New Idea

Toward a New Alliance: Psychiatric Residents and Family Support Groups

James G. Barbee, M.D. Agnes M. Kasten, M.A., M.LS. Marilyn K. Rosenson, M.S.W.

In an attempt to assess the status of residency training in psychoeducational approaches for families of chronically ill patients, the authors conducted a national suroey of u.s. res-idency training programs. Responses from 154 programs (75%) indicated a wide varia-tion in time allotted, activities, and participants in such training among the respondents. Less than 50% of the programs indicated formal involvement of family support groups such as the National Alliance for the Mentally III (NAMI) and the National Depressive and Manic-Depressive Association (NDMDA). The authors describe a program they have initiated that incorporates organized family support groups in such training efforts.

I n what one author has referred to as the "debacle of deinstitutionalization" (1),

large numbers of chronically mentally ill pa-tients have been released back into the com-munity since the 1950s. Recent estimates are that almost 40% of these patients live with their families (2) and that 49%-66% of pa-tients discharged from the hospital after acute stays return to live with their families (3). In a home atmosphere that has been described as a "daily quandary" (4), families must often assume active roles in the "clini-cal" management of their "patients," attend-

Dr. Barbee is an Associate Professor in the Depart-ment of Psychiatry, School of Medicine, Louisiana State University, New Orleans, Louisiana. Ms. Kasten, a Clin-ical Instructor in the LSU Department of Psyciatry, is the founder of the New Orleans chapter of the National Depressive and Manic-Depressive Association. Ms. Rosenson, a Clinical Instructor in the LSU Department of Psychiatry, is a member ofthe Curriculum and Train-ing Network of the National Alliance for the Mentally Ill. Address reprint requests to Dr. Barbee, Department of Psychiatry, 1542 Tulane Avenue, New Orleans, LA 70112.

Copyright © 1991 Academic Psychiatry.

ing to such issues as medication compliance, social behavior, and even violence.

Given an environment in which larger numbers of chronically ill patients are cared for in the community, often by families, it is imperative that residency training programs in psychiatry prepare clinicians to address these patients' needs. In decrying the na-tional shortage of psychiatrists interested in treating the chronically mentally ill, Nielsen et at. (5) have pointed out that" guilt, rational argument, consciousness-raising, and pub-licity are relatively unlikely to turn the tide of neglect of chronic patients. A more pow-erful tool is medical education and, specific-ally, the psychiatric residency." Focusing on training deficits, the Committee for Psychia-try and the Community of the Group for the Advancement of Psychiatry (GAP) has called for changes in residency programs to prepare young psychiatrists to work effec-tively with seriously mentally ill patients and their families. Given that 79% of residen-cies in the United States utilize community care settings in their programs (6), it seems clear that simple exposure is not enough.

Minkoff and Stem (7), in their review, high-light the multiple issues that discourage res-idents in their work with chronic patients.

Psychoeducational approaches to the care of the chronically mentally ill offer an

TABLE 1. A national swvey of family support group training programs in U.S. psy-chiatric residencies

Total number of swveys distributed 205 Total number of swveys returned 154 Residency programs discontinued 1 Residency programs consisting of one-year

programs only (no responses forwarded) 2

1) Does your program formally expose residents to training in psychoeducational approaches to families of the chronically mentally ill?

Yes 111 No 40

2) U yes, is this done through (please check all relevant categories):

Didactics 106 Clinical conferences 92 Assigned reading 61

Please estimate the total number of hours during the residency allotted to such exposure in the formal curriculum:

No response given 18 Positive responses 93 Average time, hrs 12.2-

3) Does your program formally arrange for con-tact between residents and family support groups, such as the National Alliance fOT the Mentally Dl (NAMI) or the National Depres-sive and Manic-Depressive Association (NDMDA)?

Yes 60 No 82 Informally 9

Specific Groups Involved NAMI 51 NDMDA 9 Mental health centers 4 Narcotics Anonymous/

Alcoholics Anonymous 3 4) Have any residents in your program ever taken

an active part in advocacy efforts by educating and forming coalitions with families?

