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

Abstract

This article describes Filial Therapy, a structured and straightforward approach to working with parents and young children in family therapy; it highlights the congruence between Filial Therapy and the values and principles of family therapy. The historical, theoretical and research foundations of Filial Therapy are described. The family science and child socialisation literatures are also briefly reviewed, linking key predictors of positive child outcome with the goals of Filial Therapy. Finally, we discuss the consistencies between Filial Therapy and experiential and structural models of family therapy. We conclude with a description of Filial Therapy followed by a case example to illustrate the process.

Full text

Filial Therapy: A Structured
and Straightforward Approach
to Including Young Children
in Family Therapy
Glade L. Topham1and Risë VanFleet2
1Oklahoma State University, United States of America
2Family Enhancement and Play Therapy Center Inc., Boiling Springs, Pennsylvania, United States of America
This article describes Filial Therapy, a structured and straightforward approach to
working with parents and young children in family therapy; it highlights the congru-
ence between Filial Therapy and the values and principles of family therapy. The
historical, theoretical and research foundations of Filial Therapy are described. The
family science and child socialisation literatures are also briefly reviewed, linking key
predictors of positive child outcome with the goals of Filial Therapy. Finally, we
discuss the consistencies between Filial Therapy and experiential and structural
models of family therapy. We conclude with a description of Filial Therapy followed
by a case example to illustrate the process.
Keywords: filial therapy, family therapy, young children, parent
Although many couple and family therapists routinely and effectively involve children
in family therapy sessions, research shows a substantial portion fail to do so (Johnson
& Thomas, 1999; Korner & Brown, 1990; Lund, Zimmerman, & Haddock, 2002).
The most common reasons given are therapist discomfort (Johnson & Thomas,
1999) and a lack of understanding of how to effectively involve children and adults
concurrently in sessions (Kindred, 2003; Korner & Brown, 1990). Since the develop-
ment of family therapy over 60 years ago, a multitude of family therapy models have
been developed, each with a unique and complex set of ideas about treating families.
While some models have well-developed guidelines for treating children in family
sessions, such as narrative therapy (Epston, Freeman, Lobovits, 1997), many are
144 THE AUSTRALIAN AN D NEW ZEALAND JOU RNAL OF FAMILY THERAPY
Volume 32 Number 22011 pp. 144–158
Address for correspondence: Glade L. Topham, Department of Human Development and Family
Science, Oklahoma State University, 233 Human Environmental Sciences, Stillwater, OK 74078-
6122. E-mail: glade.topham@okstate.edu

complex and difficult to translate into work with children particularly for therapists
new to family treatment.
For some therapists, including children in family therapy sessions can be confusing
and overwhelming, it adds an element of unpredictability and uncertainty; the skills
required to be effective are unique and do not easily translate from traditional talk
therapy with adults. Filial Therapy, a play-based and relationship-focused treatment
approach, provides a model for treating young children in family therapy that is struc-
tured and straightforward and can be learned in a relatively short amount of time.
Training in Filial Therapy could be particularly valuable in helping therapists develop
comfort and confidence when conducting family therapy with young children.
In this article we expand on previous calls for increased use of Filial Therapy by
family therapists (Johnson 1995; Kellam, 2001; Sori, 2005; Winek et al., 2003). We
describe the treatment model and the historical, theoretical, and research foundations
of Filial Therapy as well as its congruence with two popular models of family therapy.
We describe the Filial Therapy treatment process and illustrate it with a case example.
Play as a Foundation for Treatment
In a definitive clinical report for the American Academy of Pediatrics (AAP),
Ginsburg (2007) concluded that ‘play … is essential to the cognitive, physical,
social, and emotional well-being of children and youth’ (p. 183). Play is the
means through which children learn perspective taking, language skills, problem
solving, memory, creativity, self-confidence, motivation and an awareness of the
needs of others (Davidson, 1998; Newman, 1990; Shonkoff & Phillips, 2000;
Singer, Singer, Plaskon, & Schweder, 2008). Play facilitates the development of
turn-taking, empathy, self regulation, impulse control, and motivation (Corsaro,
1988; Krafft & Berk, 1998). Furthermore, children are able to try on adult roles
and conquer their fears by developing mastery over them (Barnett, 1990; Tsao,
2002).
Perhaps most importantly, through play with their caregivers, children learn they
are loved and important and develop self-confidence and self-esteem (Powers,
2009). Because of the central role of play in healthy child development and as a
form of communication, parent–child play offers parents a unique opportunity to
connect with their child and understand their feelings, motives, perceptions,
thoughts and behaviours (Ginsburg, 2007; VanFleet, 2005). In his AAP report,
Ginsburg stated that healthy child development and resilience are rooted in the
fundamental connection that occurs when parents engage in child-led play.
Given the important role of play in promoting a healthy parent–child relation-
ship, nondirective parent–child play is a central component of several treatment
approaches. For example, parent–child interaction therapy (PCIT; McNeil &
Hembree-Kigin, 2010), Watch Wait and Wonder (Lojkasek, Muir, & Cohen, 2008)
and child parent psychotherapy (CPP; Lieberman & Van Horn, 2008) all use forms
of non-directive parent–child play to promote positive change. While each
approach has its strengths, we believe Filial Therapy to be a particularly good fit for
family therapists for several reasons. First, all children are included in treatment, not
just a designated target child; second, the nature of play in Filial Therapy allows for
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the inclusion of a wide range of ages of children (ages 2 to 12); third, it is designed
to treat a broad range of presenting problems (i.e., trauma, behavioural disruption,
grief and loss, problematic family processes, and so on); and fourth, Filial Therapy
is time limited, structured, and straightforward. The above-mentioned treatment
approaches lack one or more of these characteristics.
