Chapter Fifteen – Interventions with Caretakers and Family Members5
ITCT-A includes interventions directed at the survivor’s parents/caretakers and, in many cases, his or her family.
Interventions with caretakers tend to focus on one or more of five functions:
- increasing caretaker understanding of the adolescent’s difficulties and behaviors, so that they may be more supportive;
- providing non-offending caretakers with support, given the stress and demands associated with raising a traumatized youth;
- working to increase the caretakers’ parenting skills;
- assisting caretakers with significant problems of their own that interfere with their caring for the client; and
- intervening in dysfunctional family dynamics to help resolve conflicts and unhelpful/nonsupportive interactions.
Such goals can only be addressed if the youth has caretakers or family members who are willing to participate in treatment; a significant proportion of severely maltreated adolescents are separated and/or significantly alienated from their families. This can be because (1) intrafamilial abuse has made it difficult for the survivor to interact with caretakers (either because the youth is unwilling to do so, or because the caretaker’s maltreatment is ongoing and/or includes current neglect), (2) the client has run away from home, (3) the youth is functionally emancipated, and neither party views the caretakers as having a current role, (4) caretakers are separated from one another or are incarcerated, (5) the adolescent’s behavior has alienated the caretakers, or (6) the youth is in residential treatment or foster placement.
For these reasons, caretaker and family interventions are most appropriate for youth who still live in a dependent role within a family unit. Thus, it is not as relevant to youth who live on the streets or in shelters, or who, for whatever reason, are separated or emancipated from their caretakers. Even in these cases, however, therapy involving caretakers may still be helpful, since many separated adolescents continue to have significant contact with their parents or other family caretakers (e.g., a grandparent or aunt) and thus continue to be influenced by them.
Working with Caretakers
A central goal of the ITCT-A interventions for caretakers is to increase their understanding of the youth’s difficulties and behaviors, so that they may be more supportive. Many parents experience considerable distress over their child’s behavior, or may have almost given up hope at the severity or chronicity of his or her depression, verbal combativeness, self-destructiveness, or aggression. Many lack information about what the effects of abuse are, and the logic behind what appears to be “bad” behavior. As well, they may not understand developmental issues that complicate the adolescent’s reactions to abuse.
The caretaker’s own issues often impact the course of the young person’s treatment, as well. In general, low caretaker involvement and minimal or absent emotional support complicates the treatment of traumatized youth (Friedrich, 1990; Gil, 1996, 2006). For example, many younger adolescents are unable to attend sessions without their caretaker’s consent, or are dependent on a caretaker to bring them to sessions. More subtly, it is important that caretakers not undermine the adolescent’s therapy by belittling the process, discounting or arguing against therapist statements or recommendations, interrogating the youth after sessions, or by failing to support him or her during the treatment process.
Often, the clinician will find it necessary to improve the caretaker’s ability to parent the youth, so that he or she may provide developmentally appropriate emotional support, attachment resources, positive discipline, and protection from further victimization. In this regard, it is not just child maltreatment or peer assaults that negatively impact the adolescent; it is also the degree to which he or she experiences a lack of support, caring, attunement, and protection from his or her parents or caretakers.
Given the stress and demands associated with raising a traumatized youth, caretakers should be provided with opportunities to discuss and express feelings, and reach out to helpers and peers for support. The unsupported caretaker is unlikely to be as good a parent as otherwise might be possible, and may be more reactive to the challenges of raising an adolescent, let alone a traumatized one.
When caretakers were not involved in sexual abuse or major physical maltreatment of the child, and are willing to engage in the process, individual and group meetings can be quite helpful. As noted above, a significant number of caretakers of adolescent trauma survivors lack good parenting skills, and may treat their own children in the way they, themselves were treated in their own dysfunctional or abusive families of origin. When caretakers, themselves, have significant trauma histories, and/or suffer from significant psychological symptomatology, their care of their children may be further compromised by behavioral withdrawal, instability, substance abuse, chaotic parenting styles, or negative mood states.