Yes 40 No No response

-See adjustment noted in text.

107 4

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innovative supplement to traditional treat-ment techniques. Successful outcome is measured in the overall enhancement of the quality of life for the patient and his or her family. In follow-up studies, such tech-niques are found to be effective in prevent-ing relapse (8,9). Training in the education of families is routinely incorporated in most of the model programs that have been sug-gested for residents working with chronic patients (10-12). Such training is very much in keeping with the desires of families of individuals with schizophrenia, for whom knowledge about the illness was the most frequently mentioned need in an oft-cited survey (4).

This report explores how psychiatric residency training programs are meeting the GAP recommendations to prepare trainees to work with families and demonstrates how support groups can be involved. We will present the results of a national survey we recently conducted in order to assess the status of psychoeducational training in ac-credited programs, and, specifically, the ex-tent to which groups such as the National Alliance for the Medically III (NAMI) and National Depressive and Manic-Depressive Association (NDMDA) currently participate in these programs. We will then describe a program for residents that we have initiated locally that relies on collaboration with these organizations for its success.

PSYCHOEDUCATIONAL APPROACHES IN RESIDENCY

TRAINING: A NATIONAL SURVEY

To assess the current status of residency training in psychoeducational approaches, we conducted a survey in the winter of 1989. Questionnaires were mailed out to all of the 205 currently accredited programs in the United States listed in the directory pub-lished by the American Medical Association (13). One hundred fifty-four surveys were returned for a total response rate of 75%. Items as they appeared in the questionnaire

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are listed in Table 1 with a tabulation of responses in each category.

Seventy-four percent of the respondents include in their programs formal exposure to psychoeducational techniques in working with families of the chronically mentally ill. When such training is provided, it is often accomplished through didactics and clinical conferences, accompanied by assigned read-ing in about one-half of the cases. Of the programs that listed the number of hours devoted to such topics in the 4 years of train-ing, the average is 39.6 (range: 0-1,000 hours). However, this figure is misleading, as there are five programs that list responses in this category in excess of 100 hours. Ex-cluding these programs, the adjusted aver-age is 12.2 hours.

Less than one-half of the responding programs expose their residents to formally organized groups, such as NAMI or NDMDA. Among these organizations, NAMI is clearly the most widely involved, perhaps due to its large membership and widespread organization.

Answers to the fourth inquiry reflect confusion about the exact meaning of "advo-cacy efforts." Twenty-six percent of the pro-grams responded that residents take part in such efforts, although the bulk of the an-swers to the follow-up question, "If yes, what did the residents do?" list such activi-ties as attendance or presentation at support group meetings or participation in family groups. Two programs (the University of Florida, Gainesville and the Sinai Hospital of Detroit) stated that individual residents have become involved in lobbying efforts with state legislators on behalf of the chron-ically mentally ill.

Of the programs listing innovative tech-niques to facilitate contacts between resi-dents and families, the most frequently mentioned activity (18 responses) was that of resident participation in inpatient/ out-patient-based clinical programs that use a psychoeducational approach. Twelve re-spondents mentioned that residents attend

NAMI or NDMDA meetings as observers, group leaders, or speakers. Nine mentioned resident participation in multi-family groups, and seven mentioned departmental conferences that include presentations by NAMI/NDMDA members. In three pro-grams residents use educational videotapes with families; two of the three specifically mentioned a set of videotapes for educating parents of patients with major mental illness prepared by Robert Liberman at UCLA. Two program directors stated that NAMI mem-bers routinely attend their courses in com-munity psychiatry. Interestingly, only one program includes a structured didactic course for residents in psychoeducational methods. If accurate, this is a puzzling omis-sion in view of the strong recommendation by expert educators who note that clinicians, as teachers of psychoeducational ap-proaches, must be taught how to teach (14). Finally, one program (Oregon State Hospi-tal) was just beginning a pilot project, in which each first-year resident would be as-signed a family to follow as a "friend and advocate" throughout the remainder of training.

