ASSIGNMENT

Traditional family therapists often work with family members of similar cognitive levels and exclude small children from the therapeutic process. Recent research indicates that children and families benefit when all family members can be involved in counseling (e.g., Thompson, Bender, Cordoso, & Flynn, 2011). Using an integrative intervention model, this article will focus on specific playbased activities which can be used to effectively include children in family therapy. A developmental, step-by step protocol is introduced and specific play-based activities are discussed.

INTRODUCTION

Several family therapists are expanding their clinical practice to include family therapy techniques and strategies that benefit children. Nims and Duba (2011) note a current movement in the counseling profession to combine family counseling and play therapy so that all members of the family benefit from creative, therapeutic interventions. This combination may be referred to as “play based activities in family counseling” which emphasizes the use of creative, play oriented activities that all family members participate in together. In contrast, play therapy encourages children to work through their thoughts and feelings via play and focuses on the specific relationship building between child and counselor, communication through play, assessment, healing and growth (Orton, 1997). In the past and in some current practice, family counseling primarily focuses on adults in the family and adolescents who are developmentally capable of benefitting from traditional talk therapy that is insight oriented. Yet, the current trend which integrates children into family therapy has produced promising empirical results. Thompson, Bender,

Address correspondence to Joseph D. Wehrman, Department of Counseling and Human Services, University of Colorado, 1420 Austin Bluffs Parkway, Colorado Springs, CO 80918. E-mail: [email protected]

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Cordoso, and Flynn (2011) found that using experiential activities while including children in family counseling led to an increase in positive family interactions and enhanced communication skills among family members. Despite this trend, family therapy with parents/caregivers and children can be challenging to facilitate as a counselor. The dissimilarity in age represents significant differences in language skills, cognitive development, understanding and reasoning and verbal processing which can dramatically affect the structure and format of the counseling session. Adults and children function in different cognitive worlds and often expect the other to understand their perspective or view. To further complicate the challenges, adults often invite or encourage children to participate in ‘their world’ resulting in often unsuccessful interactions (Wittenborn et al., 2006). Because of the power differential between adults and children, children are often expected to think, talk, understand and relate at the level of adult functioning. If the counselor does not tailor or does not know how to structure a session to be developmentally relevant for kids, young children who are less verbal may be left out or relegated to an observer role of the “parentified” conversation taking place in the session. As a result of their exclusion, children may engage in attention seeking or anxiety driven behaviors that are distracting to the adults. These family sessions can seem chaotic, less productive and feel overwhelming for both the counselor and the family members. Counselors may frequently be at a disadvantage when they attempt to plan for a family session which fully includes young children. Counselor training programs often encourage students to tailor their fieldwork experience to working with children and adolescents or adults, meaning more counseling experience with one age group over another. In practice, family counseling training and caseloads tend to focus on adults and less on working with children (Miller & McLeod, 2001). For example, the Research and Educational Foundation of the American Association for Marriage and Family Counseling (AAMFT) found in a large, randomized study that only 12% of participants’ caseloads included families. Caseloads were primarily made up of individuals and couples (Doherty & Simmons, 1996). Additionally, Smith et al. (1996) found that a significant error made by counselors was to not involve children in the process, while they were present, and work instead with only the parents or adults. This article will focus on specific activities and strategies for effectively including children in family therapy. Families benefit when all members are able to actively participate in the therapeutic process. Interestingly, many families enter counseling for the first time because their child (or children) becomes the “identified patient” or the individual targeted as the one which “causes” family discontent or dysfunction. This variable underscores the importance of including children to create new communication and relational patterns among all family members. The following article will explore specific play-based activities in the family counseling process as well as offer

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an integrative intervention model that can be utilized by family counselors while working with parents and children. A family case study is included to further illustrate these concepts.

