Family System Play Therapy An Integrative Approach 2019
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The American Journal of Family Therapy
ISSN: 0192-6187 (Print) 1521-0383 (Online) Journal homepage: https://www.tandfonline.com/loi/uaft20
Family System Play Therapy: An Integrative Approach Lexie Pfeifer Daley, Richard B. Miller, Roy A. Bean & Megan Oka To cite this article: Lexie Pfeifer Daley, Richard B. Miller, Roy A. Bean & Megan Oka (2018) Family System Play Therapy: An Integrative Approach, The American Journal of Family Therapy, 46:5, 421-436, DOI: 10.1080/01926187.2019.1570386 To link to this article: https://doi.org/10.1080/01926187.2019.1570386
Published online: 01 Mar 2019.
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THE AMERICAN JOURNAL OF FAMILY THERAPY 2018, VOL. 46, NO. 5, 421–436 https://doi.org/10.1080/01926187.2019.1570386
Family System Play Therapy: An Integrative Approach Lexie Pfeifer Daleya, Richard B. Millera, Roy A. Beana, and Megan Okab a
Brigham Young University, Provo, Utah, USA; bUtah State University, Logan, Utah, USA ABSTRACT
ARTICLE HISTORY
Although the roots of family therapy are firmly embedded in a family systems approach to treating child-focused problems, recent research suggests that the treatment of young children is relatively uncommon among family therapists. One possible reason is the dearth of family systems-based approaches for treating children. After reviewing existing treatments for children’s presenting problems, an integrated approach to family play therapy which draws upon structural, attachment, and play therapies, is theoretically conceptualized. This approach is applied to a case example of family therapy with a 9-year old boy with behavior problems and his parents. Implications for clinical application and future research are discussed.
Received 13 September 2018 Revised 9 January 2019 Accepted 10 January 2019 KEYWORDS
Family & couples therapy training; family therapy interventions; play therapy
There is substantial evidence that family therapy is an effective therapeutic approach for addressing childhood mental health problems (Carr, 2014; Kaslow, Broth, Smith & Collins, 2012). A major review of family therapy interventions for common childhood diagnoses (i.e., childhood depression, anxiety, ADHD, and ODD) reported that Family Cognitive Behavior Therapy (FCBT), Parent Child Interaction Therapy (PCIT) and similar behavioral or parent-training programs have been shown to be effective using RCTs (Carr, 2014). In addition, family therapy approaches have also been shown effectiveness for decreasing symptoms associated with infant attachment problems, child abuse, conduct, emotional, and somatic problems. Finally, a meta-analysis of 48 studies that directly compared the effectiveness of individual child therapy with that of family therapy with children found that family therapy was significantly more effective (Dowell & Ogles, 2010). However, most of these child family therapy approaches have been adapted from established individual child therapy models. Empirically supported treatments for childhood diagnoses within the field of marriage and family therapy are heavily weighted towards behaviorally-oriented family psycho-educational models, FCBT, and parent-training models (Northey, 2002). Family psycho-educational models and FCBT consist of teaching parents parenting skills and parallel cognitive work with the parents CONTACT Megan Oka [email protected] 6453 Old Main Hill, Logan, Utah 84322, USA. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uaft. ß 2019 Taylor & Francis Group, LLC
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(Sanders & McFarland, 2000). Parent-training models are characterized by their methods of training parents in warmth, positive attention, discipline, limit-setting, consistency, and other parenting skills (Kaminski, Valle, Filene, & Boyle, 2008, Herschell, Calzada, Eyberg, & McNeil, 2002). What is missing in current popular child family therapy treatment models is a systemic conceptualization of childhood mental illnesses and treatment that focuses on multiple subsystems within the family as they interact to maintain symptomatic behavior in children. The focus in traditional marriage and family therapy models is on the interaction between internal, individual child and parent factors, as well as the interaction of family subsystems (such as the marital subsystem or sibling subsystem) as they contribute to the development and maintenance of functional symptomatic behaviors. Systemic therapists consider the interplay between multiple levels of systemic interactions (Nichols & Davis, 2017). Often the presenting symptomatic behavior of one family member plays a functional role for the family, such as when a child’s acting out behaviors function to diffuse marital tension. Ironically, the roots of family therapy are firmly embedded in the systemic treatment of families to reduce children’s symptomology. Carl Whitaker, like many of the original founders of family therapy, held a firm belief in the vitality that young children bring to the family therapy process (Keith & Whitaker, 1981). Virginia Satir is another prominent example of early work with young children and their families. Her techniques, such as family sculpting, focused on understanding family interactions to understand the diagnosed child (Gil, 2015). Salvador Minuchin, the founder of structural family therapy, also was interested in the functional symptomatic nature of children’s presenting concerns and did much of his work with families of young children (Minuchin, et al., 1975). Despite its historical roots, the field has drifted away from the systemic treatment of childhood problems. In a survey of randomly selected AAMFT clinical members, marriage and family therapists reported that the majority of their clients were adults, with only 13% of private practice and 36% of institutional clients under 18 years of age. They reported that child behavior problems ranked lowest among commonly reported presenting problems. Further, of MFTs’ reported clinical work with children and adolescents, a large proportion was individual therapy, as opposed to family therapy (Northey, 2002). MFTs’ comfort level working with children (Sori & Sprenkle, 2004) and a lack of specific MFT models of child-focused treatment may explain MFTs’ exclusion of children in family therapy. This article introduces a systemic perspective to treating families of young children that integrates the principles of structural family therapy (Minuchin, 1974) with techniques and principles of individual play therapy.
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This approach conceptualizes family play interactions into a systemic framework and intervenes systemically within the play metaphor presented by the family. This approach continues in the tradition of early family systems therapy models, while drawing upon more recent advances in the play therapy field. Literature review Family therapy
Basic research supports a systemic perspective of the development of internalizing and externalizing disorders in children. Exposure to anger, aggression, and conflict in the family are risk factors for children’s poor mental health (Slopen, Kubzansky, McLaughlin, & Koenen, 2013). Controlling, neglectful and punishing family dynamics are other factors associated with the development of oppositional defiant disorder (ODD), specifically (Barkley, 2013). In addition, the ability of parents to work together is an important, but typically neglected, aspect of effective parenting. Co-parenting can be characterized by antagonism, undermining between partners, or triangulating children (Fosco & Grych, 2010) and has been linked to child symptomology. Popular family therapy approaches generally use behavioral and attachment principles that potentially miss a litany of family dynamics that maintain and coexist with children’s mental health problems (Carr, 2014). Missing from these existing approaches with children are components that investigate the familial contextual stressors that contribute to poor mental health of family members and the altered family structures and roles that develop around the parent or child’s mental health needs. There is a need to return to facilitating and working with spontaneous interactions that are created between family members, family subsystems, and the unique temperaments and experiences each family member brings to these interactions. Play therapy
The strength play therapists bring to family therapy with children is their understanding of developmentally appropriate therapy. The National Institute of Mental Health, in a review of childhood intervention research, noted the importance of developmentally sensitive models to treat childhood mental health disorders (Hoagwood & Olin, 2002). For example, traditional talk-therapy employs a variety of cognitive and verbal strategies that can be beyond the attention span and the cognitive and verbal skills of young children (Sori & Sprenkle, 2004). Play therapy models address this
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limitation of traditional therapy and are shown to be generally effective with a range of behavioral and emotional issues (Bratton, Ray, Rhine, & Jones, 2005). Further, children want to be included in play therapy, and young children, in particular, report liking play activities included as part of therapy (Stith, Rosen, McCollum, Coleman, & Herman, 1996). Play therapy stems from psychoanalytic tradition and has been an individual, child-centered model. Similar to adult models of psychoanalysis, traditional play therapy viewed the relationship between therapist and client as the most important healing relationship, which is a notion that family therapy has largely rejected (Landreth, 2012). Filial therapy is an exception (Landreth & Bratton, 2005). Filial therapy is a family play therapy model that coaches caregivers to learn the basic principles of child-centered play therapy. Outcome research shows larger effect sizes for filial therapy provided by parents, as opposed to play therapy with a professional (Bratton, Ray, Rhine, & Jones, 2005). Filial therapy integrates psychoanalytic, developmental, behavioral, and attachment theories to treat the child (Topham & Vanfleet, 2011). Parents are trained to set aside their emotions and needs and provide a secure attachment for their child. They are coached in structuring, empathic listening, child-centered imaginary play, and limit setting, and practice in a non-directed play session with their child and then process their emotional reactions to the experience in the play room with the therapist separately. Filial therapy and structural therapy have organizing principles that correlate, such as enactments, hierarchy, and boundaries (Topham & Vanfleet, 2011). However, filial therapy differs from traditional systemic family therapy by separating the parents’ emotional processes from the here-and-now of parent-child interaction. In filial therapy, the parent is required to maintain a grounded emotional state to provide a therapeutic presence for the child. Their emotional reactions are processed following the play experience. Parents are instructed to have the child lead the play and only participate in play as specified by the child. This structure may preclude the opportunity to fully address problematic parent-child cycles systemically, as parents’ typical trigger points and reactions are sublimated in order to create a safe space for the children. In addition, the role of other subsystems (marital/ sibling) are not a strong focus of filial therapy. Other family therapists have made adaptations and developed interventions based in systems theory with the inclusion of play in order to engage young children in family therapy (Rotter & Bush, 2000). Eliana Gil was in the forefront in her work of integrating play techniques and family therapy (Gil, 2015). She assigned joint play activities to assess how families work together and achieve tasks, and to promote joy, enjoyment, and enhanced attachment. By using a combination of family play techniques, such as