In summary, our survey yield suggests several trends. A healthy majority of re-sponding programs do include training in psychoeducational approaches, although the average time devoted to such training, with few exceptions, seems relatively small. Interestingly, organized family support groups are involved in these efforts in less than one-half of the programs, and only one program provides training in educational techniques.

A MODEL PROGRAM FOR INCLUDING FAMILY SUPPORT

GROUPS IN RESIDENT TRAINING

K. F. Bernheim has emphasized "sensiti-zation to the plight, burden, and tasks of families" as the first issue in training profes-sionals about psychoeducational approach-es (14). The psychoeducational training

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program that we have established as part of the Louisiana State University (lSU) psychi-atry residency actively involves interested, informed family members who participate in NAMI and NDMDA in the education of our residents. We believe the particular value of our program is in building bridges of communication and empathy between residents and families. The lSU program has evolved over the last 5 years and currently consists of two primary components: 1) res-ident attendance at evening meetings of community support groups and 2) encoun-ter sessions between residents and family members from NAMI and NDMDA. These activities supplement (rather than replace) the didactic and clinical training experiences in family therapy required in other portions of the residency.

Community Support Groups

Our national survey found 12 other pro-grams that involve residents as lecturers, rap group facilitators, or discussion leaders at local support group meetings much as we do. An example from our experience will indicate the potential benefits to be gained from interactions between residents and families at such community meetings.

A resident serued as facilitator for a family rap session at a local NDMDA affiliate meeting. One woman, who initially voiced concern about the mental stability of family members, began to talk about her suspicions regarding their illegal activities. Not recognizing that the woman was paranoid, a group member advised her to con-sult a lawyer. The resident skillfully steered the conversation in another direction, helping the disturbed woman to voice her fears, open up about her own past diagnosis of serious depres-sion, and agree to go back to her psychiatrist for help. In the social period after the session, group members said they had gained insight about handling a paranoid person by watching and listening to the resident psychiatrist.

Participation in family support groups is available to residents on a volunteer basis

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during the second through fourth years of training. Approximately one-third of our residents have elected to participate, many at multiple points during their training. One of us (A.M.K.) coordinates the scheduling with the family groups, while as training director, another of us (J.G.B.) provides the administrative support for this elective. All meetings are held in the evenings when fam-ilies and residents can be available.

Encounter Groups

Incidents like the one described above might occur whenever residents are in-volved in group meetings, but residents are unlikely to gain the experience of the second component of our program, the encounter groups, elsewhere in their training. The au-thors are indebted to Dr. Charles Goldman of the University of South Carolina for the role-playing technique in such encounters, described below.

The encounters occur in two sequential meetings scheduled in lieu of Departmental Grand Rounds 4 weeks apart, once each year. Our program has been small enough that all residents at all levels can attend the meetings simultaneously. Approximately 2~25 residents meet with 8-10 family mem-bers from 5 or 6 families selected by the co-authors, who serve as contacts to NAMI (M.K.R.) and NDMDA (A.M.K.). To date, this group size has been manageable, al-though the continued growth of our pro-gram will likely limit attendance in the future to first- and second-year residents. Such a choice is based on our observation that although junior residents tend to be ini-tially timid and reluctant to participate in the group process, they are more "trainable" and more likely to incorporate these experi-ences into their professional world view.

Each of the two sessions is 90 minutes long. The first has no formal structure other than initial introductions and an opening statement of goals. The group leader tells residents and patients' families that the ses-

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sion hopes to provide a forum for an ex-change of views on issues of mutual concern and to use this process to see each other as individuals, rather than as stereotypes of "physicians" or "family members."

This latter goal is important in preparing the two groups for participation in the sec-ond meeting, which tends to be more threat-ening. This session uses the clinical vignettes listed in Table 2 as creative stimuli for dis-cussion. As suggested by Dr. Goldman, the roles of family member and psychiatrist in the vignettes are reversed, with residents acting as family members and family mem-bers acting as psychiatrists. Other than the suggestion that they parrot their experiences in contacts from the past as closely as possi-ble, no other instructions are given. Each vignette is then acted out for approximately 5-10 minutes and is followed by 1(~20 min-utes of general discussion. In the list that follows, we summarize some of the major themes for residents and families that have emerged from this process.

