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Family Systems Consultation:
Opportunities for Teaching
in Family Medicine
Susan H. McDaniel, Ph.D., Thomas Campbell, M.D.,
Lyman C. Wynne, M.D., Ph.D., and
Timothy Weber, Ph.D.
Family-systems
consultation offers opportunities to teach
residents
basic concepts and relevant skills for working with families in
family medicine. The application of systems theory to the con-
sultation process helps clarify the role of the consultant-teacher
in relation to the patient or family and the consultee-practitioner.
Residents are able to gain experience interviewing and assessing
families from their own practices with immediate feedback and
assistance
from the consultant. Supervision is distinguished from
consultation in that the supervisor-teacher retains primary re-
sponsibility for the initiation, decision making, and management
of
clinical
care; the consultant-teacher eschews taking these re-
sponsibilities from the consultee while providing recommenda-
tions and performing
selected
functions on behalf of the consultee.
As residents progress through residency and improve their skills,
the teacher's role shifts from supervision to consultation and res-
idents assume more responsibility and autonomy. We present our
model and procedure for family-systems consultation, provide a
method for its evaluation, and
illustrate
it with a
clinical
example.
One of the challenges of teaching about the family in family medicine,
especially at the graduate level, has been to translate family-systems concepts
and principles into easily understandable, usable skills that are clinically
Susan H. McDaniel, Ph.D., is associate professor of Psychiatry and Family Medicine; Thomas Campbell,
M.D., is assistant professor of Family Medicine and Psychiatry; and Lyman C. Wynne, M.D., is professor
of Psychiatry at the University of Rochester, School of Medicine and Dentistry, Rochester, NY. Timothy
Weber, Ph.D., is a family therapist in private practice at the Colorado Center for Psychology, Colorado
Springs, CO.
Family Systems Medicine,
Vol.
6, No. 4,1988
©
FSM,
Inc.
391
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
392
Family
Systems
Medicine,
Vol.
6, No. 4,
Winter 1988
relevant
and
useful
to
primary care.
The
richest
and
most obvious vehicle
for this teaching
is the
true-life clinical situation.
It is in
clinical practice that
family-systems theory stops sounding impractical
or
esoteric
and
begins
to
make important contributions
to
patient diagnosis
and
treatment.
The con-
sultation format offers
an
important tool
for
teaching about
the
family
in
family medicine
in the
clinical context.
Consultation
has a
long tradition
in
both medical treatment
and
medical
education. However,
the
role
of a
consultant, particularly
in the
teaching
setting,
has
been somewhat ambiguous with regard
to the
limits
of his or
her responsibility versus that
of the
resident. This article will apply
the
concept
of
systems consultation
(14) to the
endeavor
of
teaching about
the
family
in
family medicine with
the
goals
of
clarifying
the
role
of the con-
sultant-teacher
and
proposing
a
relevant format
for
teaching family systems
medicine.
PRINCIPLES
OF
SYSTEMS CONSULTATION
Many consultation models have been proposed
in
medicine
(8, 9), psy-
chology
(3), and
business
(1).
Recently, Wynne, McDaniel,
and
Weber
(14)
developed
a
systems consultation model that recognizes
the
multilevel
sys-
Ecosystem
/
/
Community
/
Agencies
1
\
Practitioner
\
Consultee
\
Legal
\
Systems
Educational
Systems
Family Systems Consultant
A
/ Consultative
\
/ Systems
\
/
X
Social
«^_^ Networks ^__^-
\
Medical
Specialists
Other
\
Medical
\
Care
\
Providers
••patient/
Family
Extended /
Family /
Figure
1. The
Systems Consultation Model
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Family Systems
Consultation 393
terns inherent in any consultation. In this article, we will focus on family-
systems consultation rather than on organizational systems consultation,
because our focus is teaching clinical skills relevant to patient care. Applied
to teaching within family medicine, the family-systems consultation model
seeks to clarify role relationships with the goal of increasing productive
collaboration among the family consultant, the practitioner-consultee, and
the patient or family. This application of systems theory to the consultation
endeavor encourages using consultation for family evaluation, treatment
planning, and reviewing the progress of treatment. It gives special emphasis
to clarifying the role of the consultant as part of the consultation system
rather than focusing only on the family or family-consultee interaction, as
advocated by other models. In addition to this tripartite consultative system,
other professionals and community agencies need to be taken into consid-
eration when a network of systems extends beyond these core participants
(Figure 1). The dyadic teaching relationship can fit comfortably into the
triadic consultative relationship as long as roles and lines of authority are
clarified.