FAMILY COUNSELING AND PLAY THERAPY

There are many benefits of involving parents and children in the counseling process (Baggerly & Exum, 2008; Glazer & Clark, 1999; Hill, 2006; Miller & McLeod, 1996; Smith et al., 1996). Working solely with parents and not involving children may reduce the effectiveness of family counseling (Rotter & Bush, 2000). Childhood distress and parental involvement are related (Miller & McLeod, 1996) and parenting style is associated with at risk behaviors. For example, children of parents who exhibit positive parenting styles tend to be less likely to engage in high risk behaviors than those of parents with negative or authoritative parenting styles. All of these factors point to the need to work with parents and children together in family counseling to foster enriched perspectives on understanding the family and family dynamics. Gil and Sobol (2005) found that by including children in family counseling, experiential, play-based activities can have a positive impact on therapeutic productivity. For example, if parents and children are using puppets to metaphorically represent the personalities of family members, they are able to break free of or transcend the typical way that they describe family problems or issues. Family member can take turns using his/her puppet to give voice to how they perceive one another in an indirect manner. Although language skills and cognitive capacity for critical thinking differs by family member, insight can be gained when family members and the counselor listen to how a “puppet” describes each person or interactions with each person. It may assist a child who is willing to have her puppet describe how sad dad is when he is “so tired and no one listens to him”. By being experiential, family members are less analytical and intellectual and more likely to become aware of the emotions that lie beneath the behaviors (e.g., the mom who consistently demonstrates anger toward her children; but, is actually worried about her children’s safety). Because the family is communicating through play, there may be alternatives to expressing challenging emotions like mistrust or shame (Gil & Sobol, 2005). Finally, the creative aspects of play may allow family members to “try on” new ways of relating to one another (e.g., more listening, more patience, less judgment, humor, democratic methods for decision making, etc.). Many research studies validate the importance of play for children in expressing feelings and gaining mastery over fears (e.g., Levine & Kline, 2006; Carmichael, 2006; Orton, 1997; Donovan & McIntyre, 1990). Play therapy “offers the child a powerful way of mastering his or her world and is crucial to cognitive development, personality formation, and social adaptation”

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(Blitstein, 1982, p. 192). Similar to adults using words to communicate, play is the language that children use to express what they are thinking and feeling. As challenging as it might seem to orchestrate family counseling sessions with parents and children together, children are interested in being involved in the process and can contribute in meaningful ways (Gil & Sobol, 2005).

CONSIDERATIONS FOR COUNSELORS

Working in counseling sessions with parents and young children together involves a different skill set as compared to working with adults solely or children solely. Counselors should be knowledgeable of and have access to supplies which support a variety of play-based activities. Various kinds of play and techniques may engage the family in meaningful dialog and problem solving. The use of puppets, dolls, expressive arts, sand tray, and role play are just a few play-based strategies that may benefit the family. Puppets and dolls can be used with most family members of various ages (approximately 4 years old to adult) to illustrate a family member’s subjective “reality” or fantasy. A family can be asked to demonstrate a particular time of day with dolls or puppets (e.g., after school, dinner time, bed time, Saturday morning). Each family member will use his or her doll to “act out” what they do during these time frames. To enhance perspective taking, the family members may want to switch roles (e.g., mom switches to the doll used by her six-year-old daughter and “becomes” the daughter for the re-enactment) and then discuss the outcome (i.e., thoughts and feelings related to how one was “portrayed”). Dolls and puppets can also be used to illustrate a fantasy regarding how a family would like a particular time of day to play out, how they would like to communicate with one another, how they would like to solve problems, and so on. Expressive arts (e.g., markers, paint, chalk, crayons) can be used to create pictures which help to illustrate individual family member perspectives. For example, each family member can be given a large piece of butcher block paper and asked to draw three pictures in three columns: (1) a happy family memory, (2) a sad family memory, and (3) an angry family memory. Each family member can then explain their illustrated memories and discuss them with the family. Family members four and older should be able to participate in this activity and derive benefit from listening to the varied perspectives. Additionally, several other drawing/creating prompts can be useful to use, such as “draw a family secret,” “draw a family problem,” “draw a picture of the family solving a problem,” “draw a picture of family members being kind or respectful,” and so on. Like expressive arts therapy, sand tray play can serve as a therapeutic medium for family members. By manipulating toys in a large sand tray, family members can tell stories, gain mastery over a crisis or trauma, role

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play communication, and problem-solving strategies, experiment with fantasy family situations or scenarios. Family members can take turns in the sand tray while other family members watch, groups of family members can participate together (e.g., children, parents) or if the sand tray is large enough, family members can engage in structured scenarios simultaneously (e.g., show each other what you did while you tried to understand and deal with grandpa’s death). The activities described above suggest that counselors who engage in play-based family therapy use a varied counseling skill set which allows them to manage interpersonal complexity across different developmental levels. When initiating play-based family therapy, counselors should gather information from all family members in the initial counseling sessions to assist them in effectively implementing a treatment strategy tailored to the needs of both parents and children. It is important, at some point during the initial counseling sessions, to discuss therapeutic and developmentallybased benefits of play. Counselors should discuss, with family members, in a developmentally tailored way, the benefits of play including the biological, cognitive and social-emotional components (Wehrman, 2008).

