Family Functioning: Low Risk Activities to Improve Relationships

I don’t need therapy, they are the one with the problem! How does talking about it fix things between us? This will just make the fighting worse! You are meeting with a family in your office for the second time. This family is composed of a parent, grandparent, and two preteens and everyone appears on edge. You track body language and energy in the room as you begin to explore what family therapy means to each of them. You notice the crossed arms of the preteens, the angry face of the parent, and the withdrawn quality of the grandparent sitting farthest away in the room. How do you respond? What will engage each of them in this process of healing to strengthen their relationships?

Set Boundaries

When first engaging a family, it can be extremely important to set boundaries as their family therapist so you can begin to engage the family system as a whole. Identifying your role clearly, including your ‘no secrets’ policy, can be helpful for each family member to hear that you aren’t picking sides or aligning in a way that prevents cooperation from all members. Not holding secrets and describing your efforts to remain appropriately transparent with the family can convey neutrality and respect, two elements that can increase willingness to participate and rapport building in your relationship. Reviewing limits of confidentiality can also set the family system up for success in being aware of how you must respond to conflict and needs for safety.

Explore Goals

In conjunction with setting healthy boundaries, engaging each family member in exploring their goals for family therapy can increase their motivation and commitment to the work. What would the preteens like to be different? What would make things better in their home? What would the parent like to see in regards to structure of house rules and parenting? How would the grandparent like things to be between their loved ones? Once you gather information from each family member, you can support the family in identifying how these goals can be measured over time to support positive shifts within their relationships and home.

Slow Down

Positive shifts in functioning are the ideal outcome of therapy and it’s possible that the family is engaging in therapy with a sense of urgency to “fix” their problems. Some members in the family can present with a sense of demand to jump in, unpack the conflict, and tackle change in rapid fashion. However, if the therapist moves too quickly, they run the risk of other family members becoming flooded, feeling attacked, or disengaging due to the pressure they feel by other members of the family or by the pace of the process. Here are some examples of what you might notice if things are moving too fast:

• One or more family members gets quiet and refuses to participate
• Body language conveys discomfort such as crossed arms, slouched posture, clutching a pillow to their chest, or avoidant eye contact
• Responding with “I don’t know” when questions are asked
• Increased agitation including rapid speech, flushed skin, facial grimacing, and fidgeting
• Leaving the room or pulling out their cell phone

Noticing these cues can be important in acknowledging a client’s discomfort and attempting to re-engage them in ways that feel safe. Validating emotion is a powerful tool in family therapy and can ensure everyone has an equal voice in the process.

Structure Sessions

Being mindful of how you engage the family each session in pursuit of their goals can encourage structure, support, and full participation. You may need to explain to one member of the family that jumping right into conflict could deter other members from participating in the future. Addressing immediate concerns with a safety plan can acknowledge the need for structure and safety while still engaging all family members in exploration of coping skills and needs for support.

Creating Commitment

While the safety plan and goals are being established, further rapport and exploration of family functioning can occur through low-risk activities. Low-risk activities, by definition, are presented as and appear to clients as activities that feel safe and don’t require intense participation. Due to the fact that each family member has a different level of comfort in the room, low-risk therapeutic activities can be a great way to explore their communication and build positive experiences between family members to further encourage participation in the therapeutic process.

Some examples of low risk therapeutic activities:

1. Feelings Jenga or Uno with each color or block representing a) things we like, b) things we don’t like, c) things we appreciate about our family, d) things we wish for
2. Feelings chip toss game or bingo to explore emotional vocabulary and awareness including sharing of times they felt that emotion
3. Feelings charades to reach emotions and body language in each family member
4. Cooperative play board games
5. Blindfolded obstacle course, drawing or Lego exercises
6. Recipe for success with colored sand, containers, and cooperation
7. The Ungame
8. Family portrait or family tree art
9. Family playlist with songs representing their experiences
10. And many more

It is important that family therapists consider participating fully in the activities with the family to demonstrate equality, approachability, and cooperation. Many families enjoy the idea of seeing their therapist as a person with their own thoughts and feelings, and engagement in these activities can help a family feel connected. It is, however, encouraged that the family therapist only discloses and engages in activities that support healthy boundaries, and to further evaluate if self-disclosure is relevant and appropriate for their clients.

