POST-GRADUATE TRAINING OBJECTIVES
IN COUPLE AND FAMILY PSYCHOTHERAPY (Revised/08)
University of Toronto, Department of Psychiatry
Psychotherapy Program, Family and Couple Therapy Subcommittee
I.
PREAMBLE
The teaching outlined in this document is designed to enable residents to integrate psychodynamic,
cognitive and behavioral 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) meet
with the therapist to redefine the causes, the dynamics and the possible solutions to conflicts that have
obstructed 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, through
couple therapy, the dyad discovers their relationship no longer has a basis to reconstruct it. The goal
may then be an amicable separation, where the parties and the children are hurt as little as possible.
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 in
which kith and kin systems are lived and constructed.
Why must residents have some knowledge about couple and family dynamics and therapy?
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Graduating residents will increasingly work in under-serviced areas and may be responsible for
the integrated treatment of their patients, including couple and family problems, with less
possibility of referring to a specialist.
If they go into private practice, they will face an increasing demand for couples that seek help
under OHIP. In Canada, one of three marriages ends in divorce; at the same time, many
individuals remarry and seek help when they feel in danger of repeating mistakes. Blended
families of two divorced individuals with children of previous marriages increasingly seek the
psychiatrist's help, as do gay or lesbian couples with or without children, and couples where one
of 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 the
partner 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, developmental or
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 their
training; ideally they will learn:
• How to assess couple/family structure and dynamics
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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, supervision and the experience of
treating two or three couples or families during one year.
For the third level (becoming a family therapist) the Psychiatrist has to undertake a two or three year
immersion training program in the specialty. The time allotted for couple and family therapy in our
Psychiatric Residency precludes this, yet level two of training is achievable.
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 psychoeducational principles applied to understanding and assessing a couple or
a 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 or
antagonistic and without seeking premature closure in relational issues.
(3)
Combine support and challenge about where problems come from and about how they may be
solved.
(4)
In couple and family assessment interviews, manage and be aware of individual
psychopathology without getting sidetracked by it.
(5)
Regulate the emotion and aggression level of the sessions, balancing them with support and
psychoeducation, so the sessions will not be an overwhelming exercise patients will want to
avoid.
(6)
Regulate the go-between process in family triangles, given that the couple or family, more
frequently 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)
Create a contract for couple or family therapy, without closing the door to other forms of
psychotherapy or to pharmacotherapy.
C.
Attitudes
Residents must acquire:
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(1)
(2)
(3)
(4)
(5)
(6)
Acceptance of and respect for the values in couples and families from different cultures,
different socio-economic strata and in different life cycle stages.
Awareness of the personal prejudices we all have regarding couples and families; prejudices
unavoidably based on our sexual orientation, culture, family background, age, marital status,
and having or not having children or adolescent progeny.
Awareness of how the couple or family perceives the therapist.
Willingness to collaborate with social agencies, for instance when protection is needed
for abused children or adults.
Sensitivity to the fact that the therapist can create resistance by advocating only for one
partner or one family member, neglecting the needs of the other or others.
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 methods
of problem solving.
D. Commitments
(1)
(2)
Theory seminar.
Six sessions of supervised couple or family therapy (1 case)
III.PROFICIENCY TRAINING OBJECTIVES IN COUPLE OR FAMILY PSYCHOTHERAPY
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 some theories, applied to the couple and the family, such as:
i) Systems theory (Constadine, 1986)
ii) Communication theory (Watzlawick et al, 1967)
iii) Developmental life cycle theory (Carter et al, 1980)
iv) Psychodynamic theory, both classical and object relations (Scharffet al, 1987)
v) Cognitive/Behavioral theory (Jacobson et al, 1995)
vi) Sex therapy (Singer, 1987)
vii) Psychoeducation (Falloon et al, 1981)
vii) Divorce therapy (website)
viii) 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.
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(2)
(3)
(4)
(5)
(6)
(7)
C.
The ability to keep redefining goals during therapy, according to its evolution, the obstacles
found and the willingness of the couple or family to continue treatment.
The ability to handle confidentiality issues without breaking the therapeutic alliance with each
system member.
The ability to use the self as a therapeutic tool, with full awareness of how the therapist uses
his/her verbal and non-verbal communication, to support or modify couple or family stances as
the treatment proceeds.
The ability to use supervision to create his/her own therapeutic style.
The ability to perceive when counter-transference is an obstacle to the appropriate technique or
to the therapeutic alliance.
The ability to maintain ethical boundaries between the therapist and the couple or family, in
spite of patients' attempts to blur them.
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 the
patients' motivation, intelligence, patience, culture, socio-economic situation and pathology.
(2)
Patience to allow the time required for the process of working-through, thus avoiding
premature closure of therapeutic challenges.
