family problem solving therapy

Encyclopedia of Couple and Family Therapy pp 1–6 Cite as

Problem-Solving Family Therapy

• David Hale 4 &
• Dale E. Bertram 5  
• Living reference work entry
• First Online: 11 November 2017

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Name of Model

Brief strategic ; Communication approach ; Interactional approach ; MRI

Prominent Associated Figures

Problem-solving family therapy began, most notably on the West Coast, as an evolution of the Gregory Bateson Team research project that spawned Communication/Interactional theory and present day family therapy. Jay Haley ( 1987 ) is often associated with this approach because he wrote a book with the title Problem-Solving Therapy . Yet, there are many more people associated with the creation of problem-solving therapy: Gregory Bateson, Don D. Jackson, Milton Erickson, John Weakland, Jay Haley, and William Fry. Don Jackson founded the Mental Research Institute (MRI), one of the first free-standing marriage and family therapy training institute in the United States where he and Richard Fisch, John Weakland, and Paul Watzlawick developed the Brief Therapy Center, as part of the MRI, in which problem-solving family therapy was practiced and...

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Chubb, H. (1995). Outpatient clinic effectiveness with the MRI brief therapy model. In J. Weakland & W. Ray (Eds.), Propagations: Thirty years of influence from the Mental Research Institute (pp. 129–132). New York: The Haworth Press.

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Haley, J. (1993). Uncommon therapy: The psychiatric techniques of Milton H. Erickson, M.D . New York: W.W. Norton & Company.

Nardone, G., & Watzlawick, P. (2007). Brief strategic therapy . New York: Aronson.

Ray, W., Schlanger, K., & Sutton, J. (2009). One thing leads to another, redux: Contributions to brief therapy from John Weakland, Ch.E., Paul Watzlawick, Ph.D. and Richard Fisch, M.D. Journal of Brief, Strategic, and Systemic Therapies, 3 , 15–37.

Weakland, J., & Ray, W. (Eds.). (1995). Propagations: Thirty years of influence from the Mental Research Institute . New York: The Haworth Press.

Weakland, J., Fisch, R., Watzlawick, P., & Bodin, A. (1974). Brief therapy: Focused problem resolution. Family Process, 13 , 141–168.

Weakland, J., Watzlawick, P., & Riskin, J. (1995). Introduction: MRI – A little background music. In J. Weakland & W. Ray (Eds.), Propagations: Thirty years of influence from the Mental Research Institute (pp. 1–15). New York: The Haworth Press.

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Abilene Christian University, Abilene, TX, USA

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Hale, D., Bertram, D.E. (2018). Problem-Solving Family Therapy. In: Lebow, J., Chambers, A., Breunlin, D. (eds) Encyclopedia of Couple and Family Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-15877-8_332-1

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Family Therapy Methods: Exploring Family Counseling

Family therapy is a  systemic therapy  that can target various concerns between family members at any time, including conflict, communication, divorce, stress, or mental illness. It is often characterized as a strength-based treatment that aims to adjust patterns and identify individual strengths rather than blaming a specific family member or challenge. 

Different approaches 

Family therapy may be less about gathering family members in the same room and more about the methods used to address conflict and unit concerns. Depending on the concerns, your therapist may choose to have the family members meet together or separately. Some methods might involve group therapy with other families to learn new skills. If one or more of the clients present with a chronic mental health condition, these symptoms will have to be addressed as well.

Therapy might also be focused on the individual needs. For example, suppose therapy has been sought due to a child's struggles at school. In that case, the therapist might meet with the child individually and then call the family to discuss the treatment plan and instruct the parents on how to support their child best. However, the method used can vary depending on a therapist's unique approach. Below are a few standard methods utilized in family therapy. 

Bowenian therapy

If you prefer individual therapy to group options, the  Bowenian approach might suit you. This form of therapy focuses on triangulation and differentiation between family members. 

Triangulation method

Triangulation refers to involving a neutral person in a conflict between two individuals. For example, someone may be triangulating if they get into an argument with their sister and try to get their mom to see their sister as the instigator. Although this strategy might momentarily alleviate worry, it may not be a healthy response to a disagreement because it can cause an unfair power balance or misinformation. Bowenian therapy looks at how these dynamics can occur in family units. 

Family therapy can place the therapist in the role of the neutral person when you have the urge to triangulate. By hearing your concerns, marriage and therapists can identify potential errors in your thinking and strategies for connecting with your family. This strategy may be done in individual therapy, with sessions afterward.

Differentiation method

Many individuals seeking family therapy may struggle with how they see others in their family and their world. They may be exhibiting volatile emotional responses and unsure how to handle their feelings or views.

The goal of differentiation in Bowenian family therapy is to free oneself from unwanted beliefs. It is the process of learning how to form your own opinions and live your life in a way that is free from labeling or negative influences. You can learn that you are separate from your parents, siblings, or other family members and that you can have varying personalities and beliefs. 

Seeing yourself and your family as unique individuals and differentiating your views from theirs and the world around you, may help you understand the conflicts you have and offer the family clarity and communication.

Structural method

The  structural family therapy  approach may be an option for those looking to reorganize how power and family dynamics are distributed among individuals within the unit. It often takes a structured problem-solving approach to therapy. 

Structural family therapy might be utilized when a child is involved in a conflict. The therapist may begin by drawing a chart of your family and noting the relationships between you. Once positions of power are identified, they may help clarify potential changes or techniques to address conflicts and communication between each pairing. 

This therapy method was developed based on the belief that the root of many childhood problems comes from concerns that go unsolved, not from the child or their behavior. Many studies back up this belief, showing that children raised with dysfunctional family dynamics are at a greater disposition  for depression and other mental health and behavioral concerns. 

Clients may learn to restructure the family dynamic in structural family therapy after identifying key issues. Your therapist might have you participate in roleplays, acting out problematic situations that occurred in the months or weeks before your session. At times, your therapist may pretend to take certain sides or model how family members relate. This method may break up negative patterns and promote a healthier family dynamic.

Additionally, concerns within a family might come from a power imbalance, such as one parent making all of the decisions and excluding the other parent or a child making choices for their parents. No matter your concerns, reaching out to a mental health professional may help you restructure your family life. 

Strategic method

Strategic family therapy  may be ideal for families seeking a quick approach to conflict resolution. Structural therapy focuses on using specific techniques explicitly tailored toward your family, developed within a few sessions. The therapist may act as a coach or mentor for a family unit looking to learn new skills. 

Strategic therapy may not focus on your past or what has occurred in your life. Instead, it can focus on current patterns, thoughts, and behaviors you want to change and develop an immediate plan to change them, as long as you are willing. 

Your treatment plan might begin with identifying fixable concerns. You can then move on to setting goals and creating pathways to reach those goals. Once you arrive at your plan, your therapist can observe the responses and actions of your family during the session. Based on these observations, they may evaluate the overall goal for therapy as a whole. 

A licensed therapist in family therapy can be heavily involved and hands-on in your treatment. They may remain actively interested in your well-being and do all they can to ensure your outcome is long-lasting and positive. As a benefit, this type of therapy is often highly personalized. If you're looking for a unique therapy form, try strategic family therapy. You can also try strategy psychotherapy in an individual setting. 

Systemic family therapy method

Systemic family therapy believes family conflict may occur from the subconscious influence of the family members rather than actions or behaviors. Systemic therapists may believe that conflict within the family stems from interlocked issues beneath the surface. For example, a therapist might believe that each individual has connections and conflicts on a subconscious level that could contribute to their family role. 

For example, one family member experiencing a breakup in their personal life may bring personal challenges to their relationships with the whole family. Unlike structural therapy, systemic family therapy does not place power on one individual or a group. It may posit that identifying power roles could harm the family members' subconscious beliefs. 

If you choose to engage in the systemic model of family therapy strategies, your counselor or therapist may help you uncover the subconscious issues with your family members and discuss strategies for addressing them. They may help you identify cycles, games, or rituals in which you are participating, and help your family strengthen roles within the family unit. 

Systemic family therapy may offer a fresh perspective on the conflicts that many families experience and how family members interact. If you have tried many other types of therapy without results, consider this form of counseling. 

Functional family therapy method

Functional Family Therapy (FFT)  is a short-term evidence-based family therapy designed to address at-risk youth ages 11-18 years old. The family therapists that use this method will build therapeutic relationships with all members of the family as well as extra-family influences to help establish a better functioning home environment. The family plays a large role in the process, with each family unit seen as completely unique. This is one of the family interventions that can be useful for strengthening the family environment to help an adolescent who may be experiencing a mental health condition, substance abuse, or trauma.

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

If you are experiencing trauma, support is available. Please see our Get Help Now page for more resources.

Counseling options 

Individuals may be able to address family conflicts and concerns in individual therapy and family settings. If you are looking for a more personalized therapy focused on your experiences in your family, consider individual therapy. Even if you face barriers to counseling, such as cost and distance, various options, including online therapy, are available.  Family therapy counseling online  is an effective way for people to get their needed help.

The world is increasingly interconnected through technology. The use of technology in psychological care, such as text messaging and video calls, may enhance personalized care for those who seek psychological services for mental health problems. One study on  the effectiveness of online therapy  found that it was more effective than in-person treatment methods in addressing depression and common concerns like worrying, stress, or life challenges. 

Many online platforms offer flexible communication options for talk therapy. For example, you may choose between phone, video, or live chat sessions with licensed therapists. You may also gain connection to resources like journal prompts or worksheets from your therapist to use at home directly after your sessions. If you are interested in learning more about online counseling but are unsure where to start, consider using resources offered by a platform like  BetterHelp , which provides over 30,000 licensed and vetted therapists. 

Family therapy or marriage counseling offers families a deeper understanding of healthy life boundaries and functional family practices. Many types of family therapy are available to those seeking support with conflict, communication, mental health conditions, substance abuse, parenting skills, or other concerns. If you're interested in learning more about how family therapy might serve you, consider reaching out to a therapist for further guidance and support. 

Frequently Asked Questions (FAQs) 

Below are a few commonly asked questions about family therapy. , what are the methods used in family therapy.

Family therapy uses several techniques to help families relate to each other and reach their goals. Many of these techniques are utilized as part of a specific type of counseling. These techniques include:

• Bowenian family therapy, also known as family systems therapy
• Strategic family therapy
• Structural family therapy
• Systemic family therapy

These specific therapy techniques might utilize concepts from popular psychotherapy methods used by mental health professionals, like psychodynamic and cognitive-behavioral techniques.

What are the four stages of therapy?