THE RESIDENT'S PERSPECTIVE

1. Reconceptualizing the major psychiatric dis-orders as "no-fault" illnesses. In years past, families were regarded as the "cause" of major psychiatric disorders in a variety of theoretical models seeking to explain these illnesses. With recent biological advances, it has become clear that the influence of the family or particular family members does not explain the etiology of these disorders, although the family environment certainly is a factor in shaping their outcome. Through the psychoeducational model, this influence can be used in a very positive way to favor-ably affect prognosis. Residents may have difficulty in reframing their expectations of the family from that of being a cause of the patient's problems to that of being a poten-tial ally in treatment. Some family members (particularly parents) are quite sensitive to the issue of ''blame'' for the illness, based upon prior experiences with medical profes-

TABLE 2. Case vignettes

1. A young woman with a past history of para-noia is brought to the hospital emergency room. In the last week, she had begun to believe that a fellow employee was picking on her, and after an argument with the person earlier that morn-ing at work, she was fired. She then went home, threatening to commit suicide.

2. A 19-year-old man who has been hospitalized twice for hearing voices is brought in to the emergency room by police. He had gotten into a fight with his younger brother over the televi-sion, and his sister had been hit while trying to break up the fight. He has been prescribed Haldol in the past, but refuses to take it because "my family is the one with the problem."

3. A 28-year-old woman is brought to the emer-gency room by police for "trespassing." She re-fuses to give any history but is obviously hearing voices. She also initially denies she has any relatives in New Orleans but later admits she does and agrees that they may be contacted for further information. When called, the family states that they have been trying to locate her for weeks and requests that the patient be com-mitted; the young woman demands that she be discharged immediately.

4. A psychiatrist has just completed a session with a paranoid woman. Upon exiting the office, the patient's husband walks up to the psychiatrist and demands to know if the patient has been taking her medication. The patient has pre-viously requested during a private session that the psychiatrist not disclose any information to anyone in her family.

sionals. This issue arose in a heated ex-change between family members and resi-dents during the discussion after a role play with the first vignette.

The residents who were role playing the two parents chose to present a split over the issue of the nature of their daughter's problem. The patient's mother was portrayed as believing the patient was merely having "hormone trouble," while the patient's father believed she was "sick" and should be hospitalized. In the discus-sion that followed the role play, two real-life parents spoke movingly about the angry rift that initially opened up between them as the wife struggled with the fear of having "caused" their child's illness. In the ensuing discussion, one resident stated he felt that families could precipitate a relapse in their patients. Family

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members in the group were indignant, with one mother angrily exclaiming that they were voic-ing the "old attitude of blame the family." One resident countered by pointing out that it was clear that the environment affected the course of many illnesses, including diabetes, hyperten-sion, etc. "Why not schizophrenia?" he asked. At this point the tension in the room relaxed considerably.

2. Understanding the family's perspective. Particularly in the early phases of accepting an illness, family members may be angry and frustrated as they attempt to understand what has occurred. In their confusion, fami-lies may feel hopeless or demoralized about the future. Participation in the groups facili-tates an empathic bond between residents and families, emphasizing the rewards available for all who participate in efforts at rehabilitation.

At the beginning of the first session, which was unstructured, one of the psychiatrists asked one of the families "What are your frustrations with psychiatry?" The families, who at first had been reluctant to speak, responded in a torrent of feel-ing. One mother accusingly replied "You can't cure my son. There's no letup, no future."

3. Appredating the family's view of the mental health system. As care-giving participants in the mental health system, residents may be unaware of how the system is experienced by those on the receiving end-families and their patients. The complexity (and, at times, inadequacy) of the mental health system may leave its consumers feeling ignored and alienated. Even when care and support are offered, families may be paralyzed by their own confusion and thus unable to respond. In the environment of the groups, residents and families can share their mutual concerns about working effectively together within the health care system.