Most problematic is the possibility that the disengaged or angry caretaker will discontinue therapy for the traumatized youth. For this reason, among others, the therapist should make special efforts to engage the caretaker in the therapy process. This may involve soliciting his or her opinion about the basis for the adolescent’s difficulties, as well as how the therapist might be most useful to both the adolescent and the caretaker. Also important will be explicit efforts on the therapist’s part to recognize and support the caretaker’s feelings about the youth’s trauma. By facilitating the caretaker’s expression of his or her own feelings about what transpired, while not overly confronting any denial he or she may need to engage early in the process, the clinician can help the caretaker feel like an important collaborator in the child’s treatment, and will increase the extent to which the caretaker can support the youth. The reader is referred to specific guidelines by Pearce & Pezzot-Pearce (2007) for facilitating support from caretakers following disclosures of abuse.
Another reason to engage the caretaker early in the treatment process is to proactively intervene in his or her response to the youth’s trauma-related, problematic behavior. Stressed caretakers, and those whose childhood experience or cultural background support physical discipline, may require specific counseling and education regarding what is acceptable punishment for the adolescent’s perceived transgressions. Personal or cultural values can contribute to disciplinary behavior that might escalate to physical child abuse, requiring the therapist to report the caretaker to a child protection agency. At the onset of treatment, adolescent clients and their caretakers should be informed of what legally constitutes child maltreatment, and under what circumstances a suspected child abuse report must be made. Equally important, the therapist should explore with caretakers alternative, positive parenting practices that will not only not traumatize the youth, but also help him or her to learn more functional behaviors. Regardless of culturally- or historically family-based parenting practices, it is important for caretakers to understand that positive reinforcement for appropriate behavior can contribute to a more positive relationship with the adolescent.
ITCT-A provides two modalities of caretaker intervention: Individual collateral meetings and caretaker groups.
Individual meetings
Individual parent/caretaker sessions usually occur on a weekly to biweekly basis, often for 30-45 minutes per meeting, and may be for a limited number of sessions, or may extend for the full duration of the adolescent’s treatment. These sessions typically involve some combination — depending on caretaker needs — of support, parenting skills development, psychoeducation on abuse and the adolescent’s response to it, general developmental issues, and ways in which the caretaker’s response to the youth may be affected by their own history of abuse or trauma.
If the caretaker has mental health issues (for example, involving their own history of childhood trauma), it may be appropriate to refer them to another agency for separate therapy. However, for more disadvantaged and traumatized caretakers, it may be important for therapy to be provided at the same agency where the adolescent client attends individual therapy. When services are provided at one agency, opportunities for closer coordination and collaborative treatment planning are maximized. With appropriate consents, collaboration between the youth’s and his or her caretaker’s therapist may be both efficient and helpful. Finally, when both caretakers and children receive treatment at the same general time at the same place, the likelihood of regular attendance typically increases. We discuss issues associated with caretaker individual therapy later in this chapter.
Caretaker groups
Caretaker groups generally run for 12 weeks, on a weekly basis. Caretakers sometimes repeat a group module a second time, or advance to a second series of group sessions focused more on their own issues as trauma survivors. Two types of groups are typically offered in ITCT-A: a didactic parenting group, adapted to address specific cultural issues, and a caretaker support group. In some cases, an older adolescent client is also a parent. When this is true, the youth may concurrently attend his or her own individual therapy sessions as well as participate in a caretaker group.
Didactic parenting groups
These groups can be especially helpful for caretakers who (a) can benefit from material and discussion focused on their ability to manage behavior, increase communication, and improve age-appropriate expectations of their children, yet (b) do not want to address trauma-focused issues and feelings in depth. Other caretaker groups, especially those more focused on addressing trauma-related issues, can provide support that, ultimately, facilitates the caretaker’s readiness to seek his or her own individual therapy.
