CREATIVE FAMILY THffiqlry TECHNIeUES:

PI.AY ART, AND EXPRESSIVE THERAPIES

TO ENGAGE CHILDREN IN NAMILY SESSIONS

Edited by

LIANA LOWENSTETN

Champion Press
Toronto

/oao

Theoretical Oveniew
play and arts therapies'
be well trained in issuesspecific to
clinicians using this book should
theoretical and practical
key
Below is a brief presentation of
as well as family sy,tnm, thnory.
of this book' Readers
scope
presentation is beyond the
guidelines.A more detailed thoretical
suggestions for
training'
standard texts and obtain further
arethereoreencouragedto review
A list of
section'
Reading"
in the "References and suggested
additional reading can be found

. I thank the
to Tnldy
chniques.
p".lbilcaon.I
repper. Greg

organizationsthatproviderelevanttrainingisalsoincludedatthebackofthisbook.
u'lr-r.--cript
and
a:,i Patricia
fl Brck
rg e cover.
rragement. I
l irl' they bring

THERAPY
THE RATIONALE FOR CONDUCTING
WITH ALL FAI\{ILY MEMBERS
(2007)
in family therapy for a variety of reasons' Taibbi
Many therapists do not include children
Two
therapy'
family
in
children
awkwari about including
eloquentlystates, "Some clinicians feel
explored
be
to
need
both
adults'
of
the children and those
cultures,two different *orr, ,io." of
around
feel they have to be careful what they say
Parents
itn."ft.
and understood, yet it',
by the
office'
the
by
intimidated
yo,rng' often feel
the children; children, especiallyif they are
may
therapists
Family
understand'"
they don't
questions,by the seriour.,n$ oi all the talk that
because
or
children
with
working
feel omfortable
excludechildren fro* ,"r.lons becausethey
with children'
working
in
training
"v f"nt they lack adequate
And'yet,thefamilysystemsperspectivecontendsthatthemosteffectivewaytoworkwith
Uu
In fact, "from the existing research' it could ?T1lv
individualsis in the context oitn, families.
children
for
of
intervention
point
most important
argued that targeting iu*,r, ,rrrr", is th_esingle
groundbreakingbook, The Fam19Crucble
their
In
1998).
al.,
et
(Henggeler
and adolescents,,
.working dlrectly with the totality of the forces that
(1g7s), Napier u., wi;rcr wrote,
(1970)
it is hard to deny its validity'" Ackerman
influence the individual is such a logical idea tat
generations'
the
across
meaningful interchange
also stated, "without engaging the children in a
the
childr in the family therapy provides
the
all
Involving
there can be no family therapy."
rules'
and
patterns,
interactional
therapist *itt, u *ore uclu* urr.rr*nrrt of dynamics,
the identified patient (l'P')' "shifts
than
ratlier
ust
sessions,
Including all the children in family
product of
.otio. ihut it i' a family problem' a
the focus away from the I.P., and reinforce, ttt"
own
their
add
children
(Taibbi, 2007\. Moreover,
interaction, rather than the iuult of the I.p."
novel ideas to family problems and solutions
without exception' every one of my clients
Moffatt (2004) writes, "ln all my years as a counselor,
years of
from childhood' clients 40 or 50
has spent sessiontime talking with me about issues
agehaveshedtearsoverthingsthathappenedwhentheywerechildren.oftentheseissues
Family
their prents either did or did not do'"
were directly or indirectly the result of .o,,",nthi.g
yearsforty
waiting
while the children u.n yo,r.tg instead of
therapy offers clients;;G

.
!

I
L

The analogy of a
parents may need to be educatedabout a systemsapproach to therapy'
,,When one part is moved all the other parts are set in motion' The same
mobile can be used:

thing happens in families: when

one p"rrr has a probrem it impacts
other famiry members,
s *rcryone needs to be involved
in order to accurately "tnr*.i
how each person is affected

psychotherapetrtic pr
of the more b-dditixr
traditional rrethod of
-pople
d
know that
another more bctiecapacities in their r*p
corrununicate effecfiv

h",ingtheiichidrenramis
H.ff ;H:l,,ll::;??',?l;'.i.;::'#mlil#ffiffi
THE USE OF CREATTT/ETHERAPIES
IN EAMTLYTHERAPY
The techniquespresentedin thiS
book incorporatea varietyof creative
therapeuticapproaches,

il.r, ofthese
##:rTil;i1roo"u' "n' or"r'"'"-",andphotoTh""'v.
approaches
are

moder
toestabrish
an.interpersonar
i;:;i:'; ::"5:;td:'tr :: ffi ?f ,ff reticar
process

Eliana Gil- ore o{ dx

together in a cqrr,r:
(1994l'. SmlaL". Ba
from the intelsndspontarieity'. rrebptr
the twilght zse bar
2005).

.i*,?"::,:;ff:T::#::,:,.';.
ffi
ffi
:":H;[i,.,ffi
ffiH::];r;0.iiffi;ffi
&ndtray therapv i1ln exT.essive
and projective.mode of psychotherapv-invorng
a.d processing of intra- and
the unfording
interpersonJ ,rru", through
,nL r" ,] specific sandtray
materiarsas
i"Juut'n

ilffH:fl:fft;Smmuniation'

'l'"i,rriunlJ,ln"*"
bvatrained
therapist

Art therapy uses the creative

process of art-making to
improve and enhance the physicar,
rrsrtal' and emotional w.ell-being
rr "Jrilr*
or ul ug"r:-lt-ir-u"r"o on the
oeatire process invorved
belief that the
in artistic serf-expission_
herps pnopt"-to ,"rolve conflicts
problems, deverop interpersonar
and
skiils, manage behau.r,'r"Jr."
rirl'rr, in.r"us" serf_esteemand
seff-awaeness,and achieve
t.r,;h, d;;.",
On Therapy Association, zo70).
PsYhodramo employs guided
dramatic action to examine probrems
an indidual' using experientiar
or issuesraised by
methods, ,o.ro,n.t.y, ,ol" ir"ory,
psphodrama faciritates
und group dynamics,
insight, p"rro'd-s-;h,
ur,;"n;;;;;,i.og.,itiu",
behaoral revers.rt crarifies"issu,;;;;;hysicar
affective, and
leaming, and develops n"*,kiii;
enhances
B;irril orri,l"orama ".d;;;;;l*",,-u",nn,
Association, 2010).
Photo Therapy Techn.