Introducing creative, low-risk activities can support positive experiences as the foundation for which improvement and repair in the family system can be built. Many activities can encourage new perspective and shifts in thinking by highlighting areas for growth and processing change throughout the activity. Therefore, it is encouraged that we continue to recognize the approachability of therapeutic games and activities in the therapeutic relationship not only as motivators for ongoing participation but insights into the family system as a whole.

Engaging Teens: Staying Current in their World

Teenagers may be reluctant to engage in therapy due to stigma, stereotype, or pressure from their parents or guardians to “get it together,” stop a behavior, or cope with the stressors of their lives. Regardless of why they come into your office, you can support them in ways that allow them to feel safe enough to access emotion and engage fully in their own therapeutic process. Many teens have engaged in therapy in the past and few have positive things to say about their experience. A valuable question to ask in building rapport could be, “what did you absolutely not like in therapy before? Anything you want to make sure I don’t repeat?” This engages the teen to speak plainly about what their needs are in the therapeutic relationship as well as feel heard by you in asking their preferences, a client-centered approach that assures them of their active participation in the therapy process.

“I’m not your _______.”

Helping a teenager feel heard is one of many valuable tips in building rapport. Another element at intake to consider is your role in their process. It is important to establish healthy boundaries and clarify your role with teens prior to engaging them in ongoing work. Your explanation may go something like this: “I am your therapist which means I’m here to support you. I’m not your parent, teacher, friend, or probation officer as you may have those in your life already. My job is to be someone you can talk to who is non-judgmental and supports you in finding solutions to things that are stressful in your life right now. How does that sound?” By naming your role and asking for feedback, you are establishing both a professional connection and expectations of your work together from a place of respect and unconditional positive regard.

Keeping Secrets

Privacy is important to teens as they build their identities, form new relationships, and begin to seek autonomy in their world. Exploring the limits of confidentiality is vital to supporting them in their process in that they seek clarify of what truly is confidential and what is not. Many teens may be aware of your role to keep them safe if they were to disclose suicidal thoughts or threaten to harm someone else. But do they know you are a mandatory reporter who is required to report any abuse? Do they understand you may monitor the age of their sexual partners to make sure they are of legal age to consent? Do they know what self-harm looks like in working with you? Do they understand the implications of experimenting with drugs and alcohol and how you many need to respond if they are driving under the influence or violating probation? Having conversations about these limits can support a teen in knowing what is truly private and can allow them to more fully be themselves in your office in having a clear understanding of the consequences.

Recipe for Success

Now that you’ve gotten the formalities out of the way, what are some ideas for how you can connect with a teen? It is recommended you start by getting to know their interests, friends, and goals. One favorite rapport building intervention is having a teen build a playlist of their life, identifying songs that represent them and their experiences. They can discuss the songs in detail, allowing the therapist to build rapport and gain insight into their life. My personal favorite exercise is a ‘recipe for success’ that involves colored sand art and a teen’s ability to identify what they need to be successful in their life such as love, independence, time with friends, etc. They build a recipe of these elements as they converse with you and the art serves as both a low-risk therapeutic activity and a symbolic reminder of their success that they get to take home.

Below are other therapeutic intervention ideas that could be considered when working with a teen to build rapport:

• Life mapping their interests and relationships
• Vision boarding their wants, needs, and goals
• Self-portrait in paint, clay, pencil, etc.
• Family tree or genogram

Remaining ‘In the Know’

Teens will be the first to give you feedback on how they think therapy is going, but only if you encourage them to have a voice. Once way to do this is to support them in speaking how they wish to, whether it be slang, cursing, or other modern expressions of communication. Encouraging a teen client from the beginning to speak as they would outside of your office can support them bringing their shields down to fully participate. You may want to make sure they understand all ways of speaking are permitted as long as they are respectful to both themselves and you in the room. In response, many teens will express relief in being able to be themselves.

