Filial Therapy: A Structured and Straightforward Approach to Including Young Children in Family Therapy

Filial Therapy: A Structured

and Straightforward Approach

to Including Young Children

in Family Therapy

Glade L. Topham1 and Risë VanFleet2

1 Oklahoma State University, United States of America2 Family Enhancement and Play Therapy Center Inc., Boiling Springs, Pennsylvania, United States of America

This article describes Filial Therapy, a structured and straightforward approach toworking with parents and young children in family therapy; it highlights the congru-ence between Filial Therapy and the values and principles of family therapy. Thehistorical, theoretical and research foundations of Filial Therapy are described. Thefamily science and child socialisation literatures are also briefly reviewed, linking keypredictors of positive child outcome with the goals of Filial Therapy. Finally, wediscuss the consistencies between Filial Therapy and experiential and structuralmodels of family therapy. We conclude with a description of Filial Therapy followedby a case example to illustrate the process.

Keywords: filial therapy, family therapy, young children, parent

Although many couple and family therapists routinely and effectively involve childrenin family therapy sessions, research shows a substantial portion fail to do so (Johnson& Thomas, 1999; Korner & Brown, 1990; Lund, Zimmerman, & Haddock, 2002).The most common reasons given are therapist discomfort (Johnson & Thomas,1999) and a lack of understanding of how to effectively involve children and adultsconcurrently in sessions (Kindred, 2003; Korner & Brown, 1990). Since the develop-ment of family therapy over 60 years ago, a multitude of family therapy models havebeen developed, each with a unique and complex set of ideas about treating families.While some models have well-developed guidelines for treating children in familysessions, such as narrative therapy (Epston, Freeman, Lobovits, 1997), many are

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Address for correspondence: Glade L. Topham, Department of Human Development and FamilyScience, Oklahoma State University, 233 Human Environmental Sciences, Stillwater, OK 74078-6122. E-mail: [email protected]

complex and difficult to translate into work with children particularly for therapistsnew to family treatment.

For some therapists, including children in family therapy sessions can be confusingand overwhelming, it adds an element of unpredictability and uncertainty; the skillsrequired to be effective are unique and do not easily translate from traditional talktherapy with adults. Filial Therapy, a play-based and relationship-focused treatmentapproach, provides a model for treating young children in family therapy that is struc-tured and straightforward and can be learned in a relatively short amount of time.Training in Filial Therapy could be particularly valuable in helping therapists developcomfort and confidence when conducting family therapy with young children.

In this article we expand on previous calls for increased use of Filial Therapy byfamily therapists (Johnson 1995; Kellam, 2001; Sori, 2005; Winek et al., 2003). Wedescribe the treatment model and the historical, theoretical, and research foundationsof Filial Therapy as well as its congruence with two popular models of family therapy.We describe the Filial Therapy treatment process and illustrate it with a case example.

Play as a Foundation for Treatment

In a definitive clinical report for the American Academy of Pediatrics (AAP),Ginsburg (2007) concluded that ‘play … is essential to the cognitive, physical,social, and emotional well-being of children and youth’ (p. 183). Play is themeans through which children learn perspective taking, language skills, problemsolving, memory, creativity, self-confidence, motivation and an awareness of theneeds of others (Davidson, 1998; Newman, 1990; Shonkoff & Phillips, 2000;Singer, Singer, Plaskon, & Schweder, 2008). Play facilitates the development ofturn-taking, empathy, self regulation, impulse control, and motivation (Corsaro,1988; Krafft & Berk, 1998). Furthermore, children are able to try on adult rolesand conquer their fears by developing mastery over them (Barnett, 1990; Tsao,2002).

Perhaps most importantly, through play with their caregivers, children learn theyare loved and important and develop self-confidence and self-esteem (Powers,2009). Because of the central role of play in healthy child development and as aform of communication, parent–child play offers parents a unique opportunity toconnect with their child and understand their feelings, motives, perceptions,thoughts and behaviours (Ginsburg, 2007; VanFleet, 2005). In his AAP report,Ginsburg stated that healthy child development and resilience are rooted in thefundamental connection that occurs when parents engage in child-led play.

