johnson, 1987), while the other offered potential
value to a richer engagement with the family.
Unsure of how to proceed after that first visit, James almost immediately solved
the dilemma for me. In his second session James reported a significant trauma history perpetrated by a male that had not yet been shared with his prior female family
therapists. A heated motherson conflict ensued while I sat motionless, confused how
best to proceed. In contrast to the controlled and educative movements of the prior
work, things seemed wild, alive, and powerful. I recall feeling numbed by the intensity of the argument and the rawness of the trauma, and I somehow felt complicit.
As the first male provider and as the first to be told by the family system of their
perception of the violence of men, I felt strongly pulled into the system. Regardless
of past biases through medical education towards concrete neuropsychiatric models
of schizophrenia, it was immediately clear that multiple intense and complex processes were alive and reachable through psychotherapeutic intervention. At that time
in my training I did not have the experience to understand the complex interaction
between biology and psychosocial systems; things often felt all or none. Thus, at
that time I felt neurobiology was limited and an engagement with the systems
approach felt warranted.
Over the next few months James, June, and I began to discuss the meanings and
functions of James problem behaviours. These were brought in to our sessions by
report and then by enactment. At first June would confront James in session that she
knew, for example, that he had failed to present for his vocational rehabilitation services program on a given day. I would directly see James shame. We would discuss
how these behaviours, which provoked June into checking in on James, kept him
dependent and restrained by his mothers vigilance. Soon, James began to show up
late to our sessions, or to not show at all. The symptom had been brought into the
therapy. With time I learned only to note these interactions rather than to comment
on them and worsen James shame. With the help of my supervisor, our goal became
to intervene towards helping James and June to feel comfortable.
2016 Australian Association of Family Therapy

79

Family Therapy Training in Psychiatric Education

James and Junes first session when James was at the age of 25 was emotionally
distant and rote with introductions made and treatment goals discussed. James understood the treatment goals as to continue my recovery from schizophrenia, and June,
to better support James. James presented as accepting the role of identified patient
of the family, and June generally wished to retain the therapeutic focus upon James.
Conflict between neuropsychiatric and family system models

As a new trainee, I recall feeling conflicted between understanding James disability as

a neuropsychiatric disorder and as a function of the family system. I had little cognitive or emotional flexibility at that time to see the determinants of his condition as
multifactorial and laid out on a spectrum between those two extremes; the intensity
of James presentation made it easier for me to see it as all one or the other. The
emphasis in medical education upon biology initially served only to foreclose on
opportunities to understand James condition as an attempt to convey family disequilibrium (Bateson, 1972; Bowen, 1978; Watzlawick, Weakland, & Fisch, 1974), pain
(Satir, 1964), structural inflexibility (Minuchin, 1974), or a pluralistic mix of these
perspectives in interaction with psychodynamic or behavioural models. As an early
trainee I shared the feeling of being handicapped in working with the individual
with schizophrenia (Haley, 1979). The traditional medical perspective dictated primarily educational interventions (Johnson, 1987), while the other offered potential
value to a richer engagement with the family.
Unsure of how to proceed after that first visit, James almost immediately solved
the dilemma for me. In his second session James reported a significant trauma history perpetrated by a male that had not yet been shared with his prior female family
therapists. A heated motherson conflict ensued while I sat motionless, confused how
best to proceed. In contrast to the controlled and educative movements of the prior
work, things seemed wild, alive, and powerful. I recall feeling numbed by the intensity of the argument and the rawness of the trauma, and I somehow felt complicit.
As the first male provider and as the first to be told by the family system of their
perception of the violence of men, I felt strongly pulled into the system. Regardless
of past biases through medical education towards concrete neuropsychiatric models
of schizophrenia, it was immediately clear that multiple intense and complex processes were alive and reachable through psychotherapeutic intervention. At that time
in my training I did not have the experience to understand the complex interaction
between biology and psychosocial systems; things often felt all or none. Thus, at
that time I felt neurobiology was limited and an engagement with the systems
approach felt warranted.
Over the next few months James, June, and I began to discuss the meanings and
functions of James problem behaviours. These were brought in to our sessions by
report and then by enactment. At first June would confront James in session that she
knew, for example, that he had failed to present for his vocational rehabilitation services program on a given day. I would directly see James shame. We would discuss
how these behaviours, which provoked June into checking in on James, kept him
dependent and restrained by his mothers vigilance. Soon, James began to show up
late to our sessions, or to not show at all. The symptom had been brought into the
therapy. With time I learned only to note these interactions rather than to comment
on them and worsen James shame. With the help of my supervisor, our goal became
to intervene towards helping James and June to feel comfortable.
2016 Australian Association of Family Therapy