Counseling can be broken down into four stages, including the following: 

• Preparation: The family therapist helps the family plan a course of action
• Transition: The family members may work through acceptance and transition into the treatment plan 
• Consolidation: The family starts putting the therapy techniques into practice
• Termination: The family prepares for the end of treatment and learns how to retain what they've learned to maintain healthy family functioning long-term 

What are the benefits? 

Counseling may benefit families looking to address and overcome challenges affecting their home environments. The benefits of counseling may include solving family problems, coping with mental illness, improving conflict management, and setting boundaries.

While families often use counseling to address emotional concerns, you do not need to have dysfunctional family patterns or mental illness to see a family therapist. Families may benefit from counseling by learning communication, problem-solving skills, and a different perspective. 

What are the stages of the family life cycle?

The family life cycle may be described through the following stages:

• Independence or leaving home
• Having young children 
• Raising adolescents 
• Having independent adult children 
• Being an older adult, over 50 

What are three goals of therapy?

The goals of counseling will typically depend on the types of counseling being provided, the family members participating, and the mental health professional administering the modality. The three goals of counseling may include the following:

• Improving communication and problem-solving skills
• Addressing conflicts affecting the family dynamic
• Strengthening the family bond and reinforcing family roles

By attending sessions, family therapy may offer families a way to create a healthier family system and functioning home environment. 

What do you talk about in therapy?

You can talk about any subject in family therapy. Like many other forms of therapy, family therapy can proceed differently based on the clients. Sometimes, a family therapist will help members of the family discuss conflicts that have been affecting them negatively. In other cases, family therapists may prompt participants to address the mental health challenges of an individual family member. Whatever the issue is, a qualified family therapist can guide you in the direction of resolution and teach you new skills personalized to your concerns. 

• Eight situations that commonly cause family conflict Medically reviewed by Laura Angers Maddox , NCC, LPC
• Six Ways To Thrive As A Blended Family Medically reviewed by Nikki Ciletti , M.Ed, LPC
• Relationships and Relations

Counseling and psychotherapy for individuals, couples and families in San Diego.

We all start this life with a family, whether that family is composed of blood relatives, adopted parents, a close-knit neighborhood, or a foster family. This family that we acquire when we are born influences every aspect of our lives, from our first moments to our last.

Our family affects who we are and who we become, for better and for worse. We learn our vocabulary, our habits, our customs and rituals, and how to view and observe the world around us.

We also learn how to love and how to interact with others from these first important relationships.

If we are born into a healthy family with healthy relationships, we are likely to learn how to maintain healthy relationships. If we are born into a dysfunctional family that struggles to connect, we may also struggle to connect with others.

While it is certainly unlucky to be born into the second kind of family, it’s not an unchangeable situation. Nearly all families deal with some sort of dysfunction at one time or another, yet most families retain or regain a sense of wholeness and happiness.

Family therapy offers families a way to do this—a way to develop or maintain a healthy, functional family.

What is Family Therapy / Family Counseling?

Family therapy or family counseling is a form of treatment that is designed to address specific issues affecting the health and functioning of a family. It can be used to help a family through a difficult period, a major transition, or mental or behavioral health problems in family members (“Family Therapy”, 2014).

As Dr. Michael Herkov explains, family therapy views individuals’ problems in the context of the larger unit: the family (2016). The assumption of this type of therapy is that problems cannot be successfully addressed or solved without understanding the dynamics of the group .

The way the family operates influences how the client’s problems formed and how they are encouraged or enabled by other members of their family.

Family therapy can employ techniques and exercises from cognitive therapy, behavior therapy, interpersonal therapy, or other types of individual therapy. Like with other types of treatment, the techniques employed will depend on the specific problems the client or clients present with.

Behavioral or emotional problems in children are common reasons to visit a family therapist. A child’s problems do not exist in a vacuum; they exist, and will likely need to be addressed, within the context of the family (Herkov, 2016).

It should be noted that in family therapy or counseling, the term “family” does not necessarily mean blood relatives. In this context, “family” is anyone who “plays a long-term supportive role in one’s life, which may not mean blood relations or family members in the same household” (King, 2017).

According to Licensed Clinical Social Worker Laney Cline King, these are the most common types of family therapy:

• Bowenian: this form of family therapy is best suited for situations in which individuals cannot or do not want to involve other family members in the treatment. Bowenian therapy is built on two core concepts: triangulation (the natural tendency to vent or distress by talking to a third party) and differentiation (learning to become less emotionally reactive in family relationships);
• Structural: Structural therapy focuses on adjusting and strengthening the family system to ensure that the parents are in control and that both children and adults set appropriate boundaries. In this form of therapy, the therapist “joins” the family in order to observe, learn, and enhance their ability to help the family strengthen their relationships;
• Systemic: The Systemic model refers to the type of therapy that focuses on the unconscious communications and  meanings behind family members’ behaviors. The therapist in this form of treatment is neutral and distant, allowing the family members to dive deeper into their issues and problems as a family;
• Strategic: This form of therapy is more brief and direct than the others, in which the therapist assigns homework to the family. This homework is intended to change the way family members interact by assessing and adjusting the way the family communicates and makes decisions. The therapist takes the position of power in this type of therapy, which allows other family members who may not usually hold as much power to communicate more effectively (King, 2017).

What is a Family Counselor Trained For?

As the different types of therapy described above show, a family therapist may be called upon to take on many different roles. These many roles require a family therapist to undergo a great deal of training, formal education, and testing to ensure that the therapist is up to the task.

“In this therapy, the therapist takes responsibility for the outcome of the therapy. This has nothing to do with good or bad, guilt or innocence, right or wrong. It is the simple acknowledgement that you make a difference.” – Eileen Bobrow

While therapists may have different methods and preferred treatment techniques, they must all have at least a minimum level of experience with the treatment of:

• Child and adolescent behavioral problems;
• Depression and anxiety;
• LGBTQ issues;
• Domestic violence;
• Infertility;
• Marital conflicts;
• Substance abuse (All Psychology Schools, 2017).

In order to treat these and other family issues, therapists must:

• Observe how people interact within units;
• Evaluate and resolve relationship problems;
• Diagnose and treat psychological disorders within a family context;
• Guide clients through transitional crises such as divorce or death;
• Highlight problematic relational or behavioral patterns;
• Help replace dysfunctional behaviors with healthy alternatives;
• Take a holistic ( mind-body ) approach to wellness (All Psychology Schools, 2017).

In order to gain the skills necessary to perform these functions, a family therapist usually obtains a bachelor’s degree in counseling, psychology, sociology, or social work, followed by a master’s degree in counseling or marriage and family therapy.

Next, the therapist will most likely need to complete two years of supervised work after graduation, for a total of 2,000 to 4,000 hours of clinical experience. When these requirements are met, the therapist will also likely need to pass a state-sanctioned exam, as well as complete annual continuing education courses.

This education trains therapists for guidance with a wide range of problems, including:

• Personal conflicts within couples or families;
• Unexpected illness, death, or unemployment;
• Developing or maintaining a healthy romantic relationship at any stage;
• Behavioral problems in children ;
• Divorce or separation;
• Substance abuse or addiction;
• Mental health problems like depression and anxiety .

This wide range of problems makes it clear that the answer to “What is a family therapist NOT trained to do?” may be shorter than the question of what they ARE trained to do!

To learn more about how marriage and family therapists are trained and how they practice their craft, the following websites are great resources:

• The American Association for Marriage and Family Therapy website ;
• The All Psychology Schools website ;
• The Careers in Psychology website ;
• The Marriage and Family Therapist Licensure website ;
• The Learn website .

What is the Goal of Family Therapy?

“To put the world right in order, we must first put the nation in order; to put the nation in order, we must first put the family in order; to put the family in order, we must first cultivate our personal life; we must first set our hearts right.” – Confucius

In a nutshell, the goal of family therapy is to work together to heal any mental, emotional, or psychological problems tearing your family apart (Lee, 2010). To guide a family towards a healthy life, family therapists aim to aid people in improving communication , solving family problems, understanding and handling family situations, and creating a better functioning home environment (Family Therapy, 2017A).

The goals of family therapy depend on the presenting problems of the clients. For example, goals may differ based on the following scenarios:

• A family member is suffering from schizophrenia or severe psychosis: The goal is to help other family members understand the disorder and adjust to the psychological changes that the patient may be undergoing;
• Problems arising from cross-generational boundaries, such as when parents share a home with grandparents, or children are being raised by grandparents: The goal is to improve communication and help the family members set healthy boundaries;
• Families deviating from social norms (unmarried parents, gay couples raising children, etc.): The goals here are not always to address any specific internal problems, but the family members may need help coping with external factors like societal attitudes;
• Family members who come from mixed racial, cultural, or religious backgrounds: The goal is to help family members further their understanding of one another and develop healthy relationships;
• One member is being scapegoated or having their treatment in individual therapy undermined: When one family member is struggling with feeling like the outcast or receives limited support from other family members, the goal is to facilitate increased empathy and understanding for the individual within their family and provide support for them to continue their treatment;
• The patient’s problems seem inextricably tied to problems with other family members: In cases where the problem or problems are deeply rooted in problems with other family members, the goal is to address each of the contributing issues and solve or mitigate the effects of this pattern of problems;
• A blended family (i.e., step-family): Blended families can suffer from problems unique to their situations. In blended families, the goal of family therapy is to enhance understanding and facilitate healthy interactions between family members (Family Therapy, 2017B).

Family Psychotherapy: Taking it One Step Further

We tend to think of therapy and psychotherapy as two different forms of treatment, but in fact, they are the same thing. This ambiguity is enhanced when we introduce the term “counseling” as well.

In truth, therapy is simply a shortened form of the word “psychotherapy” ( www.drpatrick.com ). However, counseling is sometimes called “talk therapy,” blurring the lines even further (Eder, “What is the Difference”).

Generally, counseling is applied in situations where an individual (or, in the case of family counseling, a family) engages the services of a counselor or other mental health professional to help with a specific problem or set of problems. Therapy, or psychotherapy, is a more in-depth and usually long-term form of treatment in which the client or clients discuss a wider range of issues and chronic patterns of problematic feelings, thoughts, and behaviors (Eder, “What is the Difference”).

A family who is struggling with a situation that brings added stress , such as the death of a family member, addiction, or dire financial straits, may benefit from counseling to help them through their struggles to emerge on the other side as a stronger and more cohesive unit.

If a family is struggling with more chronic mental or behavioral problems, such as a father dealing with schizophrenia, a mother fighting depression, or a child who has been abused, psychotherapy is likely the better choice.