Given the important role of play in promoting a healthy parent–child relation-ship, nondirective parent–child play is a central component of several treatmentapproaches. For example, parent–child interaction therapy (PCIT; McNeil &Hembree-Kigin, 2010), Watch Wait and Wonder (Lojkasek, Muir, & Cohen, 2008)and child parent psychotherapy (CPP; Lieberman & Van Horn, 2008) all use formsof non-directive parent–child play to promote positive change. While eachapproach has its strengths, we believe Filial Therapy to be a particularly good fit forfamily therapists for several reasons. First, all children are included in treatment, notjust a designated target child; second, the nature of play in Filial Therapy allows for

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Young Children in Family Therapy

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the inclusion of a wide range of ages of children (ages 2 to 12); third, it is designedto treat a broad range of presenting problems (i.e., trauma, behavioural disruption,grief and loss, problematic family processes, and so on); and fourth, Filial Therapyis time limited, structured, and straightforward. The above-mentioned treatmentapproaches lack one or more of these characteristics.

In Filial Therapy parents learn and implement a set of skills that maximise thechild’s ability to use play to develop, grow and, if necessary, heal from traumaticexperiences. Furthermore, through filial play sessions, parents and children interactand see each other in new ways, strengthening the parent–child relationship. In theprocess parents replace non-productive parenting behaviours with ones thatpromote healthy child development.

Filial Therapy Background and History

Filial therapy was first developed in the late 1950s and early 1960s by Bernard andLouise Guerney (Guerney, 1964; VanFleet, 2005). The Guerneys were wellacquainted with the effectiveness of play therapy in treating children’s social,emotional, and behavioural problems, and hypothesised that parents could betrained to conduct special play sessions with their children, much like a play thera-pist. They believed because of the emotional bond parents share with their children,it would be more effective to have the parent rather than the therapist conduct theseplay sessions. The Guerneys experimented with parent–child conjoint sessionsabout the same time other family therapy pioneers began conjoint family sessions.

The professional community responded to the Guerneys much like they did toother family therapy pioneers, with scepticism and concern. However, early researchdemonstrated positive results not just for children but also with parents and thequality of the parent–child relationship (Oxman, 1972; Stover & Guerney, 1967).Since those early studies, Filial Therapy has continued to grow in clinical use andpopularity and is supported by an expanding body of research demonstrating itseffectiveness (VanFleet, Ryan, & Smith, 2005).

Filial therapy is offered in several different formats, including the original groupformat developed by the Guerneys (Ginsberg, Stutman, & Hummel, 1978;Guerney, 1964), a short-term, 10-session group format adapted by Gary Landreth(Landreth, 1991; Landreth & Bratton, 2006), and an individual family therapymodel adapted by Rise VanFleet (VanFleet, 1994; VanFleet & Guerney, 2003).While there is a great deal of consistency across these different models there aresome important differences. To avoid confusion we focus exclusively in this articleon the individual family therapy model.

In Filial Therapy, parents are taught to set aside their own feelings and needsand provide empathy and validation to their child during special 30-minutenondirective play times. Filial therapy is typically used with 2- to 12-year-oldchildren, but ‘special times’ can be substituted for nondirective play sessions withadolescents. Parents conduct one-on-one nondirective play sessions with eachchild each week, or ‘special times’ with adolescents. They learn four skills neededto conduct nondirective play sessions: structuring, empathic listening, child-centered imaginary play, and limit-setting.

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Structuring: Parents are taught how to begin and end a play session to make thetransitions clear to the child.

Empathic listening: Parents are taught to temporarily put their own thoughts andfeelings aside; to attend fully to their child’s behaviors, intentions and feelings; andto verbally reflect their child’s behaviours and feelings throughout the play session.

Child-centred imaginary play: Parents engage in pretend play when invited andenact their child-assigned role as closely as possible in accordance with the child’swishes. They learn to use facial expression, intonation and a little drama in theirplay, but at all times they follow the child’s lead.

Limit setting: Parents set limits to maintain safety and boundaries during thesession. They learn to use a firm but nonpunitive tone of voice to state limits clearlyand specifically, to provide a warning if the child does not comply and to carry outthe consequence. The child has two chances to self-correct after which the parentapplies the consequence, usually ending the play session.

These four skills, when used effectively together, help parents balance their accept-ance and nurturance with necessary boundaries. After teaching parents the skillsand practicing them in role-play, therapists observe play sessions and provide directfeedback following the play sessions. If two parents or caregivers are participating intreatment they observe each other’s play sessions and participate in joint feedbacksessions with the therapist.