79

Timothy Rice

In time, we moved towards a discussion of the intensity of Junes reactions to

which James reacted with shame as a precipitant to further avoidance in James. This
made the first space for June to move with me away from a biologically oriented linear model of symptoms. We struggled with this movement. Despite best efforts to
reduce his shame, James continued to fail to present for sessions, or he would show
up very late. He would enact various feelings, often leading to feelings of worry or
frustration in myself and in June as we waited for him to arrive, or not to arrive. The
specter of psychosis often seemed in the room was James taking his medications?
Was he organised and on his way, or lost to reason and at risk of violence towards
himself or to others?
In this setting the new male psychiatry trainee who provided James medication
management recommended a transition to a monthly intramuscular injection of an
antipsychotic. Despite its rationality given James medication nonadherence, there
were several complicated matters related to James conflicts. James was ambivalent
and resistant at best to this plan, and the struggle to convince him to submit to
the injection showed increasing parallels to his prior trauma. James passive
and ineffective rejection of this plan precipitated his enactment of a complete
rejection of his oral antipsychotic medication doses during the cross-over period.
James again experienced severe psychotic symptoms resulting in his third
hospitalisation.
This third hospitalisation occurred after more than two years of stability and just
several months of my working with James. Several objective signs, including James
re-hospitalisation, functional decompensating, and decreased autonomy and individuation from June, suggested a sense of therapeutic failure or even of harm. I privately
wondered whether I had erred in applying family therapy interventions to a patient
with a major neurobiological illness. In a parallel process, I felt slight shame and a
wish to hide my doubts about family therapy from my family therapy supervisor. I
wondered if I had pushed the patient into violent enactments through distressing
him with non-pharmacological therapeutic interventions. Following the hospitalisation, a regressive focus emerged on more concrete, circumscribed efforts to assist
James to work through problems related to his inability to hold down a job. These
efforts were similar to those of a solution-focused brief therapy (Pichot & Dolan,
2003). They were repeatedly frustrated. James continued to find himself in a pattern
of walking off the job after confrontations with male supervisors and of being fired,
just as James had seemed to attempt with me during our second session when he
provoked me with the intense history of his trauma. James again acted out his presenting problem of telling mistruths by hiding his firings from June and clinicians
for several days and then announcing them in family sessions. We seemed to be
stuck.
Yet, simultaneously, June had become more engaged in the process of exploring
the potential motivators of James repetition of a disruptive pattern. She began to
make use of the time when James would not present for treatment to explore her
own thoughts and feelings. She became more comfortable, allowing the focus of the
therapy to be on herself, and I began to feel more comfortable sharing in supervision
a focus on my own reactions with the family. For the first time, I was able to consider myself as part of the system. I gained confidence in my ability to tolerate joining
a family with psychosis and the intense feelings that this joining process could generate (Minuchin, 1974).