A family-systems consultation offers a resident the opportunity to assess,
interview, and treat a family with input and feedback from the consultant
teacher. Consultation also offers the educational and clinical opportunity
to review the involvement of multiple caretakers and their diverse ideas and
intentions in relation to a distressed family or a family with some medical
illness. Finally, consultation can help the resident-consultee to focus on fam-
ily and community strengths so these resources are used in the most re-
spectful, efficient, and cost-effective way.
SUPERVISION VERSUS CONSULTATION
Considerable confusion exists about the roles of supervision and consul-
tation in the training of residents. The most important distinction between
supervision and consultation is who is primarily responsible for the case. In
supervision, primary responsibility and authority lies with the supervisor.
The supervisee may diagnose the patient or implement a treatment plan, but
the supervisor retains decision-making, legal, ethical, and educational re-
sponsibility for the case. In consultation, by contrast, the consultee retains
control of the case. It is the consultee's prerogative to request and initiate
and to accept or reject the consultant's recommendations because the con-
sultee retains responsibility for implementing and coordinating implemen-
tation of diagnosis and treatment. The consultant is an advisor; the
supervisor is an executive.
In the educational context of a residency, the supervision-consultation
distinction can be most accurately depicted on a continuum (Table 1).
The medical education model is frequently described as "see one, do one,
teach one." While this emphasis on autonomy and practical experience is
very important in training clinicians, it can result in an ambivalent and
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394
Family Systems
Medicine,
Vol. 6, No. 4, Winter 1988
TABLE 1
The Supervision-Consultation Continuum
R-l R-2 R-3
SUPERVISION CONSULTATION
Supervisor initiates supervision process Resident initiates consultation process
Supervisor retains authority Resident retains authority
Supervisor is responsible for case Resident is responsible for case
Resident cannot reject recommendations Resident can reject recommendations
Supervisor is executive Consultant is advisor
ambiguous approach to the role of the teacher in this process. Is the teacher
a supervisor or a consultant? Clarification of the teacher's role at each phase
of the educational process is the teacher's responsibility; failure to clarify
the lines of authority can result in resident confusion or dissatisfaction with
the teaching as well as inappropriate care of the patient/family.
Our proposal, as illustrated by Table 1, is that faculty approach first-year
residents with a teaching style that is close to the supervisory end of the
continuum. First-year residents (R-ls) are relatively new to clinical medicine
and should have more frequent and intensive precepting. They will and
should make many decisions about the details of patient care within the
framework of plans discussed with the supervisor; faculty and senior resi-
dents should retain overall responsibility for major patient-care decisions.
Through demonstrating competence, residents earn the right to be consultees
rather than supervisees. R-2s take over a supervisory position themselves
vis-a-vis the R-ls, but they often continue to need some mixture of super-
vision and consultation from the faculty. Hopefully, by the time a resident
enters his or her R-3 year, that resident is prepared to operate on the con-
sultation end of the continuum when interacting with faculty. Of course,
each resident has different educational needs, and faculty need to place
residents on the supervision-consultation continuum based on the individual
resident's skills. Most important, whatever the criteria used, is that faculty
be clear with themselves and with the residents about who is holding au-
thority, decision-making power, and responsibility in interactions regarding
patient care.
TEACHING RESIDENTS THROUGH FAMILY-SYSTEMS
CONSULTATION
We will now present our procedure for family-systems consultation with
R-2s and R-3s. (The procedure used with R-ls would be more accurately
termed family-systems supervision.) Residents are required to bring in two
families from their practice for consultation, as part of the family practicum,
a 16-week intensive seminar on the family in family medicine that is part
of the psychiatry rotation. The consultations are an application of the theory
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Family Systems
Consultation 3 95
and concepts learned in the seminar. Consultations typically are done with
the residents individually with the videotape being shown to the seminar
group as a whole. However, it is possible to use this format with a group
or team as a consultant (10). The family-systems consultations aim at being
comprehensive, educational, and clinically useful. They serve a much more
in-depth, formal educational purpose than "hallway consultations," which
also may be useful when carried out within the context of a relationship in
which roles are mutually understood. Follow-up consultations, beyond those
in the practicum, are requested by residents as needed.