In some cases, grandparents, aunts, uncles or other relatives are the legal guardians and primary caretakers, because the biological parent or parents have abandoned the youth, are incarcerated, are incapacitated due to illness or substance abuse, have died, or have chosen to remain allied with an abusive partner. In such instances, there is usually much to talk about, gain support for, learn about, and process. Foster parents also should be encouraged to attend individual collateral sessions and caretaker groups. Unfortunately, a minority may not be interested — at least initially — in participating in the adolescent’s treatment. Even when this is true, the therapist should make every attempt to encourage their participation in (or at least support for) the adolescent’s treatment. Supportive phone calls can sometimes facilitate this process, as does collaboration with child protection workers to encourage the foster parent to attend appointments.
Caretaker support groups
These groups typically involve multiple topic areas, including interactions with systems (e.g., law enforcement), parenting, identity issues, their own history of trauma, reactions to their child(ren)’s trauma exposures, gender and cultural issues, sexuality and relationship issues, and prevention strategies. Books or other materials can be useful in caretaker support groups — especially with mothers of sexually abused adolescents. The sense of isolation and shame that a non-offending caretaker may feel can be reduced through participation in a group with other caretakers who have experienced similar issues.
The following model is used for caretakers of adolescents who have been sexually or physically abused, or exposed to domestic violence. This is only a suggested sequence, however; more sessions may be devoted to a particular topic area, or the order of sessions may also be adjusted according to the needs of group members. We recommend 12 to 16 weeks of group sessions in this model.
Although the group presented below focuses more on the dynamics and impacts of sexual abuse, the majority of adolescents treated with the ITCT-A model have experienced more than one type of trauma, for example, exposure to domestic violence and/or substance abuse, physical abuse, emotional abuse, and community violence. When this is the case, the model below can be adjusted accordingly.
This group is typically used with caretakers who have had a successful course of parenting classes or a parenting-focused support group, and usually have attended collateral sessions so that they are more able to address their own trauma issues. Although sessions include some didactic material, and exploration of parenting issues, the focus is more on the exploration of the caretaker’s own trauma history, family of origin concerns, attachment issues, as well as more general discussion and support among group members. This model is designed to increase self-awareness and positive identity, facilitate more in-depth trauma processing, explore sex role/gender issues, develop relaxation and coping skills, explore relationships with partners, and increase safety for themselves and their families. Group members may, or may not, journal their experiences in the context of the group. At the beginning or end of each session, members may choose to participate in a brief breathing exercise or relaxation activity (see Chapter 7).
The recommended session-by-session structure of the caretakers group is as follows:
Session 1: Introductions and planning.
Topics and activities: Introductions, overview of the group, confidentiality, and rapport/trust building.
Group members describe how they were referred to the group and why they are attending. Each member completes a written “contract” stating their goals for the group and their commitment to attend all planned weekly sessions, arrive on time, and stay for the entire session. Group guidelines about respecting one another, not interrupting, limits of confidentiality, and limiting communication with each other to sessions are discussed. Group members complete self-portraits and share how they are feeling about participating in the group. An overview of the group sessions is provided and discussed. Group members are encouraged to provide input so that the topics for all sessions will meet their needs.
Session 2: Information regarding child abuse and domestic violence. Dealing with systems.
Topics and activities: Psychoeducation regarding common reactions to child abuse and domestic violence; processing activated experiences; and strategies for dealing with systems.
Didactic information is provided regarding short- and long-term impacts of child abuse and domestic violence on children, and themselves, including symptoms, feelings, and behaviors. Because many caretakers are raising younger children as well as adolescents, developmental differencesare also included in the discussion.This session may include viewing a DVD on the impacts ofabuse, in order to promote more in-depth discussion and understanding about ways in which their children may have been affected. Group members also describe and debrief one another regarding their experiences and strategies for coping with various systems such as Criminal Court, Dependency Court, Family Court, law enforcement, and child protection agencies.