This type of therapy is appropriate for families with problems such as these because a family therapist has a different perspective on treatment than an individual therapist. While the individual therapist works with one client on solving or curing a problem, the family therapist views problems in the context of the “system” of the family. To solve a problem in a system, you need to consider all parts of the system.

Fixing the alternator in a car will not fix the problem if it also has flat tires, a faulty transmission, and a plugged exhaust pipe.

Issues within a family are similar to the car with several problems. A parent struggling with alcoholism is not a problem in isolation; the parent’s struggle has likely affected their spouse and their children as well. A family therapist believes that problems must be addressed at the level of the whole family rather than on an individual level (Schwartz, 2009).

What are the Benefits of Family Therapy?

This more holistic approach to treating problems within a family has proven to be extremely effective in many cases. In family therapy, families can work on their problems with the guidance of a mental health professional in a safe and controlled environment.

The benefits of family therapy include:

• A better understanding of healthy boundaries and family patterns and dynamics;
• Enhanced communication;
• Improved problem solving;
• Deeper empathy;
• Reduced conflict and better anger management skills (10 Acre Ranch, 2017).

More specifically, family therapy can improve family relationships through:

• Bringing the family together after a crisis;
• Creating honesty between family members;
• Instilling trust in family members;
• Developing a supportive family environment;
• Reducing sources of tension and stress within the family;
• Helping family members forgive each other;
• Conflict resolution for family members;
• Bringing back family members who have been isolated (American Addiction Centers, 2017).

Family therapy enhances the skills required for healthy family functioning, including communication, conflict resolution, and problem-solving. Improving these skills also increases the potential for success in overcoming and addressing family problems.

In family therapy, the focus is on providing all family members with the tools they need to facilitate healing (Teen Treatment Center, 2014).

6 Examples and Exercises

If family therapy sounds like a treatment that would benefit you and your loved ones, the best course of action is to find a licensed professional with whom you can build a good working relationship and address the problems your family is facing.

However, if you’re not quite ready for this step, or there are obstacles between you and getting treatment, there are many exercises and suggestions that you may find to be good alternatives.

The exercises and techniques below are meant to be used within the context of a therapeutic working relationship, but some also have applications for those who wish to explore the possibilities of family therapy before committing to long-term treatment with a therapist. If you are a therapist or other mental health professional, you may find these exercises to be useful additions to your therapy toolbox.

The Miracle Question

This exercise can be used in individual, couples, or family therapy, and is intended to help the client(s) explore the type of future they would like to build. We all struggle at times, but sometimes the struggle is greater because we simply do not know what our goals actually are.

The Miracle Question is an excellent way to help the client or clients probe their own dreams and desires. When used in the context of couples or family therapy, it can aid clients in understanding what their significant other or family member needs in order to be happy with their relationship .

This Miracle Question is posed as follows:

“Suppose tonight, while you slept, a miracle occurred. When you awake tomorrow, what would be some of the things you would notice that would tell you life had suddenly gotten better?” (Howes, 2010)

While the client may give an answer that is an impossibility in their waking life, their answer can still be useful. If they do give an impossible answer, the therapist can dive deeper into the clients’ preferred miracle with this question: “How would that make a difference?”

This question aids both the client and the therapist—the client in envisioning a positive future in which their problems are addressed or mitigated, and the therapist in learning how they can best help their client in their sessions.

You can learn more about this exercise at this link .

Colored Candy Go Around

If you’re looking for a fun and creative icebreaker or introduction to family therapy, this exercise can be a great way to start.

To engage in this exercise with your family, you need a package of Skittles, M&Ms, or a similar colorful candy. Distribute seven pieces to each family member, and instruct them to sort their candy by color (and refraining from eating it just yet!).

Next, ask a family member to pick a color and share how many they have. For however many candies of this color they have, instruct them to give the same number of responses to the following prompts based on the color:

• Green – words to describe your family;
• Purple – ways your family has fun;
• Orange – things you would like to improve about your family;
• Red – things you worry about;
• Yellow – favorite memories with your family.

When the first family member has given their answers, tell them to choose the next family member to answer the same prompt based on the number of candies that person has.

Once the prompt has been answered, the candies can be eaten.

When all family members have responded to these prompts, initiate a discussion based on the answers provided by the family. The following questions can facilitate discussion:

• What did you learn?
• What was the most surprising thing you learned about someone else?
• How will you work towards making changes/improvements?

Given the high sugar content in this exercise, you can see that this is a great game to play with young children! If this sounds like a useful exercise that you would like to try with your family, you can find further information and instructions on page 3 of  this PDF  from therapist Liana Lowenstein.

Emotions Ball

This is a simple exercise, requiring only a ball and a pen or marker to write with. It is frequently used with children and teenagers in many contexts, as it takes the pressure off of talking about emotions for those who may be uncomfortable sharing their feelings.

A beach ball is a perfect ball for this activity—big enough to write several emotions on and easy to throw back and forth in a circle. Write several emotions on the ball, such as “joyful,” “lonely,” “silly,” or “sad.”

Gather your family into a circle and begin to toss the ball back and forth between family members. When a family member catches the ball, have them describe a time when they felt the emotion facing them. Alternatively, you could have the catcher act out an emotion, an activity specially suited for children.

The intent of this exercise is to discuss emotions with your family and practice listening to one another and expressing your feelings.

You can read more about this exercise here .

The Family Gift

This exercise can help a therapist to get to know a family better. If you are using it without the guidance of a therapist, it can help you to further your understanding of your own family and provoke thoughtful discussion.

To give this exercise a try, gather a variety of art supplies and a gift bag. Explain to the family that they are going to create a gift from the materials provided. This gift will be a gift for the whole family, that everyone in the family wants. They must decide together on this gift and how it can be used within their family.

They have 30 minutes to decide on this gift and craft it. Once they have created the gift, they must place it in the gift bag. Within the context of family therapy, this exercise provides the therapist with a look at the inner workings of the family, how they make decisions and complete tasks as a unit.

If you are engaging in this exercise as a family without the presence of a therapist, it can help you to start a meaningful conversation.

Use these questions or prompts to facilitate the discussion:

• Describe your gift.
• Tell how you each felt as you were creating your gift.
• Who made the decisions? For example, who decided what the gift should be?
• Were two or more people in your family able to work well together?
• Did anyone cause any difficulties or disagreements, and if so, how was this handled?
• Is there anything about the way you did the activity that reminds you of how things work in your family at home?
• How can the gift help your family? What else can help your family?

There is a wealth of information to be gained from observing these types of interactions or engaging in these kinds of discussion.

To read more about this exercise, see pages 3 and 4 of the PDF mentioned earlier.

Mirroring Activity

This fun exercise is a great way to help family members relate to each other and work together.

The activity can be explained to a family by the therapist with the following instructions:

“I want you to stand in front of me just right there (pointing to a spot about two feet in front of the practitioner). You are going to be my mirror. Everything I do you will try to copy, but the trick is to copy me at exactly the same time that I am doing it, so that you are my mirror. I will go slowly so you have a chance to think about where I will be moving and so that we can do it exactly at the same time. We can’t touch each other. I will lead first and then you will take a turn leading. Ready? Here we go!”

First, the therapist can model this exercise with one of the family members, then that person can take a turn leading another.

This is an especially useful exercise for children, but it can be used with family members of any age. It requires the family members to give each other their full attention, cooperate with one another, and communicate with both words and body language.

It also allows the family members to become more in tune with one another and can be applied with siblings, a parent, a child, or even couples in marriage counseling.

To see the instructions and read more about this exercise, see page 20 of  this booklet , also from Liana Lowenstein.

A genogram is a schematic or graphic representation of a client’s family tree. However, unlike the typical family tree, the genogram provides far more information on the relationships among members of the family.

It can be used to map out blood relations, medical conditions in the family, and, most often in the case of family therapy, emotional relationships.

Genograms contain two levels of information—that which is present on the traditional family tree and that which provides a much more comprehensive look at the family:

• Basic Information: name, gender, date of birth, date of death (if any);
• Additional Information: education, occupation, major life events, chronic illnesses, social behaviors, nature of family relationships, emotional relationships, social relationships, alcoholism, depression, diseases, alliances, and living situations (GenoPro, 2017).

By including this additional information, the therapist and client(s) can work together to identify patterns in the family history that may have influenced the client’s current emotions and behaviors. Sometimes the simple act of mapping out and observing this information can make clear things that were previously unnoticed.

The information on emotional relationships can include points of interest and any aspects of the relationship that may have impacted the client(s), such as whether the relationship is marked by abuse, whether a marriage is separated or intact, if a relationship is characterized by love or indifference, whether a relationship could be considered “normal” or dysfunctional, etc.

This exercise could be completed individually, but it is likely to be most effective when completed in conjunction with a qualified professional.

You can read more about the genogram here , and learn about how to use them in family therapy here .

Recommended Books

The Seven Principles for Making Marriage Work: A Practical Guide from the Country’s Foremost Relationship Expert by John M. Gottman

This is an excellent read for any non-professionals who wish to learn more about what family therapy can do for couples. Although this is intended for married couples, any individuals in a long-term relationship can benefit from this resource of practical wisdom.

Why Marriages Succeed or Fail: And How You Can Make Yours Last by John M. Gottman

Another entry from Dr. Gottman, this book provides an in-depth look at the inner workings of marriage and gives advice on how to ensure that your marriage is one of the successful ones.

Family Therapy: Concepts and Methods by Michael P. Nichols and Sean Davis

Those with only a casual interest in family therapy may not find much of interest in this book , but anyone who wishes to gain a deeper understanding of the theory and practice of family therapy will find this book invaluable. It gives the reader a solid foundation in the techniques, methods, and academic foundations of family therapy. If you are interested in becoming a family therapist, or simply learning more about the practice of therapy within the context of the family, this book is a perfect place to start.

Essential Skills in Family Therapy: From the First Termination by JoEllen Patterson, Lee Williams, Todd M. Edwards, Larry Chamow, Claudi Grauf-Grounds, and Douglas H. Sprenkle

This book is a fantastic resource for those with little or no experience in family therapy. The language is simple and accessible, and each chapter provides a guide for students and newly minted therapists who wish to prepare for their first sessions. Topics include intake and assessment, treatment planning, building and maintaining the therapeutic relationship , and problem-solving when treatment is not progressing.