In the initial session, the families had begun talking about their feelings of helplessness in dealing with a chronic illness. This led to a dis-cussion of the mysteries and misconceptions at-tendant on diagnostic labels. One mother stated

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"We got hit with the diagnosis 'paranoid schizophrenia' and all of our misunder-standing about what the term meant. It took 3 or 4 years before I started to under-stand it ... someone did try to discuss it with me, but I was so upset it went in one ear and out the other."

4. Gaining insight into families' lack of knowl-edge about mental illness. As illustrated in the example above, clinicians are likely to use diagnostic labels without appreciating that their implications may not be understood by families. In particular, it may be surprising to residents to learn how little families know about prognosis and how vital this informa-tion can be to the family in its attempt to accommodate a member with a major men-tal illness.

5. Providing the opportunity for ventilation of shared insecurities among the residents. While the limitations and frustration of working with chronic patients are obvious to season-ed psychiatrists, residents (particularly at ju-nior levels) may fail to realize that their own feelings in this regard are acceptable and manageable. Typically, these sessions pro-vide an opportunity for residents to express their insecurity and find that others share these feelings, yet function effectively.

6. Developing a greater self-awareness of "blind spots." One of the difficulties facing a resi-dency director is that of motivating trainees. Encountering families in a relaxed, inter-active setting seems to provoke a more criti-cal self-awareness by residents of their training needs as evidenced by the following example.

One of the residents said "I don't really know what to tell families about the illness and how to interact with patients. I know about high EE [expressed emotion], but I don't know what you're supposed to do with it."

7. Obtaining exposure to and interacting con-structively with many "types" of families in a

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single setting. Residents may tend to stereo-type families, lacking appreciation of the enormous variation in the "personalities" of families. In the groups, residents are able to see that even family members who at times are quite hostile are clearly committed to the care of their "patients."

One interesting issue that has been raised by residents is their belief that families who join family support groups are not typ-ical of the "real" families whom they treat. A study recently reported by c.R. Goldman and S.P. Norton at the 1989 NAMI Conven-tion compared families belonging to NAMI with a sample of non-member families drawn from a community mental health cen-ter. NAMI member families were more likely to be white, educated, employed, have higher incomes, and have their mentally ill relative residing in psychiatric hospitals or other unspecified living situations than non-member families, who were more likely to have their ill relative living in their home. Non-member families were often unaware of the existence of family support groups, and the authors conclude that professionals can be helpful by providing information to such families about self-help groups.

8. Learning not to overgeneralize. Partici-pants in our group sessions included par-ents, spouses, siblings, and children of patients. The issue of differences in perspec-tive was made clear by the variation in pri-orities expressed by different family members.

9. Expressing discomfort about giving "advice" as therapists. In psychodynamically ori-ented therapies, solicitation of advice by pa-tients is explicitly (and appropriately) seen as a therapeutic issue, ripe for interpretation. Residents may feel uncomfortable in making the theoretical shift from a psychodynamic to a psychoeducational model.

As described previously, the two residents act-ing out vignette #1 presented a parental pair

split over the source of their daughter's trouble. A family member, acting in the role of the psy-chiatrist, told the pair of "parents" that their daughter should "get a job." During the ensu-ing discussion, one of the residents voiced her discomfort as a professional at the idea of telling someone directly to "get a job."

THE FAMILY'S PERSPECTIVE

Although the primary learners in these ses-sions were the residents, there were some unexpected but clear-cut benefits to the par-ticipating family members. While the les-sons for the family members overlap those of the residents, there are important differ-ences related to the different backgrounds, levels of medical sophistication, and vantage points in the mental health care system of families and residents. The benefits to the families include the following:

1. Facing the issue of "blame." This dynamic is probably the most sensitive and poten-tially divisive matter separating residents and families. Judging from the amount of affect generated among families, it is a prob-lem which, sadly, has not been completely resolved in most family members' minds, even those who have a thorough grounding in recent biological concepts about mental illness. Understandably, this is an issue to which parents of chronic patients are partic-ularly vulnerable.