Hanq;'s da9'ti-ler-q
these expressir.e fla1'
Therapernic da!-ard
on a deeper. rrtre m
abilirr* to address ei
their ongoirg @-ter
Whn ir erlo,noria
eve4dag da!{'r-d .afi
resor:rcefr.resstc ad
arttter+*=fu
h4
interctirs ar hrrr
family.

Narratle duapns F
focus ar*ag'frsi tix r
for *$.

:ffi,?,,",'i:ff
j,"i:ffi
::fiIii::n?,,,:T
:;lili,,lilT::.,;"J
*;ffi
J:lnir::,f
therapv
o'."r"r"lins
possibte
sessions
*n". **;X[T]|'Jffi:,|}:'it;5ir
i., ways
not

hasitsuniquetherapeutic
properties
depending
on itsapprication,

Art tlrerapy,b abo an

famihes rnag'har,e a
rrny find a t*4'i: do
fami\'rrurers
erga
ard feergs d-nr riA'
talk ther-ap-r.'A'r arli

,erasv,,,;,h;il;;";';::,::X".'1,::,:n?ffi*:T.T,?T*:,1f
:il:iln:Tffi
11:,
ntff:ff*:fi,T*{"'nt"t

a healingforce' and creatively

enable.l;;r;;;*press
their probtenisand conflicts(Marchiodi,
2oo5)' Thereare snun'ur.rorip",**
;;.i,
,1...............,nn
art
and pray
in the contextof the famiry.do.d;;;pi"",
,,.ig.,in.untrv when workingwith chirdren
u.prL and deepenthe

'
l A Violent ffur:
for my cotrrndinE *r
and paper. I irrstrucg
for them and. basd (

ts orher family members,

r.'each person is affected
3ir"g their chiidren to familv

Y THERAPY
,e ne rapeuticapproaches,
ol ll-reseapproaches are

a-. :--.:rpersonalprocess
he-: cents prevent or
oF'=..-.
: r.{ssociation for

a;,- -:..oh'ing the unfolding

rc-:: srrdtay materials as
k :,- a ained therapist

*,:,:e drc physical,

n --*e oelief that the
", ::::flicts and
, L,::e.a= self-esteemand
r -f - 1 t
'is-s+.es
raised by
group dynamics,
gn:tive. affective, and
Ileing. enhances

10r
unis. and picfures taken
l} as catalyststo deepen
srle5 in ways not

rdi;^,gon its application,

fron raditional "talk
srale creative energy as
rd conflicts (Malchiodi,
,.'..orkingwith children
t and deepen the

psychotherapeutic process, engaging people more directly and more immediately than do any
the
of ih" nor" tditonal verbaltherapies" (Zwerling,1979l. Additionally, while talk is still
therapies
practitioners
expressive
of
traditional method of exchange in therapy and counseling,
visual,
know that "people also have different expressive styles--one individual may be more
expressive
these
various
include
.
another more tactile, and so forth. When therapists are able to
person's
to
ability
each
capacitiesin their work with clients, they can more fully enhance
communicate effectively and authentically" (Malchiodi' 2005)'
"can bring people
Eliana Gil, one of the pioneers of family play therapy, emphasizesthat play
promotes
disinhibition and enjoyment"
together in a common, pleasurabletask, which inherently
"Family
play
therapy moves treatrnent
(l9g4l. Similarly, Bailey and Sori {2000) aptly put it,
from the intellectual, cerebral, abstract world familiar to adults, to the world of imagination,
"lives in
spontaneity, metaphor, and creativity that is familiar to children." Family play therapy
(Ariel.
alert"
on
the
the twilight zonebelween cognition and emotion, where the defensesare not

2005\.
Harvey's play therapy approach combines play, art, movement, deo, and drama. Through
these expressiveplay activities, family interactive patterns, themes, and metaphors are identifiedTherapeutic play and art activities encourage family relatednessand help families reconnect
on a deepe more meaningful level. Harvey emphasizeshow "families have the creative
ability to addresstheir conflicts in a naturalistic manner and that they can and do use play in
their ongoing day-to-day life to both problem solve and resolve their basic emotional conflicts.
When their emotional distressbecomes too high, families lose their resourcefulness,and their
everyday playful exchangesbecome negatively impacted...Play therapy can help families develop
resourcefulnessto addressand problem solve their more specific concerns" (2009). Play and
art therapies also help families explore any parallels between the dynamics in sessionand the
interactions at home. This leads to greater insight and, ultimately, to positive changes within the
family.
Narrative therapists Freeman, Epston, and Lobots (79971use playful approaches to "direct the
focus away from the child as a problem and onto the child-problem relationship in a way that is
meaningful for adults as well as intriguing, not heavy-handedor boring, for children'"
those censors that
Art therapy is also an effeclivetechnique with families because"it b5rpasses
families may have adeptly construed. A family that did not know how to express{eelings directly
may find a way to do so when given an opportunity to draw-or paint" (Klorer' 2006). When
family members engage in an arts or play-basedtherapeutic activity, they often express thoughts
and feelings that they otherwise may not feel comfortable expressing through traditional family
talk therapy. Art and play-basedactivities can unlock a deeper level of communication.
ln A Violent Heart, Moffat (2002) shares, "A few years ago I was demonstrating this principal
for my counseling students.I gave one student Playdough, another Legos, and another crayons
and paper. I instructed them to create anything they wanted using the medium that I providec
for them and. based on what their creations communicated to me, I would tell each of thern

_ -. __::str".es.
As family therapists

we too car
:.; =,,:asedfamilytherap
y caneffectivel,
b";r'":.:J:,;1.,[il:r."J::,r:#.
,=::e; i,.'orld
and help them to gain
insigit.