In Filial Therapy parents learn and implement a set of skills that maximise the
child’s ability to use play to develop, grow and, if necessary, heal from traumatic
experiences. Furthermore, through filial play sessions, parents and children interact
and see each other in new ways, strengthening the parent–child relationship. In the
process parents replace non-productive parenting behaviours with ones that
promote healthy child development.
Filial Therapy Background and History
Filial therapy was first developed in the late 1950s and early 1960s by Bernard and
Louise Guerney (Guerney, 1964; VanFleet, 2005). The Guerneys were well
acquainted with the effectiveness of play therapy in treating children’s social,
emotional, and behavioural problems, and hypothesised that parents could be
trained to conduct special play sessions with their children, much like a play thera-
pist. They believed because of the emotional bond parents share with their children,
it would be more effective to have the parent rather than the therapist conduct these
play sessions. The Guerneys experimented with parent–child conjoint sessions
about the same time other family therapy pioneers began conjoint family sessions.
The professional community responded to the Guerneys much like they did to
other family therapy pioneers, with scepticism and concern. However, early research
demonstrated positive results not just for children but also with parents and the
quality of the parent–child relationship (Oxman, 1972; Stover & Guerney, 1967).
Since those early studies, Filial Therapy has continued to grow in clinical use and
popularity and is supported by an expanding body of research demonstrating its
effectiveness (VanFleet, Ryan, & Smith, 2005).
Filial therapy is offered in several different formats, including the original group
format developed by the Guerneys (Ginsberg, Stutman, & Hummel, 1978;
Guerney, 1964), a short-term, 10-session group format adapted by Gary Landreth
(Landreth, 1991; Landreth & Bratton, 2006), and an individual family therapy
model adapted by Rise VanFleet (VanFleet, 1994; VanFleet & Guerney, 2003).
While there is a great deal of consistency across these different models there are
some important differences. To avoid confusion we focus exclusively in this article
on the individual family therapy model.
In Filial Therapy, parents are taught to set aside their own feelings and needs
and provide empathy and validation to their child during special 30-minute
nondirective play times. Filial therapy is typically used with 2- to 12-year-old
children, but ‘special times’ can be substituted for nondirective play sessions with
adolescents. Parents conduct one-on-one nondirective play sessions with each
child each week, or ‘special times’ with adolescents. They learn four skills needed
to conduct nondirective play sessions: structuring, empathic listening, child-
centered imaginary play, and limit-setting.
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Structuring: Parents are taught how to begin and end a play session to make the
transitions clear to the child.
Empathic listening: Parents are taught to temporarily put their own thoughts and
feelings aside; to attend fully to their child’s behaviors, intentions and feelings; and
to verbally reflect their child’s behaviours and feelings throughout the play session.
Child-centred imaginary play: Parents engage in pretend play when invited and
enact their child-assigned role as closely as possible in accordance with the child’s
wishes. They learn to use facial expression, intonation and a little drama in their
play, but at all times they follow the child’s lead.
Limit setting: Parents set limits to maintain safety and boundaries during the
session. They learn to use a firm but nonpunitive tone of voice to state limits clearly
and specifically, to provide a warning if the child does not comply and to carry out
the consequence. The child has two chances to self-correct after which the parent
applies the consequence, usually ending the play session.
These four skills, when used effectively together, help parents balance their accept-
ance and nurturance with necessary boundaries. After teaching parents the skills
and practicing them in role-play, therapists observe play sessions and provide direct
feedback following the play sessions. If two parents or caregivers are participating in
treatment they observe each other’s play sessions and participate in joint feedback
sessions with the therapist.
In these feedback discussions, therapists help parents to continue to improve
their skills and awareness of their child’s feelings and needs, and understand what
might prevent them from being fully attentive and available to their child. After
parents become comfortable with the skills, they begin play sessions at home during
the week and the therapist begins to work with the parent to generalise the filial
skills to daily parent–child interaction.
Theoretical Background
Filial therapy is an integrated approach that draws from several different theoretical
orientations including humanistic, interpersonal, psychodynamic, developmental,
attachment, and behavioral and social learning theories. Parent–child play sessions
are conducted in accordance with the principles of nondirective play therapy
(Axline, 1947) based on the concepts of Rogerian therapy. Parents learn to provide
their child with unconditional acceptance as they attend to and empathically reflect
their child’s feelings and actions in play. Similarly, in sessions with the parents, the
therapist strives to create an accepting, nonjudgmental atmosphere to feel safe,
respected, and understood.
In this atmosphere parents are able to attend more fully to the experiences and
needs of their child and can discuss their own negative reactions and behaviours
nondefensively as they work with the therapist to improve the parent–child
relationship. Furthermore, as parents experience acceptance and respect from the
therapist they tend to experience increased respect and acceptance for their child,
and are also more receptive to the corrective guidance of the therapist.
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The work of Harry Stack Sullivan (1953) and interpersonal theory had an
important impact on Bernard Guerney and the development of Filial Therapy, as it
did on many of the founders of family therapy. Sullivan abandoned Freud’s drive
theory and structural models of the mind in favour of understanding personality
development as learning that takes place through interpersonal connectedness.