(3)
Openness to recognize when the therapeutic relationship becomes dysfunctional, and it is
better for all concerned to refer the couple or family to another therapist, or for the therapist to
seek a consultation with a colleague.
D.
(1)
Commitments
Minimum of 2 supervised family or couple cases – each case a minimum of 6 sessions
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REFERENCES AND RECOMMENDED READING
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Bacon. 2002
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Carter E, McGoldrick M: The family life cycle and family therapy: An overview. in Carter EA, McGoldrick M
(eds): The Family Life Cycle. A Framework for Family Therapy. New York. Gardner Press Inc. 1980 p 3-20
Chagoya L, Chagoya C: Training eclectic family therapists. Unpublished manuscript. McMaster University,
1983.
Cleghorn J, Levin S: Training family therapists by setting learning objectives. Am J Orthopsychiat 43:439-446,
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Constadine L: Family Paradigms: the Practice of Theory in Family Therapy. New York-London. Guilford. 1986
de Shazer S, Berg IK, Lipchik E, Nunnally E, Molnar A, Gingerich W, Weiner-Davis M: Brief therapy: Focused
solution development. Family Process 25: 207-222, 1986.
Ehrlich FM: Psychoanalysis and couple therapy. Psych Times 15: #12, Dec 1998
Dickerson V, Simmerman J: A narrative approach to families with adolescents. In Friedman S (ed): The New
Language of Change: Constructive Collaboration in Psychotherapy. New York. Guilford. 1993.
Falloon IR II, Boyd JL, McGill GW, et al.: Family management training in the community care of schizophrenia.
in: Goldstein M (Ed) New Developments in Interventions with Families of Schizophrenics. San Francisco CA:
Jossey-Bass, 1981.
Fisch R, Weakland H, Segal L: The Tactics of Change: Doing Therapy Briefly. San Francisco. Jossy-Bass. 1982
Freeman J, Combs G: Narrative Therapy: The Social Construction of Preferred Realities. New York
WW Norton. 1996
Freeman J, Epston D, Lobovits D: Playful Approaches to Serious Problems: Narrative Therapy with
Children and their Families. New York. WW Norton. 1997
Frelick LF, Waring EM (Eds): Marital Therapy in Psychiatric Practice: An Overview. New York.
Brunner/Mazel Publishers. 1987
Furman B, Ahola T: Solution Talk: Hosting Therapeutic Conversations. New York. WW Norton. 1992
Gottman J: Why Marriages Succeed or Fail. New York-London-Toronto-Sydney-Tokyo-Singapore.
Fireside Books. Simon & Schuster. 1994
Gottman J M: The Marriage Clinic. A Scientifically Based Marital Therapy. New York-London W W
Norton & Co. 1999
Gurman AS, Jacobson NS (eds): Clinical Handbook of Couple Therapy. 3rd. ed. New York-LondonThe Guilford Press. 2002
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Hoyt MF (ed): Constructive Therapies. New York. Guilford Press. 1996
Hubble MA, Miller SD, Duncan BI (eds): The Heart and Soul of Change: What Works in Therapy
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Kadis LB, McClendon R: Concise Guide to Marital and Family Therapy. American Psychiatric
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Miller W, Rollnick S: Motivational Interviewing: Preparing People for Change. 2nd ed New York
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Minuchin S: Families and Family Therapy. Cambridge Mass. Harvard. 1978
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Psychotherapy and the Family 3(4): 15-46, 1988.
Myers Avis J: Where are all the family therapists? Abuse and violence within families and family
therapy's response. Journal of Marital and Family Therapy 18(3):225-232, 1992.
Roth S, Epston D: Consulting the problem about the problematic relationship: An exercise in
experiencing a relationship with an externalized problem, in Hoyt M (ed): Constructive Therapies New
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Satir V: Conjoint Family Therapy. Palo Alto CA. Science and Behavioral Books. 1967.
Scharff DE, Scharff JS: Object Relations Family Therapy. Northvale, New Jersey-London: Jason
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Publishers. 1987.
Tomm K: Interventive interviewing. Part I: Strategizing as a fourth guideline for the therapist. Family
Process 26:3-13, 1987
Tomm K: Interventive interviewing. Part II: Reflective questioning as a means to enable self healing
Family Process 26: 167-184, 1987a
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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interview. Family Process 24: 357-364, 1985
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Whitaker CA, Keith DV: Chapter 6: Symbolic-Experiential Family Therapy, in: Gurman AS, Kniskem
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Websites
http://www.camh.net/about addiction mental health/couple therapy, html
http://www. articles. flndarticles.com/p/articles/mi_mOAZV/is_2_41
http://www.psyc.leeds.ac.uk/research/lftrc/index.htm
Click on Manuals: SFT&TAP
This document was prepared by
Charlotte Chagoya, RN, Fam Ther
Leopoldo Chagoya MD, FRCPC and
Richard Sugarman MSW.
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