By encouraging teens to speak in ways that feel right to them, you should also be prepared to be honest and open about slang or colloquialisms that you may not have heard before. This demonstration of vulnerability by the therapist can actually support the client in feeling empowered and serve as evening the status quo between therapist and client in the therapeutic relationship. This vulnerability also allows humor, another great tool with teens.

Media Influence

One final tool that can increase your success in engaging teens in therapy is remaining aware of the events of their world. Many teens are following popular social media stories, YouTube videos, celebrities, and TV shows that can serve as connections or analogies for concepts you want to explore in therapy. For example, a teen who is reporting difficulty making friends may resonate with the main character from The Edge of Seventeen, a movie that can speak to your teen in identifying similar stressors they could report they are experiencing. By remaining aware of pop culture references, you can engage a teen in comparisons that truly resonate with them, encouraging self-awareness and personal growth.

Tips from Teens

In review, there are many elements to keep in mind when engaging teenagers in therapy. A panel of urban teenagers here in Denver, Colorado provided meaningful feedback on how best to engage them in structured therapy. Their answers were both obvious and reassuring and I am happy to pass them on in the hopes that fellow therapists will find success in engaging teens in their therapeutic work!

Teenagers shared with professionals:

• Don’t talk down to us
• Don’t censor us
• Don’t be so much older that we can’t connect with you
• Don’t read our file and think you know us
• Don’t say you understand what we are going through when it’s our own experience
• Don’t label us
• Don’t tell our secrets to others
• Don’t be afraid of our tests to see if you are trustworthy
• Don’t give up on us

“Some are young people who don't know who they are, what they can be or even want to be. They are afraid, but they don't know of what. They are angry, but they don't know at whom. They are rejected and they don't know why. All they want is to be somebody.” 
― Thomas S. Monson, Pathways To Perfection: Discourses Of Thomas S. Monson

Suicide Assessment: Starting a Conversation

Are you thinking about suicide? Do you want to kill yourself? Several of the most respected trainings nationwide, including Applied Suicide Intervention Skills Training (ASIST) by LivingWorks and Collaborative Assessment and Management of Suicidality (CAMS) by Dr. David Jobes, are providing the skills to encourage professionals to start a conversation with a person at-risk of suicide. September is National Suicide Prevention Month! It’s time we talk about suicide, and not just in the month of September. 

Many health organizations are participating in the Zero Suicide Initiative and schools are developing protocols to support our youth as they pursue their education. Research continues to explore findings around trends in certain populations, such as our transgender individuals, Veterans, and those suffering from Anorexia, all possessing factors that may put them at a higher risk of suicide. How do we, as mental health or helping professionals, address the stigma to start a conversation to better understand suicide?

In support of professionals who are passionate about helping at-risk individuals, please allow me to introduce an interactive tool meant to engage a person at-risk in facilitating a conversation about their experience with the help of a trained professional. The Community Assessment and Coordination of Safety (CACS) is an interactive tool that supports mental health professionals and other community partners such as school staff, non-profits, caseworkers, and public safety to have the words and the tools to start a conversation on suicide. 

The Details

In using CACS, a helping professional can access standard suicide assessment questions including but not limited to risk factors, family history, and recent stressors. When a professional desires more information as to the purpose of a question or how to ask a clinical question within the risk assessment, CACS provides helpful hints, such as suggested questions you can ask to explore a particular component in more detail for the most accurate results. The assessment then uses an algorithm to determine a risk level and populates a list of resources throughout Colorado in order to identify appropriate referrals that could best help the person at risk.

In addition to using an algorithm, CACS provides an electronic, user-friendly platform to assess and explore a person’s experience, all while allowing the flow of supportive conversation with a person they can trust. CACS can take into account various information entered into the app to calculate a level of risk based on an algorithm that factors in current research trends on suicide.  Individuals found to be at high risk would be directed to resources such as hospitals, inpatient programs, or Crisis Walk-in Centers. Individuals found at moderate or low risk could explore current resources for mental health, substance use, community support, and wraparound services with filtering options of location, service, and age group served. 