Session 3: Understanding the dynamics of abuse and abusers.
Topics and activities: Activities and discussion to increase caretakers’ understanding of the dynamics of abuse and those who abuse, as well as the impacts and feelings associated with child abuse and domestic violence.
Group members discuss dynamics and impacts of sexual abuse, domestic violence, or physical abuse, on their children and their family. Members explore the impacts of trauma on their relationships (parent-child, other children in their family, and extended family). Feelings related to the offender(s), including betrayal, grief, loss, anger are explored. Members of the group discuss how the abuse happened and the reactions they had to the disclosures.
Session 4: Parenting issues and strategies.
Topics and activities: Psychoeducation, discussion, and role plays to improve group members’ parenting skills and to explore the influence of their own trauma history on parenting.
Behavioral management strategies are discussed, along with other ways that members can increase their support and empathy for the youth. Group members consider how their own trauma history may have contributed to their parenting issues. Strategies for better boundaries and communication are discussed. Group members may role play situations they have encountered with their children, and explore better ways of resolving caretaker-child conflicts. Members discuss ways to increase their functioning as caretakers, including the development of more affect regulation skills and increased self-awareness. Importantly, this session is for problem-solving and support, not for complaints about the adolescent’s “bad” behavior.
Session 5: Coping skills and self-care.
Topics and activities: Discussion and role-plays to increase healthy coping skills, self-awareness, and ability to care for themselves and others.
Group members discuss the idea of using coping skills in order to be less reactive with children and youth, and practice affect regulation skills and trigger identification (see Chapters 7 and 11). They also explore how they can further develop mindfulness in their parenting and in other aspects of their lives. Group members may engage in more role-plays to practice skills they have learned through the group, including ways that they can be more assertive and empowered. Caretakers explore and develop strategies and skills to increase safety for themselves and their families. This may also include developing a safety plan (see Chapter 5) to protect them from further abuse and/or violence.
Session 6: Families of origin.
Topics and activities: Group members complete family genograms and discuss family issues and themes.
Group member explore issues related to their own family-of-origin and attachment relationships. Each member presents their family genogram (described later in this chapter), with special attention to family-of-origin relationships, intergenerational issues related to trauma and loss, and ways in which their parenting has been influenced by their experiences while growing up.
Sessions 7 and 8: Trauma narratives.
Topics and activities: Members share their narratives through writing activities and/or creating a collage or timeline, and discussion.
To the extent they are comfortable doing so, each group member briefly describes his or her personal trauma or neglect history, explores how the youth’s trauma (presently or in the past) may have triggered memories of his or her own victimization, and provides support for other members during this disclosure process. Beyond direct disclosures, this also may be done by sharing journal entries, writing and reading letters to the offender, or engaging in (and sharing) other writing activities. Members also may create a time-line (as described later in this chapter) or a collage, focusing on their trauma experiences and ways they have used their strengths and resources to survive traumatic experiences. Breath or relaxation exercises are especially used at the end of these sessions.
Session 9: Gender and cultural identity issues.
Topics and activities: Group members explore their sense of self related to gender and cultural background, and practice increasing assertiveness.
Gender issues, sex roles, cultural beliefs and background, and spirituality are discussed and explored. Members may complete a collage representing their culturally-based self-perceptions as a child or youth, as well as their current views of themselves. If relevant, discussion also may include members’ experiences of racial, gender, or economic discrimination.
Session 10: Attachment relationships.
Topics and activities: Group members explore their attachment relationships from childhood and in their current lives, and discuss ways to improve their attachment relationships with their children .
In this session, members describe their relationships with their children, partners, and others (e.g., friends, co-workers), and explore ways in which their childhoods may have made it difficult to form and maintain secure relationships — including with their children. Group members discuss ways in which members might improve their relationships with others, and provide supportive feedback to one another.
Session 11: Intimacy.