80

2016 Australian Association of Family Therapy

Family Therapy Training in Psychiatric Education

An integrated model

Aware of the way in which this progress could again raise my reduced confidence in
the role of the therapy, I began to develop a more nuanced and integrated understanding of James difficulties. This occurred as I was transitioning into my training
in child and adolescent psychiatry and in developing a treatment manual for children
with disruptive behaviours (Hoffman, Rice, & Prout, 2016). The biological model of
implicit emotion regulation (Gyurak, Gross, & Etkin, 2011), which we had harnessed
to describe disruptive behaviours as maladaptive self-protective manoeuvers against
painful affects (Rice & Hoffman, 2014), was helpful for myself and for James family
to understand his behaviours. The biologically based emotion regulation system is relevant to major neuropsychiatric conditions (Etkin, Gyurak, & OHara, 2013) and
acceptable to trainees in contemporary models of psychiatric education (Fung, Akil,
Widge, Roberts, & Etkin, 2014); this model seemed a good way to collapse the binary of biological versus psychosocial models of James impairment. Similarities
between this model and defence mechanisms (Rice & Hoffman, 2014) helped to
broadened the dyadic reflective capacity and curiosity in unconscious processes and in
the past as a motivator of the present. June consolidated her increasing openness to
engaging in the sessions with whatever was on her own mind, rather than upon a predetermined list of problems that had arisen with her son. While we all still had a
fresh reminder of the importance of medications in James recovery and the biological
factors of his problems, we seemed to be working towards an integrated explanatory
model.
A pivotal session occurred when James and June revealed that, as a child, James
had appeared on a popular childrens television show. June asked the writers permission to show the internet-based footage on his work computer and the request was
permitted. This was performed in the service of gaining historical information. The
decision also continued a flexible relatedness and modelled reflective functioning.
Upon viewing the video, I recall an immediate awareness of developmental delays in
James as a young child that had previously been underreported. James showed hesitancy and mild discomfort in watching both the video and in Junes reaction to the
video. In contrast June showed joy and pride. This contrast enabled an entry into
directly exploring James and Junes reactions to his deficits. Over many sessions, June
was helped to experience warm feelings at the same time as acknowledging James real
deficits. James was helped to feel less uncomfortable with Junes experience of him as
an individual.
This session took place at the end of the trainees training in adult psychiatry, just
prior to his graduation and entry into child and adolescent training. He had little
exposure to the developmental perspective that is so integral to child and adolescent
training and clinical work, and he had not yet had the diversity of experience that
comes with transition to a new peer and a new supervisory setting.
Training transition and benefit of a developmental perspective

Having remained at the same institution for my further training, I had the option to
continue with James and June for my child and adolescent training. Several factors
contributed to the decision to continue with the family. An important factor was my
growing awareness that my work with James and June helped me to grow. I felt
James and June had grown as well. Though they reported great appreciation for my

2016 Australian Association of Family Therapy

81

Timothy Rice

decision to continue with them, almost immediately the family spoke through frequent last-minute cancellations and disengagement. In sessions we discussed the warm
emotions and closeness that the decision to continue to work together generated
alongside the reasons the family might need to respond protectively though disengagement. We also discussed the loss of the previous pattern of working in one-year
stretches with adult residents and the challenge to stasis this brought. What too did it
mean to James and June to now be working with a child and adolescent trainee and
the accouterments this transition entailed, including meeting in a child and adolescent
clinic and waiting in a room filled with young children and their parents?
For me, it meant, among many things, a change in educational models and supervisory programs. To this point, my working with James and June in my adult residency had been in satisfaction of an elective requirement. Now, it was entirely in my
own time. Supervision had been in a weekly small group of three residents who were
interested in this modality. Now, James and June would be intermittently discussed
with all residents regardless of their interest in family therapy. As no other resident
had elected to carry a family case, James and June became the only case that was
actively in treatment and discussed in seminar throughout the course of the year.
I believe that I too would not have elected to begin work with a family at the start of
a child and adolescent training program. The time was filled with new opportunities
and responsibilities. These reflections suggest the value of family therapy training in
adult residency training as a prelude to training in child and adolescent training. In addition, I found that working with two grown adults on issues common in a family of an
earlier developmental age helped my transition to working with families with actual children. Some of the challenges that I had overcome in working with James psychosis
helped me to feel comfortable and confident in grappling with the challenges of young
children and their families. I felt more comfortable in joining family with children by
comparing it to the experience of joining James family, where there was always the concern that through psychosis violent fantasies could be enacted. At the same time, it also
felt familiar in comparison by virtue of the developmental ages of the issues at hand.
My work with children also helped me to better understand James. I gained a
greater understanding of James developmental history. The session in which June
presented James on television became a pivotal moment in my understanding of the
family (Minuchin, 1974). The discomfort James exhibited in watching that clip, in
contrast with Junes pride in her young idealised son, revealed a very concrete image
of the problems wrought by a family systems inflexible stasis. James was pulled by
his wish to support Junes happiness to remain an idealisation of a child that his
developmental deficits could not allow him to be. I came to believe that a reversal of
James deficits and current psychosis was less of an appropriate goal than helping the
family systems appropriate acceptance of James reality.
This development allowed me the confidence to challenge the historical narrative
that James had been a successful, functioning adolescent and college student who was
thwarted suddenly when the symptoms of psychosis developed. The traditional psychiatric model of schizophrenia with an onset in the adult years had been supplanted by
a developmental model with family system determinants that could be engaged with
by using a family therapy approach. I would come to feel more nuanced in working
with adults with schizophrenia on my return to adult work following my training, but
I felt more motivated to engage with my child patients using primary and secondary
prevention measures, and I was now more attuned to the family system issues at hand.