In these feedback discussions, therapists help parents to continue to improvetheir skills and awareness of their child’s feelings and needs, and understand whatmight prevent them from being fully attentive and available to their child. Afterparents become comfortable with the skills, they begin play sessions at home duringthe week and the therapist begins to work with the parent to generalise the filialskills to daily parent–child interaction.

Theoretical Background

Filial therapy is an integrated approach that draws from several different theoreticalorientations including humanistic, interpersonal, psychodynamic, developmental,attachment, and behavioral and social learning theories. Parent–child play sessionsare conducted in accordance with the principles of nondirective play therapy(Axline, 1947) based on the concepts of Rogerian therapy. Parents learn to providetheir child with unconditional acceptance as they attend to and empathically reflecttheir child’s feelings and actions in play. Similarly, in sessions with the parents, thetherapist strives to create an accepting, nonjudgmental atmosphere to feel safe,respected, and understood.

In this atmosphere parents are able to attend more fully to the experiences andneeds of their child and can discuss their own negative reactions and behavioursnondefensively as they work with the therapist to improve the parent–childrelationship. Furthermore, as parents experience acceptance and respect from thetherapist they tend to experience increased respect and acceptance for their child,and are also more receptive to the corrective guidance of the therapist.

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The work of Harry Stack Sullivan (1953) and interpersonal theory had animportant impact on Bernard Guerney and the development of Filial Therapy, as itdid on many of the founders of family therapy. Sullivan abandoned Freud’s drivetheory and structural models of the mind in favour of understanding personalitydevelopment as learning that takes place through interpersonal connectedness.Sullivan looked beyond the symptoms of an individual to the interpersonal context.He emphasised that human experience is the product of dynamic interactionbetween interpersonal influences and the internal meaning systems (intrapsychicprocesses and experiences) of the individuals (Evans, 1996). Guerney was also influ-enced by Leary (1957) who built upon and extended many of Sullivan’s ideas.Leary suggested that individuals develop ‘interpersonal reflexes’ based on theirexperiences in relationships that can become unconscious, automatic and rigid anddriven by the need to reduce anxiety.

In Filial Therapy an important focus of the post-play-session discussion with theparents is the dynamic relationship between parents’ behavioural responses to theirchild in play (‘interpersonal reflexes’) and their associated emotional or cognitive(intrapsychic) reactions. Therapists guide parents in recognising their reflexiveresponses to their child (e.g., inability to let the child take the lead in the playsession), help parents explore and understand their emotional reactions (e.g., ‘I feltvulnerable and weak’), and help parents challenge associated constraining beliefs(e.g., ‘He just wants to make this miserable for me’).

Therapists may briefly help parents connect their current reflexive responses andemotional and cognitive reactions to previous interpersonal experiences (e.g., pastrelationships when parents felt controlled). Through dynamic discussions acrosssessions, the rigidity of unconscious and automatic responses to the child areweakened, freeing parents to develop more productive and intentional patterns ofinteraction with their child.

Psychodynamic and developmental theories come into play, particularly in post-play discussions with parents. In these discussions, therapists help draw parents’attention to the developmental aspects of the child’s play, such as problem-solvingor mastery, and help them become attuned to what may be going on for their childboth in and outside of the play sessions. Children’s play is also viewed through apsychodynamic lens in that their play is viewed as symbolic of their internal worlds,including needs, anxieties, hopes, and fears. Tentative discussions with parentsabout the possible meaning of the child’s play using both these perspectives increasecuriosity about the child’s internal world.

Filial therapy also integrates ideas from attachment theory. An important focusof the dyadic parent–child work is to help parents develop greater attunement andappropriate responsiveness to each of their children and promote healthy and secureparent–child attachment relationships. Research has demonstrated the latterpromote better adjustment among family members, healthier sibling relationshipsand improve family functioning as a whole (Berlin, Cassidy, & Appleyard, 2008).Finally, Filial Therapy also draws from behavioural and social learning theoryprinciples, such as modelling, behavioural rehearsal, shaping, and reinforcement,particularly in training parents in nondirective play skills.