Sullivan looked beyond the symptoms of an individual to the interpersonal context.
He emphasised that human experience is the product of dynamic interaction
between interpersonal influences and the internal meaning systems (intrapsychic
processes and experiences) of the individuals (Evans, 1996). Guerney was also influ-
enced by Leary (1957) who built upon and extended many of Sullivan’s ideas.
Leary suggested that individuals develop ‘interpersonal reflexes’ based on their
experiences in relationships that can become unconscious, automatic and rigid and
driven by the need to reduce anxiety.
In Filial Therapy an important focus of the post-play-session discussion with the
parents is the dynamic relationship between parents’ behavioural responses to their
child in play (‘interpersonal reflexes’) and their associated emotional or cognitive
(intrapsychic) reactions. Therapists guide parents in recognising their reflexive
responses to their child (e.g., inability to let the child take the lead in the play
session), help parents explore and understand their emotional reactions (e.g., ‘I felt
vulnerable and weak’), and help parents challenge associated constraining beliefs
(e.g., ‘He just wants to make this miserable for me’).
Therapists may briefly help parents connect their current reflexive responses and
emotional and cognitive reactions to previous interpersonal experiences (e.g., past
relationships when parents felt controlled). Through dynamic discussions across
sessions, the rigidity of unconscious and automatic responses to the child are
weakened, freeing parents to develop more productive and intentional patterns of
interaction with their child.
Psychodynamic and developmental theories come into play, particularly in post-
play discussions with parents. In these discussions, therapists help draw parents’
attention to the developmental aspects of the child’s play, such as problem-solving
or mastery, and help them become attuned to what may be going on for their child
both in and outside of the play sessions. Children’s play is also viewed through a
psychodynamic lens in that their play is viewed as symbolic of their internal worlds,
including needs, anxieties, hopes, and fears. Tentative discussions with parents
about the possible meaning of the child’s play using both these perspectives increase
curiosity about the child’s internal world.
Filial therapy also integrates ideas from attachment theory. An important focus
of the dyadic parent–child work is to help parents develop greater attunement and
appropriate responsiveness to each of their children and promote healthy and secure
parent–child attachment relationships. Research has demonstrated the latter
promote better adjustment among family members, healthier sibling relationships
and improve family functioning as a whole (Berlin, Cassidy, & Appleyard, 2008).
Finally, Filial Therapy also draws from behavioural and social learning theory
principles, such as modelling, behavioural rehearsal, shaping, and reinforcement,
particularly in training parents in nondirective play skills.
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Goals of Filial Therapy
The majority of treatment programs targeting the parent–child relationship take
what Cavell and Elledge (2003) refer to as an ‘intervention-as-intervention’
approach. These target the immediate reduction of problem behaviours while
neglecting broader relationship issues important for successful child socialisation.
In contrast, Filial Therapy takes a ‘socialisation-as-intervention’ approach, which
assists families with immediate needs, while fostering and strengthening patterns
of interaction most predictive of healthy child development and positive child
outcomes. Therefore the process of Filial Therapy would be the same whether
used as prevention or as treatment for an existing problem.
A number of parenting attitudes and practices have been shown to be key to
healthy child socialisation and outcome. These include being aware of and
responsive to children’s needs and wishes (Belsky & Fearon, 2009); parent
emotional warmth and support (Baumrind, Larzelere, & Owens, 2010); parent-
ing that values and validates children’s expression of negative emotion and helps
work through it (Gottman, Katz, & Hooven, 1996); and effective limit setting
with clear expectations, firm limits and use of reasoning (Baumrind et al.,
2010). In contrast, parenting that is hostile and coercive, or permissive and
indulgent (Baumrind et al., 2010), or psychologically controlling (i.e., parental
intrusiveness, guilt induction and love withdrawal — Barber, Stolz, & Olsen,
2005) are particularly damaging to healthy child socialisation and the parent–
child relationship.
Consistent with this research literature, Filial Therapy helps parents to (a)
become attuned to, accepting of and responsive to their child’s as well as their
own internal experience (e.g., emotions, needs, desires); (b) understand child
development in general, and specifically their child’s developmental needs and
challenges; (c) increase confidence in their parenting ability; (d) learn to calmly
and consistently set limits; and (e) identify and address issues that may negatively
affect the way they relate to their children.
Goals for children include: (a) learning to recognise, accept, and express their
emotions fully; (b) increasing their self-confidence and self-esteem; (c) developing
effective problem-solving and coping strategies and skills; (d) reducing or elimi-
nating maladaptive behaviours and presenting problems; and (e) developing
proactive and prosocial behaviors.
In terms of overall family relationships, the goals of Filial Therapy are to: (a)
increase children’s trust and confidence in their parents; (b) increase parents’
warmth for and acceptance of their children; (c) for parents in two-parent families
to work together more effectively as a team; and (d) in general, to promote an
accepting and cohesive family climate that fosters healthy child development
(VanFleet, 2005). Ideally all primary caregivers (whether it be a single parent, two
parents, or a parent and a grandparent) participate in play sessions (or ‘special
times’ with adolescents) with each of the children each week. This increases the
influence of Filial Therapy in helping families replace negative family patterns
with those that are more productive and growth promoting.