Prior to the consultation, suggestions are made as to the kinds of patients
or families for whom a consultation might be most useful. The most common
categories are patients whom the residents find interpersonally frustrating,
patients resisting needed lifestyle changes, patients with behavior problems,
patients for whom residents have inadequate family or psychosocial infor-
mation, patients who "should" be getting better but who are not, patients
with somatic fixation, families dealing with loss or with a chronically ill
member, and families in a medical crisis or life-cycle transition. Once a
patient and his or her family has been selected, the following procedure is
followed:
Procedure
for
Family-Systems
Consultation
1) Convening the family. Before scheduling a meeting with the family, the
resident reviews with the consultant exactly what the problem is and who
is involved in the problem. Then together they decide whom to invite and
how to invite them. The consultant is presented to the family as a faculty
member who will be sitting in to aid the resident and act as a resource
for the family.
2) Planning the session. (A) Genogram: The resident presents the family
genogram to the consultant as it is known before the consultation. (B)
Hypotheses and
goals:
The resident presents specific hypotheses and goals
for the session, as well as any specific consultation questions. The con-
sultant-teacher often will help the resident pare down and develop ap-
propriate goals for the session.
3) Interview. Typically, the resident conducts at least the first half of the
interview. The consultant then asks the important, unasked questions,
and models interviewing skills for the resident. Frequently, the consultant
and resident take a brief break to discuss strategy and a proposed treat-
ment plan. The resident then presents and negotiates a treatment plan
with the family and concludes the interview.
4) Debriefing. The consultant-teacher asks the resident to assess the family
and discuss the experience of the interview. He or she then gives verbal
feedback about the resident's performance. Treatment planning issues
are also discussed.
5) Chart report. The resident writes a family assessment report for the chart,
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396
Family Systems
Medicine,
Vol. 6, No. 4, Winter 1988
including any treatment recommendations that come out of the consul-
tation. The resident also updates the genogram.
6) Resident evaluation form. The consultant-teacher fills out a Family Con-
sultation Resident Evaluation form evaluating the performance of the
resident in the consultation (Table 2).
The goals of this process are to teach in vivo family-assessment skills,
family-interviewing skills, and treatment planning. The one-to-one contact
between the resident and the consultant-teacher also allows the teacher to
help the resident discover his or her own particular tendencies toward dis-
tortion or countertransference as well as helping to delineate the resident's
threshold for referral of problems to a family therapist or other specialist.
The
Family
Consultation Resident Evaluation
The following is the Family Consultation Resident Evaluation form we
use to evaluate the resident's performance in the family-systems consultation
educational experience. This form is a revision and adaptation of the Family
Assessment Skills Evaluation form developed by Talbot (12). We give this
form to the residents prior to the consultation, and we include it here because
it delineates clearly what we think is important for the resident to learn.
The following is a clinical example of a family-systems consultation with
a resident.
BATTLING ABOUT PREGNANCY: A CASE EXAMPLE OF A
FAMILY-SYSTEMS CONSULTATION
Presession
Consultation
Dr. K, a second-year family-medicine resident, expressed interest in
obtaining a consultation for a couple that had troubled him in his
practice. He stated he felt the husband should be involved in this proc-
ess,
but he did not think that the husband would come in for a session.
His patient, Mary Adams, was 19 years old and 32 weeks pregnant.
She described a history of physical and psychological abuse by her
husband Jim during this and a previous pregnancy.
Mary had had multiple sexually transmitted diseases, which she at-
tributed to her husband's extramarital affairs. On several occasions,
Dr. K had asked Mary to invite her husband in for prenatal visits to
discuss the problems they were having, but he refused to come. Dr. K
became increasingly concerned when Mary developed premature labor.