Parent Resistance Parent resistance to play is a common challenge. There are a number of reasons that parents may resist and it is important to note that it should be seen as a normal part of the process. Some of the reasons cited by VanFleet (2000), founder and director of the Family Enhancement and Play Therapy Center, include: parents may be unsure of the value of the counseling and may be uncomfortable with play as part of the process, they may feel uncomfortable with the counselor, or they may be wary of the process if the services are mandated vs. voluntary. Parents may view ‘talking’ about family problems as the key to making changes and play-based activities as detracting from the real work that they think needs to be completed. Parents may ask such questions as, “How can just playing help me or my child?” In response, the counselor should provide explanations that help to co-construct a different way of viewing play with the parents. It must be noted that some parents may feel very uncomfortable with participating in play themselves because they lack self-esteem, self-efficacy or the sense of psychological freedom that permits spontaneous creatively. Parents who are themselves emotionally vulnerable may feel overwhelmed by the expectation to “go off script” with how they normally interact with adults and their children. Given these challenges, it is important for the counselor to fully explain the purpose and importance of using play-based activities in the sessions and model how an adult can play or engage in experiential activities. Taking risks during counseling should be encouraged, acknowledged and reinforced. Self-consciousness

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on the part of the counselor can certainly reinforce the trepidation felt by parents.

Counselor Resistance Counselors may find themselves feeling resistant to using play-based activities in the family counseling process. Often working with young children can feel unpredictable and overwhelming as counselors do not “control” spontaneous play. Further, it can be challenging to connect with children in the presence of their parents if counselors feel inhibited or embarrassed. New counselors especially may feel competing urges to appear competent or as an “expert” and engage in creative activities that will engage the family. Studies have found that a main variable for counselors regarding whether or not to include children in family counseling sessions is their own comfort level (Johnson & Thomas, 1999). A counselor’s work environment, including space, furniture and safety concerns can also be a factor (Millier & McLeod, 2001). Additionally, it may be challenging for counselors to obtain basic supplies needed for the inclusion of play-based activities into family sessions. While counselors may face these external dilemmas (i.e., space and supplies), family counselors who are comfortable will play and believe in its therapeutic benefits, often find creative ways to use experiential play-based activities.

Multicultural Considerations Multicultural considerations are essential in working with children and parents in family counseling. Counselors should discuss activities with parents and ask for their involvement to ensure that the play-based activities are sensitive to the cultural make up of the family. If parents are uncomfortable with a proposed activity, the counselor should explore the origin of the parents’ concerns and invite the parents to make modifications to the activity that will be in keeping with their beliefs, values and customs. For example, a mother from Korea may not feel comfortable with a counselor sitting on the floor and appearing potentially “lower” than the family members; however, she may be willing to sit at a table and chairs and complete the proposed activity. Another consideration is the types of supplies utilized for the play-based activities. For example, if using human figure puppets or dolls, a variety of ethnic groups and both genders should be represented. As an alternative, the counselor can use animal puppets or dolls to allow for the multitude of family configurations. It is also helpful to have a variety of occupations represented to avoid perpetuating stereotypes.

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AN INTEGRATIVE MODEL AND INTERVENTION

In an attempt to organize and structure family sessions which include parents and children, an integrative model based on a variety of approaches (e.g., Strategic Family Therapy, Structural Family Therapy, Solution Focused Therapy, Narrative Therapy, Individual Psychology (Adlerian), and Cognitive Behavioral Therapy) can be useful. The goal of this integrative model is to engage all family members in the therapeutic process while understanding that each member may have a different goal for counseling. Additionally, family members’ ages may range widely requiring the counselor to communicate and intervene on multiple developmental levels simultaneously. The following will outline this model and provide a case example which uses this approach. Using this model, each session is approximately 50 minutes. The format of each session includes: Introduction Phase (5 minutes), Working Phase (30 to 35 minutes), and Inter-Session Break and Special Message Time Phase (15 to 20 minutes).

Supplies It is helpful to have an easel or large sheets of construction paper, a toy box with a wide range of expressive toys, markers, crayons, puppets, and some type of puppet stage in your office or family counseling room (Carmichael, 2006). With puppets, it is important to have a wide range of them for family members to select from. It is also useful to have puppets with dichotomous characteristics such as a puppy and a wolf, a lion and a lamb, etc. This can help identify family dynamics and allow children a variety of expressions.