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Filial Therapy Research
In Filial Therapy, parent–child play is used as a medium for addressing a host of
child, parenting and parent–child relationship difficulties. The research literature
demonstrates the effectiveness of this approach (Ray, Bratton, Rhine, & Jones,
2001; VanFleet, Ryan, & Smith, 2005). Some positive child outcomes include an
increase in children’s expression of emotion (Glass, 1986), reduction in child
depression and anxiety (e.g., Tew, Landreth, Joiner, & Solt, 2002), an increase in
child self-confidence (e.g., Costas & Landreth, 1999; Yuen et al., 2002) and a
decrease in child behavior problems (e.g., Grskovic & Goetze, 2008; Jang, 2000).
Parenting outcomes include a decrease in parent stress (e.g., Kale & Landreth,
1999; Yuen et al., 2002), an increase in parent acceptance of the child (e.g., Bratton
& Landreth, 1995; Landreth & Lobaugh, 1998), parents allowing more self-direc-
tion for the child (Smith & Landreth, 2003) and increased parent empathy (Glover
& Landreth, 2000; Jang, 2000) and improved parent–child relationships (Grskovic
& Goetze, 2008).
Filial therapy has been shown to be an effective intervention for parents and
children from a wide range of backgrounds and presenting issues or complaints
including foster parents (Guerney & Gavigan, 1981), single parents (Bratton &
Landreth, 1995), incarcerated mothers and fathers (Harris & Landreth, 1997;
Landreth & Lobaugh, 1998), parents from a variety of cultural and ethnic
backgrounds (e.g., Grskovic & Goetze, 2008; Kidron & Landreth, 2010), parents
of chronically ill children (e.g., Tew et al., 2002), parents of children with conduct
problems (Johnson-Clark, 1996), parents of children with pervasive developmental
disorders (Beckloff, 1997), parents of children with learning difficulties (Kale &
Landreth, 1999), non-offending parents of sexually abused children (Costas &
Landreth, 1999), and parents of children who have witnessed domestic violence
(Smith & Landreth, 2003).
Although researchers have not examined the relationship between Filial Therapy
and broader systemic change using quantitative methodology, this has been consis-
tently demonstrated by a few qualitative studies. Parents report family communica-
tion has become more effective with more open discussion, give and take,
expression of emotion and respect for others’ opinions and feelings. They also
report transferring skills of empathy, validation, and acceptance into their couple
relationships resulting in increased understanding and a stronger sense of unity
(Bavin-Hoffman, 1997; Lahti, 1992; Wickstrom, 2009).
Congruence Between Filial Therapy and Family Therapy
Several principles of Filial Therapy highlight its congruence with family therapy.
These include avoiding pathologising the child or parent, focusing on the parent-
child relationship as the primary mechanism for change and challenging a linear or
medical model of therapy. Rather than seeking to uncover and treat pathology Filial
therapy is a strength-based approach focusing on education and skill development
in identifying and working through barriers to family progress. It assumes individu-
als and families naturally resolve problems and overcome challenges in the context
of well functioning family relationships.
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While Filial Therapy addresses many of the goals of parent training it is much
broader in scope, targeting not only parenting skills and treating child problems,
but also family relationships and family functioning. As a family-systems interven-
tion it specifically targets family subsystems (i.e., all parent–child subsystems and
the co-parent subsystems) and generalises individual and subsystem change to
broader family dynamics. This approach to family systems change is supported by
attachment research, which shows the quality of attachment in the parent–child
dyad affects family relationships (Berlin et al., 2008) and by Filial Therapy research,
which shows participants consistently report improvements in family communica-
tion, conflict management and mutual empathy and respect (Bavin-Hoffman,
1997; Lahti, 1992; Wickstrom, 2009).
Because of the emphasis on fostering healthy family relationships, Filial Therapy
is consistent with a variety of family therapy theoretical perspectives and here we
discuss parallels with experiential and structural family therapy models.
Consistency With Experiential Family Therapy
Within experiential family therapy problems are viewed as resulting from a denial of
emotional experience. Individuals learn to ignore and discount their own emotional
experience and avoid emotional expression in order to meet expectation of society
and family members. This begins in early childhood when parents see negative
emotion to require correction and punishment like child misbehavior. One result of
emotion suppression is family relationships may be distant and lack emotional
intimacy (Nichols, 2009).
Experiential family therapy helps family members develop an awareness of and
acceptance of their own and other family members’ emotional experience, leading
to increased respect for individuality and increased self-esteem of family members.
This is achieved by creating an in-session emotional experience and helping family
members establish honest and genuine emotional contact with each other (Napier
& Whitaker, 1978; Satir, 1972).
Likewise Filial Therapy helps family members develop awareness and acceptance
of their own and each other’s emotions where the primary experiential activity is
the parent–child play session. These play sessions provide an opportunity for
children to express their feelings, needs and fantasies, and for parents to develop
understanding and acceptance for and validate their children’s experience. They also
help parents become less constrained and more playful with their children. Parents
develop awareness and acceptance of their own emotion in post-play discussions
with the therapists as they explore their reactions to the play sessions in the context
of therapist validation. As parents conduct play sessions with each of their children,
observe the other parent’s play sessions and meet with the therapist in post-play
discussions, emotional expression becomes an integrated part of family culture.