One derivative of the anger and frustra-tion engendered by the sense of blame is the often hostile reaction of many family mem-bers to the concept of "expressed emotion" influencing the course of illness. In the ear-lier vignette, the resident's comparison of the effects of the interpersonal environment upon schizophrenia as being similar to the effects on other chronic non-psychiatric illnesses set the stage for viewing constructs such as "expressed emotion" as having the potential to guide therapeutic interventions in which family members can be agents for positive change.

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2. Discovering that "psychiatrists are people too." Family members often have certain magical expectations of omnipotence on the part of physicians, perhaps because there is potential comfort in such beliefs given the uncertainty and fear surrounding chronic mental illness. Although there may be some short-term relief in such expectations, the inevitable disappointment that follows the experience of repeated hospitalizations or incomplete symptom control can be hard to bear. We believe it is important for both groups to realize that the disappointment is shared-an acknowledgement that can serve to strengthen the therapeutic alliance to the benefit of all concerned.

3. Realizing that families have valuable in-sights. Another derivative of such idealized expectations that may appear in families is the belief that residents somehow learn ev-erything that they need to know through processes that are completely disconnected from anything that families have to offer. Families learn that their feedback to the phy-sician about the patient's prodromal symp-toms, community functioning, medication compliance, etc. is an important component of the treatment process, and that their expe-rience and insight can be a valuable resource for training physicians.

4. Getting a chance to "tell it like it is" to a supportive audience of physicians. In view of the insecurity and doubts that family mem-bers face in coping with chronic mental ill-ness, it is no surprise that they are often angry, sensing that very few people under-stand the burdens they feel. These feelings are compounded by experiences between families and psychiatrists in which the doc-tor has been perceived as distant, insensitive, or indifferent. Such contacts foster stereo-types that in turn lead to further alienation and anger, thus perpetuating the cycle the next time the clinician is faced with a hostile family member. Participation in the group training sessions provides an opportunity

for ventilation by family members and ac-knowledgement of their burden by the psy-chiatrists.

5. Acknowledging the limits of confidentiality. From our experience, families feel caught between the need to participate as a part of the treatment team and sensitivity about confidentiality between therapist and pa-tient. Our training sessions gave families the opportunity to discuss these issues. The problem of confidentiality is particularly thorny when the patient explicitly states that information is not to be shared with family members.

A role-play exercise using vignette #4 led to a discussion about confidentiality. One resident defended the concept of confidentiality, point-ing out that family members did not always have the best interests of family members at heart when requesting information. A mother of a schizophrenic patient exclaimed with sur-prise "1 thought every family member wanted the best for their patient. It's hard for me to be-lieve there are families that don'tl" Several fam-ily members subsequently expressed disbelief that the legal construct of confidentiality in-cludes such caregiving essentials as diagnosis, information about medications and their possi-ble side effects, and management guidance. They saw this kind of sharing as quite different from privileged patient/physician confidences.

Too often it is forgotten that the privi-lege of confidentiality rests with the patient. When the psychiatrist explains the benefits to be derived from educating family mem-bers about their illness, the patient usually welcomes such family involvement (15).

DISCUSSION

Several issues regarding the structure of our training sessions merit comment. The first is the use of role playing, and, particularly, the device of switching roles between residents and family members. We have found that role playing is a far more stimulating and provocative exercise than the unstructured

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encounters. The level of affective intensity is heightened in the role-play sessions, partic-ularly during discussions of "blame." The initial unstructured encounters seem neces-sary to get the residents and families com-fortable enough with each other to work creatively in role-playing sessions.

One may question the lack of inclusion of patients in these activities. We feel that their absence allows both residents and fam-ily members to be frank in their expression of views. In addition, Terkelsen suggests that a schizophrenic patient's presence in family sessions affects the functioning of the other family members (16). He found that when the patients were absent, "Parents were clearer in their thinking, more able to develop as an executive subsystem, and manifested increased healthy self-interest."