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genograms with figurines, art activities, sand trays, puppet shows, and mutual story-telling, the family achieves enhanced communication and empathy toward each other (Gil, 2015). Gil noted that family structural dynamics (interactional patterns or alliances) are observable in family play therapy sessions. Researchers and clinicians in the field of marriage and family therapy and play therapy both highlight the importance of family intervention, but there is a divide between the two fields where valuable knowledge and skills are not being shared. Play therapists bring a strong attachment focus and proficiency in the child’s language of play. Family therapists bring a strong systemic conceptualization of family patterns that create and maintain child symptomatic behavior. There is a gap in our current literature and practice for integration of traditional family therapy, with its emphasis on hierarchy, subsystems, roles, rules, triangles, and other family patterns, and play therapy, with its emphasis on developmentally appropriate methods to include children in their own therapy. These two methods, though not commonly used together, are not mutually exclusive. The balance of this paper will examine the integration of these two approaches, with an overview of the theoretical underpinnings borrowed from each, and a case study applying this approach to a family with a young child. We will include a description of the case, the treatment interventions used, and commentary about the rationale throughout. Model overview Theoretical background
The proposed treatment approach is an integration of structural and play therapy perspectives. We acknowledge that this is not the first attempt to integrate structural family therapy with play therapy, as even Minuchin was known to say that structural therapy with children was mean to be playful (Sori, 2006), and others have integrated play or art therapy with structural therapy (Dermer, Olund, & Sori, 2006; Hoshino, 2008). Our purpose in this paper is to provide practical application of an integrated theory from top to bottom. Structural family therapy includes attention to hierarchy, triangulation, excessively rigid or diffuse boundaries, and family rules in the conceptualization of functional symptomatic behavior (Minuchin, 1974). The proposed approach also draws upon the developmental strengths of play therapy. Children express themselves through play and symbolic representation (Rotter & Bush, 2000). Young children are still developing language and cognitive ability, which may contribute to difficulty with traditional talk-based models of therapy because young children do not have the words to articulate their emotion and experience. Play is a
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Figure 1. Integration of play therapy and family therapy.
developmentally attuned method of giving young children a voice in therapy (Rotter & Bush, 2000). These two theories integrate well, using the directive components of structural family therapy to make changes to the hierarchy while retaining the play aspects of play therapy to give children a way to voice their experiences (See Figure 1). Assessment
In this model, assessment is conducted in two phases. First, in a parent consultation meeting, parents describe the presenting problem, and the therapist describes the process of family play therapy. The parent consultation meeting without the child present defines the parental subsystem as distinct from the child or children, and reinforces the family hierarchy and direction of caregiving from parents to children. Parents are reminded of basic principles of child development and presented with the rationale for play as the language of therapy. Parents prepare their child for therapy by explaining, “The therapist wants to help us know how to help you with [presenting problem]”. This explanation minimizes the child’s anxiety about being the identified patient. Parents are told that the first two sessions will be for the purpose of understanding the child and problem in the context of family interactions (how the problem impacts or is impacted by family dynamics). For the second part of assessment, the therapist observes initial family sessions with minimal intervention, observing for family structural dynamics. These dynamics can include family roles, hierarchy, alliances, triangles and/or family implicit rules, such as unspoken restrictions against expressing certain emotions, engaging in certain behaviors or broaching taboo subjects. The therapist pays attention to ways in which the child invites or
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does not invite adult participation in the play. The therapist also observes the emotions triggered in the parents and child that are associated with their roles and patterns of interaction. For example, a parent may become uncomfortable and discourage angry themes in play or distract from deep and uncomfortable emotions, like sadness and fear. The therapist observes instances when the parent(s) shift from a child-focused orientation (following the child’s lead) to a parent-oriented reaction (disciplining, lecturing/moralizing or distracting). The therapist will ask him/herself: What conditions provoked the shift? What is the step-by-step process of interaction and escalation during these moments? Finally, the therapist pays attention to themes and symbols the child introduces. Treatment
The treatment phase of therapy draws the family’s attention to observed family dynamics that maintain symptomatic behavior and suggesting altered structures that could alleviate the child’s symptoms. Observed family dynamics will vary. Common themes for restructuring include defining and strengthening boundaries around the parental subsystem or establishing the parents as authoritative leaders in the hierarchy, helping the parents work together as a team, and facilitating less rigid or less diffuse boundaries for communication and emotional expression. These suggestions should utilize the play metaphor presented by the family and be responsive to here-and-now play moments. The therapist uses play to draw the family’s attention to these dynamics and the emotional impact of the existing structure on individual family members and children. Based on these observations, the therapist may suggest or guide play to explore different roles, structures, and rules that can reduce symptomatic behavior in children. To facilitate a family play therapy session, the therapist should have a few basic play materials on hand, including basic art material, balls, foam swords, play food, toy cash register, doctor’s kit, or dolls. These materials invite relational transactions and emotional expression. Hats, dress-up accessories, puppets, or figurines can provide information about family roles and relationships. For example, a doctor may suggest a care-taking or fixing role. Puppets and figurines should represent a wide range of characteristics and come from a range of environments to offer the best range of expression for different family personalities. Throughout treatment, the therapist also conducts monthly parent consultation sessions in which the therapist and parent discuss themes, meaning, and experience of family play. This helps increase the parent(s) perspective and empathy for the child’s symptomatic behavior. The
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therapist can also use these parent consultation sessions to discuss and collaborate with the parents about more adaptive roles they can take on in the play sessions or to address couple or marital issues that have emerged during family play sessions that should be kept separate from the children. Parent consultation sessions may go against the Whitaker “family crucible” style therapy (with all family members present). However, this component remains consistent with systems theory as their concerns specific to the marital/parental subsystem that are better discussed without the child present, and this process takes the child of that triangle. Termination
Closure of therapy is initiated upon parent reports of reduction in child symptomatic behaviors and as the therapist observes and the client reports comfort with newly established structure and patterns of interaction. Often, therapy may reveal dynamics in other subsystems of the family (such as the couple) that may become the focus of therapy. Implications for family therapy/Practice—Case example
The following case example illustrates what this process looks like with a specific family. The identified patient was a 9-year-old Caucasian male. His parents sought treatment for behavioral problems exhibited at home and school. He reportedly became physically aggressive with family members and friends, and, when he got frustrated, he would hit and kick others. His behavior problems and nonconformance to rules at school had led his parents to try homeschooling. His parents were also concerned about his social adjustment with same-aged peers. The parents also had difficulty establishing and maintaining clear and consistent boundaries for his behavior, and all became emotionally reactive during power struggles. The parents were in their forties, and they were middle income. The father was often away on business trips, and the mother was a homemaker. There were also three much older sisters (15, 17, and 18 years) in the family. In Jason’s (fictional name) first play sessions, two prominent dynamics emerged. First was an alliance or triangle between Dad and Jason (against Mom). During a game of checkers, Jason and Dad teamed up against Mom. Before jumping Mom’s checkers, Jason teased, “Time for public humiliation.” Mom replied in a sarcastic tone, “I love public humiliation.” Then, Dad joined with Jason, continuing to bait Mom, “How public? Jason, [are] we gonna put it in the newspaper?” On another occasion, Jason recruited the therapist to help him get the “bad guy” (played by Mom). The therapist made a normalizing statement to Mom: “That happens in
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therapy.” Mom emphasized, “That always happens in our house,” which suggested that she resented being ganged up on when there was an alliance between Dad and Jason. Second, the parents’ authority was inconsistent, and they often felt powerless to effectively redirect Jason. In game play between Jason and Dad, Jason would change rules to favor his winning, and Dad became frustrated. At first, Dad responded in the parent role by teaching and redirecting Jason towards fair game-play. When Jason ignored this redirection, Dad responded to his powerlessness to enforce proper game-play by breaking rules also. He relinquished control of game-play to Jason, but with teasing, passive-aggressive comments about the unfair playing field Jason had created. Mom sat by quietly, without intervening during these interactions. This shift from Dad’s hierarchal role to a peer-level interaction indicated an emotion-laden theme to explore. In this case, the therapist focused on strengthening the parental alliance by suggesting that for the next game Mom and Dad be on a team, strengthening the parental subsystem. Exploring alliances and triangulation. The parents had previously described that play between Jason and his father commonly escalated, like siblings, and Mom became the mediator when the play became too rough. Mom described that after intervening between Jason and his father, her husband resented her. She disliked being the “bad guy.” This dynamic manifested in a cops-and-robbers game with Mom and Dad as criminals and Jason and therapist as cops. Dad was provoking Jason by shooting him while Jason was still preparing for the game. The therapist highlighted this dynamic, observing, “It looks like the game has started.” Jason protested, “No, it hasn’t.” The therapist reinforced Jason’s message, “Oh, so [Dad] is jumping the gun a bit.” Jason agreed, “Yeah, I’m trying to get away so I can actually start the game.” Dad continuing to ignore Jason’s boundary and grabbed Jason’s sheriff badge to steal it. Jason found a whistle and blew loudly three times, “Dad! Don’t do that!” Dad relinquished and responded, “I just want to be the good cop.” The therapist reinforced Jason’s attempts to set a boundary by observing, “It seems like [Jason] is trying to get order.” At this point, Dad returned to his chair. Mom watched these escalating interactions as a bystander. The therapist observed, “They don’t give up easily, do they?” Mom replied, “I normally sit back and watch”. Later in the play, Dad and Jason were struggling over a toy gun and Dad had playfully wrestled Jason to the ground. Jason again grabbed and blew the whistle. The therapist reinforced, “It looks like Jason is trying to get order again.” Then, to Jason she asked, “What does the whistle mean?” Dad offered, “Does that mean ‘Help’?” Jason concurred with the request, “Help,” freeing himself from Dad’s pin. Then, still handcuffed, with gun pointed at Dad, he asserted, “I may have handcuffs, but I am still capable.”