Lastly, CACS allows the helping professional to complete a wellness safety plan with the person at risk, empowering them to identify facets of their life that they can track and address with positive coping skills or engagement within their communities. Research is pointing us to the power of communities, therefore it could be valuable to explore how communities can support or enhance our interactions in pursuit of personal wellness. 

Resources

Let us begin a conversation and demonstrate our willingness to speak of the challenges in order to support those that need it most. You can learn more about the Community Assessment and Coordination of Safety (CACS) at www.cacs-co.com.

If you are interested in a suicide assessment training, check out ASIST by LivingWorks at livingworks.net or CAMS Integrated Training at CAMS-Care.com.

If you are feeling suicidal and need immediate support, please call 9-1-1 or go to your nearest emergency room. Trained professionals are available 24/7 at the National Suicide Prevention Hotline by calling 1-800-273-TALK.

Bolstering Boundaries: Exploring Needs in Community Practice

She calls at 10pm, he gives you a present, they ask for a hug, she asks for a ride.  How do we navigate the gray area that is clinical practice in community or home settings? Mental health professionals have found several benefits to working with clients in their homes or communities, including more consistent access to resources by meeting clients in alternate settings. Perhaps the client can’t get to an office due to transportation limitations or anxiety preventing them from feeling comfortable in your office? Could the family dynamic be better observed in the home to support current treatment goals?

Boundaries continue to be important in conveying professional roles and limitations to clients, including interaction with their therapist outside of scheduled sessions. Boundaries can look different to each individual, including being physical, such as proximity and touch, or emotional, such as how much we disclose about ourselves to clients in our effort to build rapport. Boundaries are necessary to prevent burnout, which can manifest as fatigue, avoidance, and increased irritability and concern of clients taking advantage of us when boundaries are inconsistent.

Self-Exploration

Can you ask yourself how you would respond to the following questions?

• Do you feel taken advantage of by those you care about?
• Do you tend to meet other’s needs before your own?
• Do you say yes to avoid a confrontation?
• Do you worry about the loss of a relationship if you say no?

If you answered yes to all of these questions, you may want to look further at your boundaries and their limits in supporting your well-being. Many mental health professionals are inspired to help and serve others, sometimes at the risk of our own health. It would benefit each of us to explore and strengthen our boundaries to allow the most supportive interaction between us as providers and the clients we serve.

Bolstering Boundaries

So how do we navigate implementing boundaries? Has your agency supported you in providing expectations of your role in writing to your client? Does your disclosure statement clearly identify your limits in communication outside of scheduled sessions? Can your voicemail redirect callers after hours to a crisis service? These are just a few examples of boundaries in the mental health workplace that can provide the consistency we are seeking in implementing healthy boundaries with our clients. Just as when we guide clients in developing boundaries of their own, new expectations take work to implement and remain consistent. Anticipate push-back from those who are used to old patterns, as they may struggle to accept the change. Remain firm with new boundaries to allow adjustment and acknowledge any anxiety or fear that can come with implementing new boundaries. Lastly, consider putting boundaries or expectations in writing to discuss with your client so that they may have a copy for future reference and can consider signing a copy for your records.

Support from Others

Implementing boundaries can be easier with the support of supervisors, consultants, and colleagues. Consider reaching out for support around implementing boundaries with a client, as many professionals have experienced similar concerns and have had to navigate the discomfort of boundary setting in their own work. Would they take the same steps you are considering when reinforcing boundaries? Can they support you when your feelings of guilt or anxiety attempt to derail the boundaries you’ve created? It can be helpful to share your boundary goals so others can support you and you can do the same for them.  

Burnout

Burnout can be the result of poor or unhealthy boundaries. Can you relate to any of the following symptoms of burnout?

• I don’t know how to relax.
• My road rage has gotten worse.
• I feel disconnected from my emotions.
• I escape into eating sweets.
• I’m ignoring my relationships.
• I can’t seem to disconnect from work.
• I’m self-critical.