82

2016 Australian Association of Family Therapy

Family Therapy Training in Psychiatric Education

An additional perspective: Pauline Boss and Ambiguous Loss

My new supervisor had assigned as a requirement of the child and adolescent family
seminar a presentation on the work of Pauline Boss and her theory of Ambiguous
Loss (Boss, 2000, 2006). Boss background and theory, at odds with my own theoretical orientation, was an effective concrete complement to developing a working model
of James familys current challenges. This development acknowledges the importance
of the didactic seminars in an integrated educational experience. I started to help the
family move beyond what was understood as the loss of Junes idealised son. James as
an idealisation had never existed. Rather than solely encourage greater functioning in
James through family interventions, it became more possible to build acknowledgement within the family of the grief and loss of the idealised James. The enduring
physical presence of James coupled with the absence of the idealised James made this
loss of the latter difficult to grieve.
In my review of Boss first book (Boss, 2000), I became more appreciative of
Junes exhaustion. Boss writes that the failure to achieve a concrete termination of the
fantasised presence of a family member permits the fantasy to endure. Family members become exhausted. Whereas June had shown such joy in James as a star, every
week she showed her fatigue, exasperation, and sense of personal defeat over her sons
repeated shortcomings. I found new empathy for June and recognised a need to produce a grieving process to enable a conclusion to the loss and opportunity for further
growth and reconnection with her son in a new equilibrium.
Boss theory was also applicable to role of the father, Kent. Throughout James
childhood, Kent was physically present but at times psychologically distant through
the effects of a psychotic illness. Equally important was Kents physical absence alongside his continued psychological presence following his departure from the family.
This twinship of paternal absence is a familiar and longstanding theme in the work of
Boss (1986). Whereas clinical supervision had already identified the importance of
attending to the importance of the transition of the family therapy modality to a male
therapist for the first time, Boss emphasis upon the importance of absent fathers
explicitly symbolised this focus. I became better able to understand my initial feeling
of slight complicity for James trauma dating back to the very beginning of my work
with the family. I gained a very valuable visceral experience of transference and countertransference. I continue today to reference this in reflecting upon strong feelings
generated through work with children and adolescents.
Though Boss (2007) names several challenges in the use of ambiguous loss theory
for clinicians, my experience suggests that the trainee can overcome these. Boss
(2000) advocates for an organisation of intervention within the triad of psychoeducational, experiential, and structural work. Building upon previous psychoeducational
work, I reflected upon my inhibition and failure to have earlier questioned James
development and understood experientially through countertransference the power of
June to erect a barrier to preserve her fantasy of her idealised son. A realistic appraisal
of the son, enabled through the review of the psychoeducational material including
the medicalised course of a severe psychotic illness with clear childhood precipitants,
was slowly and gently moved to the forefront and reinforced within sessions over the
course of several months.
The goal in family therapy from Boss perspective became to help the family see if
there was some point of agreement on how to understand the loss. This concrete