Introduction Phase The Introduction Phase begins with the counselor greeting the family, shaking each person’s hand, and addressing each by their first name. From the moment of first contact, the counselor should closely observe the behaviors and communication style of each family member. The counselor should note nonverbal communication, the seating arrangement, children’s choice of toys, family power structure/hierarchy, parental discipline and any overt emotions present in the room (e.g., anxiety). Additionally, the counselor should pay attention to how a parent manages a child or multiple children. What are the parents’ expectations for greeting a new adult, managing the child’s belongings, entering a new space/room, etc. (Wachtel, 1994). Shortly after the session begins and introductions have been made, most children will begin exploring the various toys and items in the room. At this time, it can be beneficial to incorporate puppets to give children and parents guidance on how to participate in the therapy session. For example, the counselor might have each family member choose a puppet they think most

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represents them or have them select one without instructions and discuss what interested them in the puppet they chose. The puppets can assist in facilitating the remainder of the session as they help engage children and allow the family to communicate in metaphorical or abstract means about topics that are challenging to address directly. Through a puppet, family members may be more likely to describe what happens in the family and how the family member’s feel about the identified problem. For example, the family can discuss the bark coming from dad’s puppet as opposed to how dad raises his voice at the children when he is angry.

Working Phase A recommendation is that the working phase of counseling be initiated with the counselor and family constructing a family genogram. After explaining what a genogram is and why this activity can be useful for the family, the counselor should specifically inform the children how they can help with constructing the genogram. Drawing sample genograms on a sheet of paper will provide visual examples of what a genogram looks like. Using a large sheet of easel paper and markers, family members can see a representation of different generations and family patterns. This process often uncovers family strengths, interesting stories and family history that children may not be aware of. The counselor may sit on the floor with the child (if appropriate) and begin asking the family questions to construct the genogram. It may be useful to initiate the genogram by first drawing each child and then move to the parents, involving all family members in the process. The counselor utilizes strength based questions to elicit family successes and coping abilities as well as highlight resiliency. Next, the counselor explores the family’s reason for coming to counseling hearing each member’s response. If family members interrupt one another or move to new topics, the counselor can use a blocking strategy and state something such as, “We will come back to that but first I feel that it is important to hear from each member of the family.” If emotions become intense, the counselor can acknowledge the strong feelings while still making sure that each family member is able to explain their perspective about an identified family problem. The final task of the Working Phase is the construction of the “Weekly Check-In Scale”. The counselor asks the family, as a group, to identify when the concern/problem that brought them to counseling was the worst and allows the family to negotiate a specific time, i.e. last March. On the bottom of the paper that the genogram was drawn on, the counselor labels the identified time as a “1” and draw a line across the bottom of the paper with a “10” on the other side. The counselor states to the family that each number above a one indicates that the problem is getting smaller and that the family is doing better. A ten on the scale may represent that things are betterPlay-Based Activities in Family Counseling 349

and counseling is no longer needed. The counselor then asks each family member, individually, to identify where the family problem is on the scale and why he or she has given the problem this ranking. As family members state their number, the counselor records it on the scale along with the family member’s name and date of session. There are variations in constructing the weekly check in scale. For example, the scale can be drawn as a range from smiley (10) to frowning (1) faces (Duncan, Miller, & Sparks, 2004). Additionally, the counselor can ask each family member what he or she could do to move the family “problem” toward a ten on the scale. The counselor should explore and expand upon the family member’s understanding of his or her reported numbers and the accompanying behaviors from a Solution Focused perspective.

Inter-Session Break and Special Message Time Phase Next, the counselor takes a break and excuses him or herself from the session. Prior to leaving the room, the counselor should state how long he or she will be gone as well as invite the family to continue to play, engage in an activity or start to pick up the space if several different toys or props were used during the session. The counselor leaves the room and takes the break in another office or meeting room. During the break, the counselor collects his or her thoughts regarding the overall themes and direction of the session. This includes identifying particularly powerful interactions in the session and what the interactions represent for the family. During this time, the counselor constructs a special message, brief puppet show, bibliotherapy activity or other intervention to highlight what happened in the session and share with the family. The intent of the intervention is to provide an opportunity for the child to experience validation and normalization of the presenting concern (e.g., their behavior) and educate and reorient the child away from the problematic behavior (e.g., what the child wants the family to know—that is demonstrated through the behavior). The message or activity could also indirectly target the parents through validating their efforts or providing a model from which they can better assist their child. If using bibliotherapy, it is helpful to have a book shelf or file box with books organized by topic area. Then, if the session theme is anger, for example, the counselor can quickly extract the appropriate book for the bibliotherapy activity. A benefit of taking a break during the session is that the family is in a heightened state of receptivity to the counselor’s message or activity. The counselor has been gone from the session for a while and the family is curious to know what he or she will say and do upon returning. Families are commonly interested in feedback about how their family is functioning according to the counselor. Delivering a special message allows the counselor to reinforce behaviors that are working to address the family concern and discourage behaviors that maintain the problem in a nonthreatening manner.

