Douglas S. Rait

The Therapeutic Alliance in Couples and Family Therapy

The therapeutic alliance is central to couples and family therapy. Although the formal concept of therapeutic alliance has not been used widely within the family therapy field, virtually every prominent clinical theorist has addressed the importance of establishing and maintaining a positive therapeutic relationship with the family. The alliance in couples and family treatment differs from the alliance in individual psychotherapy in that the couples and family therapist must establish and maintain multiple alliances. They also must adopt a conceptual framework that accounts for the interactions within triangles or three-person systems, recognize the influence of the system operating on him or her, and appreciate how different models of family therapy define the position of the therapist in relation to the couple or family. An integrative review of the therapeutic alliance in couples and family therapy is followed by a discussion of problems in the therapeutic relationship. Two general clinical strategies for managing difficulties in the alliance then are illustrated through case vignettes.

Family Therapy Training in Child and Adolescent Psychiatry Fellowship Programs.

ObjectiveThis study describes the current state of family therapy training in a sample of child and adolescent psychiatry fellowship programs.MethodChild and adolescent psychiatry fellows (N=66) from seven training programs completed a questionnaire assessing demographics, family therapy training experiences, common models of treatment and supervision, attitudes about family therapy, and perspectives on clinical training and clinical skill.ResultsFellows ascribed a high degree of importance to family therapy skills, yet most had not seen more than one outpatient family with family therapy supervision during their training. They identified structural family therapy and family psychoeducation as the primary family treatment orientations in their programs.ConclusionAlthough child psychiatry fellows believed that strong family therapy skills would benefit their patients, most had limited supervised experiences with families. Child and adolescent psychiatry training programs appear to offer exposure to family therapy without sufficient opportunities to develop proficiency. The author discusses educational implications for child and adolescent psychiatry.

Reintegrating Family Therapy Training in Psychiatric Residency Programs: Making the Case

ObjectiveGiven the marginalization of couples and family therapy in psychiatric residency programs over the past two decades, the authors propose a rationale for the reintegration of these important psychosocial treatments into the mainstream of general psychiatric residency education.MethodsAfter reviewing recent trends in the field that call for a more prominent role for couples and family therapy in residency training, the authors summarize the literature on family therapy training in psychiatry over the past four decades.ResultsBecause biopsychosocial systemic thinking provides a powerful framework for looking at multiple levels of systems and their interrelationships, developing a strong family-systems perspective and acquiring basic “family skills” represent the minimum requirement for general psychiatric training. The authors argue for the addition of couples and family therapy to the five required psychotherapy competencies defined by the residency review committee in psychiatry.ConclusionA rationale for a family-systems training model is proposed with the objective of encouraging residency programs to integrate the family-systems model more fully into their curricula.

A Model for Reintegrating Couples and Family Therapy Training in Psychiatric Residency Programs

ObjectiveThe authors propose a family-systems training model for general residency training programs in psychiatry based on the couples and family therapy training program in Stanford’s Department of Psychiatry and Behavioral Sciences.MethodsThe authors review key elements in couples and family therapy training. Examples are drawn from the family therapy training curriculum in a general psychiatric residency program.ResultsConceptual and practical skills taught over the span of a psychiatric residency training program are described, focusing on: joining with the couple or family; seeing systemic patterns, recognizing the family’s developmental stage, history, and culture; identifying family structure; and intervening systemically.ConclusionThis family-systems training model can serve as a resource for residency programs interested in integrating the couples and family therapy model more fully into their curricula.

The Impact of Postgraduate Health Technology Innovation Training: Outcomes of the Stanford Biodesign Fellowship

Stanford Biodesign launched its Innovation Fellowship in 2001 as a first-of-its kind postgraduate training experience for teaching biomedical technology innovators a need-driven process for developing medical technologies and delivering them to patients. Since then, many design-oriented educational programs have been initiated, yet the impact of this type of training remains poorly understood. This study measures the career focus, leadership trajectory, and productivity of 114 Biodesign Innovation Fellowship alumni based on survey data and public career information. It also compares alumni on certain publicly available metrics to finalists interviewed but not selected. Overall, 60% of alumni are employed in health technology in contrast to 35% of finalists interviewed but not selected. On leadership, 72% of alumni hold managerial or higher positions compared to 48% of the finalist group. A total of 67% of alumni reported that the fellowship had been “extremely beneficial” on their careers. As a measure of technology translation, more than 440,000 patients have been reached with technologies developed directly out of the Biodesign Innovation Fellowship, with another 1,000,000+ aided by solutions initiated by alumni after their training. This study suggests a positive impact of the fellowship program on the career focus, leadership, and productivity of its alumni.

Primary treatment approaches in child and adolescent psychiatry training.

The Accreditation Council for Graduate Medical Education requires that child and adolescent psychiatric fellows acquire skills in a range of treatment modalities. However, little is known about what models of treatment are being provided to child and adolescent psychiatry fellows in their training. This study reports on the primary treatment approaches described by fellows (N566) in seven child and adolescent psychiatry fellowship programs. Requirements for the Accreditation Council for Graduate Medical Education (ACGME) in Child and Adolescent Psychiatry stipulate that fellows must have “clinical experiences with children and adolescents for the development of conceptual understanding and beginning clinical skills in major treatment modalities, which include brief and longterm individual therapy, family therapy, group therapy, crisis intervention, supportive therapy, psychodynamic psychotherapy, cognitive-behavioral therapy, and pharmacotherapy” (1). Nevertheless, our knowledge about the treatment approaches currently taught in child and adolescent psychiatry training programs is limited. Two older studies examined common treatment modalities in child psychiatry training. Stubbe (2) surveyed early career graduates of child and adolescent psychiatry fellowships and looked at their training and its relevance for their present positions in five outpatient treatment approaches: outpatient therapy, cognitive-behavioral therapy, family therapy, group therapy, and school consultation. In a sample of child and adolescent psychiatry trainees in the U.K., Smart and Cottrell (3) found systemic, biological, behavioral, cognitive-behavioral, and psychodynamic therapies to be common treatment orientations. Both of these studies considered only a subset of the educational experiences offered in most child psychiatry training programs. Child and adolescent psychiatry fellowship programs likely select treatment emphases that are influenced by accrediting bodies, outcome research, practice guidelines, faculty interests and availability, popular clinical trends, and the preferences of training directorswho shape their curricula:

A Family-Systems Approach to the Patient with Cancer

AbstractThe assumption that family relationships play an important role in the care and well-being of the cancer patient may be overlooked simply because it is so universal. Patients live in families, become sick in families, and receive medical care in families. Indeed, as Griffin (1) has noted, almost all medical treatment eventually becomes the obligation of family members: