Journal of Genetic Counseling, Vol. 7, No. 2, 1998
Experiential Family Therapy: An Innovative Approach to the Resolution of Family Conflict in Genetic Counseling Lisa C. Tuttle1,2
Experiential family therapy is an intuitive approach that utilizes active, multisensory techniques. These techniques, such as role plays and drawings, increase the family's expression of affect and uncover new information. Increased affect and uncovered information stimulate change and growth in the family system. Experiential techniques are especially useful when more traditional, verbal-based communication is not effective. In this article, I will present a pediatric case in which the patient, a 7-year-old boy diagnosed with autism, was referred to the genetics clinic to rule out the presence of an associated genetic disorder. I will then describe a hypothetical second counseling session with the same family and suggest how three experiential family therapy techniques: family drawing, "empty chair" technique, and continuums might be used in the session to help resolve a marital conflict between the patient's parents. KEY WORDS: experiential family therapy; genetic counseling; family conflict; constructs; multisensory techniques.
INTRODUCTION In the course of our daily work, genetic counselors meet with people in crisis. Most of our patients are at risk for genetic disease, struggling with a diagnosis, or concerned about risks to their offspring. These situ1
Genetic Counseling Department, Brandeis University, Waltham, Massachusetts. Correspondence should be directed to Lisa C. Tuttle, Kaiser Permanente Genetics Department, 260 International Circle, San Jose, California 95119-1197.
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ations often cause anxiety and have implications for other family members. Because of this, many of the families we meet are in conflict, which may escalate to the point of interfering with family functioning. As counselors, we must sometimes address family conflict and work with our patients to help them resolve their problems. Because of the sensitive nature of our work and the fact that our time with families is often limited, we must be familiar with many counseling theories and techniques if we hope to assist in producing change in a family system. One such theory that is seldom applied to the genetic counseling field is experiential family therapy. In this paper, I will review the principles and techniques of experiential family therapy. I will also present a case in which a 7-year-old boy, diagnosed with autism, came to a large urban hospital's genetics clinic to rule out a genetic syndrome. I will then hypothesize a second session with his family and suggest how experiential family therapy techniques might be used to help them to resolve their conflict. My focus will be on three techniques commonly used in experiential family therapy: family drawings, the "empty chair" technique, and continuums.
EXPERIENTIAL FAMILY THERAPY
Experiential family therapy is a nontraditional school of therapy influenced by Gestalt therapy, psychodrama, client-centered therapy, and the encounter group movement (Bischof, 1993). Experiential therapists are concerned with using clients' in-session experiences to produce family growth and change. Experiential therapists steer away from traditional "talking about" conflict and instead utilize active, multisensory techniques to address family problems. Family problems are thought to be caused by lack of awareness of feelings, lack of ability to express feelings, rigidity in responding to problems, and denial of impulses (Walsh, 1993; Nystul, 1993). The goals of experiential therapy are to increase the awareness and expression of feelings, to promote flexibility in response to problems, and to promote spontaneity and playfulness within the family. In addition, this approach to therapy is concerned with uncovering new information by lowering family members' defenses (Goldenberg and Goldenberg, 1995; Walsh, 1993). The overriding goal is not just the reduction of symptoms, but personal and interpersonal growth and change (Walsh, 1993). Four major principles of experiential family therapy are outlined below: (1) the power of
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experience, (2) active, multisensory techniques, (3) affect and anxiety, and (4) spontaneity and playfulness. The Power of Experience An important concept in experiential family therapy is the power of experience (Harris, 1996). The therapist provides the family with new experiences during the session. These different experiences may change the constructs that each family member uses to view the family, its members, or the problem (Connell et al., 1993). Constructs are the sets of internal "rules" that each of us uses to assign meanings to the thoughts and behaviors of others or ourselves. For example, suppose one of my constructs is that patients referred to counseling because of prenatal alcohol exposure are irresponsible. This construct may have arisen from several experiences in which individuals with this indication failed to keep their counseling appointments. Every time a patient coming to discuss prenatal alcohol exposure fails to keep an appointment, I may attribute this to her being an irresponsible person. My interpretation of the patient's actions, as filtered through my construct, is likely to be incorrect as often as it is correct. Changing the constructs operating within a family is likely to change how the family members respond to each other and to the problem (Harris, 1996). For example, suppose a mother and teenage daughter present for genetic counseling, because the daughter has been diagnosed with a dominantly-inherited genetic disorder. Since the diagnosis, mother and daughter have been fighting constantly because the daughter has started dating excessively. Using experiential therapy techniques (see below), it emerges that the daughter feels as though her mother is discouraging her from dating because of a fear that she will then marry and have children who will inherit the disorder. The mother responds that the disorder has nothing to do with her reaction to her daughter's dating. The mother reveals that she regrets marrying and having children at a very young age, and she simply does not want her daughter to make the same mistakes. Uncovering this information changes the construct that the daughter has of her mother. The daughter no longer defines her mother as a domineering woman who wants to interfere with her future, but instead as a mother who simply wants more for her daughter than she had for herself. This change of construct in the daughter's mind may change the way that the daughter responds to her mother when dating issues arise. Also, if part of the daughter's motive for excessive dating was to rebel against her
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mother, a change in construct may even cause the daughter to be more discriminating in her dating habits. Active, Multisensory Techniques The experiential therapist utilizes active, multisensory techniques to allow for a fuller, more intense experiencing of other family members (Bischof, 1993). These techniques catalyze spontaneity, exploration, and communication of feelings (Walsh, 1993). As Vos (1988) stated in her review of experiential therapy techniques, "they've heard it all before, but they've seldom seen it all before," meaning that while most families have verbally stated their problems over and over again, few families have had the opportunity to express their feelings in a nonverbal fashion. Changing the medium within which feelings are expressed may change the meanings of these feelings for family members. In addition, using multisensory techniques helps to make information available to all family members, including children who can be actively involved in experiential family therapy sessions (Vos, 1988). Active techniques, which are often viewed as fun and interesting, also help to sidestep defense mechanisms. Because of this lowering of defenses, participants often reveal thoughts and feelings that had been unexpressed, even within their own minds. To illustrate the power of active, multisensory techniques, I will use the example of a family drawing, in which family members are asked to draw a picture of their family. Imagine a couple who has been referred for genetic counseling. Amniocentesis has revealed that their fetus has Down syndrome, and they are struggling with the decision of whether to terminate the pregnancy. The counselor might ask the couple to make a family drawing of what they think their family will be like if they continue the pregnancy and have a child with Down syndrome. Asking them to express their feelings in a different way (i.e., through pictures rather than words) may extract "unspeakable" information. Suppose the father draws a picture in which their child with Down syndrome is lying in bed, as the rest of the family stands around the bed, frowning. The house is surrounded with dark clouds. The counselor might ask the father to describe what he is portraying in the picture. He may have had difficulty expressing his feelings verbally, but when he is faced with describing his picture, hidden feelings may emerge. Family drawings can be used to uncover new information in a variety of ways. Family members may be asked to draw a picture of their family doing something together, fighting, or solving a problem. In addition, they may be asked to draw a picture of what they wished the family could be
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like (Bischof, 1993). Each of these variations may introduce slightly different information. However, the important themes underlying the conflict, such as "I can not raise a disabled child" or "My husband will not accept my diagnosis" are likely to be extracted from virtually any family drawing scenario. Other techniques commonly used in experiential therapy are role plays, the Kvebaek technique, family sculptures, continuums, and the "empty chair" technique. Role plays are skits in which each family member plays either themselves or another person in enacting a family scenario, such as a problematic incident. Role reversals, in which two conflicting family members play each other, are often especially useful for gaining an understanding of how family members view one another and in getting at new solutions to old problems. The Kvebaek technique involves the use of a chess-like board and pawns representing family members, who are asked to place their pawns on the board to indicate the closeness, distance, conflicts, and loyalties existing between family members (Bischof, 1993). For instance, suppose the mother of a family places her pawn in the middle of the board, indicating her centrality in the family. Her daughter, who has spina bifida, places her pawn on a corner square as far away from her mother as possible. This may indicate a feeling of distance. Another, unaffected daughter may place her pawn on the same square as her sister's pawn. This could indicate a feeling of closeness or of competitiveness between the sisters. A discussion of why the mother and daughters placed their pawns where they did may clarify how they see their roles within the family as well as how they cope with the daughter's disability. Family sculptures are similar to family drawings in that they are pictorial representations of the way in which the family interacts. Instead of drawing a picture of the family on paper, a family member is asked to physically arrange the other family members to make a sculpture that represents the family (Nystul, 1993). The therapist may ask each family member to make their own sculpture and then discuss why each of them arranged their family members as they did. The therapist may manipulate the sculpture and gauge the reactions of family members to the new sculpture (Vos, 1988). The empty chair technique is one in which an individual speaks to an empty chair as though it was occupied by a family member (Vos, 1988). This technique can be used to enable a family member to freely express his or her feelings to another member of their family with whom there is some conflict. The person "in" the chair may or may not be present in the session. Speaking to the empty chair allows an individual to express feelings and concerns freely and safely, with no risk of interruption or angry re-
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sponses. If the individual "in" the empty chair is present in the room, s/he gets the opportunity to hear the other person's feelings, perhaps for the first time. An "empty chair" may also provide a practice session for a face to face discussion, with the individual modeling for himself or herself how such a discussion might be conducted. For example, suppose a patient has been found to carry a fragile X premutation and expresses her worry about sharing this result with her sister. The counselor might suggest that the patient pretend her sister is sitting in the empty chair. The patient could then practice sharing her carrier status with her sister until she feels comfortable enough to divulge the information in person. A therapist using continuums utilizes the therapy room as a scale, with each side of the room representing one extreme of the scale. The therapist names a dimension for the scale to measure, such as power. In this case, one side of the room would represent omnipotence, and the other side of the room would represent powerlessness. Each family member would be instructed to stand at the place on the continuum corresponding to the amount of power they felt they had (Bischof, 1993). In a genetic counseling setting, continuums could be used with a couple having difficulty deciding whether to pursue prenatal testing. The dimension of the scale might be "desire to have an amniocentesis." Each member of the couple would be asked to stand at a point on the scale which corresponded to the strength (or lack) of his/her interest in amniocentesis. For clients who are very uncomfortable physically moving around the room, the continuum could be drawn on a sheet of paper. Affect and Anxiety Experiential therapists believe that affect is therapeutic and growthproducing (Bischof, 1993). Affect can be defined as a verbal or nonverbal expression of feeling. The active, multisensory techniques employed in experiential family therapy often increase the level of affect in the room. This increase in affect is frequently coupled with an increase in anxiety. Because this emerging anxiety is difficult to tolerate, families mobilize their resources for change in an effort to relieve it. For example, suppose a brother and sister come in to discuss a family history of cystic fibrosis. They have recently lost a sibling to the disorder, and it becomes evident that they have some unresolved feelings about their deceased sibling which they are not expressing verbally. An experiential family therapist might suggest the use of the Kvebaek technique. The therapist asks each sibling to place their pawn in relation to the piece representing their deceased sibling. Both the brother and sister place their pawns
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far from the deceased sibling, but close to each other. This may be the first time that they have allowed themselves to express the distance that each felt from their sibling. Having finally done so may cause an immense amount of anxiety, guilt, sadness, or anger. Because this new situation is difficult to "sit with," the siblings may now be mobilized to explore why the feelings of distance existed so that the guilt, sadness, and anger can be worked through and the unsettling anxiety relieved. Spontaneity/Playfulness In experiential family therapy, techniques flow from the moment; they are not pre-planned (Connell and Russell, 1987). Although an experiential therapist may have a repertoire of techniques, he or she does not go into a session planning to use any particular technique. The therapist is intuitive and spontaneous in choosing techniques. In addition, the therapist encourages the family to be spontaneous and to have fun with each other. Fostering such a "free" environment adds to the new experience of the family in the session and helps to lower family members' defenses, allowing new information to emerge (Bischof, 1993; Connell and Russell, 1987). For example, suppose a couple came for counseling because of advanced maternal age. The couple is conflicted about whether to have an amniocentesis. She is worried about the miscarriage risk, but he thinks that risk is too small to be concerned about. The discussion goes around and around, with no decision in sight. An experiential family therapist may suggest that the couple switch roles and continue the discussion. Asking them to switch roles may uncover new information and increase the couple's understanding of one another. Asking the couple to be spontaneous and do something unusual may also lower their defenses, and allow them to speak more freely about their feelings. They may even have fun with this opportunity to "play" each other. The experiential therapist would not discourage this playfulness. The couple's enjoying of each other during the process of making this difficult decision may result in their increased motivation to work together to reach a compromise.
CASE PRESENTATION I will now briefly describe a case that I observed at a genetics clinic held in large urban hospital. A 7-year-old boy, "David," had been diagnosed with autism at the age of four. David had delays in cognitive, speech, and social functions and spoke about 15 words, all characteristic of autism
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(Autism Society of America, 1996). David also exhibited other autistic features, such as repetitive clapping behavior and self-injurious behavior, at times wringing his hands violently. David's neurologist referred him to the genetics clinic to rule out a genetic syndrome as the cause of his autism. There are several genetic syndromes in which a subset of affected individuals have autism or autistic-like behaviors, such as basal cell nevus syndrome, fetal alcohol syndrome, fragile X syndrome, Noonan syndrome, Sotos syndrome, tuberous sclerosis, velocardiofacial syndrome, and Williams syndrome (Swillen et al., 1996). David was the product of an uncomplicated pregnancy and delivery. His developmental milestones were normal until between the ages of 2 and 3 years, during which time his parents began to worry about his speech delay. All of his tests were normal, including chromosome analysis and fragile X testing. David arrived at his appointment with his father, Anthony. The medical geneticist and I showed David and Anthony into the counseling room and proceeded to take a family history. The family history was unremarkable with the exception of two monozygotic male twins, who were David's maternal first cousins-once-removed. One of the twins was autistic, and the other had unspecified learning disabilities. David's physical exam showed a variety of minor abnormalities, including brachycephaly, prominent ears, strabismus, and upward-slanting eyes. He had a thin vermilion, flat philtrum, oligodontia (upper central and lateral incisors missing), a high-arched palate, a small penis, curved toes, hypoplastic nipples, and broad proximal interphalyngeal joints. The last finding was especially perplexing, and we asked that Anthony take David to radiology for hand X-rays. We were not sure if the finding was clinically significant or merely a consequence of his hand-wringing. During the history-taking portion of the session, David was fidgety and kept reaching for the telephone and the stethoscope, but in general was well-behaved. However, when the physical examination began, he began to scream and cry. A typical feature of autism is a misprocessing of sensory stimuli, which causes many children with autism to dislike being touched (Autism Society of America, 1996). David may have disliked the physical contact, or perhaps he had just learned to resist exams and doctors. We managed to distract him with movement and noises enough to perform a full physical exam. However, once the exam was done, it was evident that it was time for Anthony to take David home. Therefore, this was a short session, mostly involving information gathering, and we did not have an opportunity to fully explore psychosocial issues. Throughout the session, Anthony's speech and behavior revealed that he was clearly frustrated by the fact that the cause of David's autism was
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undetermined. He noted that every laboratory test was normal, but David obviously was not. He asked us why no one could figure out what was causing David's problems. Another source of his frustration was the discrepancy between what David could understand and what he could express. Anthony described David as "smart" several times and cited as evidence David's ability to respond correctly to directions to get a Sprite vs. a Coke from the refrigerator. While David was unable to express even his most basic feelings and desires, he was able to understand the difference between Sprite and Coke. At points throughout the session, it seemed as though Anthony was trying to prove to us how "smart" David was. Anthony tested him by instructing him to touch various parts of his face and to remove his own shoes. David failed to perform these tasks, which seemed to cause even more frustration for Anthony. Anthony also stated that he felt frustration for David, because David could understand so much but express little in return. Toward the end of the session, Anthony suddenly stated, "You know, these things (autism) break up marriages, Doctor." Unfortunately, the issue was not pursued, but it left lingering questions in my mind. Why had he brought that up? During the family history, he had reported that he was married to David's mother, Janine. A few weeks after the session, I called David's house to inquire about the hand X-rays, because there was still no radiology report in the hospital's computer system. No one was home, and my suspicions about Anthony's comment were renewed when I heard that the answering machine recording was a woman's voice saying, "I am not home right now." Of course, there could be other explanations for his comment and for the recording, but the instances were enough to leave me wondering about the state of their marriage.
APPLICATION OF EXPERIENTIAL FAMILY THERAPY TECHNIQUES TO A HYPOTHETICAL SECOND SESSION In order to illustrate three experiential family therapy interventions: family drawings, "empty chair" technique, and continuums and their potential applicability to genetic counseling, I will portray Janine, Anthony, and their speculated conflict in simplistic terms. For the purposes of this article, I will hypothesize that Janine feels Anthony is preoccupied with finding a diagnosis for David, at the expense of ignoring his role as a husband and father. Meanwhile, Anthony feels that Janine does not care about David's well-being because she is not as concerned with finding a diagnosis. Suppose that, a few weeks after the first session, we meet again with this family to discuss the progress made in arriving at a diagnosis for David
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and what our next steps might be. This time, we request that Anthony, David, and Janine all attend the session. We greet them and show them into the counseling room. Anthony immediately asks whether we have found a diagnosis. We admit that we have not. This sparks off the following possible argument between Anthony and Janine: J:
A: J: A:
Well, Anthony, are you satisfied? Another shot in the dark! And I took a day off of work to come here. Anthony is on a mission to find a diagnosis for David. He's crazy...he doesn't care about anything else. He's either reading about some new treatment or dragging David to some new doctor. He's never therefor us anymore as a husband or a father. I couldn't take it anymore, so... So, you kicked me out of the house—isn't that a fine way to break up a family!! We haven't been a family for a long time. At least I care about our son...you couldn't care less about finding out what is wrong with him.
At this point in the session, after listening to Anthony and Janine angrily arguing with each other, the counselor might decide to try an experiential approach: GC: It seems like you two are so angry with one another. I want to try something with you that might seem a little crazy or weird, but that I think might help us get to the heart of what's going on in a calmer way. Are you willing to give it a try? A: Sure, I'll try anything to resolve this. Janine? J: OK..Whynot? Intervention #1: Family Drawings GC: OK, I'm going to give each of you a piece of paper, and I want each of you to draw a picture of your family as you see it. I want you to represent yourselves with circles (Vos, 1988). So, each of you, when you're done, will have three circles drawn. OK? [Anthony and Janine draw their pictures.] GC: All set? Let's see what each of you has drawn. A: Here's mine (Fig. 1). GC: Why did you draw your picture the way you did? A: Well, I want to be with my son, but my wife is standing in my way; she has kicked me out of our home, and now I can't be with David. GC: Why isn't your wife's circle connected with David's?
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Fig. 1. Anthony's family drawing.
Fig. 2. Janine's family drawing.
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Because I don't feel like she wants to be connected with him. She does a good job taking care of him, I guess, but she doesn't want to be involved in figuring out what's going on with his autism. GC: Janine, what do you think about what Anthony drew? J: I feel badly that he feels cut off from David. I didn't want that to happen. I just couldn't stand it...the constant attention to the autism and not to the David inside. Anthony, I love David very much...he and I are connected. GC: Janine, let's see your picture (Fig. 2). J: Here are David and I, connected as mother and son. There's Anthony, off to the side, preoccupied with diagnosing David, and meanwhile ignoring David and me. A: Well, I do spend a lot of time away from Janine, reading and stuff like that—about autism. But, I spend time with David, everyday while Janine is at work. GC: How do you feel about Janine's drawing? A: I feel really hurt to be put off to the side like that. I'm only trying to help my family by doing the things I do. I love them both so much...
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GC: Now, we have an idea how you see each other.,.I want you to try the same exercise again—only this time, draw what you'd like your family to look like. [Anthony and Janine draw their pictures] GC: OK, let's see them at the same time. J: They're the same (Fig. 3 and 4)!! GC: Well, that says a lot...it looks like you both want the same things. What is one small thing that each of you could do to make that picture happen? J: Well, I guess I could be more supportive of Anthony and come to some of these appointments—the necessary appointments—with him and David. I want to show him that I really do care about David's progress and I would like to find some answers, too. A: I'd like that...I think David would, too. Sometimes, he gets scared at the doctor's, and I'm not always good at calming him down. I
Fig. 3. Anthony's "ideal family" drawing.
Fig. 4. Janine's "ideal family" drawing.
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guess I could cut down on the number of doctors and appointments. I know I go overboard. I just feel so frustrated. Me too. For the first time in a while, I feel like we're in this together.
In this example, the process of drawing and discussing family pictures produced remarkable changes in both Anthony's and Janine's constructs. Janine had interpreted Anthony's pursuit of a diagnosis as serving to distance himself from the family. Her construct was challenged when she learned that he was hurt and surprised to be portrayed that way. In actuality, Anthony desired more intimacy with Janine and David. Anthony had viewed Janine as not caring about David because of her lack of interest in a diagnosis. He also saw his separation from Janine as her effort to keep him apart from David. These constructs were challenged in the discussion of the drawings, when Janine stated her love for David and her desire for Anthony and David to have a close relationship. The process of seeing each other's feelings rather than hearing them forced Anthony and Janine to confront their roles within the family, and how those roles affect David. For each, seeing their spouse's view of them raised their level of affect as they realized that there was some truth to the other's drawing. The discussion of the drawings increased the understanding that each had for the other. The second drawing exercise, in which they drew how they would like the family to be, solidified that understanding by dramatically illustrating that despite their arguing, their goals were the same. Neither was as alone as they had felt. Another approach that might have produced a similar outcome is family sculpture. A family sculpture would allow Janine and Anthony to "draw" their pictures using each other, rather than pen and paper. Sculpting may have an even greater affective effect because, in addition to stimulating the auditory and visual senses, it incorporates a third sense—kinesthetic. For instance, if Janine was to move Anthony into the corner of the room, facing away from her and David, Anthony's affect may have intensified even more than if the same image was depicted in a drawing. However, in this case a drawing may have been a better choice than sculpting. Because of his condition, David may have objected to being physically maneuvered for a sculpture, and is unlikely to have been cooperative. However, his lack of cooperation may provide a poignant symbolization of Anthony and Janine's failed efforts to reach him. Another consideration in deciding between drawing and sculpting techniques is which family members are present at the session. A drawing would allow nonpresent family members to be in the picture and may be more effective if key family members are not present. A final consideration is the comfort level of the family. Some families
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are self-conscious about participating in these techniques, and they may be more comfortable drawing rather than sculpting. In many cases, children in the family could also be involved in drawing activities. However, in this case, it is unlikely that David would have been able to participate in the exercise. Another caution in using this technique (or any experiential technique) with children, especially autistic children, is that the inferences and connections that make sense to adults may not apply to children. For instance, suppose David understood the instruction to draw his family and was able to produce a recognizable picture of his father standing far away from himself and his mother. Does this mean that David agrees with Janine that Anthony is disconnected from them, or did David just happen to draw his father at the edge of the paper? Does distance on paper correlate with emotional distance in David's mind, as it might in our minds when we interpret these drawings? Consider the drawing of a child with Williams syndrome, a genetic condition in which affected individuals have unusual spatial perceptions. One would have difficulty in determining whether a disjointed drawing done by a child with Williams syndrome was representative of an undesirable family environment or simply a manifestation of the child's disorder. Intervention #2: Empty Chair Technique GC: Janine, I want you to pretend that Anthony is sitting in this chair. I want you to tell him how you feel and what you need from him. You may feel a little silly doing this, but think of it as your chance to tell Anthony everything you've been wanting to tell him. He can't argue with you or interrupt you...he can only listen. Are you ready? J: [talking to the empty chair] Anthony, I feel alone. I feel tike you are never there...I mean, you're there, but you're either reading some medical journal or speaking with the autism society or getting ready for a doctor's appointment. You're so focused on David as a patient that you seem to have forgotten that he's your son! He needs more of you. I need you, too. I need a husband. Talk to me about something besides David's last appointment or his next one. I miss you...don't abandon me. I don't want to live apart from you, but something has to change. A: Wow! You need me? Why would you need me? I'm a failure as a father and a husband. I can't take care of my famify...I can't do anything for my son, no matter how hard I try. I'm so frustrated not to be able to help him. J: So am I.
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A: J:
You are? I thought you were against finding outside help. I'm not against it, Anthony...you're just so for it, that if I don't balance you out, you'll go even more overboard than you do! A: Hmm...I was afraid you just didn't care...it felt like I didn't know you anymore, J: That's how I feel. I want to know you again. Here, the empty-chair technique has allowed Janine to express her feelings without fear of backlash. Janine presented her case without interruption, possibly for the first time. The information that emerged was new to Anthony and provided a topic for discussion and new understanding. In addition, some of the information may have been new to Janine, who may never have expressed her feelings before, even to herself. However, although Anthony could not counter her arguments or interrupt her while she was speaking to the empty chair, Janine knew that he was listening. Because of this, she may censor her speech somewhat. Another way in which this technique might have been useful is if the counselor had asked either Janine or Anthony to pretend that David was in the empty chair. This would provide them with perhaps their first opportunity to express their feelings to David as though he could truly understand them. They may share their frustration about not being able to reach him, their sorrow that he has to live his life as an autistic child, or their fear that he does not love them because he does not express it. The empty chair technique could even be used to provide an opportunity to explore how David might respond. Suppose Janine is speaking "to" David in the empty chair. She could role play his part, as well, and respond to what she says. For instance, suppose Janine expresses "to" David the guilt she feels that he must live his life as an autistic child. She then role plays how she thinks David might respond, if he could, to her statement. Playing him, she may say, "I blame you for my condition; I hate you for having me." Expressing this fear may start the process of exploring her (and likely Anthony's) feelings of guilt. Part of this exploration might involve the counselor asking Janine to role play David forgiving her and Anthony and expressing his love for them. A caution in having Janine and Anthony speak to David as though he was in the empty chair is that one does not know how much the real David, if he is in the counseling room, would understand. He may become confused or scared upon hearing his parents speaking to "him" in unfamiliar terms in a strange situation. Also, Janine and Anthony may be reluctant to even pretend to express any negative feelings about David, regardless of whether or not David was in the room. A possible way to avoid this discomfort might be to place "autism" in the empty chair, thus making the
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diagnosis the target of any negative feelings instead of the child. Anthony and Janine may then feel more comfortable exploring their anger and sadness. David would also be less likely to understand this more abstract scenario, and he probably would not interpret what his parents say as being directed toward him. One can also use the empty chair technique to bring family members who are not present into the room. Suppose that Anthony stated that one of the factors feeding into his desire to help David so much is that Anthony never felt that his own father loved him. The counselor could ask Anthony to "empty chair" with his father in the chair. This would allow Anthony to express his feelings "to" his father. Because his father is not present, Anthony will most likely be comfortable enough to speak freely, without censure. Intervention #3: Continuums
GC: I want you to pretend that this room is a scale. This side of the room is one extreme, and that side of the room is the other extreme. I'll name the dimension that the scale is measuring, and each of you will walk to the place where you "belong" on the scale. The first dimension is control. Stand on this side of the room if you feel in complete control over what happens—in your marriage, with David, in your life—and stand on that side of the room if you feel like you have no control over what happens. [Janine and Anthony both walk to the "no control" side of the room.] J: 7 don't know why he's standing over here. He is in complete control. He determines everything about all of our lives. He says which doctors David goes to, which school he attends, how we spend our time... A: 7 have no control over what happens! If I had any control, David wouldn't be this way. I try to make things better for him, and nothing works. I have absolutely no control at all. I'm helpless. J: I feel like I have no say in David's life...I'm helpless, too. GC: Let's try one more of these scales. This time, stand on this side of the room if you have a very strong commitment to your marriage and stand on the other side if you have a very weak commitment to your marriage. [Janine and Anthony both walk to the "strong commitment" side of the room.] J: Lately, I've been feeling like you didn't care about us.