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Additionally, taking the break at the end of the session allows the message or activity to be the last thing the family members hear. Following the break, the counselor reenters the room for the Special Message Time. The counselor conducts the activity (e.g., puppet show, draws a picture that depicts the feedback, etc.) or reads the message to the family and asks each family member to reflect what they hear. Upon finishing the message or activity, the counselor ends the session.

Subsequent Sessions At the beginning of each subsequent session, during the Introduction Phase, the counselor and family revisit the Weekly Check-In Scale. Each family member is asked to report their number on the scale the day of the session compared to previous sessions. On the scale, the counselor records each family member’s name and reported number as well as the session date. Beginning each session in this manner provides a measure of change between sessions that can be monitored over the course of counseling. Family members are routinely asked to talk about the behaviors that they use which makes the problem smaller and the family stronger. The Working Phase follows and will change each week depending on the family and their therapeutic needs. Each session ends with an Inter-Session Break and Special Message Time.

A Case Example: The Smith Family Names have been changed to respect privacy and confidentiality of the family members. The Smith family consisted of mom, age 25, Bobby, age 7, and Suzie, age 5. The family came to counseling as a result of Bobby’s declining grades and increasing number of disciplinary referrals at school. Upon arriving to the first session, it was quickly identifiable that mom was exhausted. Bobby had been diagnosed with ADHD and mom reported feeling overwhelmed with her responsibilities of being a parent. She had become somewhat paralyzed in her role as a mother. Initially, Bobby was angry and felt persecuted as he was the reason the family was coming to counseling. Suzie appeared well adjusted and content with being present. The session began with Bobby racing around the room going from item to item. Initially, mom attempted to correct his behavior but after a few minutes gave up and turned control over to whoever wanted to take charge of the situation whether it was the counselor or Bobby. The session began with the incorporation of puppets. The counselor moved to the floor, invited the children to pick a puppet, and began engaging them using the puppets. Initially mom sat in a chair adjacent to the children holding a puppet in her lap. After some time and observation passed, mom moved to the floor and began to use the puppet. In future sessions, the counselor utilized sand

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tray and therapeutic games to provide other methods of family interaction. Bobby was able to express his anxiety related to attempting to control his environment and understand that his mother was ready to be “in charge” and provide structure and stability for their family. While the specific play portion of the session changed each week, every session ended with an inter session break and special message time which the family often accepted with excitement. The benefit of incorporating play into the family sessions was that it artfully engaged Bobby and allowed him and his mother to communicate differently. Rather than using his behaviors to act out his emotions, he vented through play to a receptive mother who had time, space, and support to understand what he could not voice. After a few sessions, little correction of his behavior was needed and Bobby and his mother began scheduling regular, mutual play time at home. Over the course of counseling, Bobby was able to receive encouragement and validation for his hard work in changing his behavior. Mom was able to observe limit setting and a variety of skills modeled by the counselor and began to incorporate them into her parenting. Ultimately, the family began incorporating many of the activities learned in the sessions into their daily routines and soon no longer required therapeutic services. Bobby felt encouraged and loved. Mom felt love reciprocated from her children as well as self confidence in her ability to provide familial structure and stability as she raised two children in a single parent household.

CONCLUSION

Working in a family counseling session with parents and children can seem overwhelming. This article presents a model to assist family counselors in incorporating play-based interventions into their work with families. Children have much to offer in the sessions, and if structured effectively, play therapy can result in progress and success for the entire family (Thompson, Bender, Cardoso, & Flynn, 2011). It is important to expect some parent resistance to play-based activities, explain the importance of the activities for the children in the session, and work to be comfortable with the activities in the session to serve as a model for parents. In implementing the strategies outlined, family counselors can take steps to not only incorporate children into their family sessions but also work toward therapeutic change for the whole family.

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