The Family Therapy Treatment Planner by Frank M. Dattilio, Arthur E. Jongsma, Jr., and Sean D. Davis

This is another helpful resource for new therapists. The Family Therapy Treatment Planner will aid the therapist in planning treatment for clients, dealing with health insurance companies and health providers, and navigating the complex ocean of rules and regulations. In addition, this book includes many treatment plan options, a sample treatment plan, and guidelines on dealing with the most common presenting problems for family therapists.

A Take-Home Message

Family therapy is a way for you and your family to learn how to maintain healthy family relationships, communicate effectively with family members, and work cooperatively to solve family problems. This type of therapy is unique, in that problems are viewed through a broader lens and as part of the complex system of the family.

This perspective allows family therapists to help families get to the root of their problems and facilitates healing for all members of the family, whether the problem is related to substance abuse or addiction, abuse, mental health disorders, unexpected or dire circumstances, or just the ordinary everyday stress we all struggle with on occasion.

This piece described the benefits and goals of family therapy, introduced four of the most common types of therapy, contrasted family counseling with family psychotherapy, and provided examples of the exercises and techniques used in family therapy.

My hope is that you find this information useful whether you are interested in engaging with a family therapist, becoming a family therapist, or just learning more about family therapy.

If you have ever participated in family therapy or if you have practiced family therapy in your work as a mental health professional, we’d love to hear about your experiences in the comments. Did you find engaging in family therapy helpful?

Did you get to reap the benefits described here? If you have practiced family therapy, what are some of the most valuable things you have learned from your practice?

Thank you for reading!

Originally posted at Positive Psychology

References:

• 10 Acre Ranch. (2017, January 23). 10 Acre Ranch. Retrieved from https://www.10acreranch.org/blog/2017/01/23/5-benefits-family-therapy/
• American Addiction Centers. (2017). The benefits of family therapy. Forterus. Retrieved from http://forterustreatment.com/therapy/family-therapy/
• http://www.drpatrick.com/
• Eder, A. What is the difference between counseling & psychotherapy? Ashley EderCounseling & Psychotherapy. Retrieved from http://www.ashleyeder.com/counseling-psychotherapy/
• “Family Therapy”. (2014, January 14). Good Therapy. Retrieved from http://www.goodtherapy.org/learn-about-therapy/modes/family-therapy
• Family therapy. (2017A). In Encyclopedia of Children’s Health. Retrieved from http://libguides.dixie.edu/c.php?g=57887&p=371718
• Family therapy. (2017B). In Encyclopedia of Mental Disorders. Retrieved from http://www.minddisorders.com/Del-Fi/Family-therapy.html
• GenoPro. (2017). Introduction to the genogram. GenoPro. Retrieved from https://www.genopro.com/genogram/
• Herkov, M. (2016). About family therapy. Psych Central. Retrieved from https://psychcentral.com/lib/about-family-therapy/
• Howes, R. (2010, January 17). The ten coolest therapy interventions: Introduction. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/in-therapy/201001/the-ten-coolest-therapy-interventions-introduction
• Schwartz, A. (2009, March 31). Family therapy: A different approach to psychotherapy. Mental Help. Retrieved from https://www.mentalhelp.net/blogs/family-therapy-a-different-approach-to-psychotherapy/
• Teen Treatment Center. (2014, March 20). The benefits of family therapy. Teen Treatment Center. Retrieved from https://www.teentreatmentcenter.com/blog/the-benefits-of-family-therapy/

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What Is Strategic Family Therapy?

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Ivy Kwong, LMFT, is a psychotherapist specializing in relationships, love and intimacy, trauma and codependency, and AAPI mental health.  

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Effectiveness

Things to consider, how to get started.

Strategic family therapy (SFT) is a short-term family therapy treatment that is often used with children and adolescents who are dealing with behavioral issues. A therapist designs individualized interventions to resolve specific problems and create behavioral change.

Strategic family therapy is based on the premise that the family plays the most important role in the life and development of children. This type of therapy seeks to identify and change the structural interaction patterns that make up the family environment. By addressing family behaviors and interactions that contribute to problem behavior, this approach helps families function better so that kids can overcome issues they are experiencing.

This article discusses how strategic family therapy works, its uses, and its efficacy. It also covers how to get started if you think this approach could be helpful for your family.

Types of Strategic Family Therapy

Brief strategic family therapy is a short-term model that typically takes place over 12 sessions. It is often used to address specific behavioral problems such as delinquency, drug use, and high-risk sexual behavior.

Related types of therapy that also focus on treating families include family systems therapy , functional family therapy, and structural family therapy . 

Techniques of Strategic Family Therapy

SFT is individualized and tailored to each family's unique situation. Some of the techniques that a therapist may draw on as they coach families through interactions designed to produce change are listed below.

The first step involves creating a therapeutic alliance with the family. This relationship involves mutual respect and consideration that helps the family feel that the therapist is on their side.

It allows the therapist to temporarily gain acceptance into the family unit so that they can better understand the family's experiences, relationships, and interactions.

Tracking and Diagnosing

Once a therapeutic relationship has been established, the therapist will then work to learn more about the family's behavior patterns and problems . In doing so, they can identify strengths and weaknesses that will allow them to develop a treatment plan.

Restructuring

This technique involves applying different strategies to help address the problems with behaviors and relationships that are contributing to behavioral issues. This might involve utilizing a variety of techniques centered around behavior management, communication, parenting skills, and conflict resolution.

The goal of restructuring is to help promote more productive, constructive interactions that then motivate people to change.

A strategic family therapist will utilize techniques including joining, tracking and diagnosing, and restructuring to understand and change problematic family dynamics and behaviors.

What Strategic Family Therapy Can Help With

Strategic family therapy can be helpful for:

• Aggressive behaviors
• Conduct problems
• Delinquency
• Noncompliance
• Substance use problems
• Risky sexual behavior
• Violent behavior

This approach is often used in situations where young people have come into the juvenile justice system due to drug use, delinquency, or violent behaviors. It can be helpful for improving family functioning, increasing positive parental interactions and parental involvement, strengthening peer relationships, and improving prosocial behaviors.

Benefits of Strategic Family Therapy

Strategic family therapy can benefit families in a number of different ways. Some of the key benefits of this type of therapy are that it: 

• Improves communication between family members
• Helps form, strengthen, or enforce healthy boundaries
• Improves positive parenting
• Strengthens conflict resolution skills
• Builds family cohesion

The basic premise of strategic family therapy is that how the family functions and interacts plays a pivotal role in a child's symptoms. By changing how the family functions, this treatment reduces the risk factors that contribute to behavior problems and helps protect kids from future issues that may arise. 

Flexibility is another important benefit of structural family therapy. Because it is adaptable, it can be utilized in a broad variety of family situations including single-parent households, multigenerational households, and stepfamilies. 

Strategic family therapy can help people from a range of different backgrounds when practiced by a culturally-sensitive therapist. 

Some of the key benefits of strategic family therapy include improving family cohesiveness, improving communication, and improving parenting behaviors.

Evidence suggests that strategic family therapy can be effective in treating teens who are experiencing substance use, mental health conditions, and other difficulties.

• One clinical trial found that a Brief Strategic Family Therapy (BSFT) improved family engagement and retention. It also improved parent-reported family functioning. However, there were no significant differences in self-reported adolescent drug use between the BSFT group and the treatment-as-usual group.
• Another study found that teens who had mental health problems exhibited fewer internalizing and externalizing symptoms after treatment with strategic family therapy. In post-therapy interviews, parents also reported feeling more effective as parents and engaged in more authoritative parenting practices as opposed to permissive or authoritarian ones.  

While strategic family therapy can be beneficial and effective, it is important to recognize that there may also be some challenges. While strategic family therapy can be helpful in many cases, it is not always the right choice for every problem or issue.

Participation

It is important for family members to participate in the treatment process. One problem, however, is that the same dynamics that play a part in contributing to behavior problems can often interfere with families working together to get help. It is not uncommon for some family members to be less cooperative or to refuse to attend therapy sessions altogether.

How people come into treatment may also have an impact on participation and outcomes. Teens are often referred to strategic family therapy through the criminal justice system. Researchers suggest that those entering treatment often feel hopeless and blame others, including family members, for their problems. This can make initiating and maintaining treatment more challenging.

Difficult Emotions

It is also important to recognize that the treatment process involves talking in-depth about emotional problems, conflicts, and difficult relationships. This can be upsetting for many people and it isn't uncommon to go through a period of feeling worse before the situation improves. Because of this, it is important to work with a skilled professional who can help members of the family deal with strong or difficult emotions.

Strategic family therapy isn't right for every situation and there can be challenges that may affect the treatment process. Working with a skilled therapist can help address some of these issues.

The brief form of strategic family therapy is typically short-term, lasting a period of approximately 12 weeks. However, it may also last longer depending on a family's needs and the problems that are being treated. 

It may involve all members of the family, but in some cases, it may involve those who are able or willing to take part in treatment.

If you think this type of treatment would be helpful for your family, you can start by asking your healthcare provider for a referral to a professional in your area. You may also be referred to a therapist through a social worker or a school counselor.

Another option is to search for a therapist using the online directory provided by the American Association for Marriage and Family Therapy. 

Once you find a potential therapist , ask them about their background, experience, and approach to treatment. Therapists who offer this type of treatment often have a master's or doctorate degree in a field such as psychology, social work, counseling, or marriage and family therapy .

American Psychological Association. Strategic family therapy . APA Dictionary of Psychology.

Szapocznik J, Schwartz SJ, Muir JA, Brown CH. Brief strategic family therapy: an intervention to reduce adolescent risk behavior . Couple Family Psychol . 2012;1(2):134-145. doi:10.1037/a0029002

Szapocznik J, Muir JA, Duff JH, Schwartz SJ, Brown CH. Brief Strategic Family Therapy: implementing evidence-based models in community settings . Psychother Res . 2015;25(1):121-133. doi:10.1080/10503307.2013.856044

Florida Department of Juvenile Justice. Brief strategic family therapy (BSFT) . A Sourcebook of Delinquency Interventions .

Robbins MS, Feaster DJ, Horigian VE, Rohrbaugh M, Shoham V, Bachrach K, Miller M, Burlew KA, Hodgkins C, Carrion I, Vandermark N, Schindler E, Werstlein R, Szapocznik J. Brief strategic family therapy versus treatment as usual: results of a multisite randomized trial for substance using adolescents . J Consult Clin Psychol . 2011;79(6):713-27. doi: 10.1037/a0025477

Jiménez L, Hidalgo V, Baena S, León A, Lorence B. Effectiveness of structural⁻strategic family therapy in the treatment of adolescents with mental health problems and their families . Int J Environ Res Public Health . 2019;16(7):1255. doi:10.3390/ijerph16071255

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Recovery Trajectories of Child and Family Outcomes Following Online Family Problem-Solving Therapy for Children and Adolescents after Traumatic Brain Injury

Shari l. wade.