Topics and activities: Group members discuss issues related to dating, intimacy in relationships, and maintaining their personal safety.
Trust issues are explored, and group members discuss the challenges they face in dating or ongoing relationships with romantic partners, including issues associated with sexual intimacy. Members explore self-protection and prevention strategies in instances where a partner or date might become abusive or violent, and discuss how they could increase the safety of their children and themselves.
Session 12: Ending group and planning for the future.
Topics and activities: Overview/recap of the group.
Group members review the goals written in their contracts at the beginning of the group, and their progress in meeting those goals. Members may choose to share more of their journals entries written during the course of the group. Each group member briefly discusses his or her goals for the future. Members complete self-portraits and discuss positive changes they have noticed in themselves and others over the course of the group.
Caretaker individual therapy
The psychological treatment of caretakers proceeds in essentially the same way as it would for any other traumatized adult client. However, this work may be most helpful to the adolescent if the caretaker is able to explore their own trauma experiences, feelings, and reactions in much the same way that their adolescent son or daughter is hopefully doing in their own therapy sessions. The caretaker with unresolved trauma and/or a disorganized/insecure attachment to his or her child is likely to benefit from opportunities to increase affect regulation skills and self-capacities, as well as to explore and process their own traumatic experiences cognitively and emotionally. The reader is referred to recent sources on the treatment of adolescents and adults with complex trauma (e.g., Blaustein & Kinniburgh, 2010; Briere & Scott, 2012; Habib, 2009; Cloitre, Cohen, & Koenen, 2006; Ford & Courtois, 2013) for further information on how these goals might be accomplished.
Because of the interpersonal complexities, boundary issues, and role conflicts inherent in a single clinician treating multiple family members, it is strongly recommended that someone other than the adolescent’s therapist be assigned to treat his or her caretaker(s). This is particularly important for the older adolescent, whose relationship with his or her therapist could be compromised if the caretaker (who may have contributed to the youth’s trauma) is also seeing his or her therapist in individual collateral sessions. Similarly, if siblings are also participating in individual sessions, they should be treated by different therapists. When this is not possible within an agency, individual family members should be referred to other clinics or practitioners.
Working with the Family
The family therapy component of ITCT-A is indicated when negative family dynamics or intrafamilial conflicts have a negative effect on the adolescent’s psychological functioning. These interventions are often most helpful for adolescents who have not yet left the familial home. In addition, appropriate candidates for family therapy should not be overwhelmed by posttraumatic symptoms, and should have caretakers or family members who are willing to participate in treatment and are at least somewhat supportive of the client.
As noted earlier, a significant proportion of severely maltreated adolescents are separated or alienated from their families. When this is true, the clinician should nevertheless try to involve the caretakers in the youth’s treatment as much as possible. Even if caretakers are non-protective or emotionally abusive, or are seemingly undermining the adolescent’s therapy, attempts should still be made to involve them in collateral sessions — while assuring the adolescent client that, with the exceptions associated with mandated reporting and extreme suicidality, what he or she shares with the therapist is kept confidential. In the unfortunate event that needed family therapy is not possible, a therapist who can engage with caretakers and form a therapeutic alliance, while maintaining a strong therapeutic alliance with the adolescent client, is more likely to facilitate positive change in the family system and to improve the outcome of the adolescent’s therapy (Gil, 1996; Karver, Handelsman, Fields, & Bickman, 2006).
Engaging traumatized adolescents and their families in family therapy may be difficult, for the reasons outlined above. However, perhaps especially after the youth has had some individual therapy and the caretakers have attended parenting (and perhaps group) sessions, family therapy is often appropriate, and the involved family members may be amenable to treatment. Generally, the focus is on improving family communication patterns, exposing and attempting to resolve family conflicts that impact the adolescent, clarifying appropriate boundaries, attempting to increase the general level of attunement and emotional support within the family, and preventing further traumatization of the adolescent.