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In these interactions, the therapist drew attention to the immediate family process, and particularly, what Jason was communicating with the whistle. The therapist helped Dad to increase his awareness of Jason’s cues, and helped Jason to articulate his feelings and boundaries to Dad. The therapist intentionally facilitated this interaction without involving Mom. By acting in a hierarchal, parent role, Dad raised himself to the parent level in the family hierarchy, without Mom intervening reinforcing his sibling-level interaction with his son. This created an atmosphere for Jason where both his parents were safe, responsible and in charge. Also emerging in this dialog was a theme of competence or adequacy that underlay Jason and his father’s competitive interactions. This theme was evidenced by statements such as “I just want to be the good cop” (Dad) and “I am still capable” (Jason). In a subsequent parent consultation, the therapist explored this theme with Jason’s father to increase his emotional awareness of himself and Jason when they engaged in competitive, escalating interactions. Dad noted that these interactions mirrored his control issues with Jason. He reported getting frustrated with Jason when he wanted control and teasing him until he got upset. The therapist connected Dad’s frustration over his lack of control to Jason’s frustration and desire for control, which Dad readily acknowledged. Exploring the parents’ emotions surrounding these competitive, escalating interactions between Jason and his father served two purposes. First, it increased the parents’ awareness of how Jason may perceive those interactions. Second, it increased Dad’s self-awareness of feelings of inadequacy, not only in the parenting relationship, but in his relationship with his wife. The therapist hypothesized that Dad felt his marriage is “stacked unfairly” and he often loses the battle for control with his wife. Similarly, the therapist surmised from Mom’s comments that she felt “left out,” not only with Jason, but alienated and isolated in their marriage. These hypotheses were later confirmed in subsequent marital therapy sessions. Exploring functional symptomatic behavior. Subsequent therapy sessions revealed another symptomatic behavior. Jason would alternate between using his normal, age-appropriate voice and a small, “baby” voice. The therapist noticed that the baby voice tended to surface when there was confusion about hierarchy in relationships or who was in charge of leading the activity. The therapist made this confusion explicit, and helped the parents and child negotiate leadership of the play activity (see below): Jason: (baby voice) Dad, you get to choose … (changing his mind) No, Dad, do you wantto hide the toys or do you want to come over here with me? Dad: Did you want me to go over there with you?
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Jason:
(baby voice) It depends which one you want. What do you want? Dad: Well, I don’t care, but you told me that the person that won [rock paper scissors] was supposed to [hide items in sand]. But I would be happy to [do it the other way]. Jason: (No response to Dad. Goes over to where Mom is standing in the corner) Therapist: Jason, can we take a time out for a minute? You’re deciding what everyone does, but I’m wondering if you want that or if you’d like Mom and Dad to decide? Jason: (shift to normal voice) Well, that’s what I was kinda hoping Dad would do. Therapist: Do you want for the rest of the time to be the kid (conjecture to the functional symptomatic role of the baby voice), and Mom and Dad decide how you play? Or do you want to keep deciding? Jason: Um, we should take turns. Therapist: Okay, you let them know when you want them to decide. Once the confusion about who was in charge of the play activity was made explicit and Jason was aided to articulate what he was feeling and wanted, his voice shifted to a tone and quality consistent with his age. This negotiation between parents and Jason provided an opportunity to learn age-appropriate autonomy and leadership (Erikson, 1998). The play activity made explicit this developmental task and afforded an opportunity for the therapist to facilitate parents’ and child successful resolution of this negotiation around leadership and autonomy. The parents had an experience with successfully negotiating and communicating with Jason, but in the context of a 50-minute play session, it is unlikely that this particular interaction stood out to them such that they would agree with the therapist’s conjecture regarding the functional symptomatic nature of the problem behavior. Even if they were to agree, it is unlikely the parents were aware of the importance of the interaction and the potential to replicate this kind of interaction at home. The therapist followed up with a parent consultation session to collaborate with the parents to brainstorm the function of the problematic behavior (baby voice) in the context of their family dynamics. The therapist noted that Jason was often confused about when to lead and when to follow in session and suggested that the parents acknowledge that confusion by saying something like, “Oh, you seem confused. Do you want me to lead this or do you want to lead this?” to clarify roles in the moment.