1 Division of Pediatric Rehabilitation Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA

2 Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA

Allison P. Fisher

Eloise e. kaizar.

3 Department of Statistics, The Ohio State University, Columbus, OH 43210, USA

Keith O. Yeates

4 Department of Psychology, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada

H. Gerry Taylor

5 Center for Biobehavioral Health, Nationwide Children’s Hospital Research Institute, Columbus, OH 43205-2664, USA

Nanhua Zhang

6 Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA

Objectives:

We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time.

We examined data from 359 children with complicated mild to severe TBI, aged 5–18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent–child conflict).

We found a main effect for measure for both child and family outcomes [ F (3, 731) = 7.35, p < .001; F (3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [ t (731) = −5.15, p < .001, and t (731) = −3.90, p = .002, respectively, for child outcomes; t (532) = −4.81, p < .001, and t (532) = −3.80, p < .001, respectively, for family outcomes].

Conclusions:

The results suggest limited differences in the measures’ responsiveness to treatment while highlighting OFPST’s utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

INTRODUCTION

Sustaining a traumatic brain injury (TBI) in childhood can lead to impairments across many domains, including motor skills, physical functioning, attention, executive and intellectual functioning, social competence, global functioning, and quality of life ( Catroppa et al., 2017 ; Finnanger et al., 2015 ). Deficits in executive functioning are one of the most common and persistent impairments following TBI ( Aaro Jonsson, Smedler, Leis Ljungmark, & Emanuelson, 2009 ; Beauchamp & Anderson, 2013 ; Sesma, Slomine, Ding, & McCarthy, 2008 ). In one study, 26% of children who sustained a moderate TBI and 42% of those who sustained a severe TBI demonstrated significant impairments in executive functioning 10 years post injury ( Muscara, Catroppa, & Anderson, 2008 ). In addition, rates of new psychiatric diagnoses in children with TBI are higher than in healthy controls, and most pre-injury mental health disorders continue or worsen following TBI ( Catroppa et al., 2015 ; Max et al., 2012 ; Schachar, Park, & Dennis, 2015 ). For example, the rate of secondary ADHD in children after TBI is greater than in children with orthopedic injuries and healthy controls ( Narad et al., 2018 ; Yeates et al., 2005 ). Similarly, internalizing disorders and post-traumatic stress disorders are over-represented among children with TBI ( Max et al., 1998 ; Schachar et al., 2015 ). Children with TBI also show short-term and long-term impairments in social cognition and participation, which can negatively affect friendships and other social relationships ( Anaby, Law, Hanna, & Dematteo, 2012 ; Catroppa et al., 2015 ; Dennis et al., 2013 ; Prigatano & Gupta, 2006 ; Renstrom, Soderman, Domellof, & Emanuelson, 2012 ; Yeates et al., 2013 ).

TBI is also associated with caregiver burden and distress ( Aitken et al., 2009 ; Stancin, Wade, Walz, Yeates, & Taylor, 2008 ). Caregivers of children with TBI face significant stressors during their child’s recovery, including financial strain and coping with changes in their child’s behavior and cognition, which can lead to clinically elevated levels of distress ( Ganesalingam et al., 2008 ; Hawley, Ward, Magnay, & Long, 2003 ; Rivara et al., 1992 ; Rivara et al., 1996 ; Wade et al., 2002 ). An increase in caregiver distress is particularly concerning given the well-documented association between parent and family functioning and child outcomes after TBI ( Catroppa et al., 2017 ; Chapman et al., 2010 ; Durber et al., 2017 ; Yeates, Taylor, Walz, Stancin, & Wade, 2010 ). Parental mental health is predictive of academic, behavioral, and social outcomes for children with TBI ( Catroppa et al., 2017 ). Furthermore, higher quality family and home environments are associated with better academic achievement and classroom functioning in children with TBI, whereas poorer home environments and parental mental health predict poorer quality of life ( Durber et al., 2017 ; Sluys, Lannge, Iselius, & Eriksson, 2015 ; Stancin et al., 2002 ).

Given the importance of parental mental health and family functioning for children’s recovery after TBI, parenting or family-centered interventions may be an effective strategy to improve family functioning, parental mental health, and child outcomes. All online family problem-solving therapies (OFPST) reported here teach children and their caregivers cognitive reframing, problem-solving strategies, communication skills, and behavior management. The therapy helps families define goals and involves real-life exercises and continual practice of learned skills.

Although problem-solving therapy was originally developed as a cognitive-behavioral treatment to promote more effective coping with life stresses ( Nezu & D’Zurilla, 2006 ), OFPST may be particularly beneficial for children with TBI because it also provides injured youth with problem-solving strategies for addressing post-injury challenges. Similarly, OFPST may help children and adolescents cope with stressors and symptoms of anxiety and depression following TBI. In fact, OFPST has shown promise in decreasing externalizing and internalizing behavior problems in children and adolescents after TBI ( Wade et al., 2011 ; Wade et al., 2013 ; Wade et al., 2015 ; Wade, Taylor, et al., 2018b ). OFPST may also improve executive functioning, but outcomes in this domain have been less consistent across age groups and family income levels ( Kurowski et al., 2013 ; Wade, Carey, & Wolfe, 2006a ; Wade et al., 2010 , Wade, Taylor, et al., 2018b ). However, only one study found improvements in social competence, and improvements were only seen for younger teens with moderate injuries and older teens with severe injuries ( Tlustos et al., 2016 ). Additionally, because OFPST involves both caregivers and children, it has demonstrated utility in improving family functioning and alleviating caregiver distress ( Narad et al., 2015 ; Petranovich et al., 2015 ; Wade, Carey, & Wolfe, 2006b ; Wade, Walz, Carey, & McMullen, 2012 ).

Although some benefits of OFPST may be immediate, other benefits may not appear until adolescence or later during recovery. For example, one study found that following OFPST with children aged 12–17, improvements in family functioning were not seen until 18 months after baseline ( Narad et al., 2015 ). Subtle or delayed treatment effects such as these may be more readily detected by aggregating results across multiple randomized trials. More specifically, joint analysis of results from separate OFPST randomized clinical trials (RCTs) can help us better understand the timing of treatment effects and which child and family outcomes are most sensitive to treatment.

We therefore conducted an individual-level profile meta-analysis of five RCTs of OFPST to better understand behavioral, family, and social outcomes of this intervention and the timing of improvements across domains. Researchers have used profile analysis of single studies to improve our understanding of neurological profiles and adaptive functioning in children who sustained a TBI ( Shultz et al., 2016 ; Treble-Barna et al., 2017 ). However, prior research has not used profile analysis to understand intervention effects for children with TBI, nor are we aware of similar analyses based on multiple studies in the TBI literature. We aim to further our understanding of OFPST and facilitate translation of these interventions into clinical practice by identifying those aspects of behavioral and family profiles that are most sensitive to treatment. We hypothesized that improvements following OFPST would be more pronounced for externalizing problems, executive function behaviors, and parental depression in comparison to improvements in social competence, with greater improvements immediately post treatment and with longer time post treatment.

We report on the joint analysis of five randomized trials of OFPST for pediatric TBI, conducted between 2000 and 2015. In total, the trials included 359 children between the ages of 5 and 18, randomized to treatment or control up to 24 months post injury. A research librarian’s search identified only these five trials of a telehealth problem-solving intervention for pediatric TBI. The trials were conducted by largely the same set of Principal Investigators (PIs), reducing study-to-study heterogeneity that could reduce power but also the potential generalizability of the study results. In all studies, parents and children with TBI provided informed consent/assent, completed pretreatment questionnaires, and, upon completion of the pretreatment assessment, were randomly assigned to either OFPST or a control condition. Follow-up assessments were completed 6 months later in all studies. Maintenance of treatment effects was examined at 12 months (3 studies) or 18 months (1 study) after baseline.

The project used fully de-identified data and was approved by the Institutional Review Board at the primary site. Each study used the Trauma Registries of participating hospitals to identify potentially eligible participants. Some studies used additional means of identification (see Wade, Kaizar, et al., 2018a ) All participants were hospitalized overnight following TBI and met criteria for a complicated mild (Glasgow Coma Scale score of 13–15 with positive findings on neuroimaging) to severe TBI (lowest Glasgow Coma Scale score of 3–8). Studies did not select for children already experiencing problems.

Treatment and Control Groups

Online family problem-solving therapy (ofpst).

The original eight-session OFPST program, tested in the initial two trials (Online and CDC), provided training in cognitive reframing, problem solving, behavior management, and family communication targeted to families of children aged 5–18. The content was subsequently adapted to target adolescents (TOPS, TOPS-RRTC and CAPS) with the modified modules and treatment goals placing greater emphasis on the adolescent’s self-regulation, problem solving, and anger management, with the overarching goal of promoting more independent functioning. The 10-session Teen Online Problem-Solving program, tested in two trials (TOPS, TOPS-RRTC), included two additional modules on nonverbal communication and social problem solving. Across all five studies, OFPST combined either 8 or 10 core self-guided online modules and live videoconference sessions with a therapist to teach families (i.e., the child with TBI, parents/caregivers, and siblings when available) targeted skills. Families had the option of completing up to four additional supplemental sessions to address specific issues (i.e., marital stress, sibling behavior, pain, or sleep difficulties). Videoconference sessions, during which a trained therapist reviewed online content and problem solved around a family-identified goal, were 45–60 minutes in length.

Control groups

In four studies, the control group was given access to internet resources for pediatric TBI; in one study, the control group involved usual psychosocial care. We treated these two types of groups as a single composite control group based on their similar performance across studies. Participants randomized to conditions other than OFPST or the control group in two of the trials ( n = 85) were excluded from the analysis.

The analyses relied on measures collected via interview and questionnaire completion before treatment initiation which reflected current functioning 0–24 months post injury, at treatment completion 6 months later, and, depending on the study, at follow-up assessments 12 or 18 months post baseline.

Background interview

In each study, the parent/primary caregiver completed an interview regarding the child’s medical and educational history. We used parents’ highest level of education as a proxy for socioeconomic status.

Parental Depression and Distress

The center for epidemiological studies depression scale (ces-d).