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A: I always care about us...all of us. I was afraid you'd walk to the other side. J: It's good to see we're still on the same side. Like family sculptures, continuums provide the family with kinesthetic as well as auditory and visual input. In the example above, as they walk to the "no control" end of the first continuum, Janine and Anthony both acknowledge that they feel out of control. It appears that this is the first time that each of them has realized that the other person feels helpless, too. Each had thought that their spouse was firmly in control. After Janine and Anthony had both walked to the "no control" side of the room, the therapist could have asked where each of them would place David on the control continuum. Suppose that they both placed him on the opposite side of the room. In this instance, performing this exercise might have caused them to realize, perhaps for the first time, the control that David has over both of their lives. The "commitment to the marriage" continuum indicates, as the second set of family drawings did, that their goals are the same. Despite their arguing, they both want the marriage to succeed. Their affect around learning this may be more intensified with this technique than with the family drawing, because of the physical nature of the continuum technique. Walking together to the "committed" end of the continuum may reinforce their feeling that they are a couple. The physical aspect of this technique also introduces a fear of abandonment that Anthony expresses when he says "I was afraid you'd walk to the other side." The anxiety that each experiences, as they fear the other will walk to the "no commitment" end of the continuum, may cause them to more intensely experience their union when each of them realizes that their spouse wishes to stand by them, physically and emotionally. Of course, this brief counseling intervention is unlikely to be sufficient for a couple facing serious marital problems, and the counselor may wish to accompany this continuum with a thoughtful referral for longer term couples counseling.
APPLICATIONS TO OTHER GENETIC COUNSELING SETTINGS Throughout this article, I have attempted to emphasize the many potential applications of experiential family therapy techniques to genetic counseling. However, two common genetic counseling settings have not been mentioned in my examples, and I would be remiss not to do so here. These two settings are: (1) cancer counseling, and (2) support groups. In a cancer counseling setting, experiential techniques could aid clients in
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making decisions about genetic testing. For example, the counselor could ask a client considering breast cancer predisposition testing to draw a picture of her family's reaction to her receiving a positive (or negative) BRCA1 result. Role plays might be used to allow clients undergoing genetic testing to practice how they will inform family members of their results. These techniques could also be used to encourage the expression of feelings surrounding a diagnosis. For example, the counselor could ask a patient to do an "empty chair" with breast cancer or with an affected relative. Because of the wide range of support groups facilitated by genetic counselors, I will attempt to illustrate applications to only two types of support groups: termination support groups and sibling support groups. In a support group for couples who have elected to terminate a pregnancy in which a genetic abnormality was discovered, role reversals between partners could be very helpful in eliciting their feelings about the experience and to explore which stage of grieving each is at. Role plays could also aid in exploring the decision of when (and whether) to attempt another pregnancy. In a support group for siblings of individuals with a genetic disorder, the empty chair techniques may permit healthy siblings to express their feelings to their affected siblings. In a sibling support group that includes young children, puppets could be used to role play family situations. The use of puppets is an experiential technique that aids in exploring the feelings of young children, who are not mature enough to engage in more sophisticated techniques such as continuums and empty chairs.
CONCLUSIONS I have reviewed the principles and goals of experiential family therapy, an approach that utilizes active, multisensory techniques to elicit change and growth in the family system. The three examples of experiential interventions—family drawings, "empty chair" technique, and continuums—illustrate how experiential techniques can be applied to resolve family conflict in the context of a genetic counseling session. These techniques, which draw upon nonverbal senses and lower defenses, are an innovative and efficient way to explore emotional and sensitive issues, such as illness and pregnancy termination, with clients. Experiential techniques are especially useful when traditional verbal communication proves to be ineffective, as in the case of Anthony and Janine, in which emotions were elevated and intense (Vos, 1988). It is likely that strictly verbal interventions would have only resulted in an angry rehashing of the same negative comments. Experiential techniques are also likely to be helpful in the opposite situ-
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ation, in which there is no verbal expression of emotion, and the counselor needs some means of eliciting feelings (Vos, 1988). Experiential techniques can be useful to genetic counselors. As the time allotted for each session continues to decrease, our repertoire of counseling strategies must expand in order to maximize their efficacy. We do not have the option of repeating ineffective strategies. However, some may ask whether there is time to incorporate experiential techniques, which can be time-consuming, into our busy clinical practices. Certainly, there will not be time for these techniques in every counseling session, nor would it be appropriate to try them with every client. When and with whom to use them must be left to the discretion of the genetic counselor. However, I believe that even counselors in a busy clinic setting can find a place for experiential techniques in their practices. When these techniques are used appropriately, even in the context of a brief session, they may stimulate discussion and motivate family members to resolve conflict. Clients can even be encouraged to try a technique, such as a role play or an empty chair, at home if there is not enough time to do so during the session, or they could be asked to return for a follow-up visit, if possible. I believe that genetic counselors can (and should) immediately begin to introduce some of the experiential tools described in this article into their counseling sessions. For those counselors who are interested in receiving more information or training in experiential therapy, the psychology department at your local college or university may be able to assist you. In addition, many cities have psychotherapy resource networks that can help you to locate educational opportunities in the field of experiential therapy.