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This parent consultation increased Jason’s parents’ awareness of the context of his regressed speech. The parents became co-investigators of the function that Jason’s symptomatic nature played in the family. In addition, the therapist gained more information about the function of the baby voice when Dad suggested that Mom “likes having a little baby at home.” This parent consultation also revealed subtle conflict and disagreement between the parents about Jason’s behavior, which could be indicative of the previous theme of Jason’s being triangulated into marital conflict. The therapist chose to address potential triangulation by strengthening the parental alliance through a team approach to investigating and addressing Jason’s behavior. Exploring mutual reactivity. Throughout therapy, the therapist intervened by increasing the parents’ and child’s emotional awareness of self and other in the play interaction. The therapist was particularly attuned to how family structural dynamics impacted the emotional experience between parents and child. An example of a therapist intervention around this theme is illustrated by the following session in which Jason and Mom played cops-and-werewolves: Therapist: Before we leave, I have two questions for you and your Mom. How did it feel to be the cop and how did it feel to be the criminal? Jason: Awesome. Therapist: (Directs them to look at chart depicting feelings with illustrations and words). So you feel “awesome,” and pick one other feeling. Jason: Happy and Hysterical. Therapist: Happy and Hysterical. To be which one (cop or criminal)? Jason: Both … the criminal was more hysterical though. Therapist: How about you, Mom? Mom: As the criminal? Frightened. And as the cop? Confused … (nervous laughter). Therapist: I was thinking that one too. I was feeling a little scared and confused sometimes because … Jason: (interrupting) I felt guilty and suspicious also when I was the … Mom: Criminal? Therapist: I was thinking, I don’t know if I’d like to be that criminal and feel like I had to hide all the time like that. Jason: (to Mom) Why did I have to be the werewolf? Mom: I don’t know. It just came to me. Jason was initially superficial in his description of his feelings playing the role of the criminal or werewolf. His mother’s higher cognitive and verbal
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skills at recognizing, articulating and holding multiple emotions modeled for Jason how to talk about feelings. His mother’s vulnerability about her feelings playing cop and criminal also invited Jason to share more depth of emotion. Mother and child connected as each shared their feelings about what it was like to be the “bad guy” or the “good guy” in the family, or to feel powerful or powerless in relationships. This dialog even created space for Jason to question his role as the “werewolf,” which could reflect his discomfort with his parents’ view of his behavioral problems. Jason and his parents participated in eight family play therapy sessions together. There was also an initial parent consultation session and midtherapy consultation for a total duration of ten sessions. At the end of therapy, the parents reported less occurrences of Jason behavioral acting out and positive accounts of Jason’s relations with peers. Also, in therapy, Jason became more assertive and articulate in voicing his feelings and needs in age-appropriate ways. Frequency of the “baby voice” decreased across sessions. These family therapy sessions also helped to align the parents, de-triangulate Jason from marital concerns, and increase emotional and relational awareness. The couple decided to shift therapy away from a focus on Jason’s symptomatic behaviors and work on their couple relationship in marital therapy, which was further indication of progress toward more clear boundaries separating the parental subsystem from the child. Discussion
Using components of both structural family therapy and play therapy worked to both restructure the family hierarchy and abate the child’s symptomatic behavior in several ways. First, the use of play therapy became an equalizer for this family. When all members were playing together, cognitively and verbally they were all at the same level. This allowed for problematic structural dynamics to emerge, like Mom being left out of interactions, or power struggles between Jason and Dad. Using play therapy language, the therapist was able to comment on these dynamics in a way that allowed Jason to feel heard and acknowledged, which translated to him being able to articulate his feelings toward his parents, rather than expressing his frustrations through negative behavior. The structural components of this approach were particularly salient for the parents. Helping the parents to recognize the roles they played in their family, with Dad and Jason in a coalition, Mom taking on the role of both parent and villain, helped the parents to change their behavior outside of therapy. Activities that strengthened the executive subsystem in therapy helped parents experience healthier roles and interactions, and parent
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consultation sessions with the therapist helped them to internalize these changes and carry them forward. It is clear that, for this family, structural therapy without play would have reinforced the triangulation of Jason into adult issues that he was already experiencing with his parents. Play therapy without the structural component could have maintained the dynamic of Dad and Jason ganging up on Mom or competing with each other like siblings. By integrating these two, we were able to strengthen the parent-child hierarchy while still giving voice to the child’s concerns and emotions. Limitations
This model lends itself well to the family described in the above scenario: weak parental alliance, coalitions, and diffuse parental boundaries. In other words, this case study resembles those described often by Minuchin and his colleagues. We recognize that not every family’s presenting problems may fit a structural approach as neatly as this family did, and therefore, it is hard to generalize this model to a variety of presenting problems. Additionally, what is presented in this paper is a case study, which is appropriate for a new theoretical orientation, as it allows readers to examine the theory in-depth, with one case (Kazdin, 2003). However, the sample size is small, and the data are anecdotal and descriptive, so it is harder to draw conclusions about the effectiveness of this model across participants. Future directions
The purpose of this paper was to present an integrated model for working with families. This model is still in its early stages and needs more development. For example, a future paper could include more systematic development of the model, offering beginning, middle, and end of therapy tasks. Further, given the need for family therapy models that treat specific childhood disorders, future work may examine how this model applies to other child problems, such as ADHD, ODD, depression, or anxiety. Future studies could include more empirical validation of the model, collecting preand post-therapy assessments that examine both family functioning and child outcomes. Conclusion
This article has presented a proposed treatment approach for engaging children in a theoretically systems-based approach to family play therapy. This therapeutic approach is a call for a return to the foundational principles of systems theory when treating child-focused problems. The advantages of
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this approach include a more comprehensive perspective of child symptomatic behavior as a function of family systemic dynamics, engagement of the child’s voice in family therapy through play, engagement of the family as a tool in actively addressing parent-child interaction and child presenting problems, and a gateway to parent awareness and willingness to participate in couple therapy for adult subsystem concerns. Child and family therapists from all disciplines are invited to apply the principles proposed in this approach and contribute to future research that will refine and validate the practice of family play therapy with young children and their families. References Barkley, R. A. (2013). Defiant children: A clinician’s manual for assessment and parent training. New York: Guilford Press. Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 376–390. doi:10.1037/0735-7028.36.4.376 Carr, A. (2014). The evidence base for family therapy and systemic interventions for childfocused problems. Journal of Family Therapy, 36(2), 107–157. doi:10.1111/1467-6427.12032 Dermer, S., Olund, D., & Sori, C. F. (2006). Integrating play in family therapy theories. In C.F. Sori (Ed.), Engaging children in family therapy: Creative approaches to integrating theory and research in clinical practice (pp. 37–65). New York: Routledge. Dowell, K. A., & Ogles, B. M. (2010). The effects of parent participation on child psychotherapy outcome: A meta-analytic study. Journal of Clinical Child & Adolescent Psychology, 39, 151–162. doi:10.1080/15374410903532585 Erikson, E. H., & Erikson, J. M. (1998). The life cycle completed (extended version). New York: WW Norton & Company. Fosco, G. M., & Grych, J. H. (2010). Adolescent Triangulation into Parental Conflicts: Longitudinal Implications for Appraisals and Adolescent-Parent Relations. Journal of Marriage and Family, 72(2), 254–266. doi:10.1111/j.1741-3737.2010.00697.x Gil, E. (2015). Play in family therapy (2nd Ed). New York: Guilford. Herschell, A. D., Calzada, E. J., Eyberg, S. M., & McNeil, C. B. (2002). Clinical issues in parent-child interaction therapy. Cognitive and Behavioral Practice, 9(1), 16–27. doi: 10.1016/S1077-7229(02)80035-9 Hoagwood, K., & Olin, S. S. (2002). The NIMH blueprint for change report: Research priorities in child and adolescent mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 760–767. doi:10.1097/00004583-200207000-00006 Hoshino, J. (2008). Structural family art therapy. In C. Kerr, J. Hoshino, J. Sutherland, S. Parashak, & L., McCarley (Eds.), Family art therapy: Foundations of theory and practice (pp. 119–166). New York: Routledge. Kaslow, N. J., Broth, M. R., Smith, C. O., & Collins, M. H. (2012). Family-based interventions for child and adolescent disorders. Journal of Marital and Family Therapy, 38(1), 82–100. doi:10.1111/j.1752-0606.2011.00257.x Keith, D. V., & Whitaker, C. A. (1981). Play therapy: A paradigm for work with families. Journal of Marital and Family Therapy, 7(3), 243–254. doi:10.1111/j.17520606.1981.tb01376.x
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Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567–589. doi:10.1007/s10802-007-9201-9 Kazdin, A. E. (2003). Drawing valid inferences from case studies. In A.E. Kazdin (ed.), Methodological issues & strategies in clinical research 3rd ed. Washington D.C.: American Psychological Association. Landreth, G. L. (2012). Play therapy: The art of the relationship. New York: Routledge. Landreth, G. L., & Bratton, S. C. (2005). Child parent relationship therapy (CPRT): A 10-session filial therapy model. Brunner-Routledge. Minuchin, S. (1974). Families and family therapy Oxford, England: Harvard U. Press. doi: 10.1093/sw/20.1.72 Minuchin, S., Baker, L., Rosman, B. L., Liebman, R., Milman, L., & Todd, T. C. (1975). A conceptual model of psychosomatic illness in children: Family organization and family therapy. Archives of general psychiatry, 32(8), 1031–1038. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods, 11th ed. New York: Pearson. Northey, W. F. (2002). Characteristics and clinical practices of marriage and family therapists: A national survey. Journal of Marital and Family Therapy, 28(4), 487–494. doi: 10.1111/j.1752-0606.2002.tb00373.x Rotter, J. C., & Bush, M. V. (2000). Play and family therapy. The Family Journal: Counseling and Therapy for Couples and Families, 8(2), 172–176. doi:10.1177/ 1066480700082010 Sanders, M. R., & McFarland, M. (2000). Treatment of depressed mothers with disruptive children: A controlled evaluation of cognitive behavioral family intervention. Behavior Therapy, 31(1), 89–112. doi:10.1016/S0005-7894(00)80006-4 Slopen, N., Kubzansky, L. D., McLaughlin, K. A., & Koenen, K. C. (2013). Childhood adversity and inflammatory processes in youth: A prospective study. Psychoneuroendocrinology, 38(2), 188–200. doi:10.1016/j.psyneuen.2012.05.013 Sori, C. F. (2006). Reflections on children in family therapy: An interview with Salvador Minuchin. In C.F. Sori (Ed.), Engaging children in family therapy: Creative approaches to integrating theory and research in clinical practice (pp. 139–158). New York: Routledge. Sori, C. F., & Sprenkle, D. H. (2004). Training family therapists to work with children and families: A modified Delphi study. Journal of Marital and Family Therapy, 30(4), 479–495. Stith, S. M., Rosen, K. H., McCollum, E. E., Coleman, J. U., & Herman, S. A. (1996). The voices of children: Preadolescent children’s experiences in family therapy. Journal of Marital and Family Therapy, 22(1), 69–86. doi:10.1111/j.1752-0606.1996.tb00188.x Topham, G. L., & Vanfleet, R. (2011). Filial therapy: A structured and straightforward approach to including young children in family therapy. The Australian and New Zealand Journal of Family Therapy, 32(2), 144–158. doi:10.1375/anft.32.2.144
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Family System Play Therapy: An Integrative Approach Lexie Pfeifer Daley, Richard B. Miller, Roy A. Bean & Megan Oka To cite this article: Lexie Pfeifer Daley, Richard B. Miller, Roy A. Bean & Megan Oka (2018) Family System Play Therapy: An Integrative Approach, The American Journal of Family Therapy, 46:5, 421-436, DOI: 10.1080/01926187.2019.1570386 To link to this article: https://doi.org/10.1080/01926187.2019.1570386
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THE AMERICAN JOURNAL OF FAMILY THERAPY 2018, VOL. 46, NO. 5, 421–436 https://doi.org/10.1080/01926187.2019.1570386
Family System Play Therapy: An Integrative Approach Lexie Pfeifer Daleya, Richard B. Millera, Roy A. Beana, and Megan Okab a
Brigham Young University, Provo, Utah, USA; bUtah State University, Logan, Utah, USA ABSTRACT
ARTICLE HISTORY
Although the roots of family therapy are firmly embedded in a family systems approach to treating child-focused problems, recent research suggests that the treatment of young children is relatively uncommon among family therapists. One possible reason is the dearth of family systems-based approaches for treating children. After reviewing existing treatments for children’s presenting problems, an integrated approach to family play therapy which draws upon structural, attachment, and play therapies, is theoretically conceptualized. This approach is applied to a case example of family therapy with a 9-year old boy with behavior problems and his parents. Implications for clinical application and future research are discussed.