Family therapy can facilitate system change as well as increase the youth’s sense of well-being and functioning. However, it is essential that all participating members feel safe and supported. Hughes (2007) suggests that the therapist have an attitude of relaxed engagement that includes qualities of playfulness, acceptance, curiosity, and empathy (P.A.C.E.). Emotionally attuned interactions between therapist and participating family members enhance the therapeutic relationship, and model secure attachment relationships (Byng-Hall, 1999; Hughes, 2007). As ITCT-A activates these “old” attachment patterns within the context of “new” caring and attunement, trauma-related behaviors and feelings can be processed in somewhat the same manner described in Chapter 13, leading to more secure and healthy attachment relationships between caretakers and their children.
A particular challenge in doing family therapy arises when multiple children or adolescents have been victimized, are all considered primary clients, and have been assigned to individual therapists. We advise that, following a significant course of individual therapy, all therapists and clients participate in family therapy. In such instances, or whenever working with complicated family dynamics, pre-session planning and post-session debriefing by all therapists involved becomes paramount. This includes clinicians reflecting on the therapeutic process, specific events that transpired, and countertransferential feelings, as well as being open to feedback from the other therapists and consultants/supervisors about ways in which the family’s dynamics may influence the therapist’s perceptions and actions, or may be mirrored in the working relationship between the co-therapists.
Cultural factors are often relevant in family and caretaker therapy. Caretakers and other family members may have been raised in social-cultural contexts in which issues like acceptance of corporal punishment, rigid sex roles, and parental authoritarianism — or seeming insufficient supervision — result in considerable strain with family members (including the youth) who do not endorse these perspectives. As noted by Gil and Drewes (2005), it is important for the therapist to transform cultural knowledge into appropriate therapeutic behaviors. The cultural background of the client and their family may vary within a given family, resulting in different family members identifying with different cultures. For example, a client who is biracial (African-American/Latino) may identify more with Latino culture because of important family relationships, whereas a sibling who is African-American/White may identify more with African-American culture. In addition, in the case of caretakers within a given supposed cultural group, for example “Latino” or “Hispanic,” each may be from a different subgroup (e.g., with ancestors in Mexico, Central America, South America, Puerto Rico, or Cuba), and thus endorse widely different perspectives, histories, and languages or dialects. Religious or spiritual beliefs may also vary within the family, and can influence the extent to which family members value therapy.
For these reasons, it is often important to ask the client and family members how they perceive themselves regarding cultural or ethnic issues, as opposed to making potentially erroneous assumptions. We refer the clinician to Gil and Drewes (2005) for specific advice on how to adjust interventions according to the specific cultural background of the client and his or her family. Other resources for the therapist wanting to understand effects of cultural background and associated family values include Fontes (2005) and McGoldrick, Giordano, and Pierce (1996). All of these resources directly describe specific aspects of a wide range of cultures and provide guidelines for appropriate assessment and treatment.
The family may be impacted by other systems issues, such as police or child welfare involvement regarding reported child abuse or domestic violence, and ongoing legal processes such as family members being involved in the criminal justice system. There may be custody, dependency, foster-parent, and reunification issues that present further complications. Many of these issues and concerns can be worked out, to some extent, if there is motivation, good family communication, and sufficient support. As communication increases, all family members have a chance to understand why things are happening as they are, and how some problematic family patterns can be changed. Dynamics such as scapegoating, splitting, inappropriate or excessive expectations of the adolescent or caretaker, verbal aggression, and emotional detachment can be brought to light, and hopefully reduced or eliminated over time.
The adolescent client’s role in all this is complex. On one hand, he or she is the “identified patient,” officially responsible — by virtue of his or her problems, symptoms, and behaviors — for the family being in treatment. This is especially true when the youth has been abused or neglected within the family. Intrafamilial sexual abuse, in particular, seems to involve more complicated family system issues (Gil, 2006), including isolation and lack of outside support systems, extensive denial in the family, a non-offending caretaker who may be dissociated and disengaged, blurred boundaries and inappropriate roles, alliances by family members with the perpetrator, secrecy, poor communication, and lack of empathy for each other. In this and other instances, the adolescent client may be blamed for family dynamics that may not be his or her “fault,” and, in fact, that may be the source of some of his or her behavior.