Consistency With Structural Family Therapy
Structural family therapy views problems as typically resulting from inflexible
family structures that prevent the family from adapting to the demands of changing
circumstances. Common problems include rigid role assignment in which there is
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an exaggerated complementarity in family roles that detract from individual growth;
disengagement, where boundaries between family members are rigid leaving family
members emotionally isolated; enmeshment, where boundaries between family
members are diffuse, compromising family members’ autonomy; and either little
parental hierarchy with children and parents sharing power or an exaggerated
hierarchy in which children have no voice (Minuchin, 1974).
Family structure is observed and modified during family interaction with enact-
ments, the hallmark of structural family therapy. Here the therapist encourages specific
family interaction and then works to modify family structure such as reinforcing
boundaries or solidifying parental hierarchy. As new patterns of interaction are regularly
repeated, a more functional structure is solidified in the system (Nichols, 2009).
Filial therapy is a strength-based approach that seeks to resolve difficulties by
fostering improved patterns of family interacting, with the parent–child play
sessions similar to enactments in structural family therapy. Although the therapist
does not intervene in the room in the moment during play sessions, direct feedback
is given to parents after each session to modify and shape the interaction. The
instructions and the feedback parents receive regarding the parent–child play
sessions help parents establish clear boundaries in interaction with their children.
Rigid boundaries are weakened in disengaged parent–child dyads as parents
learn to tolerate emotional intensity and learn to respond in warm and supportive
ways. Similarly, boundaries are strengthened in enmeshed parent–child dyads as
parents learn to put their needs on hold and attune to and accept their child’s
emotions, needs, and wishes. Both during the play and in post-play discussions with
the therapist parents learn to distinguish between their own and their child’s
emotions. In play sessions parents learn to let their child make his or her own
decisions and solve his or her own problems in a context of nonpossessive warmth.
In Filial Therapy a hierarchy in the family is established by clear and consistent
limit setting, but is also reinforced by the nurturing elements of warmth, reflection,
and validation. Where two parents (or caregivers) are participating, executive post-
play discussions with parents help develop a unified, co-parenting alliance. Filial
therapy also helps address the exaggerated complementarity of parental roles (e.g.,
disciplinarian vs. nurturer). The individual parent–child play sessions enable each
parent to develop confidence and comfort in various parenting roles with each of
their children without reflexively stepping aside for the other parent to fulfill less
comfortable roles.
Outline of Filial Therapy
While the process of Filial Therapy has been detailed elsewhere (VanFleet, 2005,
2006) it is briefly outlined here. The sequence of Filial Therapy involves several
phases: assessment, training, supervised play sessions, home play sessions, and
generalisation. Typically it requires 15 to 20 one hour sessions, although it can take
longer with severely distressed families. The phases of Filial Therapy are outlined
below.
Assessment: The therapist first meets with the parents to discuss their concerns and
the presenting problems, listens empathically, and obtains further information
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about the family and the situation. Without children present parents can talk freely
about their challenges and frustrations including any problems in the co-parenting
relationship. The second session typically involves a family play observation
followed by further discussion and final recommendations for treatment.
Training: Training typically takes 3-4 one hour sessions. The therapist demonstrates
short nondirective play sessions with each of the children in the family while
parents observe. The therapist then trains the parents in four play session skills,
culminating in mock play sessions in which the therapist plays the child’s role while
parents practise the skills. The therapist provides immediate and encouraging
feedback to facilitate the parents learning to conduct the play sessions.
Supervised play sessions: Parents take turns conducting filial play sessions with each
of their children while the other parent and therapist observe. Without the child
present the therapist discusses the experience with the parent(s), offers positive
feedback and suggests one or two improvements for next time. This helps parents to
make continual progress without feeling overwhelmed. Therapists typically observe
each parent conducting four to six play sessions, after which most parents become
quite skilled.
Home play sessions: Parents hold weekly half-hour play sessions with each of their
children at home and meet with the therapist to discuss the home sessions, the
children’s play themes and questions that arise. Parents often observe each other’s
home sessions as well. Home play sessions can continue as long as children and
parents wish.
Generalisation: Near the end of therapy, therapists help parents begin to use their
newly mastered skills outside the play sessions in everyday life. This is accomplished
in a deliberate way to ensure that parents become competent and confident in
applying what they have learned.
A Case Study
We now provide a case example to illustrate the process and outcomes of Filial
Therapy. Identifying information has been changed to protect the privacy of the
family involved.
Mandy and Phil were parents of two children, Carrie, age 10, and Davey, age 7,
diagnosed with diabetes a year before. While injections and blood tests were not a
problem, Davey frequently hid candy and other forbidden sweets in his room,
despite his parents being very strict about his diet and rarely bringing sweet foods
home. In the past year Davey had become increasingly oppositional, and their
paediatrician suggested therapy.
During family assessment Mandy and Phil reported more frequent disagreements,
mainly about Davey’s diabetes management, as well as increasing marital distress.
Davey’s sister, Carrie, often complained she should not be penalised in her food
choices just because her brother had a problem. She was angry and withdrawn
when informed she would have pizza without any cake or icecream for the family
celebration of her tenth birthday.
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The therapist noticed during the family play observation that Carrie played quietly in
one corner of the playroom while the parents focused on Davey and frequently
completed tasks for him when he became frustrated. During the discussion Mandy
and Phil said these patterns were typical and were concerned Davey required
inordinate amounts of their time and they were ‘probably not giving Carrie her due’.