2016 Australian Association of Family Therapy

83

Timothy Rice

focus complemented my prior guided work through supervision and my own theoretical orientation. With permission, explicit processing of the feeling of loss within the
family became possible. Contemporary formulations of defences against painful affect
(Hoffman, 2007, 2014) from its origins in the analytic child literature (Bornstein,
1945, 1949) remained the baseline onto which this new focus was made. June was
helped to understand that beneath her explosive rage were feelings of sadness and loss.
Similarly, James was helped to explore whether beneath his dismissive self-labelling as
lazy or not caring lay a multitude of feelings that were painful to express and were
more easily covered up by these labels.
My work with James and his family ended in the second year of my child training
when together the decision was made to help James transition to a residential setting.
To acknowledge and accept this transition was the product of much work. Though
James and his family would and will undoubtedly continue to face struggles, we as a
system comprising myself and the family felt satisfied in our work when it was time
to end this chapter of growth.
Conclusion

This paper aims to complement the existing literature on the role of family therapy
in psychiatric education through the perspective of a trainee. The above narrative
intends to show a unique experience that positively influenced my professional and
personal development. The limitation of this piece is that it is a personal narrative of
development, which is significant. Yet, I would suggest that elements of this narrative
are generalisable. For example, Paolo Bertrando (2009) in his contribution to this
journal entitled, Surviving in Psychiatry as a Systemic Therapist, writes:
Every day I worked in connection with the university psychiatric clinic, and I held a
benevolent psychiatric attitude to families, working in a psychoeducational way, which
did not challenge in the least the prevailing psychiatric values. Once a week, I went for
training to the Milan Centre, where I explored the consequences of Batesons rethinking psychiatric categories. In short, every week I contradicted myself, which led to a
growing sense of uneasiness. I can say that a good deal of my subsequent career was a
quest for solving this basic contradiction (pp. 1623).

The uneasiness of uncertainty regarding the perception of a basic contraindication between psychiatry and family therapy is very important. It may be precisely the
negative affect that the optimal family therapy educational program for psychiatric
trainees should address. In my narrative, and at an early point in my career development, I had the opportunity to engage under supervision with a family burdened by
psychosis. I was able to work with this family longitudinally through my formative
years as a child and adolescent psychiatrist. This experience essentially allowed me to
work through the surface contraindication between psychiatry and family therapy.
The structure of seminar didactics and of group supervision with a supportive class of
my peers helped.
Essentially, I found myself able to develop my professional identity in tandem
with my exploration of the perceived psychiatryfamily therapy contradiction. Clearly
both processes will continue. As a result of this opportunity I have found myself more
able to flexibly work with both children and adolescents, and with parents, a critical
skill which has enjoyed increased acceptance in recent years through the advocacy of

84

2016 Australian Association of Family Therapy

Family Therapy Training in Psychiatric Education

similarly inclined authors (e.g., Novick & Novick, 2013). This positive outcome in
my narrative is a data point that integrated considerations of the optimal role of family therapy in psychiatric training.
This trainee perspective aims to complement the existing writings of educators,
training directors, and family therapy supervisors and educational directors. Writing
now from the perspective of the early career psychiatrist serving an acute inpatient
unit of severely disturbed children and adolescents, each day the relevance of my work
with James and June is clear. Working with enactments, enmeshments, projections
and reality distortions, and life-threatening self-injury and violence is a daily task.
Integration of this work into the pharmacotherapy and medical decisions unhindered
by the uneasiness referenced by Bertrando (2009) seems to have been a direct product
of my training. In future years I may wish to return to this experience from a more
experienced vantage point and reflect further. For now, the voice of the recent trainee,
albeit limited in breadth of scope and experience, is here presented to inform future
decisions regarding the role of family therapy in psychiatric education.
Notes
1

Training in the American setting consisted of three years of training in a general adult psychiatric residency program and two years of training in a child and adolescent psychiatric residency program. The
shortening of the traditional four-year general adult training experience is made possible through an
option termed fast tracking wherein the fourth year of adult residency is dropped, which was designed
to increase recruitment into child and adolescent psychiatry. These combined five years of post-graduate medical education followed four years of university and four years of medical school training.
Certain details including names, ages, backgrounds, and clinical details were altered in order to protect
the familys confidentiality.