The CES-D ( Radloff, 1977 ) is a 20-item scale that assesses symptoms of depression. Parents rated the frequency of their specific depression symptoms over the past week, including depressed mood, restlessness, poor appetite, and social withdrawal. Higher scores (range 0–60) indicate more severe depressive symptoms. Raw scores of 16 and higher were used as a cut-off score to identify clinically significant depressive symptomatology ( Radloff, 1977 ).

The Symptom Checklist 90-Revised (SCL-90-R)

Parents also completed the SCL-90-R, a 90-item self-report inventory on which they rated the extent to which they have been bothered in the past week by a range of psychiatric symptoms ( Derogatis & Savitz, 1999 ). The scores are reported as a T score with a mean of 50 and standard deviation of 10. The Global Severity Index (GSI), a global scale of current level of symptomology, was examined as an overall measure of psychiatric distress. Scores of 63 were used as a cut-off to identify clinically significant levels of distress.

Injury information

A research coordinator reviewed the child’s medical chart and abstracted information regarding injury mechanism, severity, and length of stay in the hospital.

Child Behavior

Child behavior checklist (cbcl).

Parents completed the CBCL, a 112-item rating scale that asks questions about children’s problem behaviors in everyday settings. The CBCL yields Internalizing, Externalizing, and Total Behavior Problem composites. The scale is a widely used indicator of child adjustment, with high validity and reliability ( Achenbach & Rescorla, 2001 ). Our analysis focused on the Internalizing and Externalizing Problem composite scales.

Behavioral Rating Inventory of Executive Function (BRIEF)

Parents completed the BRIEF, an 86-item rating scale of executive function that has been validated in both normative and TBI samples ( Gioia, Isquith, Guy, & Kenworthy, 2000 ; Gioia & Isquith, 2004 ). The Global Executive Composite (GEC) incorporates all BRIEF subscales to provide an overall index of executive function behaviors, with elevated scores suggesting greater executive functioning deficits.

Home and Community Social Behavior Scale (HCSBS)

Parents completed the Social Competence scale of the HCSBS to assess their child’s peer relations and self-management/compliance. The HCSBS has good reliability and is well validated in relation to other social behavior measures; it yields a total score, with higher scores reflecting greater social competence ( Merrell, Streeter, Boelter, Caldarella, & Gentry, 2001 ).

Family Functioning and Parent–Child Conflict

Family assessment device (fad).

The FAD is a 60-item self-report questionnaire measuring structural, organizational, and transactional characteristics of families, with established reliability and validity ( Miller, Bishop, Epstein, & Keitner, 1985 ). Parents rated how well each statement described their own family. Examples of statements include “we don’t get along well together” and “ we confide in each other”. Scores range from 1 to 4, and higher scores indicate worse functioning ( Epstein, Baldwin, & Bishop, 1983 ). The 12-item General Function scale was used to reflect global family dysfunction ( Miller et al., 1985 ).

Interaction Behavior Questionnaire (IBQ)

The 20-item short form of the IBQ assesses parent–child communication and conflict behavior. Parents are asked to rate each statement (e.g., “we almost never seem to agree” or “at least 3 times a week, we get angry at each other”) as true or false. Total scores can range from 0 to 20 with higher scores reflecting greater conflict. The IBQ has high internal consistency ( α > .90) and has test–retest correlations ranging from .61 to .85 ( Robin & Foster, 1989 ).

Statistical Analysis

Descriptive statistics were used to summarize demographic, premorbid, and injury characteristics within each study, and simple summary statistic meta-analyses were used to characterize the combined studies. Child behavioral outcomes and parent/family outcomes in the OFPST and control groups were analyzed using a profile analysis. Profile analysis is a statistical technique for simultaneously examining differences among groups on a set of outcome variables ( Harris, 2001 ). Three primary questions are addressed:

• Level—Does the OPFST group have improved scores across the measures compared to the control group (main effect of group)?
• Flatness—Are some measures more improved than other measures in both groups (main effect of measure)?
• Shape—Do improvements in scores show a distinct pattern between groups over time (interaction of group by measure by visit)?

To facilitate comparison across scores, scores on each measure were converted to Z scores based on the means and standard deviations of the corresponding measure at baseline across studies so that all scores reflected the same metric. Social competence was reverse coded so that higher values correspond to worse outcomes, to parallel the other child behavioral outcomes. The profile analysis was conducted as an initial mixed-effect model of the standardized scores on treatment group by measure by visit and the associated lower-order interactions (group by measure, group by visit, measure by visit) and main effects, with adjustment for baseline score, time since injury at baseline, child sex, age at baseline, parental education, and study site. Repeated measures on the same participant and possible dependence of participants in the same study were accounted for through random intercepts. Iterative backward elimination was used to remove non-significant higher- and then lower-order terms. Separate analyses were conducted for child behavioral outcomes (CBCL internalizing problems, CBCL externalizing problems, BRIEF and HCSBS), and parent/family outcomes (CES-D, SCL-90, IBQ, FAD). Follow-up Post hoc ‘least squares means’ tests compared treatment groups on each measure to determine which measures were responsive to the OPFST at each follow-up visit. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC); R version 3.4.3 was used to generate plots ( R Core Team, 2017 ).

Profile Analysis of Parent-Reported Child Behavior

Baseline characteristics by study can be found in Table 1 . The profile analysis for child behavior revealed a main effect for measure [ F (3, 731) = 7.35, p < .001], indicating that the degree of improvement varied across the measures for both groups. Post hoc comparisons of the least square means revealed significantly lower average internalizing problem, externalizing problem, and executive function scores, indicating significantly greater reductions from baseline in comparison to social competence scores [ t (731) = −2.68, p = .038; t (731) = −4.65, p < .001; t (731) = −2.85, p = .023, respectively]. The internalizing problems score showed a lower average score than the externalizing problem or executive function scores, but the magnitude of the difference was less pronounced [ t (731) = −1.99, p = .047; t (731) = −1.81, p = .07, respectively].

Baseline characteristics by study; Count (%) or Mean (SD)

Although we did not find a group by measure or measure by visit interaction for child outcomes, we found a significant treatment group by visit interaction, F (3, 731) = 3.48, p = .031, indicating distinct shapes of improvement over time between the two groups. Post hoc comparisons of the least square means indicated that the OFPST group showed a significantly greater reduction in behavior problems than the control group at both 6 and 18 months [ t (731) = −5.15, p < .001, and t (731) = −3.90, p = .002, respectively], but not at 12 months post baseline. Examination of the Post hoc average score estimates in Figure 1 suggests that these differences were predominantly due to trends in the OFPST group, while the control group showed a relatively consistent and modest improvement over baseline.

Model-based Post hoc post-treatment Z score separately averaged across child behavior and family function measures within groups defined by time since treatment initiation (horizontal axis) and treatment group (shape; circle = online family problem-solving therapy [OFPST], triangle = control group). Vertical lines span 95% confidence intervals for the mean Z score in each group.

Profile Analysis of Parent and Family Outcomes

Examination of parent and family outcomes revealed a statistically significant main effect for measure [ F (3, 532) = 4.79, p = .003], indicating that improvement varied across the four measures in both groups. Specifically, Post hoc least squares comparisons suggested that there was a significantly greater reduction in impairment on the IBQ than the other three parent/family measures [ t (532) = 1.89, p = .059 for CES-D; t (532) = 2.54, p = .012 for FAD; and t (532) = 3.65, p < .001 for GSI]. The standardized CES-D scores were also on average lower than the GSI [ t (532) = 2.24, p = .026], but we found no strong evidence that the FAD had a greater reduction on average than the GSI or CES-D.

Although we did not find a group by measure or measure by visit interaction for family outcomes, we found a statistically significant treatment group by time interaction [ F (2, 532) = 6.47, p = .002], indicating distinct trajectories of improvement over time between the two groups. Post hoc least squares differences displayed in Figure 1 suggest trends that are remarkably similar to the child behavior profile analysis. Again, parent/family measure outcomes significantly differed between the control group and treatment group at both 6 and 18 months post baseline [ t (532) = −4.81, p < .001, and t (532) = −3.80, p < .001, respectively], but not at 12 months post baseline.

We used an individual-level meta-analytic approach to profile analyses to better understand the nature and timing of treatment effects following OFPST in children with moderate to severe TBI. By incorporating data from five RCTs involving 359 children and families, we found evidence of both main effects of measure and differential trajectories of improvement between the treatment and control group over time. Specifically, across groups, we found greater recovery in internalizing and externalizing behavior problems and executive function behaviors than in social competence. In testing group by measure and measure by visit interactions, we did not find that certain measures were more sensitive to treatment than others or distinct shapes of improvement over time across the measures. However, group differences in both child and parent/family outcomes were significant across outcomes, occurring both immediately post treatment and 18 months post baseline. Taken together, these findings provide further support for the efficacy of OFPST in improving child behavior, parent distress, and family functioning. Moreover, the results inform outpatient rehabilitation by highlighting variable recovery over time and the child and family outcomes that show greater improvement, regardless of treatment.

Main effects for child outcome measures suggest that behavioral symptoms such as internalizing and externalizing behavior problems and executive function behaviors may recover over time, without intervention; in contrast, social competence may show less natural improvement. Indications that internalizing behaviors may improve more than externalizing behaviors are counter to previously reported effects of behavioral interventions, which highlight improvements in externalizing problems and executive function behaviors rather than internalizing problems ( Kurowski et al., 2013 ; Wade et al., 2006a , 2006b , 2010 , 2011 , 2013 , 2014 , 2015 ; Wade, Taylor, et al., 2018b ). Although the treatment and control groups did not differ on time since injury, and time since injury was included as a covariate in the models, some measures may improve more due to natural recovery in the initial months post injury. For example, internalizing symptoms, such as fatigue and irritability, often improve acutely without intervention, perhaps accounting for some of the differential improvement among measures. This different pattern of results may also be attributable to the inclusion of moderators such as the child’s age/grade at baseline and injury severity in prior analyses demonstrating improvements in executive dysfunction following OFPST. Specifically, the effects on self-regulation and executive dysfunction may be more pronounced among older adolescents who can directly apply the executive heuristics of inhibition (stop and think) and problem solving to their daily lives ( Wade et al., 2013 ).

Main effects for measure on the parent/family profile analysis indicated that parent-reported parent–teen conflict was more improved than other outcomes, with parental depression showing more improvement relative to global parental distress. Parent–teen conflict may have prompted families to enroll in the trials and may show regression to the mean at follow-up; in contrast, parental distress and family dysfunction may be more entrenched and require active intervention.