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Goals of Filial Therapy

The majority of treatment programs targeting the parent–child relationship takewhat Cavell and Elledge (2003) refer to as an ‘intervention-as-intervention’approach. These target the immediate reduction of problem behaviours whileneglecting broader relationship issues important for successful child socialisation.In contrast, Filial Therapy takes a ‘socialisation-as-intervention’ approach, whichassists families with immediate needs, while fostering and strengthening patternsof interaction most predictive of healthy child development and positive childoutcomes. Therefore the process of Filial Therapy would be the same whetherused as prevention or as treatment for an existing problem.

A number of parenting attitudes and practices have been shown to be key tohealthy child socialisation and outcome. These include being aware of andresponsive to children’s needs and wishes (Belsky & Fearon, 2009); parentemotional warmth and support (Baumrind, Larzelere, & Owens, 2010); parent-ing that values and validates children’s expression of negative emotion and helpswork through it (Gottman, Katz, & Hooven, 1996); and effective limit settingwith clear expectations, firm limits and use of reasoning (Baumrind et al.,2010). In contrast, parenting that is hostile and coercive, or permissive andindulgent (Baumrind et al., 2010), or psychologically controlling (i.e., parentalintrusiveness, guilt induction and love withdrawal — Barber, Stolz, & Olsen,2005) are particularly damaging to healthy child socialisation and the parent–child relationship.

Consistent with this research literature, Filial Therapy helps parents to (a)become attuned to, accepting of and responsive to their child’s as well as theirown internal experience (e.g., emotions, needs, desires); (b) understand childdevelopment in general, and specifically their child’s developmental needs andchallenges; (c) increase confidence in their parenting ability; (d) learn to calmlyand consistently set limits; and (e) identify and address issues that may negativelyaffect the way they relate to their children.

Goals for children include: (a) learning to recognise, accept, and express theiremotions fully; (b) increasing their self-confidence and self-esteem; (c) developingeffective problem-solving and coping strategies and skills; (d) reducing or elimi-nating maladaptive behaviours and presenting problems; and (e) developingproactive and prosocial behaviors.

In terms of overall family relationships, the goals of Filial Therapy are to: (a)increase children’s trust and confidence in their parents; (b) increase parents’warmth for and acceptance of their children; (c) for parents in two-parent familiesto work together more effectively as a team; and (d) in general, to promote anaccepting and cohesive family climate that fosters healthy child development(VanFleet, 2005). Ideally all primary caregivers (whether it be a single parent, twoparents, or a parent and a grandparent) participate in play sessions (or ‘specialtimes’ with adolescents) with each of the children each week. This increases theinfluence of Filial Therapy in helping families replace negative family patternswith those that are more productive and growth promoting.

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Filial Therapy ResearchIn Filial Therapy, parent–child play is used as a medium for addressing a host ofchild, parenting and parent–child relationship difficulties. The research literaturedemonstrates the effectiveness of this approach (Ray, Bratton, Rhine, & Jones,2001; VanFleet, Ryan, & Smith, 2005). Some positive child outcomes include anincrease in children’s expression of emotion (Glass, 1986), reduction in childdepression and anxiety (e.g., Tew, Landreth, Joiner, & Solt, 2002), an increase inchild self-confidence (e.g., Costas & Landreth, 1999; Yuen et al., 2002) and adecrease in child behavior problems (e.g., Grskovic & Goetze, 2008; Jang, 2000).Parenting outcomes include a decrease in parent stress (e.g., Kale & Landreth,1999; Yuen et al., 2002), an increase in parent acceptance of the child (e.g., Bratton& Landreth, 1995; Landreth & Lobaugh, 1998), parents allowing more self-direc-tion for the child (Smith & Landreth, 2003) and increased parent empathy (Glover& Landreth, 2000; Jang, 2000) and improved parent–child relationships (Grskovic& Goetze, 2008).

Filial therapy has been shown to be an effective intervention for parents andchildren from a wide range of backgrounds and presenting issues or complaintsincluding foster parents (Guerney & Gavigan, 1981), single parents (Bratton &Landreth, 1995), incarcerated mothers and fathers (Harris & Landreth, 1997;Landreth & Lobaugh, 1998), parents from a variety of cultural and ethnicbackgrounds (e.g., Grskovic & Goetze, 2008; Kidron & Landreth, 2010), parentsof chronically ill children (e.g., Tew et al., 2002), parents of children with conductproblems (Johnson-Clark, 1996), parents of children with pervasive developmentaldisorders (Beckloff, 1997), parents of children with learning difficulties (Kale &Landreth, 1999), non-offending parents of sexually abused children (Costas &Landreth, 1999), and parents of children who have witnessed domestic violence(Smith & Landreth, 2003).