Received 13 September 2018 Revised 9 January 2019 Accepted 10 January 2019 KEYWORDS
Family & couples therapy training; family therapy interventions; play therapy
There is substantial evidence that family therapy is an effective therapeutic approach for addressing childhood mental health problems (Carr, 2014; Kaslow, Broth, Smith & Collins, 2012). A major review of family therapy interventions for common childhood diagnoses (i.e., childhood depression, anxiety, ADHD, and ODD) reported that Family Cognitive Behavior Therapy (FCBT), Parent Child Interaction Therapy (PCIT) and similar behavioral or parent-training programs have been shown to be effective using RCTs (Carr, 2014). In addition, family therapy approaches have also been shown effectiveness for decreasing symptoms associated with infant attachment problems, child abuse, conduct, emotional, and somatic problems. Finally, a meta-analysis of 48 studies that directly compared the effectiveness of individual child therapy with that of family therapy with children found that family therapy was significantly more effective (Dowell & Ogles, 2010). However, most of these child family therapy approaches have been adapted from established individual child therapy models. Empirically supported treatments for childhood diagnoses within the field of marriage and family therapy are heavily weighted towards behaviorally-oriented family psycho-educational models, FCBT, and parent-training models (Northey, 2002). Family psycho-educational models and FCBT consist of teaching parents parenting skills and parallel cognitive work with the parents CONTACT Megan Oka [email protected] 6453 Old Main Hill, Logan, Utah 84322, USA. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uaft. ß 2019 Taylor & Francis Group, LLC
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(Sanders & McFarland, 2000). Parent-training models are characterized by their methods of training parents in warmth, positive attention, discipline, limit-setting, consistency, and other parenting skills (Kaminski, Valle, Filene, & Boyle, 2008, Herschell, Calzada, Eyberg, & McNeil, 2002). What is missing in current popular child family therapy treatment models is a systemic conceptualization of childhood mental illnesses and treatment that focuses on multiple subsystems within the family as they interact to maintain symptomatic behavior in children. The focus in traditional marriage and family therapy models is on the interaction between internal, individual child and parent factors, as well as the interaction of family subsystems (such as the marital subsystem or sibling subsystem) as they contribute to the development and maintenance of functional symptomatic behaviors. Systemic therapists consider the interplay between multiple levels of systemic interactions (Nichols & Davis, 2017). Often the presenting symptomatic behavior of one family member plays a functional role for the family, such as when a child’s acting out behaviors function to diffuse marital tension. Ironically, the roots of family therapy are firmly embedded in the systemic treatment of families to reduce children’s symptomology. Carl Whitaker, like many of the original founders of family therapy, held a firm belief in the vitality that young children bring to the family therapy process (Keith & Whitaker, 1981). Virginia Satir is another prominent example of early work with young children and their families. Her techniques, such as family sculpting, focused on understanding family interactions to understand the diagnosed child (Gil, 2015). Salvador Minuchin, the founder of structural family therapy, also was interested in the functional symptomatic nature of children’s presenting concerns and did much of his work with families of young children (Minuchin, et al., 1975). Despite its historical roots, the field has drifted away from the systemic treatment of childhood problems. In a survey of randomly selected AAMFT clinical members, marriage and family therapists reported that the majority of their clients were adults, with only 13% of private practice and 36% of institutional clients under 18 years of age. They reported that child behavior problems ranked lowest among commonly reported presenting problems. Further, of MFTs’ reported clinical work with children and adolescents, a large proportion was individual therapy, as opposed to family therapy (Northey, 2002). MFTs’ comfort level working with children (Sori & Sprenkle, 2004) and a lack of specific MFT models of child-focused treatment may explain MFTs’ exclusion of children in family therapy. This article introduces a systemic perspective to treating families of young children that integrates the principles of structural family therapy (Minuchin, 1974) with techniques and principles of individual play therapy.
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This approach conceptualizes family play interactions into a systemic framework and intervenes systemically within the play metaphor presented by the family. This approach continues in the tradition of early family systems therapy models, while drawing upon more recent advances in the play therapy field. Literature review Family therapy
Basic research supports a systemic perspective of the development of internalizing and externalizing disorders in children. Exposure to anger, aggression, and conflict in the family are risk factors for children’s poor mental health (Slopen, Kubzansky, McLaughlin, & Koenen, 2013). Controlling, neglectful and punishing family dynamics are other factors associated with the development of oppositional defiant disorder (ODD), specifically (Barkley, 2013). In addition, the ability of parents to work together is an important, but typically neglected, aspect of effective parenting. Co-parenting can be characterized by antagonism, undermining between partners, or triangulating children (Fosco & Grych, 2010) and has been linked to child symptomology. Popular family therapy approaches generally use behavioral and attachment principles that potentially miss a litany of family dynamics that maintain and coexist with children’s mental health problems (Carr, 2014). Missing from these existing approaches with children are components that investigate the familial contextual stressors that contribute to poor mental health of family members and the altered family structures and roles that develop around the parent or child’s mental health needs. There is a need to return to facilitating and working with spontaneous interactions that are created between family members, family subsystems, and the unique temperaments and experiences each family member brings to these interactions. Play therapy
The strength play therapists bring to family therapy with children is their understanding of developmentally appropriate therapy. The National Institute of Mental Health, in a review of childhood intervention research, noted the importance of developmentally sensitive models to treat childhood mental health disorders (Hoagwood & Olin, 2002). For example, traditional talk-therapy employs a variety of cognitive and verbal strategies that can be beyond the attention span and the cognitive and verbal skills of young children (Sori & Sprenkle, 2004). Play therapy models address this
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limitation of traditional therapy and are shown to be generally effective with a range of behavioral and emotional issues (Bratton, Ray, Rhine, & Jones, 2005). Further, children want to be included in play therapy, and young children, in particular, report liking play activities included as part of therapy (Stith, Rosen, McCollum, Coleman, & Herman, 1996). Play therapy stems from psychoanalytic tradition and has been an individual, child-centered model. Similar to adult models of psychoanalysis, traditional play therapy viewed the relationship between therapist and client as the most important healing relationship, which is a notion that family therapy has largely rejected (Landreth, 2012). Filial therapy is an exception (Landreth & Bratton, 2005). Filial therapy is a family play therapy model that coaches caregivers to learn the basic principles of child-centered play therapy. Outcome research shows larger effect sizes for filial therapy provided by parents, as opposed to play therapy with a professional (Bratton, Ray, Rhine, & Jones, 2005). Filial therapy integrates psychoanalytic, developmental, behavioral, and attachment theories to treat the child (Topham & Vanfleet, 2011). Parents are trained to set aside their emotions and needs and provide a secure attachment for their child. They are coached in structuring, empathic listening, child-centered imaginary play, and limit setting, and practice in a non-directed play session with their child and then process their emotional reactions to the experience in the play room with the therapist separately. Filial therapy and structural therapy have organizing principles that correlate, such as enactments, hierarchy, and boundaries (Topham & Vanfleet, 2011). However, filial therapy differs from traditional systemic family therapy by separating the parents’ emotional processes from the here-and-now of parent-child interaction. In filial therapy, the parent is required to maintain a grounded emotional state to provide a therapeutic presence for the child. Their emotional reactions are processed following the play experience. Parents are instructed to have the child lead the play and only participate in play as specified by the child. This structure may preclude the opportunity to fully address problematic parent-child cycles systemically, as parents’ typical trigger points and reactions are sublimated in order to create a safe space for the children. In addition, the role of other subsystems (marital/ sibling) are not a strong focus of filial therapy. Other family therapists have made adaptations and developed interventions based in systems theory with the inclusion of play in order to engage young children in family therapy (Rotter & Bush, 2000). Eliana Gil was in the forefront in her work of integrating play techniques and family therapy (Gil, 2015). She assigned joint play activities to assess how families work together and achieve tasks, and to promote joy, enjoyment, and enhanced attachment. By using a combination of family play techniques, such as
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genograms with figurines, art activities, sand trays, puppet shows, and mutual story-telling, the family achieves enhanced communication and empathy toward each other (Gil, 2015). Gil noted that family structural dynamics (interactional patterns or alliances) are observable in family play therapy sessions. Researchers and clinicians in the field of marriage and family therapy and play therapy both highlight the importance of family intervention, but there is a divide between the two fields where valuable knowledge and skills are not being shared. Play therapists bring a strong attachment focus and proficiency in the child’s language of play. Family therapists bring a strong systemic conceptualization of family patterns that create and maintain child symptomatic behavior. There is a gap in our current literature and practice for integration of traditional family therapy, with its emphasis on hierarchy, subsystems, roles, rules, triangles, and other family patterns, and play therapy, with its emphasis on developmentally appropriate methods to include children in their own therapy. These two methods, though not commonly used together, are not mutually exclusive. The balance of this paper will examine the integration of these two approaches, with an overview of the theoretical underpinnings borrowed from each, and a case study applying this approach to a family with a young child. We will include a description of the case, the treatment interventions used, and commentary about the rationale throughout. Model overview Theoretical background