OINTNG WITH THE

FAMILY
o1 therapy, the family
therapistTbinswith the
famiry. Joiningmeans
::..
that
with the therapist,*il;;Jt,'j
' -,- j: - - .rersra,connectedness
urirnr when they feer
that
'

-"

'=

: :.. :,,",",
*i,;;-il"
t1"J:
iffi*:1;"::,::1
i1lifry.Ji,"il:,:::i:

1: r' .
- :' *ith your clients
tt future work. Failure
-_
*til ".np".'"ll of your
to
," ;, .-. : = :tienrs
efforts,
f.o_
assessmentto t.nut_n,]t"
will be reluctar, ,"
,l_"." ;,J:-r:::T:,.trom
-" -: ' ::':rd suggestions
iryout-ruun.r.oi-.*utnastrongi"i"r,,.
' : ':
:a:'ure
to joinwithai""rr .,',
r e r a t i o n s h i p w i tthh e m

: :- : - ::,rre
rerationship
*rtn
ir,".'ii"iiiiffi'#;t::i?""X,l;;,::,,,_"*i:$y;
ii"",r-,*o . o.;;;ir;;,J1i,r",,""

. : . . n 9w i t h t h e f a m i h , i n r k ^ L ^ ^ :

of rherapv.,,

''tiil.f,??,J1lJ:1:[:'*H;:':,':1iq'ff
?ff:'.:iffi
i:i".ihtffi
T:::;,.,
.' ': srengthfrom his
statusas a professior",
ilrjlJq

.thefamilv's therapist,Jr"*;;;;""

.,.::fii:::iil::i"jit:il:i:1i='il1,:ililJj;:"il:ti#,t.:t.
,,"".
fi::Tnf

::-:sionmaking'and
varuesRespectingiurtu.ur
'--riding
differences
is an ir:tportantaspect
Therapists
needto rrt.""ir"i"" ii
of rapport

or
,:::ff ?il:;Tl'.{*.u'
"i3;::."-o*ti;:;ffi;:,?;::: lilffif: inexperien."'""
.; ,

j:fif
H:
,i;l;Hm
;Il?*,,,1
ir, :i::"Tffi
:i,*;T
i:iillT:.l
H,
sensitive
u"Ju*u.ni
i"l"
tloshino,
2oo3).Bitter(20091"",,'s"i".Jjl,j^jTj:'p
Derorewe

tamilies,we must
come r^ i^^l,l^...I":

can know the ricj

:;r,il",:;#fu
",ffi3":t:iffi
r:i,;ffi:,::;Tj:#t**:HrJj"iifl
"
e meaningsin

"u'-

i.

"

nilies have been organized

in

Researchsuggests
that a positiveemotional
b?"d^yI!

the therapistis the

most important facror
therapy
*r,tr"l,'"r, zooorei;;,'#ii,",""..h
(Friedrander
etal
;,::,,ir::?'1ili:'in

j:n*i:*:*#:*i.
H*i::'$';:,"ill'"H,ffi
T:'.,#:*;*::tl
FAMILY
THERA'IST
rhetherapistprays
r,";T:,::ffil:E
"
describes,"
ru_irrir,n,upi.t
jujij#il:?::':,ffi:Hlrr.J;tT,:#::#::Jfi3*

u,

XXVI

Eterials to our
ls create and

rg n-,eansthat
ren ey feel that
09 stress.'The
*c'rk. Failure to
n : treatnent.
no: esablished
resisiat to or
or--<:,1o
th them.
f erap,v."
ccss.r*apier
r a-.,::: becoming
, ci:-a",.-lgtris

nc,sCIents'
ec ,; rapport
le::::e and
d ..:r ro labelor
al-. :jt? rherapist
n a",,are,es:- of oer
bn-.::lant culh,re
e,rr. :rganized in

Tip,,r:ant factor
dtra;ier et al..
: e:-.:tiona.l
'r-;-'tempy
is

L..::199i)
1'.r-.:iuding

the roles of produce stage director, protagonist, and narrator. As a produce the therapist
createsconditions for the formation of the therapeutic system; as a stage director, the therapist
introduces situations that challenge the existing structure and push the family toward more
functional patterns; as a protagonist, the therapist takes the place of an additional member of
the family and unbalancesthe {amily organization; as a narrato the therapist comments on
observedinteractions and, by questioning each person's attribution of meaning to the behavior
of other family members, helps develop new meanings. While taking on these roles, the therapist
maintains such qualities as a respectfuicuriosity, a commitment to help families change, a
preference for concrete behaoral modifications over talk about changed feelings, a constant
ieadiess to formulate and modify hypotheses based on information teceived, and the ability to
imbue the sessionswith intensity while keeping the clarity of the therapeutic goal.

THE FAMILY LIFE CYCLE

To be most effectivein helping children and their families, the therapist must understand the
developmental stagesof the family and the tasks involved at various stages. For a more thorough
summary of the Family Life Cycle Stage Model, the reader is referred to Carter and McGoldrick
999\.
The family's developmental process can be describedas a "dynamic one of oscillation between
stability and change. Transitions do not include the continuous minor adjustmentsin the behavior
of the family and its members but refer to periods of time when the family becomes used to and
adapts to a new set of circumstances"(Rivett & Street, 2009it. As an example, when a couple
have their first child, there are many changes that the family must adjust to, including the pattern
of dependency, the time the couple has together, distribution of household tasks, financial
circumstances,and possibleintroduction of other caregiversinto the home.
The typical transitions within a family involve "the setting up of a home together, the birth of
a new child, children beginning school and then leaving home, retirement, and the death of
a partner" (Rivett & Street, 2009). Families may encounter unique transitional events, such
as divorce, a significant promotion, the placement of a child in out-of-home care, chronic
illness,the untimely death of a family membe or remarriage. All families must adapt to major
transitions, but the pressureto adjust to multiple transitions may be overwhelming. Families
may seek therapy when unable to cope with a transitional crisis. When helping families deal
with stressfullife transitions, therapists must "consider the need for. flexibility and adaptability in
the face of transitional demands but also consider the family's ability to maintain stability. It is
important to concentrate on managing change as well as recognizing the value of maintaining
things as they are" (Rivett & Street, 2009).