When he thought this might be related to Jim hitting Mary, Dr. K
suggested that she leave her husband and seek refuge at the shelter for
battered women. She did not do so.
The consultant, Dr. C, recommended that Dr. K pursue the consul-
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Family Systems Consultation 397
TABLE 2
Family Consultation Resident Evaluation
Name of Resident:
Name of Consultant:
Name of Family:
Date:
Presession
A) Genogram Preparation
a) prepared detailed genogram
b) prepared sketchy genogram
c) no genogram
B) Development of Hypotheses about the Family
a) presents clear, systemic hypotheses
b) presents some ideas about what is going on
c) no presession hypotheses
C) Goal Development
a) clear and appropriate goals
b) loosely constructed goals that are over- or underambitious
c) no presession goals
In-Session
A) Convening the Family
a) all appropriate family members and relevant others present
b) some of the appropriate persons present
c) individual patient only
B) Joining
1) Greets and talks with family members within the first five minutes
a) greets all family memebrs
b) greets some of the family
c) only speaks with one person
2) Adapts his/her behavior to the predominant style and affect of the family
a) behavior appropriate to family's style and affect
b) style and affect somewhat related to that of the family's
c) style unconnected to that of the family's
3) Lines of authority
a) recognizes and respects the family hierarchy
b) partial recognition of the family hierarchy
c) goes against the family hierarchy
4) Avoids coalitions
a) resists siding, giving appropriate attention to each person's viewpoint
b) tries to resist siding but shows some partiality
c) gives inappropriate attention to one presentation of the problem
C) Data Gathering
1) Problem definition
a) obtains view of the problem from all present
b) obtains view from some of those present
c) obtains the view from only one member
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398 Family Systems Medicine, Vol. 6, No. 4, Winter 1988
2) Family organization: Elicits sufficient information to be able to assess the family
organization and complete genogram
a) elicits most of the information
b) elicits some of the information
c) elicits little of the information
What important information is missing?
3) Individual and family functioning: Elicits sufficient information to assess the family
functioning (e.g., adaptability, affect, cohesion)
a) most components elicited
b) some of the components elicited
c) few components elicited
What important components of family functioning are missing?
4) Individual and family resources: Elicits sufficient information to assess family
resources (social, cultural, religious, etc.)
a) most components elicited
b) some of the components elicited
c) few components elicited
What important family resource information is missing?
D) Problem Definition and Management
1) Problem definition: Summarizes his/her evaluation of the problem(s) to the family
a) gives an appropriate description of the problem(s)
b) omits some important issues brought up by the family
c) does not attempt to summarize the problem(s)
2) Family and individual strengths: Identifies and supports the strengths of the family
and uses them in his/her management plan
a) acknowledges and supports the family's use of its own resources
b) acknowledges strengths but does not support or use them
c) does not acknowledge family strengths to them
3) Management: Establishes a plan with the family
a) explains plan, checking for family approval
b) proposes a plan without looking for family acceptance
c) does not propose an explicit management plan
4) Pacing and closure of interview
a) session is well organized; begins and ends on time
b) some organization of session; runs over less than 10 minutes
c) session had to be cut of prematurely due to lack of organization of time
Postsession
A) Evaluation Write-up
a) turns in a carefully constructed genogram and well-formulated family assessment
b) turns in an adequate genogram and family assessment
c) fails to turn in an adequate genogram and assessment
B) Follow-up
a) carries out and reports on consultant's recommendations
b) partially carries out consultant's recommendations
c) no follow-up information
Other Comments:
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Family Systems
Consultation 399
tation with the couple. Dr. K agreed with the consultant that attempts
to distance the husband from the situation had been futile and unsuc-
cessful, but Dr. K was nervous about confronting the husband. Dr. C
gave specific suggestions on how to get the husband to come in and
then role-played the telephone call with Dr.
K
until Dr.
K
was confident
he could approach the husband constructively. After obtaining Mary's
permission, Dr. K called Jim directly and said that he was sorry that
Jim had been unable to make any of his wife's prenatal visits, and that
he understood how busy Jim was and how difficult the appointments
were to make. Dr. K apologized for not calling him sooner, explaining
that the father of the baby should be told exactly what was going on.