Although researchers have not examined the relationship between Filial Therapyand broader systemic change using quantitative methodology, this has been consis-tently demonstrated by a few qualitative studies. Parents report family communica-tion has become more effective with more open discussion, give and take,expression of emotion and respect for others’ opinions and feelings. They alsoreport transferring skills of empathy, validation, and acceptance into their couplerelationships resulting in increased understanding and a stronger sense of unity(Bavin-Hoffman, 1997; Lahti, 1992; Wickstrom, 2009).

Congruence Between Filial Therapy and Family TherapySeveral principles of Filial Therapy highlight its congruence with family therapy.These include avoiding pathologising the child or parent, focusing on the parent-child relationship as the primary mechanism for change and challenging a linear ormedical model of therapy. Rather than seeking to uncover and treat pathology Filialtherapy is a strength-based approach focusing on education and skill developmentin identifying and working through barriers to family progress. It assumes individu-als and families naturally resolve problems and overcome challenges in the contextof well functioning family relationships.

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While Filial Therapy addresses many of the goals of parent training it is muchbroader in scope, targeting not only parenting skills and treating child problems,but also family relationships and family functioning. As a family-systems interven-tion it specifically targets family subsystems (i.e., all parent–child subsystems andthe co-parent subsystems) and generalises individual and subsystem change tobroader family dynamics. This approach to family systems change is supported byattachment research, which shows the quality of attachment in the parent–childdyad affects family relationships (Berlin et al., 2008) and by Filial Therapy research,which shows participants consistently report improvements in family communica-tion, conflict management and mutual empathy and respect (Bavin-Hoffman,1997; Lahti, 1992; Wickstrom, 2009).

Because of the emphasis on fostering healthy family relationships, Filial Therapyis consistent with a variety of family therapy theoretical perspectives and here wediscuss parallels with experiential and structural family therapy models.

Consistency With Experiential Family TherapyWithin experiential family therapy problems are viewed as resulting from a denial ofemotional experience. Individuals learn to ignore and discount their own emotionalexperience and avoid emotional expression in order to meet expectation of societyand family members. This begins in early childhood when parents see negativeemotion to require correction and punishment like child misbehavior. One result ofemotion suppression is family relationships may be distant and lack emotionalintimacy (Nichols, 2009).

Experiential family therapy helps family members develop an awareness of andacceptance of their own and other family members’ emotional experience, leadingto increased respect for individuality and increased self-esteem of family members.This is achieved by creating an in-session emotional experience and helping familymembers establish honest and genuine emotional contact with each other (Napier& Whitaker, 1978; Satir, 1972).

Likewise Filial Therapy helps family members develop awareness and acceptanceof their own and each other’s emotions where the primary experiential activity isthe parent–child play session. These play sessions provide an opportunity forchildren to express their feelings, needs and fantasies, and for parents to developunderstanding and acceptance for and validate their children’s experience. They alsohelp parents become less constrained and more playful with their children. Parentsdevelop awareness and acceptance of their own emotion in post-play discussionswith the therapists as they explore their reactions to the play sessions in the contextof therapist validation. As parents conduct play sessions with each of their children,observe the other parent’s play sessions and meet with the therapist in post-playdiscussions, emotional expression becomes an integrated part of family culture.

Consistency With Structural Family TherapyStructural family therapy views problems as typically resulting from inflexiblefamily structures that prevent the family from adapting to the demands of changingcircumstances. Common problems include rigid role assignment in which there is

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an exaggerated complementarity in family roles that detract from individual growth;disengagement, where boundaries between family members are rigid leaving familymembers emotionally isolated; enmeshment, where boundaries between familymembers are diffuse, compromising family members’ autonomy; and either littleparental hierarchy with children and parents sharing power or an exaggeratedhierarchy in which children have no voice (Minuchin, 1974).

Family structure is observed and modified during family interaction with enact-ments, the hallmark of structural family therapy. Here the therapist encourages specificfamily interaction and then works to modify family structure such as reinforcingboundaries or solidifying parental hierarchy. As new patterns of interaction are regularlyrepeated, a more functional structure is solidified in the system (Nichols, 2009).