ESSENTI,AL SKILI.S IN FAMILY THERAPY

Family therapists employ a variety of core skills in their work with clients. Below is a summary of
the common skills of all therapies as they are applied to family therapy' Additional skills will be
employed based on the therapist's theoretical orientation and style of working.
xxvii

Stucturing
h is the therapist's role to take the lead
with the family and to prode a structure.
This includes
setting a time, a place, and setting for
clients to safely talk about their issues
and concerns,
initiating discussionabout rules in session,
intervening if conflict escalatesduring
a session,
selacng appropriate intervenons for
sessions,and regularly reewing treatment
goals.
Empathizing
Tlre therapist must under'standand
empathizewith every member of e family.
Rivett and street
eoo9) eloquently tupllt" the essence
or
"Empathy is essentialfor engaging
indviduals
in honest and fult participation in family "*p",r,v,
thepy. The tr,"-plt,
response encourages
far'4' members to express long felt'
but incompletely undeistoo"-pathic
u.,i seldom voiced aspects of
their experience' Empathy is therefore
u tool o. r"d";;dhg,
L].'t",.n
achieved by reflection
o{ feeling and open receptivelistenino.,,
Reflecting
The therapist listens and briefly reflects

li"t"1"ur"t#;iT[:

what is said so that each family member

feels heard. It
therapist
to establish
an openatmosphere
in sessions
andto ensurethat

onrLsroparents,n"?:ff
.T,,:'#l'?ffffi:::ll":li:,ii;,1,n;f
:*:::;"f :r!:.f,

sesion. without fear of reprisalat

home.

Ftpothesizing and Formulating

D'ring the therapeutic process, the
therapist develops a hypothesis or formulation
of what is
l-"appeningwithin the family' There
are air[.*t
ways of describing the process of hypothesizing.
Rie( and Street (2009) characterize
r-wprir."rr as "a theory abJut how a family
pattern
contributed to the probrem that
"
har b.ougi,t
them to therapy nd about what pattern
s/beriefs/
behar'iorsmight be maintaining
the probi-emnow." Hypoth.", guidn
the kinds of questionsand
issl-psthat the therapist raises in
sessions.
Tracking
D'iring the tracking process the
therapist listens intently to family stories
and carefully records
a'ents and their sequence' Through
tiacking, the family therapi i, .i" ,.
identify the sequence
iI events operating in a-system to
keep it ttre way it is. what hupp".,,
between point A and point
B or C to create D can be helpfuttvh";;";;;;g
interventions.
Using Self-Disclosure
The therapist must ensure that the
focus of the therapy is on the crieirt's
issues.Howe ver, there
are times when it is appropriate
for the therapist to disclosepersonal
information. The therapist
should be aware of his,zherown
reasons tor rlrr-ir.rori"g pr;;;;il.,ior,,.,u,,on
and atrempt to
ancipate the impact on the client.
only information that is therapeutically
beneficial
to the client
should be disclosed' The sharing
p".r".,uii.rformation
il;;;;f
the
therapist
is
driven by
"r
a combination of personal stvre, theoretical
""
orilntation, and
client consideration.

Using Questiorrs
Integrating crealiu
However, the tech
theraPeuticProces
exploration. ale*i
guide the client to
how the fami\ i-: ::
outlines four q.atas
investigative.ded'-c
are meant to exrnil
in the relaonsi::ss
or positive\' urril,re
without mor."i.ngre
therapY dnd. 'ri:l

|fqalinng
Clientsoften le. :s
therapeutic slu- :. t
have some [i-]'':I
range. Norrriir:-g
tone in therapl;

Reframirg
Reframlr'g r.S.r.i-*r
nrr*rlpm<

.1-;:--"-

(Rir,en& Sr:e: ll
Slmplorn*r

aj-r: :i

Confronting
There ae :i.'s 5.
When co-rfr:.-r:
timing mrl-sibr. :"r
s!stems.
Pacing
Pacing re{er-s:: :
influence ih :,:

changing ::-: o
emotons re,:c ::

- !-.
-^, -^ o-.{ .:
uE
*rrv\ll3

Sessionsnea::: b
progressis:,:: :.
a direciona:.:,

re, This includes

d concerns,
a session,
:nl goals.

R.,'en and Street

EaEhg indivuals
x.sencoumges
rced aspectsof
red b_t'reflection

Using Questions
Integrating creative activities into family sessions can lead to rich and meaningful therapy.
However, the techniques are not the therapy-they are merely the tools to facilitate the
therapeutic process. The therapist usesthe activities as a springboard for further discussionand
exploration. Questions asked during or after particular activities can uncover clinical information,
guide the client to face issues,or facilitate insight. The therapist asksquestions that will reveal
how the family is interconnected and how it operates as a system. Patterson et al. (2009)
outlines four types of questions:lineal, circular, strategic, and reflexive. Lineal questions are
investigative,deductive, and content loaded, and information gathered from these questions
are meant to explain the problem. Circular questions are exploratory and uncover patterns
in the relationships. Strategic questions are challenging in nature and pose new possibilies
or positively influence the family system. Reflexiue questions bring about change in the family
without moving the family in any particular direction. Questioning is an important skill in family
therapy and, when used appropriately, can foster change and growth in clients.

feelsheard. It
I : e:isurethat
. Ti,e rherapist
ngs :penly in

Normalizing
Clients often feel isolated and alone, or they believe they are crary or abnormal. An important
therapeutic skill is to normalize clients' experiences. To effectively do this, the therapist must
have some knowledge of the behaors, reactions, and experiencesthat fall within the normal
range. Normalizing helps to relieve clients' anxiety about a particular problem and sets a positive
tone in therapy.

f a: ,.'hatis
f h'-;':ihesizing
I Gnrn
-oe.liefs/
er:-s
t-= S:;nS and

Reframing
Reframing is when a therapist retells or reconstructs the language used by a family about its
problems. An effective reframing provides a new context that gives the problem a new meaning
(Rivett & Street, 2OO9l. Creativity is required on the part of the therapist in order to reinterpret
symptoms and behaviors presented in therapy.

uLl-.'records
r e -quence
ini.l. and point

Confronting
There are times in the treatment process when the therapist needs to confront the client.
When confronting clients, the therapist must do so in a careful and sensitivemanner, and the
timing must be appropriate. Confrontation is necessaryin order to bring about change in family
systems.