The therapist recommended Filial Therapy.
Mandy and Phil learned the play session skills quickly and without a problem.
During the supervised play session phase, Phil held the first play session with
Davey. Davey selected the doctor doll and began throwing it around the room,
eventually pretending to hit and kick it. Davey called the magic wand a ‘giant
needle’ and began giving painful injections to the doctor. It was difficult for Phil to
simply reflect this behaviour, but he was able to tolerate it and comment exception-
ally well on Davey’s feelings: ‘You’re really mad at that doctor. You’re punishing him.
Now he has to get a GIANT shot. The doctor is crying now. He hates that.’ During
her play session with Mandy, Carrie at first seemed uninterested. Later she asked
her mother to play ‘hangman’ with her on the whiteboard.
During the discussion both parents expressed surprise and alarm about Davey’s
aggressive play. Through empathic listening the therapist eventually helped them to
understand Davey’s feelings were quite normal, that he may have unresolved
feelings about doctors, his diabetes and a loss of control of his life circumstance.
The therapist praised Phil’s ability to reflect these feelings, while Mandy expressed
concerns about Carrie’s aloofness and apparent disinterest. The therapist urged the
parents to give the process time.
Both parents continued to improve their play session skills through the use of post-
play feedback. Their understanding of their children’s feelings also improved from
session to session. Davey continued to play aggressive medical themes before
becoming a ‘world famous doctor’ who admonished his patients about what they
could and could not eat. Mandy and Phil were able to see Davey’s distress more
clearly, and although still worried about his diabetic control they realised they
needed to become a little more relaxed with family meals.
Carrie’s play evolved over time. She enjoyed dress-up play and directed scenes in
which she was glamorous and ‘famous’, and her parents (during alternate sessions)
had to play the role of her adoring public. In discussions with the therapist, Mandy
and Phil began to see how their concerns about Davey had drawn their attention
away from Carrie. In addition to weekly play sessions, they made plans to inquire
about Carrie’s school days, friends and interests more frequently and to occasion-
ally take her for a special outing.
After five supervised sessions, the family began their home play sessions. They
noticed Davey’s oppositional behaviours decreasing with each play session. As
Davey took more control of the play and his parents offered him more choices on a
daily basis, he no longer needed to control the household. Carrie also seemed more
engaged, laughing freely as her parents dressed and played different roles based
on her requests. Mandy and Phil reported that Carrie was more relaxed at home
and took more interest in family activities.
As the therapy entered the final stage of generalisation and discharge, Mandy and
Phil said they noticed less strain, both as individuals and as a couple. They had
been so worried about the diabetes they had not been enjoying each other or their
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children. Filial therapy gave them tools for co-parenting under the difficult condi-
tions of family chronic illness, while adding an element of playfulness back into their
lives. As the family enjoyed their time together, the medical management became
more routine and less intrusive in their lives. They continued filial play sessions after
therapy finished and reported during a phone call 6 months later they were all still
doing well. Filial therapy brought the family together in a more relaxed way, helped
the parents offer more warmth and support to both children, aided the family in a
more flexible approach to diabetes management and allowed them to enjoy life
together once again.
Application to Diverse Presenting Problems
A key strength of Filial Therapy is its use of nondirective parent–child play to target
a range of child emotional and behavioural problems, parenting difficulties and
problematic patterns of family interaction. Like other family therapy approaches, it
can be integrated with various interventions — for example, psychiatric consulta-
tion and crisis intervention, marital therapy when problems extend beyond the co-
parenting relationship, or individual therapy when a parent suffers from mental
health issues like depression (VanFleet, 2005). It can also be used for difficult
challenges like integrating blended families.
Conclusion
Filial therapy is a strength-based, relationship-focused intervention that utilises
parent–child play to directly intervene in the parent–child and co-parenting subsys-
tems in order to treat a variety of child, parent, and family relationship problems.
Parents develop skills that foster their children’s’ development, establish parent–
child relationship patterns and increase role flexibility and unity in co-parenting.
Filial therapy is consistent with the values and principles of family therapy and its
structured and straightforward approach is ideal for therapists inexperienced in
treating young children in family therapy.
References
Axline, V.M. (1947). Play therapy. Cambridge, MA: Houghton-Mifflin.
Barber, B.K., Stolz, H.E., & Olsen, J.A. (2005). Parental support, psychological control, and
behavioral control: Assessing relevance across time, culture, and method: I. Introduction.
Monographs of the Society for Research in Child Development, 70(4), 1–13.
Barnett, L.A. (1990). Developmental benefits of play for children. Journal of Leisure
Research, 22, 138–153.
Baumrind, D., Larzelere, R.E., & Owens, E.B. (2010). Effects of preschool parents’ power
assertive patterns and practices on adolescent development. Parenting Science and
Practice, 10, 157–201.
Bavin-Hoffman, R., Jennings, G., & Landreth, G. (1996). International Journal of Play
Therapy, 5, 45–58.
Beckloff, D. (1997). Filial therapy with children with spectrum pervasive developmental
disorders. Dissertation Abstracts International: Section B. Sciences and Engineering,
58(11), 6224B.
155
Young Children in Family Therapy
THE AUSTRALIAN AN D NEW ZEALAND JOU RNAL OF FAMILY THERAPY

Belsky, J., & Fearon, R.M.P. (2009). Precursors of attachment theory. In J. Cassidy & P.
Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed.;
pp. 295 316). New York: Guilford.
Berlin, L.J., Cassidy, J., & Appleyard, K. (2008). The influence of early attachments on
other relationships. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory,
research, and clinical applications (2nd ed., pp. 333–347). New York: Guilford Press.
Bratton, S., & Landreth, G. (1995). Filial therapy with single parents: Effects on parental
acceptance, empathy, and stress. International Journal of Play Therapy, 4, 61–80.
Cavell, T.A., & Elledge, L.C. (2004). Working with parents of aggressive, school age
children. In J. Briesmeister & C. Schaefer (Eds.), Handbook of parenting training:
Helping parents prevent and solve problem behaviors (3rd ed.; pp. 379–423). Hoboken,
NJ: Wiley & Sons.
Corsaro, W.A. (1988). Peer culture in the preschool. Theory into Practice, 27, 19–24.
Costas, M., & Landreth, G. (1999). Filial therapy with nonoffending parents of children
who have been sexually abused. International Journal of Play Therapy, 8, 43–66.
Davidson, J.I.F. (1998). Language and play: Natural partners. In E.P. Fromberg & D.
Bergen (Eds.), Play from birth to twelve and beyond: Contexts, perspectives and meaning
(pp. 175–183). New York: Garland.
Epston, D., Freeman, J., & Lobovits, D. (1997). Playful approaches to serious problems:
Narrative therapy with children and their families. New York: Norton Professional Books.
Evans, F.B. (1996). Harry Stack Sullivan: Interpersonal theory and psychotherapy. New York:
Routledge.
Ginsberg, B.G., Stutman, S.S., & Hummel, J. (1978). Group filial therapy. Social Work, 23,
154–156.
Ginsburg, K.R. (2007). The importance of play in promoting healthy child development
and maintaining strong parent-child bonds. Pediatrics, 119, 182–191.
Glass, N.M. (1986). Parents as therapeutic agents: A study of the effects of filial therapy.
Dissertation Abstracts International: Section B: Sciences and Engineering, 47(7-A), 2457.
Glover, G.J., & Landreth, G.L. (2000). Filial therapy with Native Americans on the
Flathead Reservation. International Journal of Play Therapy, 9, 57–80.
Gottman, J.M., Katz, L.F., & Hooven, C. (1996). Parent meta-emotion philosophy and the
emotional life of families: Theoretical models and preliminary data. Journal of Family
Psychology, 10, 243–268.
Grskovic, J.A., & Goetze, H. (2008). Short-term filial therapy with German mothers:
Findings from a controlled study. International Journal of Play Therapy, 19, 39–51.
Guerney, B. (1964). Filial therapy: Description and rationale. Journal of Consulting
Psychology, 28, 303–310.
Guerney, L.F., & Gavigan, M.A. (1981). Parent acceptance and foster parents. Journal of
Clinical Child Psychology, 10, 27–32.
Harris, Z.L., & Landreth, G.L. (1997). Filial therapy with incarcerated mothers: A five week
model. International Journal of Play Therapy, 6, 53–73.
Lieberman, A.F., & Van Horn, P. (2008). Psychotherapy with infants and young children:
Repairing the effects of stress and trauma on early attachment. New York: Guilford Press.
McNeil, C.B., & Hembree-Kigin, T.L. (Eds.). (2010). Parent-child interaction therapy (2nd
ed.). New York: Springer Business.
Jang, M. (2000). Effectiveness of filial therapy for Korean parents. International Journal of
Play Therapy, 9, 21–38.
156
Glade L. Topham and Risë VanFleet
THE AUSTRALIAN AN D NEW ZEALAND JOU RNAL OF FAMILY THERAPY

Johnson, L. (1995). Filial therapy: A bridge between individual child therapy and family
therapy. Journal of Family Psychotherapy, 6, 55–70.
Johnson, L. & Thomas, V. (1999). Influences on the inclusion of children in family therapy.
Journal of Marital and Family Therapy, 25, 117–123.
Johnson-Clark, K. (1996). The effect of filial therapy on child conduct behavior problems
and the quality of the parent-child relationship. Dissertation Abstracts International:
Section B. Sciences and Engineering, 57(4), 2868B.
Kale, A.L., & Landreth, G.L. (1999). Filial therapy with parents of children experiencing
learning difficulties. International Journal of Play Therapy, 8, 35–56.
Kellam, T.L.T. (2001). Filial therapy: A family systems intervention. Family Therapy, 28, 63–
72.
Kidron, M. & Landreth, G. (2010). Intensive child parent relationship therapy with Israeli
parents in Israel. International Journal of Play Therapy, 19, 64–78.
Kindred, R. G. (2003). A qualitative study of marriage and family therapists’ knowledge,
attitudes, and behaviors about child inclusive family therapy. Dissertation Abstracts
International: Section B: The Sciences and Engineering, 63(8-B), 3922.
Korner, S. & Brown, G. (1990). Exclusion of children from family psychotherapy: Family
therapist’s beliefs and practices. Journal of Family Psychology, 4, 420–430.
Krafft, K.C., & Berk, L.E. (1998). Private speech in two preschools: Significance of open
ended activities and make-believe play for verbal self-regulation. Early Childhood
Research Quarterly, 13, 637–658.
Lahti, S. (1992). An ethnographic study of the filial therapy process. Dissertation Abstracts
International: Section B: The Sciences and Engineering, 53(8-A), 2691.