These are just a few symptoms of burnout that other professionals have reported as signs of their fatigue and ongoing challenge in the workplace. Boundaries can help address burnout along with communication, exploring your values or what drives you, and creating a wellness plan. The Professional Helper Healing Training: Supporting Boundaries to Prevent Burnout is one training in Denver, CO that supports professionals in these tasks and there are others! For more information, visit us at catalystcounselingpllc.com and search professional workshops.

Safety Planning with At-Risk Families: Exploring the Benefits

Warning signs, safety measures, plan of action, and supports. These are all vital components of crisis response and safety planning in the field of mental health. Safety planning can be considered a helpful resource to assess safety needs for each family member and develop awareness of individual needs by loved ones when participating in discussion. It can also serve as an empowerment tool to allow advocacy and engagement in positive coping skills when the family is experiencing conflict. Due to family systems becoming more diverse to meet the needs of support and connection, the term family can be defined in non-traditional ways. Not only does it capture the nuclear or biological family, it may also comprise of blended families, extended family, step-parents, foster siblings, or “chosen family.” Chosen family can include but is not limited to, close friends, mentors, and godparents.

Bringing individuals together in their roles in the family system, it has become increasingly important to include all members in safety planning when addressing mental health and safety in order to unify the family and achieve meaningful results. In serving at-risk youth and families in the Denver Metro Area, safety planning has proven to be invaluable in exploring awareness of triggers for disruption and conflict, safety needs; thus engaging the family in exploration to foster empowerment and change. Safety planning allows the whole family to explore their needs rather than isolating one individual as the “identified problem.”

The Benefits

The benefits of safety planning can be demonstrated for one family of seven suffering from neglect, domestic violence, and substance use that lead to Department of Human Services involvement due to ongoing safety concerns. The family system consisted of mom Jenna* (36), boyfriend David (27), daughters Fiona (16), Margot (14), Patricia (6), and sons Julian (9) and Bobbie (2). Jenna and her family were referred to in-home family therapy due to safety concerns with Jenna’s Post-Traumatic Stress Disorder (PTSD) resulting in substance use, domestic violence with her boyfriend David, and neglectful parenting that was negatively impacting each child.

It was the hope of the Department of Human Services to support the family in reuniting and repairing their relationship now that Jenna was sober from substances and ready to actively parent in the household.

Observing and engaging the family in rapport building, it was quickly apparent which role each member played in the family system. Jenna was able to identify her challenges in parenting her children in that they were each struggling with her absence in different ways. Fiona identified her anger that lead to running away from home and engaging in fights at school. Margot reported being a strong student and keeping to herself in her room when not parenting her younger siblings in Jenna’s absence. Patricia was observed to be childlike with attention-seeking behaviors younger than her biological age, whereas her older brother Julian escaped into video games to remain unseen. The youngest, Bobbie, was observed to struggle with meeting developmental milestones and resorted to screaming and hitting himself and others when emotionally dysregulated.

Through engaging Jenna, David, and the kids in a safety planning therapeutic activity, they were able to begin to recognize each of their individual differences regarding warning signs, as well as the coping skills needed to support connection and emotion regulation.  Jenna began to learn more about her children and their needs through identifying warning signs such as isolation, anger, and behavioral changes signifying distress for each child at their developmental level.

Jenna also identified her own triggers and reactions to her children as they related to her trauma and urge to escape.

Connection

When Jenna couldn’t escape her PTSD symptoms through work or substances, she was able to recognize the increased risk of conflict and aggression leading to fights with her boyfriend David. The safety planning served as a tool of discovery for family members and empowered each of them to advocate for their needs through healthy communication. For Jenna and her family, the safety plan served as a means of taking action to support the family in times of conflict and crisis.

Through this process, the children felt heard, Jenna identified goals for ongoing individual therapy work to maintain sobriety, and David and Jenna were able to identify new ways of communicating as a couple in order to bring the entire family closer together. Safety planning can be introduced and implemented early in the therapeutic process to explore family patterns, coping skill needs, and foster trust and safety while empowering families to remain together, connected and aware. A safety plan template is available for professional use along with a suicide risk assessment called the Community Assessment and Coordination of Safety (CACS) at www.cacs-co.com.

*Names have been changed to protect confidentiality