He further said that he was concerned about the pregnancy, and he
wanted Jim's help in deciding what to do. Dr. K asked for a specific
time when Jim could come in with his wife to discuss their pregnancy,
and he scheduled an appointment for the consultation. In a follow-up
letter, Dr. K confirmed the appointment and repeated the importance
of Jim's active involvement in Mary's prenatal care.
Prior to the session with the couple, Dr. C asked Dr. K to present
the sketchy genogram information he had to date and discuss his hy-
potheses about the case. When Dr. C asked Dr. K how he felt about
this couple, it became apparent that Dr. K was overwhelmed by the
case and furious with the husband, blaming him for the couple's prob-
lems and the pregnancy complications. In addition, he was fearful of
Jim and ambivalent about meeting him. He knew little about the family
except for the marital difficulties Mary had described. Rather than
focusing on the resident's deficits, the consultant praised Dr. K for the
information he did have regarding the case and for the hard work and
caring he had already shown in trying to help with the problem. In this
way, Dr. C gave Dr. K a positive, strengthening experience, much as
he recommended Dr. K give to Jim. Together the consultant and con-
sultee established two goals for the session: (1) to join with Jim, so he
would become an active participant in Mary's care, and (2) to gather
more information about the family to obtain a more comprehensive
assessment.
Consultation Session
Dr. C sat in on the 40-minute session with Dr. K, Mary, and Jim.
Dr. C sat next to Dr. K and supported him in carrying out the plan
developed for the session. Dr. C intervened only to clarify or to model
asking certain kinds of questions for Dr. K. During the session, Dr. K
sat next to Jim and directed most of his attention and questions to him.
He expressed interest in Jim's occupation, and he elicited Jim's concerns
about his wife and their pregnancy. Dr. K obtained a more extensive
three-generation genogram, eliciting both the couple's stresses and their
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400
Family Systems
Medicine,
Vol. 6,
No. 4,
Winter 1988
strengths. This process revealed that the couple was overwhelmed with
financial
and
housing problems, difficulties caring
for
their 18-month-
old, and the complications
of
the pregnancy. Furthermore, both
of
them
had come from chaotic families with histories
of
substance abuse,
had
dropped
out of
high school, and had
few
social
or
family supports.
But
this couple
was
committed
to
their relationship
and to
their present
and future child,
and
they wanted
to
improve their situation (Figure
2).
During
a
brief break
in the
session
to
plan treatment,
Dr. K com-
mented that
Jim was
much more likeable than
he
expected,
and
that
he
had
been unaware
of all the
difficulties they faced.
Dr. C
congrat-
ulated
Dr. K on how
well
he had
joined with
Jim and on his
identifi-
cation
of
the couple's strengths. With the consultant's help, Dr.
K
chose
the couple's most urgent problems
and
developed
an
intervention
for
each using their identified strengths.
After formulating
a
treatment plan, both returned
to the
session
and
Dr.
K
told the couple how impressed he was with how they were dealing
with
the
enormous stresses they faced,
and
that
he
understood
the
additional stress
of the
pregnancy.
He
suggested
a
contract between
Mary
and
Jim "just
to be
sure" that physical violence
was
prohibited
in their relationship.
The
couple agreed.
Dr. K
then introduced them
to the family-medicine social worker, who said she would help by giving
Figure 2. The Adams Family
/ Dr.
C
N.
/
Women's / \ Nuttin^s'taff! \
/
Shelter
/ \ Billing \
/
/ Consultative \
/
System \
\
Dr
-
K
Mary and /
\
Jim Adams /
\
Police /
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Family Systems
Consultation
401
them information
on
adult-education classes
so Jim
could obtain
his
high-school equivalency
as
well
as
arranging some child care
for the
18-month-old.
Dr. K
also introduced them
to one of the
billing
staff,
who agreed
to
help them work
out a
plan
for the
medical bills.
Dr.
K
asked
the
couple
to
sign
up for
prenatal classes together.
He
thanked
the
husband
for
coming
in,
told
him his
suggestions were very
helpful,
and
requested that
he
come
in for the
next visit
in one
week.