Filial therapy is a strength-based approach that seeks to resolve difficulties byfostering improved patterns of family interacting, with the parent–child playsessions similar to enactments in structural family therapy. Although the therapistdoes not intervene in the room in the moment during play sessions, direct feedbackis given to parents after each session to modify and shape the interaction. Theinstructions and the feedback parents receive regarding the parent–child playsessions help parents establish clear boundaries in interaction with their children.

Rigid boundaries are weakened in disengaged parent–child dyads as parentslearn to tolerate emotional intensity and learn to respond in warm and supportiveways. Similarly, boundaries are strengthened in enmeshed parent–child dyads asparents learn to put their needs on hold and attune to and accept their child’semotions, needs, and wishes. Both during the play and in post-play discussions withthe therapist parents learn to distinguish between their own and their child’semotions. In play sessions parents learn to let their child make his or her owndecisions and solve his or her own problems in a context of nonpossessive warmth.

In Filial Therapy a hierarchy in the family is established by clear and consistentlimit setting, but is also reinforced by the nurturing elements of warmth, reflection,and validation. Where two parents (or caregivers) are participating, executive post-play discussions with parents help develop a unified, co-parenting alliance. Filialtherapy also helps address the exaggerated complementarity of parental roles (e.g.,disciplinarian vs. nurturer). The individual parent–child play sessions enable eachparent to develop confidence and comfort in various parenting roles with each oftheir children without reflexively stepping aside for the other parent to fulfill lesscomfortable roles.

Outline of Filial TherapyWhile the process of Filial Therapy has been detailed elsewhere (VanFleet, 2005,2006) it is briefly outlined here. The sequence of Filial Therapy involves severalphases: assessment, training, supervised play sessions, home play sessions, andgeneralisation. Typically it requires 15 to 20 one hour sessions, although it can takelonger with severely distressed families. The phases of Filial Therapy are outlinedbelow.

Assessment: The therapist first meets with the parents to discuss their concerns andthe presenting problems, listens empathically, and obtains further information

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about the family and the situation. Without children present parents can talk freelyabout their challenges and frustrations including any problems in the co-parentingrelationship. The second session typically involves a family play observationfollowed by further discussion and final recommendations for treatment.

Training: Training typically takes 3-4 one hour sessions. The therapist demonstratesshort nondirective play sessions with each of the children in the family whileparents observe. The therapist then trains the parents in four play session skills,culminating in mock play sessions in which the therapist plays the child’s role whileparents practise the skills. The therapist provides immediate and encouragingfeedback to facilitate the parents learning to conduct the play sessions.

Supervised play sessions: Parents take turns conducting filial play sessions with eachof their children while the other parent and therapist observe. Without the childpresent the therapist discusses the experience with the parent(s), offers positivefeedback and suggests one or two improvements for next time. This helps parents tomake continual progress without feeling overwhelmed. Therapists typically observeeach parent conducting four to six play sessions, after which most parents becomequite skilled.

Home play sessions: Parents hold weekly half-hour play sessions with each of theirchildren at home and meet with the therapist to discuss the home sessions, thechildren’s play themes and questions that arise. Parents often observe each other’shome sessions as well. Home play sessions can continue as long as children andparents wish.

Generalisation: Near the end of therapy, therapists help parents begin to use theirnewly mastered skills outside the play sessions in everyday life. This is accomplishedin a deliberate way to ensure that parents become competent and confident inapplying what they have learned.

A Case Study

We now provide a case example to illustrate the process and outcomes of FilialTherapy. Identifying information has been changed to protect the privacy of thefamily involved.

Mandy and Phil were parents of two children, Carrie, age 10, and Davey, age 7,diagnosed with diabetes a year before. While injections and blood tests were not aproblem, Davey frequently hid candy and other forbidden sweets in his room,despite his parents being very strict about his diet and rarely bringing sweet foodshome. In the past year Davey had become increasingly oppositional, and theirpaediatrician suggested therapy.

During family assessment Mandy and Phil reported more frequent disagreements,mainly about Davey’s diabetes management, as well as increasing marital distress.Davey’s sister, Carrie, often complained she should not be penalised in her foodchoices just because her brother had a problem. She was angry and withdrawnwhen informed she would have pizza without any cake or icecream for the familycelebration of her tenth birthday.

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The therapist noticed during the family play observation that Carrie played quietly inone corner of the playroom while the parents focused on Davey and frequentlycompleted tasks for him when he became frustrated. During the discussion Mandyand Phil said these patterns were typical and were concerned Davey requiredinordinate amounts of their time and they were ‘probably not giving Carrie her due’.The therapist recommended Filial Therapy.