References
Accreditation Council for Graduate Medical Education. (2007). Psychiatry program requirements, 2007 update. Retrieved from https://www.acgme.org/acgmeweb/Portals/0/PFAssets/
ProgramRequirements/405pr07012007.pdf accessed 25 May, 2014.
Accreditation Council for Graduate Medical Education. (2014). Psychiatry program requirements, 2014 update. Retrieved from https://www.acgme.org/acgmeweb/Portals/0/PFAssets/
ProgramRequirements/405_child_and_adolescent_psych_07012014.pdf.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders
(5th ed.). Washington, DC: American Psychiatric Press.
Bateson, G. (1972). Steps to an Ecology of Mind. Chicago, IL: University of Chicago Press.
Beresin, E.V., Balon, R., Coverdale, J.H., & Roberts, L.W. (2012). Challenges in child and
adolescent psychiatric education. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry,
36(6), 429432. doi:10.1176/appi.ap.12090164.
Berman, E., & Heru, A.M. (2005). Family systems training in psychiatric residencies. Family
Process, 44, 321335. doi:10.1111/j.1545-5300.2005.00062.x.
Bertrando, P. (2009). Surviving in psychiatry as a systemic therapist. Australian and New Zealand Journal of Family Therapy, 30(3), 160172. doi:10.1375/anft.30.3.160.
Bornstein, B. (1945). Clinical notes on child analysis. Psychoanalytic Study of the Child, 1,
151166.
Bornstein, B. (1949). The analysis of a phobic child-some problems of thoery and technique
in child analysis. Psychoanalytic Study of the Child, 3, 181226.
2016 Australian Association of Family Therapy

85

Timothy Rice

Boss, P. (1986). Psychological absence in the intact family: A systems approaches to a study of
fathering. Marriage & Family Review, 10(1), 1139. doi:10.1300/J002v10n01.
Boss, P. (2000). Ambiguous Loss: Learning to Live with Unresolved Grief (1st ed.). Cambridge,
MA: Harvard University Press.
Boss, P. (2006). Loss, Trauma, and Resilience: Therapeutic Work with Ambiguous Loss. New
York, NY: W. W. Norton & Company.
Boss, P. (2007). Ambiguous loss theory: Challenges for scholars and practitioners. Family Relations, 56, 105111.
Bowen, M. (1978). Family Therapy in Clinical Practice. New York, NY: Aronson.
Celano, M., Croft, S., & Morrissey-Kane, E. (2002). Family evaluation clinic: Training psychiatrists to think systemically. Academic Psychiatry?: The Journal of the American Association of
Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 26(1),
1725.
Combrinck-Graham, L. (1988). Family therapy training in psychiatry, in H. Liddle, D. Breunlin, & R. Schwartz (Eds.), Handbook of Family Therapy and Supervision. New York, NY:
Guilford Press. 265277.
Etkin, A., Gyurak, A., & OHara, R. (2013). A neurobiological approach to the cognitive
deficits of psychiatric disorders. Dialogues in Clinical Neuroscience, 15(4), 419429.
Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3898680&tool=
pmcentrez&rendertype=abstract.
Fung, L.K., Akil, M., Widge, A., Roberts, L.W., & Etkin, A. (2014). Attitudes toward neuroscience education among psychiatry residents and fellows. Academic Psychiatry, 38(2), 127
134. doi:10.1007/s40596-014-0034-x.
Guttman, H.A., Feldman, R.B., Engelsmann, F., Spector, L., & Buonvino, M. (1999). The
relationship between psychiatrists couple and family therapy training experience and their
subsequent practice profile. Journal of Marital and Family Therapy, 25, 3141.
Gyurak, A., Gross, J.J., & Etkin, A. (2011). Explicit and implicit emotion regulation: A dualprocess framework. Cognition & Emotion, 25(3), 400412. doi:10.1080/
02699931.2010.544160.
Haley, J. (1979). Ideas that handicap therapy with young people. International Journal of Family Therapy, 1(1), 2945. doi:10.1007/BF00926787.
Harbin, H.T. (1980). Family therapy training for psychiatric residents. The American Journal
of Psychiatry, 137, 15951598.
Heru, A.M., Keitner, G.I., & Glick, I.D. (2012). Family therapy: The neglected core competence. Academic Psychiatry, 36(6), 433435. doi:10.1176/appi.ap.11090160.
Hoffman, L. (2007). Do children get better when we interpret their defenses against painful
feelings? The Psychoanalytic Study of the Child, 62, 291313.
Hoffman, L. (2014). Berta Bornsteins Frankie: The contemporary relevance of a classic to
the treatment of children with disruptive symptoms. The Psychoanalytic Study of the Child,
68, 152176.
Hoffman, L., Rice, T., & Prout, T. (2016). Manual for Regulation-focused Psychotherapy for
Children with Externalizing Behaviors (RFP-C): A Psychodynamic Approach. New York, NY:
Routledge.
Insel, T.R. (2014). The NIMH Research Domain Criteria (RDoC) Project: Precision medicine
for psychiatry. The American Journal of Psychiatry, 171(4), 395397. doi:10.1176/
appi.ajp.2014.14020138.
Johnson, H.C. (1987). Biologically based deficit in the identified patient: Indications for psychoeducaitonal strategies. Journal of Marital and Family Therapy, 13(4), 337348.
doi:10.1111/j.1752-0606.1987.tb00715.x.