'

ue.' ei. there

Ii:e :erapist
Care:rpr to
d:: :re client
r :s :::','en by

Pacing
Pacing refers to how slowly or quickly material is addressedin sessions.The therapist can
influence the pace by "creating opportunities for further exploration of a particular issue,
changing the focus to another topic, adding depth or breadth to the discussion,or exploring the
emotions related to the issue" (Pattersonet al., 2009) . Mnoring a client's behavior involves
moving at the client's pace. Leading is when the therapist guides the client in a certain direction
Sessionsneed to be paced appropriately-if the pace is too slow, clients may feel frustrated that
progress is not being made. On the other hand, if the therapist prematurely leads the client in
a direction that he/she is not ready for, it can lead to a negative therapeutic response- Specific

:'
techniques that hasten the pace of therapy include "asking open-ended questions, leading in a
particular direction, identifuing the process in the session,and focusing on the here and now"
(Pattersonet al., 2009).

be for-rd r
techniques can
in l.-)* afi
Further training
uootc
the end o{ this

Negative Interactional Patterns

Identifying and lnterrupting
Interactional patterns within the family are observedduring the assessmentprocess. In
later treatment sessions,the therapist employs a number of strategiesto interrupt negative
interactional patterns. The style and nature of such strategieswill depend on the therapist's
theoretical model.

fo Fr
hvolving
geserr
ofter
dole.c"ns
teens rsr
askirg
avoiding
thrn
contact with
ttrem rt se
irlvoh'e
wav to
dcrn tra
asndto write

lnformation
Offering Psychoeducational
The psychoeducationalprocess is an important element in family therapy. The therapist
assessesthe family's skill and knowledge in a variety of areas, so that the appropriate role for
psychoeducation is clarified. The therapist helps the family gain insight, educatesclients about
particular issues,and facilitatesskill-building.As the family learns and changes, progress is made,
and a positive outcome is experienced.
ldentifuing Family Strengths
Assessmentand treatment sessionsmust focus on identifuing and addressingpresenting problems
r.iin the family. However, it is equally important to focus on family strengths, as this gives the
rlrerapist and family "an opportunity to discover,or rediscover,positive qualities about individuals
r,rithin the family and the family as a whole" (Pattersonet al., 2009),

DEALING WTTH COMMON CIT.ALLENGES IN

CHITD-FOCUSED FAMILY THERAPY
Itlorking With Young Children in Family Sessions
Orp of e common challengesin family therapy is the discomfort that many therapists have
abort working with children. Therapists may be anxious about involving children in family
sssionsbecausethey fear children will be non-communicative or disruptive. Integrating engaging
ard der.relopmentallyappropriate techniques into family sessionscan help to involve children and
can prevent disruptive behaor.
Ttsapists may feel they lack the ability to communicate with children in an age-appropriate
.truier. It is helpful to use simplified languagewithout talking down to children. Using short
sntnces and concrete terms will be a more effective way to communicate with young children.
Fartugage-appropriate verbal explanations with simple sual props is'.alsoa good strategy. For
a poster depicting various emotional states(feeling faces)can be taped to the office wall
6rde.
ad refened to during a sessionthat focuseson feelings expression. Puppets, dolls, or figurines
a abo be used to communicate with young children.
Art ard play-basedtechniques, coupled with the therapist's creativity and playfulness,are key
igredie'nts neededin child-focusedfamily therapy. Hopefully, the techniques presented in this
book rill provide family therapists with creative tools to engage children and families. Additional

IJ"".

Anorertp otr

or SFe
to teach. kche'
-Yor rrrg trare a
sa9ng,
planning'

9
Engaging tbc F
dto
hare
nraY
Paents
hrnfo't
in
art technir+e
sandbox nsl!'as srl
embarrassed'or si['Pa
t
orior to ttle frst farrdY

hb
to
ad
iht-PY
{or the Parnt sessiqt

1- lnfqm Parrr I
a<arnfles oi r
drarltrtgs' PrW
2- Ask P Pilrs
qdscntu

3- A*te PilsE
of tlo; dEdB
clilfogr ied cc
chilen rc a*
drilCrm r.i[ be
I
Particnpa[in
srr
E$ain
4fkrt ertc4
wil fed crnft
'i
Pbry' de!
(c) sre da-u I
caPtiuarcd dl
hhs dfrirt
5- E:<Ptah *n t
cqrtl o{ a

snons. leadingin a
the here and now"

pr+:ess. In
er:--.lplnegative
n :l^.erirerapist's

l-L - -l ^--:^r
r t -< _.< oP51

,prriiare role for

ca:rsai.ientsabout
::]3ress is made,
l_s.

p:-nring problems
hs. s is givesthe
rDe: aout rrdividuals

i i::3pists have
fue:. :: family
Inrer:ating engaging
i:r',:r.e childrenand

tg-aDpropriate
e:: l-'s:ng short
,i _-r,ng children.
E:':': slrategy. Foi
e: ::. e office wall
. i:--s. cr figurines

,tj--.:ss. are key

pr=-nred in this
ia::.:-is.Additional

listed in the "suggested Reading" section'