The husband agreed.
Postsession
Consultation
After
the
session,
the
consultant
and
resident discussed
the
case
and
developed
a
long-term treatment plan.
Dr. K
said that
he
understood
that much
of his own
anger
and
feelings
of
being overwhelmed were
a reflection
of how the
couple
was
feeling.
He now
felt much more
sympathetic toward their plight. With
the
consultant's assistance,
he
went through
a
systematic assessment
of
the components
of
the family's
functioning (roles, communication, affect, coping, life-cycle issues, etc.),
and
how
each
of
these affected
the
pregnancy. Long-term problems
were identified
and the
following treatment plan
was
developed:
1) Continue
to
support Jim's active involvement
in the
pregnancy
by
encouraging
him to
come
to
appointments, attend prenatal classes
with Mary,
and
participate
in
labor
and
delivery;
2) Increase family
and
social supports
for the
couple
by
inviting other
important family members
in for
prenatal visits (especially Mary's
mother)
and
involving appropriate social agencies;
3) Support
the
strengths
of the
couple
and
work
to
improve their
self-
esteem with positive feedback;
4) Encourage
the
couple
to
discuss
the
stresses they face
and the
impact
on them
and
their relationship; actively monitor
the
situation with
both Mary
and Jim for
signs
of
abuse, using
the
police
and the
battered women's shelter,
if
necessary; slowly move toward referral
for counseling
to
help
the
couple cope more effectively;
5) Make
a
home visit during
the
early postpartum period
to
support
the family
and
further assess
the
home situation.
At
a
three-month follow-up,
Dr. K
reported that
Jim had
become
involved
in the
delivery
of his
baby
and
attended
the
first well-child
visit. Mary
was
being assisted
in the
care
of the
baby
by her
mother,
and
her
18-month-old
was
enrolled
in
part-time
day
care.
Jim was
planning
to go
back
to
school
and the
couple
was
considering marital
counseling. There had been no further physical abuse. Dr.
K
commented
that many more fathers
in his
practice were coming
in for
prenatal
apointments.
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402
Family
Systems
Medicine,
Vol. 6, No. 4, Winter 1988
CONCLUSION
There is now widespread acceptance of the importance of the family in
family medicine and several excellent textbooks on the application of family
systems in health care (5, 6, 7). Less attention has been paid to the teaching
of family-systems principles in residencies. Christie-Seely (4) has described
some of the basic principles of teaching family systems, and others (13) have
presented specific teaching approaches. We find family-systems consultations
to be a particularly effective approach to teaching practical skills in caring
for families. Residents enjoy this teaching strategy and find it very useful.
They feel that the consultations meet an immediate need for assistance with
a difficult problem in their practice, as well as demonstrating how a family-
systems approach can be practically applied in a primary-care setting. In
addition, residents begin to develop confidence in convening, interviewing,
and assessing families.
Our consultation model can be implemented in many residency training
programs. It requires faculty skilled in applying and teaching family systems
in medical practice. In our program, family systems medicine was once taught
by two family therapists and is now taught by a family therapist and a family
physician. While there are many challenges and obstacles to collaborative
teaching across disciplines (11), such teaching encourages an approach that
balances theory and practice and provides the best from both disciplines.
Family-systems consultation is easily integrated into behavioral science cur-
riculum. Videotapes from the consultations can be used in teaching seminars.
A structured approach to the family consultations encourages residents to
use the same disciplined approach that they use in the assessment and plan-
ning of other medical problems. Once residents have completed the two
required consultations in the second year, they usually request additional
formal and informal consultations to build upon their skills in working with
families.
To convince residents and other practitioners that the family-systems ap-
proach is valuable for family medicine, we must demonstrate its effectiveness
in daily clinical practice. Research is still at a primitive stage, but it suggests
that family interventions are effective (2). Family-systems consultations can
demonstrate that this approach is effective for specific cases in a family
physician's practice.
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Caplan, G. The theory and practice of mental health consultation. New York: Basic
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Requests for reprints should be sent to Susan H. McDaniel, Ph.D., 885 South Avenue, Rochester, NY
14620.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
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