Mandy and Phil learned the play session skills quickly and without a problem.During the supervised play session phase, Phil held the first play session withDavey. Davey selected the doctor doll and began throwing it around the room,eventually pretending to hit and kick it. Davey called the magic wand a ‘giantneedle’ and began giving painful injections to the doctor. It was difficult for Phil tosimply reflect this behaviour, but he was able to tolerate it and comment exception-ally well on Davey’s feelings: ‘You’re really mad at that doctor. You’re punishing him.Now he has to get a GIANT shot. The doctor is crying now. He hates that.’ Duringher play session with Mandy, Carrie at first seemed uninterested. Later she askedher mother to play ‘hangman’ with her on the whiteboard.

During the discussion both parents expressed surprise and alarm about Davey’saggressive play. Through empathic listening the therapist eventually helped them tounderstand Davey’s feelings were quite normal, that he may have unresolvedfeelings about doctors, his diabetes and a loss of control of his life circumstance.The therapist praised Phil’s ability to reflect these feelings, while Mandy expressedconcerns about Carrie’s aloofness and apparent disinterest. The therapist urged theparents to give the process time.

Both parents continued to improve their play session skills through the use of post-play feedback. Their understanding of their children’s feelings also improved fromsession to session. Davey continued to play aggressive medical themes beforebecoming a ‘world famous doctor’ who admonished his patients about what theycould and could not eat. Mandy and Phil were able to see Davey’s distress moreclearly, and although still worried about his diabetic control they realised theyneeded to become a little more relaxed with family meals.

Carrie’s play evolved over time. She enjoyed dress-up play and directed scenes inwhich she was glamorous and ‘famous’, and her parents (during alternate sessions)had to play the role of her adoring public. In discussions with the therapist, Mandyand Phil began to see how their concerns about Davey had drawn their attentionaway from Carrie. In addition to weekly play sessions, they made plans to inquireabout Carrie’s school days, friends and interests more frequently and to occasion-ally take her for a special outing.

After five supervised sessions, the family began their home play sessions. Theynoticed Davey’s oppositional behaviours decreasing with each play session. AsDavey took more control of the play and his parents offered him more choices on adaily basis, he no longer needed to control the household. Carrie also seemed moreengaged, laughing freely as her parents dressed and played different roles basedon her requests. Mandy and Phil reported that Carrie was more relaxed at homeand took more interest in family activities.

As the therapy entered the final stage of generalisation and discharge, Mandy andPhil said they noticed less strain, both as individuals and as a couple. They hadbeen so worried about the diabetes they had not been enjoying each other or their

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children. Filial therapy gave them tools for co-parenting under the difficult condi-tions of family chronic illness, while adding an element of playfulness back into theirlives. As the family enjoyed their time together, the medical management becamemore routine and less intrusive in their lives. They continued filial play sessions aftertherapy finished and reported during a phone call 6 months later they were all stilldoing well. Filial therapy brought the family together in a more relaxed way, helpedthe parents offer more warmth and support to both children, aided the family in amore flexible approach to diabetes management and allowed them to enjoy lifetogether once again.

Application to Diverse Presenting Problems

A key strength of Filial Therapy is its use of nondirective parent–child play to targeta range of child emotional and behavioural problems, parenting difficulties andproblematic patterns of family interaction. Like other family therapy approaches, itcan be integrated with various interventions — for example, psychiatric consulta-tion and crisis intervention, marital therapy when problems extend beyond the co-parenting relationship, or individual therapy when a parent suffers from mentalhealth issues like depression (VanFleet, 2005). It can also be used for difficultchallenges like integrating blended families.

Conclusion

Filial therapy is a strength-based, relationship-focused intervention that utilisesparent–child play to directly intervene in the parent–child and co-parenting subsys-tems in order to treat a variety of child, parent, and family relationship problems.Parents develop skills that foster their children’s’ development, establish parent–child relationship patterns and increase role flexibility and unity in co-parenting.Filial therapy is consistent with the values and principles of family therapy and itsstructured and straightforward approach is ideal for therapists inexperienced intreating young children in family therapy.

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Filial Therapy: A Structured and Straightforward Approach to Including Young Children in Family Therapy