As is clear from our survey, the need for training in psychoeducational approaches to treat the chronically mentally ill is widely perceived. The process of working with fam-ilies within the framework of psy-choeducational techniques, in which the core symptoms of illness are no longer the sole targets for intervention, offers new hope in the treatment of chronic mental illness. Trainees can be taught to reframe the role of the family from that of a problem to that of a resource for the patient and the psychia-trist.

Nationally, current efforts to teach psy-choeducational techniques in residency ap-pear disorganized, as evidenced by the wide

References

1. Torrey EF: Surviving Schizophrenia: A Family Man-ual, 2nd Edition. New York, Harper and Row, 1988

2. Lefley HP: Training professionals to work with fam-ilies of chronic patients. Community Ment Health J 1988; 24:338-357

3. McElroy EM: The beat of a different drummer, in Families of the Mentally ill: Coping and Adaptation. Edited by Hatfield AB, Lefley HP. New York, Guilford, 1987

4. Hatfield AB: The family as partner in the treatment of mental illness. Hosp Community Psychiatry 1979; 30:338-340

variations in program design reported in our survey. We recommend the systematic in-clusion of family members from groups such as NDMDA and NAMI as participants in the training program of psychiatric residents and cite our positive experience with two such group-training techniques. We believe that such training results in substantial gains in residents' understanding of families, with a minimal investment of curriculum time.

Involvement of organized support groups as trainers facilitates access for resi-dents to family members who are highly motivated and particularly dedicated to the care of their mentally ill relatives. Character-istically, such families are at an advanced stage in the process of accepting the illness and are therefore eager to obtain help from others. Resident exposure to such families challenges stereotypes about patients' fami-lies and, hopefully, raises the expectation that collaboration is possible with other fam-ilies, no matter how difficult the illness. For the families, such training sessions engender a better understanding of psychiatrists as professionals and as people involved in pa-tient care that can be both rewarding and frustrating. By participating in these group-training sessions, families and psychiatrists can learn that, although they have different roles, they are interdependent allies in defin-ing the best possible future for the chronic patient and, ultimately, for themselves as well.

5. Nielsen AC, Stein LI, Talbott JA, et al: Encouraging psychiatrists to work with chronic patients: oppor-tunities and limitations of residency education. Hosp Community Psychiatry 1981; 32:767-775

6. Faulkner LR, Eaton JS: Administrative relationships between community mental health centers and aca-demic psychiatry departments. Am J Psychiatry 1979; 136:1040-1044

7. Minkoff K, Stem R: Paradoxes faced by residents being trained in the psychosocial treatment of pe0-ple with chronic schizophrenia. Hosp Community Psychiatry 1985; 36:859-864

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8. Falloon IRH, Boyd JL, McGill CW: Family Care of Schizophrenia. New York, Guillord, 1984

9. Hogarty GE, Anderson CM, Reiss OJ, et al.: Family psychoeducation, social skills training. and mainte-nance chemotherapy in the aftercare treatment of schizophrenia, I: One-year effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry 1986; 43:633-642

10. Factor RM, Stein U, Diamond RJ: A model commu-nity psychiatry curriculum for psychiatric residents. Community Ment HealthJ 1988; 24:310-327

11. Mayo J, Gabel R, Carva1lis R: Planning for the future in psychiatric training: the place of the chronic care program. Compr Psychiatry 1982; 23:1-8

12. White HS, Bennett MB: Training psychiatric resi-dents in chronic care. Hosp Community Psychiatry

1981; 32:339--343 13. American Medical Association: Directory of Gradu-

ate Medical Education Programs. Chicago, Ameri-can Medical Association, 1989

14. Bernheim KF: Family consumerism: coping with the winds of change, in Families of the Mentally ID: Coping and Adaptation. Edited by Hatfield AS, Lefley HP. New York, Guillord, 1987

15. Bernheim KF, Lehman AF: Teaching mental health trainees to work with families of the chronic men-tally ill. Hosp Community Psychiatry 1985; 36:1109-1111

16. Terke1sen KG: Schizophrenia and the family, II. Ad-verse effects of family therapy. Fam Process 1983; 22:191-199