be found in some of the publications
can
organizations listed at
techniques
.ur, bn iouna trrro,rgh some of the
in play
training
Further
""i ".in".*y
the end of this book'
in Family Sessions
hvolving Teens
1
moody' Taffel (1991) suggests
pr"rnniin ra*ity therapy as hostile and
ottnn
eye
Adolescents
and refraining from making direct
now they fel about something
te.rrs
asking
helpful
a
be
also
avoiding
an "observer" role can
teens by gi"i";;;
pen and
contact with them. empownring
be provided with paper and
.;"
ssslons:For example, :;
in
threm
involve
to
way
askedtowritedownwnathe,/snethinkswerethethreemostimportantthingssaidduringthe
therapists to avoid the temptation
Berg and st"tl;; lioosl is for
otr"r"J'uv
tip
Another
session.
thoughts and beliefs by
unjto insteadexfu'" thn t"n't''
to teach, lecture, t' nt;-;d*;'
and aid in treatment
.,you must r,uu""u"Jo;'r;";.
for..." This can initiate conversation
saying,
planning.
and Art Activities
Engaging the Family in Play
of using play and
tn" ,ullnule and effectiveness
understanding
.parentsmay have difficulty
games, drawings' puppets' and the
sessions.Th";;;;;"w
art techniques in family therapy
Parents may also feel uncomfortable'
{r
sandbox merely u, ,o*.", ointertainment
"hildren.
to meet with parents
plavfulfamilv therapy' It is helpful
embarrassed,or sillv;;;;in
ptuv and arts actMties in familv
to-"*ptui., th" ;; ;i urig
prior to the first f.*irv ;;;r;
the following instructions
tt i, upproul. Wurt tZ-Obi outlines
therapy and to help them embrace
for the Parent session:
l.InformparentsthatplayandartactMtiesareapartofyourfamilytherapyapproach.Give
examplesofthetechniquesthatareusuallyincorporatedintosessions,suchasgames'
drawings,puppets, and sandtray
,, r -r...^-r.-^ I{ rho n:rents exoressdoubt
2 . A s k t h e p a r e n t s { o r t h e i r r e a c t i o n t o t h i s m e t h o dfeelings'
ofworking.lftheparentsexpressdr
normalize their
or discomfort *t'n 'nO approach'
i'e', "What are your ideas
u'a u*pn.tutlons 1f-l.rer1py,
3. Ask ttn pur"r,ir-iortheiimage
would help your
*lttr *iti"t? what do you think
of how therapy should be conducted
be.easv or difficult for vour
in tn"rupvl o oou think it will
children f""l ;;;;;.;"
you think your
t;;o thoughts and feelings?Do
a;;
children to talk directly and openly
help your children
tn"'""tit" ,nstLt'? What would
children will be able to sit still during

- EXli:;;T:Jtf;';u1,*no

(a)
in familvtherapv:
orusingplavandarttechniques
they

the sand' therefore

u'i"g ptipp"tt Tg.?luyi"s in
children enjoy games' drawing'
communicate through
(b)
since.children
play-bured-upprou.h;
will feel comfortable with a
"talk therapv";
easily than traditional
to expressth;;'"d;ore
play, they *rit"
more likely to be
"ur"
t., nuturn, chilren's attention is
(c) since ptuy urra art activitiresur" u.,iun
that plav
snsrio.,; and (d) research shows
drr.;;*;i;;
captivated unJ .urtuinnd for the
1996)'
affective, and sensorimotor skills {singer'
helps childre" o"*".*nitive,
play and art activities in the
fnnt i,n,itunt to participate in
behavior'
5. Explain that many parents oft.n
puy it alreadv a part of their
r;:";;;;il
context of family therapy until they

Prode exampres,such as party games,

dressing up for a costume party, backyard
sports,
etc' In addition, many parents already play
wthiheir.itlr"n
- ----- at home and, therefore,
they will have a nahrral ability to play
during therapy.
that thv wllnot be fJrced toio
anything that makes them feel
mffi,.Hparents

t
;t"Tff

"e

parents with printed information

summarizing the benefits of playfulfamily

when introducirig play and art interventions

into famiry sessions,'it is helpful to
begin with
actities that guarantee success;
these tasks should b"iury u'Jrnouu
not require an expricit
fin*he/ product' In addition, i ir,"
ruo'ilv .embers a." aried to *ork
as a group or in pairs, they
rnay {eel less consciousof their
o*n .or,ribution,, (Revell, 7997).
For family members to feel comfortable
participating in play or art actities,
they must know
tlnt -they are in the.presence of
a therapist *ho ir.Io-ioul"
The
oi"n.
therapist must be
uilling to energetically demonshat",
pui'i.ipute and encourag" f;;rv
members
in their pray,,
tRevell' 1997)' Familv members wll
ilso r"i -or"
in prayfurinterventions if the
activities "fit the family style, values,
1l;;;;Ci
and strengths,,(Wachtel, lg94).
Managing Resistance
Arderson and Stewart (1983) define
resistanceas follows: "All those behaviors
in the therapeutic
+rstem which interact to prevent the therapeutic
system from achieng the family,s goals
therapy. The therapeutic system
for
incrudesall ru*ilv *"*u"rr,
n',L.uo,u, and the context
in wtrich the therapy takes place,
that is, ti" ug".,ry in which it occurs.,,
Resistancewithin

ilffiffi;::,virttvpicailv

beeuannitv
J*,"r.riti.ur
,"*.;;;om

thefamiry
ortheir

Family therapists need to recognizethat

all clients feel ambivalent about change.
Thus, therapists
should not view resistanceas a
failure but u, u' expected part of
therapy. Nevertheless,there
ae a number of ways to address
resistance.Improving the therapeutic
alliance will often engage
resistant clients. Another strategy
invorvesfurther exproring the famiry,s
perception of the
problem and helping them to
.J *"u'ingfur'treatment goars.
Family'_emb"r.
are more apt to
embrace therapy if they are-involved
in piioritizing the terapy ug"lau.
A further remedy for

o,';.n;;th,
rhisempoweo
nffifJli".:i'1ii:llff:;,:1,il:""-'to rocus
n.r"-'v
ff Hil|]iLi;il1'li'.'*'v

chitdren,
areresistant
because
thevareboredor feerthreatened

describedi"thi,b,:ff;;::'ffiIf,T::fl
:;;H;1':1r::H**r:j**ft
rehrctant to engage in play or art
:
actiti.r,-u"j they needto un.ur"iulry
encouraged.

The
nerapist can meet with parents
ahead of time and Lxflain tnat tnrough
pray and art actities,
cl-rren will be able to express many
of the emotions that they cannot
talk about directlv.

Engaging Unmotivatc
Some clients come to th
forced to come to tlsal
therapY as hostile ard u
Earning e client's tnd
family members-

Some clients rnaY hate 1

Creating a basis for hoP
they believe it is on\'fo
stigma. Pattersoret atr-|
athletes, such as Obrnp
consulting rorlr r'i ci
help them.