The proposed treatment approach is an integration of structural and play therapy perspectives. We acknowledge that this is not the first attempt to integrate structural family therapy with play therapy, as even Minuchin was known to say that structural therapy with children was mean to be playful (Sori, 2006), and others have integrated play or art therapy with structural therapy (Dermer, Olund, & Sori, 2006; Hoshino, 2008). Our purpose in this paper is to provide practical application of an integrated theory from top to bottom. Structural family therapy includes attention to hierarchy, triangulation, excessively rigid or diffuse boundaries, and family rules in the conceptualization of functional symptomatic behavior (Minuchin, 1974). The proposed approach also draws upon the developmental strengths of play therapy. Children express themselves through play and symbolic representation (Rotter & Bush, 2000). Young children are still developing language and cognitive ability, which may contribute to difficulty with traditional talk-based models of therapy because young children do not have the words to articulate their emotion and experience. Play is a
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Figure 1. Integration of play therapy and family therapy.
developmentally attuned method of giving young children a voice in therapy (Rotter & Bush, 2000). These two theories integrate well, using the directive components of structural family therapy to make changes to the hierarchy while retaining the play aspects of play therapy to give children a way to voice their experiences (See Figure 1). Assessment
In this model, assessment is conducted in two phases. First, in a parent consultation meeting, parents describe the presenting problem, and the therapist describes the process of family play therapy. The parent consultation meeting without the child present defines the parental subsystem as distinct from the child or children, and reinforces the family hierarchy and direction of caregiving from parents to children. Parents are reminded of basic principles of child development and presented with the rationale for play as the language of therapy. Parents prepare their child for therapy by explaining, “The therapist wants to help us know how to help you with [presenting problem]”. This explanation minimizes the child’s anxiety about being the identified patient. Parents are told that the first two sessions will be for the purpose of understanding the child and problem in the context of family interactions (how the problem impacts or is impacted by family dynamics). For the second part of assessment, the therapist observes initial family sessions with minimal intervention, observing for family structural dynamics. These dynamics can include family roles, hierarchy, alliances, triangles and/or family implicit rules, such as unspoken restrictions against expressing certain emotions, engaging in certain behaviors or broaching taboo subjects. The therapist pays attention to ways in which the child invites or
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does not invite adult participation in the play. The therapist also observes the emotions triggered in the parents and child that are associated with their roles and patterns of interaction. For example, a parent may become uncomfortable and discourage angry themes in play or distract from deep and uncomfortable emotions, like sadness and fear. The therapist observes instances when the parent(s) shift from a child-focused orientation (following the child’s lead) to a parent-oriented reaction (disciplining, lecturing/moralizing or distracting). The therapist will ask him/herself: What conditions provoked the shift? What is the step-by-step process of interaction and escalation during these moments? Finally, the therapist pays attention to themes and symbols the child introduces. Treatment
The treatment phase of therapy draws the family’s attention to observed family dynamics that maintain symptomatic behavior and suggesting altered structures that could alleviate the child’s symptoms. Observed family dynamics will vary. Common themes for restructuring include defining and strengthening boundaries around the parental subsystem or establishing the parents as authoritative leaders in the hierarchy, helping the parents work together as a team, and facilitating less rigid or less diffuse boundaries for communication and emotional expression. These suggestions should utilize the play metaphor presented by the family and be responsive to here-and-now play moments. The therapist uses play to draw the family’s attention to these dynamics and the emotional impact of the existing structure on individual family members and children. Based on these observations, the therapist may suggest or guide play to explore different roles, structures, and rules that can reduce symptomatic behavior in children. To facilitate a family play therapy session, the therapist should have a few basic play materials on hand, including basic art material, balls, foam swords, play food, toy cash register, doctor’s kit, or dolls. These materials invite relational transactions and emotional expression. Hats, dress-up accessories, puppets, or figurines can provide information about family roles and relationships. For example, a doctor may suggest a care-taking or fixing role. Puppets and figurines should represent a wide range of characteristics and come from a range of environments to offer the best range of expression for different family personalities. Throughout treatment, the therapist also conducts monthly parent consultation sessions in which the therapist and parent discuss themes, meaning, and experience of family play. This helps increase the parent(s) perspective and empathy for the child’s symptomatic behavior. The
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therapist can also use these parent consultation sessions to discuss and collaborate with the parents about more adaptive roles they can take on in the play sessions or to address couple or marital issues that have emerged during family play sessions that should be kept separate from the children. Parent consultation sessions may go against the Whitaker “family crucible” style therapy (with all family members present). However, this component remains consistent with systems theory as their concerns specific to the marital/parental subsystem that are better discussed without the child present, and this process takes the child of that triangle. Termination
Closure of therapy is initiated upon parent reports of reduction in child symptomatic behaviors and as the therapist observes and the client reports comfort with newly established structure and patterns of interaction. Often, therapy may reveal dynamics in other subsystems of the family (such as the couple) that may become the focus of therapy. Implications for family therapy/Practice—Case example
The following case example illustrates what this process looks like with a specific family. The identified patient was a 9-year-old Caucasian male. His parents sought treatment for behavioral problems exhibited at home and school. He reportedly became physically aggressive with family members and friends, and, when he got frustrated, he would hit and kick others. His behavior problems and nonconformance to rules at school had led his parents to try homeschooling. His parents were also concerned about his social adjustment with same-aged peers. The parents also had difficulty establishing and maintaining clear and consistent boundaries for his behavior, and all became emotionally reactive during power struggles. The parents were in their forties, and they were middle income. The father was often away on business trips, and the mother was a homemaker. There were also three much older sisters (15, 17, and 18 years) in the family. In Jason’s (fictional name) first play sessions, two prominent dynamics emerged. First was an alliance or triangle between Dad and Jason (against Mom). During a game of checkers, Jason and Dad teamed up against Mom. Before jumping Mom’s checkers, Jason teased, “Time for public humiliation.” Mom replied in a sarcastic tone, “I love public humiliation.” Then, Dad joined with Jason, continuing to bait Mom, “How public? Jason, [are] we gonna put it in the newspaper?” On another occasion, Jason recruited the therapist to help him get the “bad guy” (played by Mom). The therapist made a normalizing statement to Mom: “That happens in
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therapy.” Mom emphasized, “That always happens in our house,” which suggested that she resented being ganged up on when there was an alliance between Dad and Jason. Second, the parents’ authority was inconsistent, and they often felt powerless to effectively redirect Jason. In game play between Jason and Dad, Jason would change rules to favor his winning, and Dad became frustrated. At first, Dad responded in the parent role by teaching and redirecting Jason towards fair game-play. When Jason ignored this redirection, Dad responded to his powerlessness to enforce proper game-play by breaking rules also. He relinquished control of game-play to Jason, but with teasing, passive-aggressive comments about the unfair playing field Jason had created. Mom sat by quietly, without intervening during these interactions. This shift from Dad’s hierarchal role to a peer-level interaction indicated an emotion-laden theme to explore. In this case, the therapist focused on strengthening the parental alliance by suggesting that for the next game Mom and Dad be on a team, strengthening the parental subsystem. Exploring alliances and triangulation. The parents had previously described that play between Jason and his father commonly escalated, like siblings, and Mom became the mediator when the play became too rough. Mom described that after intervening between Jason and his father, her husband resented her. She disliked being the “bad guy.” This dynamic manifested in a cops-and-robbers game with Mom and Dad as criminals and Jason and therapist as cops. Dad was provoking Jason by shooting him while Jason was still preparing for the game. The therapist highlighted this dynamic, observing, “It looks like the game has started.” Jason protested, “No, it hasn’t.” The therapist reinforced Jason’s message, “Oh, so [Dad] is jumping the gun a bit.” Jason agreed, “Yeah, I’m trying to get away so I can actually start the game.” Dad continuing to ignore Jason’s boundary and grabbed Jason’s sheriff badge to steal it. Jason found a whistle and blew loudly three times, “Dad! Don’t do that!” Dad relinquished and responded, “I just want to be the good cop.” The therapist reinforced Jason’s attempts to set a boundary by observing, “It seems like [Jason] is trying to get order.” At this point, Dad returned to his chair. Mom watched these escalating interactions as a bystander. The therapist observed, “They don’t give up easily, do they?” Mom replied, “I normally sit back and watch”. Later in the play, Dad and Jason were struggling over a toy gun and Dad had playfully wrestled Jason to the ground. Jason again grabbed and blew the whistle. The therapist reinforced, “It looks like Jason is trying to get order again.” Then, to Jason she asked, “What does the whistle mean?” Dad offered, “Does that mean ‘Help’?” Jason concurred with the request, “Help,” freeing himself from Dad’s pin. Then, still handcuffed, with gun pointed at Dad, he asserted, “I may have handcuffs, but I am still capable.”