Yet, it is often the adolescent who shakes up what is already a dysfunctional family system and brings in assistance from others. He or she may inadvertently begin a process that reveals hidden family violence, abuse of other children, covert substance abuse, and significant parental psychological disturbance. As these issues are identified and processed in therapy, the youth’s role as the problematic member may shift, to his or her (and the family’s) benefit. Effective family therapy may result in increased support for, and understanding of, the adolescent trauma survivor, as well as more general positive outcomes for the rest or the family.
ITCT-A family therapy interventions
Unfortunately, there are only a few books that specifically address family therapy with abuse or trauma survivors. These include Friedrich (1990), Gil (1996, 2006), and Pierce and Pezzot-Pierce (2007). Presented below are family interventions that have proven to be especially useful in ITCT-A.
The time-line
A version of the time-line technique can be found in Families Overcoming and Coping Under Stress (FOCUS; Saltzman, Babayon, Lester, Beardslee, & Pynoos, 2008) — a therapy model first developed for medically traumatized clients and their families. In this approach, each family member creates their own time-line, demarking all specific traumatic events or losses that he or she has experienced. Family members can explore their varied perceptions and feelings associated with traumatic experiences, and update each other’s recollections of shared – but differently experienced — events. For families with multiple traumatic exposures, it may also be helpful to identify on the time-line which events have had the greatest impact on each family member. In some cases, the clinician can suggest that a “total time-line” be created, which is a compendium and integration of all the time-lines created by individual family members. In blended or fragmented families, this overall time-line may document events that some family members may not have experienced or even been aware of, and may provide insight to family members in terms of events that affect the family but are not known to all.
The genogram
One way that family members can become more aware of the intergenerational transmission of trauma and loss, as well as relationships between family members is to create a genogram (McGoldrick, Gerson, & Shellenberger, 1999). The genogram is a graphic representation of a family tree that maps out current and former members, and their relationships to one another. Depending on their complexity, genograms may denote a wide range of people, events, and even the transmission of behavior (e.g., child abuse) from parent to offspring, across multiple generations. Family members can contribute information and impressions regarding positive and negative relationships between family members, psychological traits, conflicts, abuse and violence, neglect, substance abuse, losses, deaths, medical and psychiatric illnesses, and family themes and secrets across several generations. This activity, sometimes completed over more than one session, supports family members’ exploration of their perceptions, experiences, and feelings relative to one another, while also becoming more aware of how family dynamics and history have contributed to their trauma and distress.
Family drawings
Family members can be invited to each create a drawing of their family doing something (Kinetic Family Drawing), or depicting how they might appear in a photograph (Family Snapshot). Sometimes family members will express more information regarding family relationships and issues through drawings than they might through strictly verbal communication. Information on who is included in the drawing, their size relative to one another, and their proximity and demeanor can (a) increase the therapist’s understanding of family relationships and dynamics and (b) facilitate discussion and increased awareness among family members.
Role playing
This exercise involves family members playing the roles of other family members, under the therapist’s guidance, with a goal of increasing their understanding or appreciation of the other person’s experience. For example, a mother might role-play the adolescent son who “sits around on the couch all day,” while he role-plays her “telling me what to do all the time.” While taking on each other’s persona, and speaking from that person’s position, the mother might come to understand better the depression and hopelessness her son has experienced since the loss of his father, and the son might gain an inkling of the pressure his mother feels at now being the sole provider in the family, and her anxiety about his well-being. Not only may such interchanges increase each family member’s insight, they may lead to more openness to communication, and a greater willingness to problem-solve conflicts as they inevitably emerge during family life.