For both child and parent/family outcomes, OFPST resulted in improvements immediately post treatment. Because of improvements in the control group between treatment completion and follow-up 6 months later (i.e., at the 12-month time point), treatment differences at the 6-month post-treatment follow-up were no longer significant, indicating some natural recovery in the control group. However, subsequent improvements in the OFPST group between the 12- and 18-month post-baseline follow-ups resulted in large group differences a full year following treatment. These findings suggest that treatment effects may consolidate over time. Given the focus of OFPST on problem-solving and self-regulation skills, further improvements with increasing time may correspond to more consistent and successful implementation of skills in their daily lives. Although promising, this pattern of findings merits further investigation given that only one of the five studies, involving 132 participants, followed participants beyond 12 months post baseline. Nonetheless, the results do suggest that children and families may reap intervention benefits over a longer period of time, leading to later improvements.

Consistent with research indicating reciprocal relationships between parent/family functioning and child recovery over time, child and parent outcomes demonstrated a similar pattern of improvement ( Taylor et al., 2001 ). The present data do not shed light on whether improvements in one drove improvements in the other, but do suggest that family-centered treatments such as OFPST may be valuable given their ability to improve outcomes at both levels. As noted previously, the focus on improving problem solving, self-regulation, and communication skills in both parents and adolescents with TBI may promote improved functioning in both parents and teens and facilitate the parent’s ability to scaffold behavior change in their child.

The results must be considered in the context of study limitations, including the exclusive reliance on parent-report measures, particularly given that parents completing OFPST may experience social desirability biases that increase their likelihood of reporting improved functioning. Independent ratings or diagnostic interviews with the child would strengthen the findings. Time since injury ranged from 1 to 24 months, with many children enrolled during the initial year post injury. Emerging evidence ( Wade, Kaizar, et al., 2018a ) suggests that children and adolescents benefit less from OFPST during the initial months post injury, likely due to acute neurocognitive challenges (e.g., slow processing speed, fatigue, headaches) that affect their ability to actively engage in the problem-solving training. Thus, the pattern of findings may differ if all participants were in the post-acute phase of recovery. Similar patterns of improvements in child behavior and parent and family functioning may be driven, in part, by shared rater variance. While the profile analysis benefits from the assessment of outcomes over time, only one study involving 132 participants included assessments at all four time points; as a consequence, this study had a disproportionate influence on the long-term profiles.

In summary, the results provide important new evidence regarding the child and parent/family outcomes that are most responsive to OFPST and the pattern of maintenance of improvements over time. The results highlight OFPST’s utility in improving both child behavior problems and parent/family functioning, with greater improvements immediately post treatment and with extended time post treatment. Further research is needed to elucidate the potential reciprocal relationships between improvements in parent and child functioning over time following OFPST.

ACKNOWLEDGEMENTS

We acknowledge the contributions of Amy Cassedy, Ph.D. and Nori Minich, B.S. to data cleaning and synthesis, and Jennifer Taylor, B.A. to regulatory oversight.

This work was funded by the NIH grant 1R21HD089076-01 from the National Institutes of Health.

Data from the following clinical trials were used in this study: An On-Line Intervention for Families Following Pediatric TBI, conducted prior to trial registration; A Trial of Two On-Line Interventions for Child Brain Injury, , https://clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT00178022","term_id":"NCT00178022"}} NCT00178022 ?term%3DNCT00178022&rank%3D1; Teen Online Problem Solving (TOPS)- An Online Intervention Following TBI (TOPS), , https://clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT00409058","term_id":"NCT00409058"}} NCT00409058 ?term%3DNCT00409058&rank%3D1; Improving Mental Health Outcomes of Childhood Brain Injury (CAPS), , https://clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT00409448","term_id":"NCT00409448"}} NCT00409448 ?term%3DNCT00409448&rank%3D1; and Rehabilitation Research and Training Center for Traumatic Brain Injury Interventions—Teen Online Problem Solving Study (RRTC—TOPS), , https://clinicaltrials.gov/ct2/show/ {"type":"clinical-trial","attrs":{"text":"NCT01042899","term_id":"NCT01042899"}} NCT01042899 ?term%3DNCT01042899&rank %3D1.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

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• Therapy Tools

10 Best Family Therapy Activities and Exercises for Happy Homes

Intergenerational trauma or intergenerational wisdom? Parents’ unhealthy habits get passed down in endless cycles but so does their inner wisdom, even if it’s hidden away. As a mental health professional, you can help people unlock that wisdom through family therapy activities.

On the surface, family therapy activities are designed to improve communication, reduce conflict and build connections. Therapists go much deeper than this by uncovering patterns, biases, assumptions, narratives, values and everything else that makes us human.

The beauty of family therapy activities is that they bring family units together within their social and cultural contexts to explore behavior. Add to that some results-based accountability and mental health professionals can truly make a difference to both the younger and the older generations.

With digital tools now at our disposal, such interventions can be even more creative and most importantly, exercises can be done at any time and from anywhere.

We’ll walk you through some of the best family therapy activities from renowned psychiatrists who have witnessed their effectiveness. We’ll also show you how a platform like Quenza offers you another level of client engagement. With Quenza, you have access to hundreds of evidence-based exercises, visualizations and worksheets to complement your family therapy activities. We’ll show you how in this article but why not sign up for the free, full-access, one-month $1-only trial and see for yourself?

The Fundamentals of Family Therapy

Family therapy evolved from Freud’s concept of the autonomous self to the relational self with Adler and others. The structural, or orderliness, model first came out in the 1960s and also evolved through to symbolic interactionism which paved the way for systems and communications theory. In symbolic interactionism, each of us has both an inner and outer self but systems theory expanded this idea into having both an “I” and a “we” [1] .

Today we have the third generation of family therapy with evidence-based systemic approaches rather than purely following theoretical models to analyze the psyche. Family therapist Charles Fishman takes this one step further by challenging the industry that not enough documentation has taken place within family therapy.

As such, it seems that many healthcare professionals previously over-relied on models without taking the family system into consideration. Within systems thinking, Fishman also encourages the use of goal-setting or results-based accountability. Not only can family therapists lead the way with evidence-based outcomes but also bring family therapy to the forefront of mental healthcare [2] .

Implementation Intentions

Now let’s consider how family therapy works. First, it’s important to take into account how the family unit has changed from the traditional nuclear model with two parents of different genders. Moreover, roles have changed within families.

Family therapy aims to uncover all those roles and how they intentionally, or unintentionally, reinforce the current family interactions. The added complexity is that behavioral and emotional problems are often passed through the generations. Again, family therapists work to explore these levels of complexity.

Like any system, the family unit is more than just individuals brought together. They have processes, feedback loops, rituals and so much more that bring them together like an orchestra. Together with their therapist, families seek to understand what this means to them. From there, they can put together strategies to optimize how they function together. It’s almost like creating policies and procedures for teams in an organization [1] .

In summary, the reason why family therapy is important relates to creating healthy and functioning units. Healthy families interact more positively with each other but also with the wider community so better serving society as a whole.

What are the benefits of family therapy activities?

Another one of the core reasons why family therapy is important is that it empowers such units to manage change and stress. More specifically, they learn and form healthy identities, boundaries and relationships within the unit  [1] .

In short, what are the benefits of family therapy if not gaining a greater sense of well-being to then operate more optimally in everyday life?

For example, some family therapy activities focus the family on dealing with loss whether through death or an event such as children starting school. Other activities give families the resilience and emotional regulation to deal with crises such as conflict, separation, redundancy, illness and more.

Some family therapy activities focus specifically on communication and how their patterns form into feedback loops with cause and effect. Nonverbal communication is also often explored through games and activities.

One example of a nonverbal communication game is where family members express various emotions using their faces and bodies. Therapists can get creative and use cards, posters or digital images. It can essentially become a type of role-playing game which is particularly engaging for families with younger members.

Knowing Your Emotions

Most importantly, family therapy activities enable families to learn successful problem-solving techniques. Consequently, they become empowered in dealing with life and its challenges.

The Overall Purpose and Goals of Family Therapy

How family therapy works depends on what type of model you follow. The main ones that still come under the systems concept are structural and strategic.

Simply put, a structural family therapist focuses on the rules that impact communication within families, both stated and unstated, so essentially fixing the structure. Conversely, a strategic family therapist focuses more on the symptoms and will guide the family to devise communication strategies to encourage healthier interactions.

Both approaches have similar goals and outcomes. These include family therapy goals such as developing conflict resolution skills, nurturing parent leadership mindsets, practicing effective behavior management, balancing out power and redefining communication  [3] .

Family therapy activities are experiential and creative ways to meet those goals. They do this by opening up communication channels with the therapist as the guide and facilitator. Some exercises even involve some form of art creation, not too dissimilar from   art therapy for teens , to allow for new brain connections.

Motivational Vision Board

Naturally, it’s particularly important for the therapist to be aware of their own family influences to ensure they remain an impartial guide during all family therapy activities. The aim is to be fully present and empathetic so as to create a safe space. As such, they can create the right conditions for deeper connections to take place within the family over time.

The Nitty Gritty of Family Therapy Activities

Family therapy activity ideas are creative ways for members to open up and connect. Most critically, they’re engaging for children, especially younger ones.

Some families might be nervous or reluctant to show themselves as vulnerable or even flawed in front of their children. Family therapy activities aim to remove those inhibitions.

Children also give a viewpoint and honesty that most of us as adults have forgotten. In many ways, we have so much to learn from them. If nothing else, the concept of play is something that many adults no longer take part in. Again, family therapy activities aim to restore a level of playfulness that we all need for greater well-being.

Therapeutic family activities also shift the balance between logic and emotions. Adults tend to operate more at the logical end of the scale while children bring in raw emotions. A skilful therapist can guide families to adopt the benefits of both  [4] .

Other family therapy topics that such activities cover could be, for example, rituals. These are a major part of every family’s life whether they are aware of them or not. How families celebrate birthdays, anniversaries or even how they organize breakfast and start or end their day all have ritualistic elements.

Family therapists can work with existing rituals or guide families to create new ones to deepen their bonds. With the right rituals, families also gain a supportive framework that boosts their individual and group resilience.

Creating Rituals Around Loss

Best Family Therapy Activity Ideas

All family therapy activities are effective for different reasons. Your list of the best ones won’t necessarily be the same as someone else’s because it depends on context and experience. Nevertheless, these ones have been successfully applied over the decades.

1- Family Orchestra

(adapted from psychiatrists Ken Gardner and Lorri Yasenik whose activity is detailed in the booklet Favorite Therapeutic Activities for Children, Adolescents and Families: Practitioners Share Their Most Effective Interventions. Edited by Liana Lowenstein, MSW) [5]

Just like an orchestra needs practice to be in harmony, a family does too. One way to make this visual and nonverbal is to encourage each family member to make a sound with their body and whatever tools are at their disposal. Tapping shoes, clicking fingers, banging the wall and so on all count.