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In these interactions, the therapist drew attention to the immediate family process, and particularly, what Jason was communicating with the whistle. The therapist helped Dad to increase his awareness of Jason’s cues, and helped Jason to articulate his feelings and boundaries to Dad. The therapist intentionally facilitated this interaction without involving Mom. By acting in a hierarchal, parent role, Dad raised himself to the parent level in the family hierarchy, without Mom intervening reinforcing his sibling-level interaction with his son. This created an atmosphere for Jason where both his parents were safe, responsible and in charge. Also emerging in this dialog was a theme of competence or adequacy that underlay Jason and his father’s competitive interactions. This theme was evidenced by statements such as “I just want to be the good cop” (Dad) and “I am still capable” (Jason). In a subsequent parent consultation, the therapist explored this theme with Jason’s father to increase his emotional awareness of himself and Jason when they engaged in competitive, escalating interactions. Dad noted that these interactions mirrored his control issues with Jason. He reported getting frustrated with Jason when he wanted control and teasing him until he got upset. The therapist connected Dad’s frustration over his lack of control to Jason’s frustration and desire for control, which Dad readily acknowledged. Exploring the parents’ emotions surrounding these competitive, escalating interactions between Jason and his father served two purposes. First, it increased the parents’ awareness of how Jason may perceive those interactions. Second, it increased Dad’s self-awareness of feelings of inadequacy, not only in the parenting relationship, but in his relationship with his wife. The therapist hypothesized that Dad felt his marriage is “stacked unfairly” and he often loses the battle for control with his wife. Similarly, the therapist surmised from Mom’s comments that she felt “left out,” not only with Jason, but alienated and isolated in their marriage. These hypotheses were later confirmed in subsequent marital therapy sessions. Exploring functional symptomatic behavior. Subsequent therapy sessions revealed another symptomatic behavior. Jason would alternate between using his normal, age-appropriate voice and a small, “baby” voice. The therapist noticed that the baby voice tended to surface when there was confusion about hierarchy in relationships or who was in charge of leading the activity. The therapist made this confusion explicit, and helped the parents and child negotiate leadership of the play activity (see below): Jason: (baby voice) Dad, you get to choose … (changing his mind) No, Dad, do you wantto hide the toys or do you want to come over here with me? Dad: Did you want me to go over there with you?
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Jason:
(baby voice) It depends which one you want. What do you want? Dad: Well, I don’t care, but you told me that the person that won [rock paper scissors] was supposed to [hide items in sand]. But I would be happy to [do it the other way]. Jason: (No response to Dad. Goes over to where Mom is standing in the corner) Therapist: Jason, can we take a time out for a minute? You’re deciding what everyone does, but I’m wondering if you want that or if you’d like Mom and Dad to decide? Jason: (shift to normal voice) Well, that’s what I was kinda hoping Dad would do. Therapist: Do you want for the rest of the time to be the kid (conjecture to the functional symptomatic role of the baby voice), and Mom and Dad decide how you play? Or do you want to keep deciding? Jason: Um, we should take turns. Therapist: Okay, you let them know when you want them to decide. Once the confusion about who was in charge of the play activity was made explicit and Jason was aided to articulate what he was feeling and wanted, his voice shifted to a tone and quality consistent with his age. This negotiation between parents and Jason provided an opportunity to learn age-appropriate autonomy and leadership (Erikson, 1998). The play activity made explicit this developmental task and afforded an opportunity for the therapist to facilitate parents’ and child successful resolution of this negotiation around leadership and autonomy. The parents had an experience with successfully negotiating and communicating with Jason, but in the context of a 50-minute play session, it is unlikely that this particular interaction stood out to them such that they would agree with the therapist’s conjecture regarding the functional symptomatic nature of the problem behavior. Even if they were to agree, it is unlikely the parents were aware of the importance of the interaction and the potential to replicate this kind of interaction at home. The therapist followed up with a parent consultation session to collaborate with the parents to brainstorm the function of the problematic behavior (baby voice) in the context of their family dynamics. The therapist noted that Jason was often confused about when to lead and when to follow in session and suggested that the parents acknowledge that confusion by saying something like, “Oh, you seem confused. Do you want me to lead this or do you want to lead this?” to clarify roles in the moment.
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This parent consultation increased Jason’s parents’ awareness of the context of his regressed speech. The parents became co-investigators of the function that Jason’s symptomatic nature played in the family. In addition, the therapist gained more information about the function of the baby voice when Dad suggested that Mom “likes having a little baby at home.” This parent consultation also revealed subtle conflict and disagreement between the parents about Jason’s behavior, which could be indicative of the previous theme of Jason’s being triangulated into marital conflict. The therapist chose to address potential triangulation by strengthening the parental alliance through a team approach to investigating and addressing Jason’s behavior. Exploring mutual reactivity. Throughout therapy, the therapist intervened by increasing the parents’ and child’s emotional awareness of self and other in the play interaction. The therapist was particularly attuned to how family structural dynamics impacted the emotional experience between parents and child. An example of a therapist intervention around this theme is illustrated by the following session in which Jason and Mom played cops-and-werewolves: Therapist: Before we leave, I have two questions for you and your Mom. How did it feel to be the cop and how did it feel to be the criminal? Jason: Awesome. Therapist: (Directs them to look at chart depicting feelings with illustrations and words). So you feel “awesome,” and pick one other feeling. Jason: Happy and Hysterical. Therapist: Happy and Hysterical. To be which one (cop or criminal)? Jason: Both … the criminal was more hysterical though. Therapist: How about you, Mom? Mom: As the criminal? Frightened. And as the cop? Confused … (nervous laughter). Therapist: I was thinking that one too. I was feeling a little scared and confused sometimes because … Jason: (interrupting) I felt guilty and suspicious also when I was the … Mom: Criminal? Therapist: I was thinking, I don’t know if I’d like to be that criminal and feel like I had to hide all the time like that. Jason: (to Mom) Why did I have to be the werewolf? Mom: I don’t know. It just came to me. Jason was initially superficial in his description of his feelings playing the role of the criminal or werewolf. His mother’s higher cognitive and verbal
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skills at recognizing, articulating and holding multiple emotions modeled for Jason how to talk about feelings. His mother’s vulnerability about her feelings playing cop and criminal also invited Jason to share more depth of emotion. Mother and child connected as each shared their feelings about what it was like to be the “bad guy” or the “good guy” in the family, or to feel powerful or powerless in relationships. This dialog even created space for Jason to question his role as the “werewolf,” which could reflect his discomfort with his parents’ view of his behavioral problems. Jason and his parents participated in eight family play therapy sessions together. There was also an initial parent consultation session and midtherapy consultation for a total duration of ten sessions. At the end of therapy, the parents reported less occurrences of Jason behavioral acting out and positive accounts of Jason’s relations with peers. Also, in therapy, Jason became more assertive and articulate in voicing his feelings and needs in age-appropriate ways. Frequency of the “baby voice” decreased across sessions. These family therapy sessions also helped to align the parents, de-triangulate Jason from marital concerns, and increase emotional and relational awareness. The couple decided to shift therapy away from a focus on Jason’s symptomatic behaviors and work on their couple relationship in marital therapy, which was further indication of progress toward more clear boundaries separating the parental subsystem from the child. Discussion