Landreth, G.L. (1991). Play therapy: the art of the relationship. Levitown, PA: Accelerated
Development.
Landreth, G.L., & Bratton, S.C. (2006). Child parent relationship therapy (CPRT): A 10-
session filial therapy model. New York: Routledge.
Landreth, G.L., & Lobaugh, A.F. (1998). Filial therapy with incarcerated fathers: Effects on
parental acceptance of child, parental stress, and child adjustment. Journal of Counseling
and Development, 76, 157–165.
Leary, T. (1957). Interpersonal diagnosis of personality. New York: The Ronald Press.
Lojkasek, M., Muir, E., & Cohen, N.J. (2008). Watch, wait, and wonder: Infants as agents
of change in a play-based approach to mother-infant psychotherapy. In C.E. Schaefer, S.
Kelly Zion, J. McCormick & A. Ohnogi (Eds.), Play therapy for very young children (pp.
279–305). Lanham, MD: Jason Aronson.
Lund, L.K., Zimmerman, T.S., & Haddock, S.A. (2002). The theory, structure, and
techniques for the inclusion of children in family therapy: A literature review. Journal of
Marital and Family Therapy, 28, 445–454.
Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University
Press.
Napier, A., & Whitaker, C. (1978). The family crucible: The intense experience of family
therapy. New York: Harper and Row.
Newman, L.S. (1990). Intentional and unintentional memory in young children:
Remembering vs. playing. Journal of Experimental Child Psychology, 50, 243–258.
Nichols, M.P. (2009). Family therapy: Concepts and methods (9th ed.). Boston, MA: Pearson.
Oxman, L.K. (1972). The effectiveness of filial therapy: A controlled study. Doctoral disser-
tation, Rutgers University, The State University of New Jersey. Dissertation Abstracts
International: Section B: The Sciences and Engineering, 32(8-A), 6656.
157
Young Children in Family Therapy
THE AUSTRALIAN AN D NEW ZEALAND JOU RNAL OF FAMILY THERAPY

158
Glade L. Topham and Risë VanFleet
THE AUSTRALIAN AN D NEW ZEALAND JOU RNAL OF FAMILY THERAPY
Powers, S. (2009). This issue and why it matters. Zero to Three, 30, 3.
Ray, D., Bratton, S., Rhine, T., & Jones, L. (2001). The effectiveness of play therapy:
Responding to the critics. International Journal of Play Therapy, 10, 85–108.
Satir, V.M. (1972). Peoplemaking. Palo Alto, CA: Science and Behavior Books.
Shonkoff, J.P., & Phillips, D.A. (Eds.). (2000). From neurons to neighborhoods: The science of
early childhood development. Washington, DC: National Academy Press.
Singer, D.G., Singer, J.L., Plaskon, S.L., & Schweder, A.E. (2003). A role for play in the
preschool curriculum. In S. Olfman (Ed.), All work and no play: How educational reforms
are harming our preschoolers (pp. 59–101). Westport, CT: Greenwood Publishing Group.
Smith, N., & Landreth, G.L. (2003). Intensive filial therapy with child witnesses of domes-
tic violence: A comparison with individual and sibling group play therapy. International
Journal of Play Therapy, 12, 67–88.
Sori, C.F. (2006). Filial therapy: An interview with Rise VanFleet. In C.F. Sori (Ed.),
Engaging children in family therapy: Creative approaches to integrating theory and research
in clinical practice (pp. 91–116). New York: Routledge.
Stover, L., & Guerney, B.G., (1967). The efficacy of training procedures for mothers in filial
therapy. Psychotherapy: Theory, Research and Practice, 4, 110–115.
Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: W.W..
Tew, K., Landreth, G.L., & Joiner, K.D. (2002). Filial therapy with parents of chronically ill
children. International Journal of Play Therapy, 11, 79–100.
Tsao, L. (2002). How much do we know about the importance of play in child develop-
ment? Childhood Education, 78, 230–233.
VanFleet, R. (1994). Filial therapy: Strengthening parent-child relationships through play.
Sarasota, FL: Professional Resource Press.
VanFleet, R. (2005). Filial therapy: Strengthening parent-child relationships through play (2nd
ed.). Sarasota, FL: Professional Resource Press.
VanFleet, R. (2006). Introduction to Filial Therapy [DVD]. Boiling Springs, PA: Play
Therapy Press.
VanFleet, R., & Guerney, L. (2003). Casebook of filial therapy. Boiling Springs, PA: Play
Therapy Press.
VanFleet, R., Ryan, S.D., & Smith, S.K. (2005). Filial therapy: A critical review. In L.A.
Reddy, T.M. Files-Hall, & C.E. Schaefer (Eds.), Empirically-based play interventions for
children (pp. 241–264). Washington, DC: American Psychological Association.
Wickstrom, A. (2009). The process of systemic change in filial therapy: A phenomenological
study of parent experience. Contemporary Family Therapy, 31, 193–208.
Winek, J., Johnson, L., Krepps, J., Lambert-Shute, J., Shaw, L., & Wiley, K. (2003).
Discover the moments of movement in filial therapy: A single case qualitative study.
International Journal of Play Therapy, 12, 89–104.
Yuen, T., Landreth, G., & Baggerly, J. (2002). Filial therapy with immigrant Chinese
families. International Journal of Play Therapy, 11, 63–90.