Dealing with Cmtrc

It is not uncommqr fq
personal style of *
be employed- lf tle tel
session ard seing faml
-no
viotr
can establish a
therapist can incorporal
the famfu can drau"a p
appropriate expressiro
show to eract *e coc,ff
more adaptiw resoh.Do
"lt is gd
tlror gou an
much that this rji no
positive corurotation" fc
something g,ou rea\' vu

Managing ffidren'r
Delkrg wtth actirg:o
therapi$s. The clriH r
feetings in ttrerafiss gl

There ae rnaR'reaso
behavior- Usla['. e c
to be engaged- rnporl
to deciptrer the nesag
addre-ssed-

Misbehavior can oirer l

sessions. The ther-pr*

ary'. baclcyardsports,
e and. therefore,
makes them feel
s o: playfuJfami.ly

Ir: ceginwith
qure an explicit
)i..t: or in pairs, they
"g-.::rust know
l-rer-::istmust be
s r:: neir play"
h:e:--'entionsif the

u:':e erapeutic
ut_.s ;:als for
e :rext
n: '.,.1in
Li.l;':: lheir

Tl^;s. erapists
hetess. there
::en engage
> nc i e
e ::ilre apt to
re:::ei_,.for
Ue:= :;le family

h:red
aS --:.: -ings

Engaging Unmotivated Clients

Some clients come to therapy becausethey are mandated by the courts to do so. Others are
forced to come to therapy by family members. In either case, these clients tend to present in
therapy as hostile and unmotivated. The therapist must work harder to join with these clients.
Earning the client's trust and respect is an essentialelement in engaging hostile or unmotivated
family members.
Some clients may have poor motivation becausethey do not feel therapy will be beneficial.
Creating a basis for hope will help build motivation. Other clients are resistant to therapy because
they believe it is only for crary people. If this is the case, the therapist must try to reduce the
stigma. Patterson et al. (2009) suggestcomparing therapy to coaching, in that even the best
athletes,such as Olympians or professionals,use coaches. Therapy can also be compared to
consulting work, with clients likened to businessesthat hire someone with special expertise to
help them.
Dealing with Conflict within a Session
It is not uncommon for therapists to struggle with conflicts that erupt in a session.While the
personal style of the therapist has an influence here, there are some general strategies
that can
be employed' If the therapist feels that the conflict might escalateinto violence, th
ending the
sessionand seeing family members separately might be the appropriate route. The therapiit
can establisha "no violence" contract with the family. When younger children are involved,
the
therapist can incorporate an engaging activity to addresssafep within the home. For
example,
the family can draw a picture of a "safe home" in which there is no violence and
rules for the
appropriate expression of anger are followed. Or the family can be asked to create a puppet
show to enact the conflictual situation, and then repeatthe puppet show to demonstrate
a
more adaptive resolution to the problem. The therapist might reframe the conflict by
saying,
"lt is good that you are able to express yourselues
and to know that you love each other so
much that this wll not affect gour deep feelings for eachother" Another strategy
is to use a
positive connotation, for example, "l know that you are choosing to show
anger becausethere is
something you really want your family to hear: What might that be?" (Rivett & Street.
20}gl.
Managing Children's Disruptive Behavior in Sessions
Dealing with acting-out behaors in family sessionsis one of the most difficult
issuesfacing
therapists. The child who is non-compliant, disruptive, or aggressivecan provoke
unpleasant
feelings in therapists such as frustration, anger, inadequu.y, .o.,.nrn,-and fear.
There are many reasons why children act out and there is always a messagebehind
the
behavior. Usually, the child's behavior is communicating an unmet need, for instance,
a need
to be engaged, empowered, nurtured, praised, heard, respected,etc. The therapist
should try
to decipher the messagebehind the child's behavior so that the child's needs can
be better
addressed.
Misbehavior can often be preempted by ensuring that the child is appropriately involved
in
sessions.The therapist should also be attuned to the child in order to addressmisbehaor
belcre

xxxll

;ffi3ff;ltr

?lj**
i!iln':?.ii:":,T[ffi:::**:ff
home.

showhowthevhandre,n".rr;.1"t""ir.

"

dirncu,ties
inthe
sessi
onso
ask

Thisprouia.lirj?I^'_:::

theparentsto

;:=::::".?:;chirdmanagemeniabiltiesiilil;#nff"'i:l3';:ft
::i:#''"
The therapistcan initiallyassume
resnonlbrjrtvfor rimit-setting
in famirytherapysessions.
will allow the therapistto
This
model*"tli"". for the .ur.giu"rr.'Ho
wever, theroreof rimit-setting
shouldbe graduallyshifted
t" olr""'L as they """r"-o."-;;"."
in this area.Transferring
'"tpo''tibiliti"t f*" od,,nl'tJ
pur"nt, strengthenstheir pos*ion
ff ::loj
in the famirv
Dscussingrulesin the initial
sessioncan alsopreventmisbehaor.
be established'
Rulesregardingsafep must
A "pass"rur".touiJJo
t" r"t in the firstr"rrron ro tamiry
feelpressured.Ruresrerated
membersdo nor
a.""nJ".i,"iity snouu b.;;r.;;;.
For exampre,askingfamiry
membersnot to sharewith others
*huiir*rpres during,"rrio.,r.
other rures_uy n to b"

*a th".;.;;;;;,i.",ortheramiryrh"J.m
i" i #;1,1T#[T:i: :Jf H1j Jtvu
irv
u,tr3n
andtaped
alv'""oo.oo.'11e

,n" ,^,Jr.
rn"n

ber-avo

at e sheetof rures,-identirv
*ni.r,"*;;',;-;:::,ilf;fflf;:".
,ur"'i]iengbroken,u,.,0o,r.ur'llll,-:?r*l thefamirvto rook
ttratsiven
moment
wh"n

*o,kin;