Using components of both structural family therapy and play therapy worked to both restructure the family hierarchy and abate the child’s symptomatic behavior in several ways. First, the use of play therapy became an equalizer for this family. When all members were playing together, cognitively and verbally they were all at the same level. This allowed for problematic structural dynamics to emerge, like Mom being left out of interactions, or power struggles between Jason and Dad. Using play therapy language, the therapist was able to comment on these dynamics in a way that allowed Jason to feel heard and acknowledged, which translated to him being able to articulate his feelings toward his parents, rather than expressing his frustrations through negative behavior. The structural components of this approach were particularly salient for the parents. Helping the parents to recognize the roles they played in their family, with Dad and Jason in a coalition, Mom taking on the role of both parent and villain, helped the parents to change their behavior outside of therapy. Activities that strengthened the executive subsystem in therapy helped parents experience healthier roles and interactions, and parent
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consultation sessions with the therapist helped them to internalize these changes and carry them forward. It is clear that, for this family, structural therapy without play would have reinforced the triangulation of Jason into adult issues that he was already experiencing with his parents. Play therapy without the structural component could have maintained the dynamic of Dad and Jason ganging up on Mom or competing with each other like siblings. By integrating these two, we were able to strengthen the parent-child hierarchy while still giving voice to the child’s concerns and emotions. Limitations
This model lends itself well to the family described in the above scenario: weak parental alliance, coalitions, and diffuse parental boundaries. In other words, this case study resembles those described often by Minuchin and his colleagues. We recognize that not every family’s presenting problems may fit a structural approach as neatly as this family did, and therefore, it is hard to generalize this model to a variety of presenting problems. Additionally, what is presented in this paper is a case study, which is appropriate for a new theoretical orientation, as it allows readers to examine the theory in-depth, with one case (Kazdin, 2003). However, the sample size is small, and the data are anecdotal and descriptive, so it is harder to draw conclusions about the effectiveness of this model across participants. Future directions
The purpose of this paper was to present an integrated model for working with families. This model is still in its early stages and needs more development. For example, a future paper could include more systematic development of the model, offering beginning, middle, and end of therapy tasks. Further, given the need for family therapy models that treat specific childhood disorders, future work may examine how this model applies to other child problems, such as ADHD, ODD, depression, or anxiety. Future studies could include more empirical validation of the model, collecting preand post-therapy assessments that examine both family functioning and child outcomes. Conclusion
This article has presented a proposed treatment approach for engaging children in a theoretically systems-based approach to family play therapy. This therapeutic approach is a call for a return to the foundational principles of systems theory when treating child-focused problems. The advantages of
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this approach include a more comprehensive perspective of child symptomatic behavior as a function of family systemic dynamics, engagement of the child’s voice in family therapy through play, engagement of the family as a tool in actively addressing parent-child interaction and child presenting problems, and a gateway to parent awareness and willingness to participate in couple therapy for adult subsystem concerns. Child and family therapists from all disciplines are invited to apply the principles proposed in this approach and contribute to future research that will refine and validate the practice of family play therapy with young children and their families. References Barkley, R. A. (2013). Defiant children: A clinician’s manual for assessment and parent training. New York: Guilford Press. Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 376–390. doi:10.1037/0735-7028.36.4.376 Carr, A. (2014). The evidence base for family therapy and systemic interventions for childfocused problems. Journal of Family Therapy, 36(2), 107–157. doi:10.1111/1467-6427.12032 Dermer, S., Olund, D., & Sori, C. F. (2006). Integrating play in family therapy theories. In C.F. Sori (Ed.), Engaging children in family therapy: Creative approaches to integrating theory and research in clinical practice (pp. 37–65). New York: Routledge. Dowell, K. A., & Ogles, B. M. (2010). The effects of parent participation on child psychotherapy outcome: A meta-analytic study. Journal of Clinical Child & Adolescent Psychology, 39, 151–162. doi:10.1080/15374410903532585 Erikson, E. H., & Erikson, J. M. (1998). The life cycle completed (extended version). New York: WW Norton & Company. Fosco, G. M., & Grych, J. H. (2010). Adolescent Triangulation into Parental Conflicts: Longitudinal Implications for Appraisals and Adolescent-Parent Relations. Journal of Marriage and Family, 72(2), 254–266. doi:10.1111/j.1741-3737.2010.00697.x Gil, E. (2015). Play in family therapy (2nd Ed). New York: Guilford. Herschell, A. D., Calzada, E. J., Eyberg, S. M., & McNeil, C. B. (2002). Clinical issues in parent-child interaction therapy. Cognitive and Behavioral Practice, 9(1), 16–27. doi: 10.1016/S1077-7229(02)80035-9 Hoagwood, K., & Olin, S. S. (2002). The NIMH blueprint for change report: Research priorities in child and adolescent mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 760–767. doi:10.1097/00004583-200207000-00006 Hoshino, J. (2008). Structural family art therapy. In C. Kerr, J. Hoshino, J. Sutherland, S. Parashak, & L., McCarley (Eds.), Family art therapy: Foundations of theory and practice (pp. 119–166). New York: Routledge. Kaslow, N. J., Broth, M. R., Smith, C. O., & Collins, M. H. (2012). Family-based interventions for child and adolescent disorders. Journal of Marital and Family Therapy, 38(1), 82–100. doi:10.1111/j.1752-0606.2011.00257.x Keith, D. V., & Whitaker, C. A. (1981). Play therapy: A paradigm for work with families. Journal of Marital and Family Therapy, 7(3), 243–254. doi:10.1111/j.17520606.1981.tb01376.x
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Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567–589. doi:10.1007/s10802-007-9201-9 Kazdin, A. E. (2003). Drawing valid inferences from case studies. In A.E. Kazdin (ed.), Methodological issues & strategies in clinical research 3rd ed. Washington D.C.: American Psychological Association. Landreth, G. L. (2012). Play therapy: The art of the relationship. New York: Routledge. Landreth, G. L., & Bratton, S. C. (2005). Child parent relationship therapy (CPRT): A 10-session filial therapy model. Brunner-Routledge. Minuchin, S. (1974). Families and family therapy Oxford, England: Harvard U. Press. doi: 10.1093/sw/20.1.72 Minuchin, S., Baker, L., Rosman, B. L., Liebman, R., Milman, L., & Todd, T. C. (1975). A conceptual model of psychosomatic illness in children: Family organization and family therapy. Archives of general psychiatry, 32(8), 1031–1038. Nichols, M. P., & Davis, S. D. (2017). Family therapy: Concepts and methods, 11th ed. New York: Pearson. Northey, W. F. (2002). Characteristics and clinical practices of marriage and family therapists: A national survey. Journal of Marital and Family Therapy, 28(4), 487–494. doi: 10.1111/j.1752-0606.2002.tb00373.x Rotter, J. C., & Bush, M. V. (2000). Play and family therapy. The Family Journal: Counseling and Therapy for Couples and Families, 8(2), 172–176. doi:10.1177/ 1066480700082010 Sanders, M. R., & McFarland, M. (2000). Treatment of depressed mothers with disruptive children: A controlled evaluation of cognitive behavioral family intervention. Behavior Therapy, 31(1), 89–112. doi:10.1016/S0005-7894(00)80006-4 Slopen, N., Kubzansky, L. D., McLaughlin, K. A., & Koenen, K. C. (2013). Childhood adversity and inflammatory processes in youth: A prospective study. Psychoneuroendocrinology, 38(2), 188–200. doi:10.1016/j.psyneuen.2012.05.013 Sori, C. F. (2006). Reflections on children in family therapy: An interview with Salvador Minuchin. In C.F. Sori (Ed.), Engaging children in family therapy: Creative approaches to integrating theory and research in clinical practice (pp. 139–158). New York: Routledge. Sori, C. F., & Sprenkle, D. H. (2004). Training family therapists to work with children and families: A modified Delphi study. Journal of Marital and Family Therapy, 30(4), 479–495. Stith, S. M., Rosen, K. H., McCollum, E. E., Coleman, J. U., & Herman, S. A. (1996). The voices of children: Preadolescent children’s experiences in family therapy. Journal of Marital and Family Therapy, 22(1), 69–86. doi:10.1111/j.1752-0606.1996.tb00188.x Topham, G. L., & Vanfleet, R. (2011). Filial therapy: A structured and straightforward approach to including young children in family therapy. The Australian and New Zealand Journal of Family Therapy, 32(2), 144–158. doi:10.1375/anft.32.2.144
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