The most interesting part is when the family takes turns being the conductor and finding nonverbal ways to set the tempo and loudness. This gives the family an opportunity to explore roles, power struggles and how in harmony, or not, they can be.

Using Music to Express Feelings

2- Build Relationships with Colored Candy Go Around

Devised by therapist Katherine Arkell, the aim behind this activity is to open up communication. This can be done with colored candy or balls or even stickers. The point of candy is that there’s something fun to eat afterwards  [6] .

Everyone gets a handful of colored candy or stickers where each color has a question attached to it. The family members then take it in turn to answer the question according to the sequence of colors they pick. For example, blue can represent how the family plays together. Orange can be family strengths but red is family weaknesses or worries.

The Wheel of Life

3- Emotions Ball Game

The best family therapy activities are often physical or artistic because they allow everyone to think and interact differently. This one also enables family members to connect with their emotions and to start developing a common language. Moreover, this game can help a therapist see if there are any major mental health issues such as depression or anxiety.

For this game, therapists buy a reasonably priced football or beach ball of whatever size they feel is appropriate. They then write on it all the possible “emotion” words that might be relevant for the family.

In the session, the family throws the ball to each other and each time they catch it, they talk about the first emotion they see written down on the ball. Depending on the situation, the therapist might ask them when they last experienced that emotion or even to mime it with the body. This helps clients connect with emotions in the body while disconnecting from the mental stories they attach to emotions  [7] .

4- Mirroring

A fun activity that often brings out laughter is where family members copy exactly each other’s movements and expressions. This game increases empathy and allows adults to experience a child’s world more closely.

Moreover, the therapist can guide the family to connect with whatever emotions come up. Consequently, they enhance further open dialogue and emotional wisdom.

Restoring the Broken Mirror Metaphor

5- Lily Pad Swamp Crossing

This interactive game promotes problem solving and collaboration. The aim is to get the whole family, who are now frogs, across a swamp with only one lily pad. The therapist can also observe how the family plans and listens to each other as they play the game  [8] .

Best Family Therapy Exercises

Of course, activities and exercises don’t replace therapy and therapists do much more than facilitate family therapy activities. Nevertheless, those activities can surface issues and allow family members to get to know each other in a whole new light. The mind is then liberated and more ready for change.

1- My Family Portrait

Therapeutic family activities often overlap with art therapy as in this exercise. For this one, the therapist cuts a large piece of drawing paper into puzzle pieces, one for each family member. Each member then takes a puzzle piece and draws another family member before they are all reconnected.

Family therapists use this activity to open awareness about how each family member is perceived as well as how they all connect back together. The discussion then revolves around what each person is doing and feeling. This allows the family to explore their roles and how this might impact their behavior and potential conflict  [9] .

A Value-Tattoo

2- Make your Genogram

This exercise usually serves as a good assessment tool for therapists but it can also be referred to during check-ins along the therapy journey. As they show family lineage as well as emotional relationships, things can, and do, shift.

A useful Therapistaid overview and worksheet on creating a genogram is a good starting point. With it, you can make sure you have the symbols and themes you need to guide a family to create their genogram. 

Once complete, it’s a beneficial visual chart for family members to start understanding how their family system operates. You can even include this step in session  feedback forms  such as whether this activity is useful and what they’re learning from it. 

Furthermore, the genogram highlights strengths and weaknesses within the family unit. So, unhealthy habits come to light as well as abilities they forgot they had. Seeing the bigger picture helps families be more empathetic towards each other for more effective problem solving.

3- Self Love 

Some of the best family therapy exercises involve connecting family members both as individuals with themselves and with the others within the family. Positive Psychology has over 20 exercises and worksheets to increase self love which, in turn, solidifies a positive self-image.

From there, it’s easier for family members to connect with what they need and to then learn how to ask assertively and patiently.

Alternatively, you can apply and customize Quenza’s ready-made exercises. With the wide choice of self love exercises, you can easily make your own set of family therapy activities. A selection of those exercises is shown below. Although, you can see the whole list of all the other self love exercises by signing up for the   free, full-access, one-month $1-only trial .

Self-Love Sentence Stems

Rating Behavior Rather Than the Self

4- What’s My Story?

Family therapy topics range in impact from conflict about who wipes down the kitchen table to physical or emotional abuse. Nothing will ever make abuse acceptable but everyone can learn to change their story and therefore, their mindset.

When children relate traumatic or bad experiences in the form of a story, it can help them create some distance. It can also feel less daunting and can even be told in the third person or drawn or role-played. Depending on the children’s ages, therapists can adapt accordingly.

Rewriting the Narrative with Humor

5- Support system

Every therapist knows that they need to close out the therapy journey at some point. Otherwise, their clients haven’t gained the empowerment and self-efficacy to operate skilfully in life. That’s why goals are an important part of the journey but are family therapy activities that give closure.

Whether a family member discusses, draws or role-plays this final exercise, the idea is for each of them to know who their support system is. Together, they commit to supporting each other according to the needs that are clearly listed as part of the exercise.

Investing in Valued Relationships

Becoming a Family Therapist or Counselor

So, what are the benefits of family therapy and is this something you want to contribute to? Many therapists are apprehensive about the idea of working with children but don’t let that stop you. 

As mentioned earlier, children contribute a new level of playfulness and creativity that even we, as mental health professionals, need to connect to. Moreover, you’ll be allowing families to potentially break the cycles of generations of trauma and abuse.

To work in this field, you need a family counselor certification. Although, the details and format will depend on the regulations in your state or country. A good place to start is by looking up the regulating bodies or major family therapy associations in your area and reviewing their list of accredited courses.

Once you complete your family counselor certification, usually after 1 or 2 years, there’s a period of supervision. There’s no replacement for experience. Moreover, working with the right supervisor is hugely motivating and will set you up on the right path to success.

How Will You Benefit from Family Therapy Activities?

None of us operate alone and forgetting the context of families and culture means that so much potential healing is missed during individual therapy. We are stronger as families, even those with major issues, and by aligning family therapy goals, therapists can guide people towards a more balanced life.

The best family therapy activities combine a host of evidence-based models and theories to create experiential learning that enables family transformation. As such, therapists become skilled facilitators who are spontaneous and adaptable as they too step in briefly into each family system.

A family counselor certification is only the starting point in this fulfilling career where learning works both ways. Your role is also to remain fresh and creative and there’s no better way to do that than by partnering with a software platform like Quenza.

The family therapy activities and exercises you’ve seen in this article don’t do justice to the size of Quenza’s library or how easy it is to customize each one. For those who aren’t admin-focused, Quenza also takes all that away from you with its online  client intake  and other  critical documentation .

Try it out yourself by signing up for the  free, full-access, one-month $1-only trial  and get access to everything Quenza has to offer.

Life is hard and we all need help at times. Reaching out to a family therapist can be a brave starting point to save your family. Simply search for local organizations and ask them about their family therapy activities. Remember that you might also rediscover the fun in life once the suffering has stopped.

• ^ Marley, J. A., Rasheed, J., & Rasheed, M. N. (2011). Family Therapy Models and Techniques. Sage Publications, Inc.
• ^ Fishman, H. C. (2022). Performance-Based Family Therapy: Is anybody better off? Family Therapy Magazine. Retrieved from: https://ftm.aamft.org/performance-based-family-therapy-is-anybody-better-off/.
• ^ McLoughlin, S. (n.d.). Strategic and Structural Family Therapy Model Comparison. Prescott College. Retrieved from: https://www.academia.edu/17619972/Strategic_and_Structural_Family_Therapy_Model_Comparison.
• ^ Lowenstein, L. (2010). Creative Family Therapy Techniques: Play, Art, and Expressive Activities to Engage Children in Family Sessions. Champion Press.
• ^ Lowenstein, L. (2011). Favorite Therapeutic Activities for Children, Adolescents, and Families: Practitioners Share Their Most Effective Interventions. Champion Press. Retrieved from: https://www.lianalowenstein.com/.
• ^ Arkell, K. (n.d.). Colored Candy Go Around. Retrieved from: https://cls.unc.edu/wp-content/uploads/sites/3019/2019/01/Skittles-Game.pdf.
• ^ CFCS (n.d.). Feelings Ball Game. Catholic Family & Child Service. Retrieved from: https://depts.washington.edu/hcsats/PDF/TF%20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Affective%20Expression/Feelings%20Ball%20Game%20Instructions.pdf.
• ^ Act for Youth (n.c.). Lily Pads. Act for Youth Center for Community Action. Retrieved from: https://www.actforyouth.net/resources/stya/stya-pd16-lilypad.pdf.
• ^ Art Therapy Resources (2022). Using Art Therapy with Families. Art Therapy Resources. Retrieved from: https://arttherapyresources.com.au/art-therapy-families/.

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10 Best Problem-Solving Therapy Worksheets & Activities

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

• Social problem-solving
• The problem
• The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

• Stressful life events
• Emotional distress and wellbeing
• Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

• Enhance positive problem orientation
• Decrease negative orientation
• Foster ability to apply rational problem-solving skills
• Reduce the tendency to avoid problem-solving
• Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

• Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
• Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
• Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
• Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
• Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
• Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
• Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
• Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
• Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
• Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
• Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
• Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
• Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
• Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

• Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
• Is PST acceptable to the client?
• Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

• Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
• Define Obtain all required facts and details of potential obstacles to define the problem.
• Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
• Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
• Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

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Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

• I can solve this problem; I’ve tackled similar ones before.
• I can cope with this.
• I just need to take a breath and relax.
• Once I start, it will be easier.
• It’s okay to look out for myself.
• I can get help if needed.
• Other people feel the same way I do.
• I’ll take one piece of the problem at a time.
• I can keep my fears in check.
• I don’t need to please everyone.

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

Ask the client to complete the following:

• Describe the problem you are facing.
• What is your goal?
• What have you tried so far to solve the problem?
• What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

• Who is involved?
• What did or did not happen, and how did it bother you?
• Where did it happen?
• When did it happen?
• Why did it happen?
• How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.

Visualization

Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

• Clarifying the problem by looking at it from multiple perspectives
• Rehearsing a solution in the mind to improve and get more practice
• Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

• Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
• Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
• Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.

If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners. Use them to help others flourish and thrive.

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While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry ,  48 (1), 27–37.
• Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
• Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies  (4th ed.). Guilford Press.
• Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
• Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
• Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
• Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

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