; Lmrv"wno;**;:,H,r?::tr,ill"::iil
eachother,a rurecanbeestabrishi
ri", Ju ," ;;;r#ffi;ioi.n
",
a particurar
bar,stufred

openly discussedbecatse <

clinical suPervision ard aq
countertransf ereric is9-6

CF

t$* F
Setect Activitie
varie{Y
of teclr
a
There are
nur
all
fam{'
that invohe
Tirt
famf,'.
in
the
children
in
shst
cr
turn
member a
Techniques sloJd be dE
assessmentdti!'ities- ard
goals- Pacirg b abo irnpo
defensi'ueressstu. be o
intense or that re+ ht
Thempisis are etul-agq
thei clierts-

ilfr1#:,:?"T:;f.^,,ft
"*_'*Ul*:lffi T:"il':iaggressive,moretime
B Well
There are times when a.
child's acting out behaor
is an attempt to seek nurturance.
If the

b"herpru," theparents
to,eacloutto
"""ur"

ffnf;::::l|nr'|iJ****:::'t.un

Shnfting Unrealistic Goals

some clients mav havS unrearisticary
high expectations or goars
parents may express the
of therapy. For exampre,
belief that their-child-'sb"haui,
wtii" *n.'o,"tery probrem-free
rlrerapv'In this situarign,the
after

ttnrupiri-urr
y1tg",i ,h; .il;rb
b more rearisticand obtainabr"
and then reframeit so that it
sr-ti.u, i"jtrar"r *".b;;;;il; Jr
d'ratae incompatible'If this
the famirymay definecoars
tt ttl .".",',ir" ih"rapist needs
to creativeryreframe
the goarss'o

m T'*Tl":il?:,:,f ^['*;*ii*fl

t"s",h".
F",;",r,", parents
may
want
their

,H.m,#;::estingthatu*r.n"'o",";',::Till'i,,iHff
T::#:ii:ff l".,:H:f:il
with Countertransference
ledi"g
Countertransferenceis

addessed
'r'"*.","o'ri;Ji:i*i::iii:ili:il:,;nr;i,:ffi,."::
ril,ir3ilir,,"
r"-i-'"rr* J.in" ,u,',,,0

oftheparents'
or' the,t *"o'.i*"u"o."i"iiono.ra
rxiv

secret
frombling

Prepared b A
r.drry
ar!'.rssssn
Prior to
gattrer
an!,:reary
and
rehearsirg P -li'"'il-r"' ui
fie r
how rell
needs. thedae" ro be fic

Considr tncmgg
Videotaprg tte sessms
h{
Videotape refl4'a:
need to ange- h a: ak
of ore of tteir aif' ses'

2OO2l.

It is also hbftl fq ra
selfdirected lear-ninE"as r
watch for or ttre uidecmf
be giwn to casac. csl

B'e Process Fooscd

The therapli* *u.& im,
interactions are rn rrs6l
keeping in mind E r:r

res in the session

so
r ask the parents
to
r a.l opporfunitv
fea:back and

openly discussedbecauseof his/her personal discomfort with the issue. Seeking appropriate
clinical supervision and exploring one's own family of origin is recommended to addressanv
countertransferenceissues(Carter & Orfanidis, lg7g).

GUIDEUNES FOR THE USE OF

CREATIVE ACTIVTTIES IN EAMILY THERAPY

4 se-ssien..*t,
le-:: ,::nit-setting
r:anSleTing
.Ec.
he :a::l9,

nE saiery,must
t:-<jC nOt
sr_:.J iamily
a-. ;.i to be
F ll.
iamily
^'-.
,.-lt
, - .= ..,,
du. I nen
i3.11.:_tO lOOk
t :.-.1:,:e in
X:-". ,: lop of
L-

e,: _ Sl-ild

Select Activities that Fit the Family's Needs

Thete are a variety of techniquesto choose from in this book. Techniques should be selected
that involve all family members and that are appropriate to the developmental capacities of the
children in the family. Turn-taking techniquesshould move fairly quickly, ging each family
member a turn in short order (Lubimiv, 2009).
Techniquesshould be chosen that fit the phase of intervention, beginning with engagement
and
assessmentactivities, and then implementing treatment techniques that connect to therapeutic
goals. Pacing is also important. The family's level of engagement in therapy
and degree of
defensivenessshould be consideredbefore implementing actities that are more
emotionallv
intense or that require family members to take greater emotionar risk.
Therapists are encouraged to be creative and modify the activities to meet the
distinct needs of
their clients.
Be Well Prepared in Advance of the Session
Prior to using any assessmentor treatment exercise, the therapist should
first review the activity
and gather any necessarymaterials. If the therapist lacks confidence, then practicing
and
rehearsingthe activity with a colleaguebefore the sessionmay be helpful.
Howevef no matter
how well prepared the therapist is for the session,the unforeseen can happen.
The therapist
needs, therefore, to be flexible and modify the plan according to the family's
needs.

lI-;.=
.f-'

..::

r :: n: l:!

Oe:-,= ;,:i:
91.- - ::
rE:.: :-.;r
r - _

--l-d

? :::'::1r

-".
[r: --: -.
- -'- '5

iI

Consider Videotaping the Sessions

Mdeotaping the sessionsand showing the family the videotape can be a powerful
intervention.
Videotape replay can help the family gain insight into their dynamics and
understand how they
need to change. It can also be helpful in the final stage of therapy to show
the family a video
of their early sessionsas a way to highlight the changes le family has made (Trepper,
9f,one

2002\.

It is also helpful for the therapist to review videotaped sessionsof clients

for their own
selfdirected learning, as well as for use in clinical supervision. For a thorough
list of what to
watch for on the deotape, see Bitter (2009). When recording sessions,
careful attention must
be given to consent, confidentiality, and the security of videotapes.
Be Process Focused
The therapist should focus on the process rather than the techniques so
that important family
interactions are not missed. Activities must be implemented carefully
and sensitively,always
keeping in mind the family's treatment obiectives.

in Fmily

The erapist should

consider how to introduc,
iihen introducingan
u.tuitr- il;l::,^:auce'.process,

Se$oG

and bring clt

J:"'Tii':.*"lmtlx'*T;"';:iili1
yri:=ffi
;16m*ff
:.yp:.""J;;;.;.,#tii"I'.il'Js::"":*"J",ij::,,*
s_i*-.

.: .;

;: T=".i:,"n1"fl""[o;;::-,:"

lc.elback
sei::::".,,'"il;;'i:;:;";ilX'xH;i:Ti'jiliht-:ll*',,:li;:.

u: aidirion to consideri
Frtcular session,,n" ,ilii:.'o

introduce,process,
and bringclosurr

;ll,T;"J[:j;'#:l{*,,*.*ffi?::j[$*i.::,r""T:,]

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