86

2016 Australian Association of Family Therapy

Family Therapy Training in Psychiatric Education

Josephson, A.M. (2008). Reinventing family therapy: Teaching family intervention as a new
treatment modality. Academic Psychiatry, 32(5), 405413. doi:10.1176/appi.ap.32.5.405.
Josephson, A.M. (2013). Family intervention as a developmental psychodynamic therapy.
Child and Adolescent Psychiatric Clinics of North America, 22(2), 241260. doi:10.1016/
j.chc.2012.12.006.
Malone, C.A. (1974). Observations on the role of family therapy in child psychiatry training.
Journal of the American Academy of Child Psychiatry, 13(3), 437458.
McDermott, J.F., & Char, W.F. (1974). The undeclared war between child and family therapy. Journal of the American Academy of Child & Adolescent Psychiatry, 13(3), 422443.
Minuchin, S. (1974). Families and Family Therapy. Cambridge, MA: Harvard University Press.
Novick, K.K., & Novick, J. (2013). Concurrent work with parents of adolescent patients. The
Psychoanalytic Study of the Child, 67, 103136.
Pichot, T., & Dolan, Y. (2003). Solution-focused Brief Therapy. New York, NY: Haworth
Press.
Rait, D.S. (2012). Family therapy training in child and adolescent psychiatry fellowship programs. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric
Residency Training and the Association for Academic Psychiatry, 36(6), 448451.
doi:10.1176/appi.ap.11040069.
Rait, D., & Glick, I. (2008). Reintegrating family therapy training in psychiatric residency
programs: Making the case. Academic Psychiatry, 32(2), 7680. doi:10.1176/
appi.ap.32.2.76.
Resnikoff, R.O., & Lapidus, D.R. (1990). Wearing different hats as a family therapist: An
integrated four-phase training model. Academic Psychiatry: The Journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 14(3), 150156. doi:10.1007/BF03341288.
Rice, T.R., & Hoffman, L. (2014). Defense mechanisms and implicit emotion regulation: A
comparison of a psychodynamic construct with one from contemporary neuroscience. Journal of the American Psychoanalytic Association, 62(4), 693708. doi:10.1177/
0003065114546746.
Satir, V. (1964). Conjoint Family Therapy. Palo Alto, CA: Science and Behavior Books Inc.
Slovik, L.S., Griffith, J.L., Forsythe, L., & Polles, A. (1997). Redefining the role of family
therapy in psychiatric residency education. Academic Psychiatry: The Journal of the American
Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 21(1), 3541. doi:10.1007/BF03341895.
Sugarman, S. (1984). Integrating family therapy training into psychiatry residency programs:
Policy issues and alternatives. Family Process, 23, 2332.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of Problem Formation
and Problem Resolution. New York, NY: Norton.

2016 Australian Association of Family Therapy

87