ACKNOWLEDGMENTS I would like to express my appreciation to Annette Kennedy, PsyD, and Kathryn Spitzer Kim, MS for their thoughtful suggestions and critical reading of a draft of this manuscript.
REFERENCES Autism Society of America (1996) What is autism? Bischof GP (1993) Solution-focused brief therapy and experiential family therapy activities: an integration. J Syst Ther 12(3):61-73. Connell GM, Russell LA (1987) Interventions for the trial of labor in symbolic-experiential family therapy. J Marital Family Ther 13(1):85-94.
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Connell GM, Mitten TJ, Whitaker CA (1993) Reshaping family symbols: A symbolic-experiential perspective. J Marital Family Ther 19(3):243-251. Goldenberg I, Goldenberg H (1995) Family therapy. In: Corsini RJ, Wedding D (eds) Current Psychotherapies (5th Ed). Itasca, IL: F.E. Peacock Publishers, pp. 363-364. Harris SM (1996) Bowen and symbolic experiential family therapy theories: Strange bedfellows or isomorphs of life? J Family Psychother 7(3):39-60. Nystul MS (1993) The art and science of counseling and psychotherapy. New York: Macmillan Publishing Company, pp. 223-224. Swillen A, Hellemans H, Steyaert J, Fryns J (1996) Autism and genetics: High incidence of specific genetic syndromes in 21 autistic adolescents and adults living in two residential homes in Belgium. Am J Med Genet 67:315-316. Vos B (1988) Guidelines for selecting experiential techniques in family therapy. Family Ther 15(2):115-131. Walsh F (1993) Conceptualization of normal family processes In: Walsh F (ed) Normal family processes, New York: The Guilford Press, pp. 41-43.
Experiential Family Therapy: An Innovative Approach to the Resolution of Family Conflict in Genetic Counseling Lisa C. Tuttle1,2
Experiential family therapy is an intuitive approach that utilizes active, multisensory techniques. These techniques, such as role plays and drawings, increase the family's expression of affect and uncover new information. Increased affect and uncovered information stimulate change and growth in the family system. Experiential techniques are especially useful when more traditional, verbal-based communication is not effective. In this article, I will present a pediatric case in which the patient, a 7-year-old boy diagnosed with autism, was referred to the genetics clinic to rule out the presence of an associated genetic disorder. I will then describe a hypothetical second counseling session with the same family and suggest how three experiential family therapy techniques: family drawing, "empty chair" technique, and continuums might be used in the session to help resolve a marital conflict between the patient's parents. KEY WORDS: experiential family therapy; genetic counseling; family conflict; constructs; multisensory techniques.
INTRODUCTION In the course of our daily work, genetic counselors meet with people in crisis. Most of our patients are at risk for genetic disease, struggling with a diagnosis, or concerned about risks to their offspring. These situ1
Genetic Counseling Department, Brandeis University, Waltham, Massachusetts. Correspondence should be directed to Lisa C. Tuttle, Kaiser Permanente Genetics Department, 260 International Circle, San Jose, California 95119-1197.
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ations often cause anxiety and have implications for other family members. Because of this, many of the families we meet are in conflict, which may escalate to the point of interfering with family functioning. As counselors, we must sometimes address family conflict and work with our patients to help them resolve their problems. Because of the sensitive nature of our work and the fact that our time with families is often limited, we must be familiar with many counseling theories and techniques if we hope to assist in producing change in a family system. One such theory that is seldom applied to the genetic counseling field is experiential family therapy. In this paper, I will review the principles and techniques of experiential family therapy. I will also present a case in which a 7-year-old boy, diagnosed with autism, came to a large urban hospital's genetics clinic to rule out a genetic syndrome. I will then hypothesize a second session with his family and suggest how experiential family therapy techniques might be used to help them to resolve their conflict. My focus will be on three techniques commonly used in experiential family therapy: family drawings, the "empty chair" technique, and continuums.
EXPERIENTIAL FAMILY THERAPY
Experiential family therapy is a nontraditional school of therapy influenced by Gestalt therapy, psychodrama, client-centered therapy, and the encounter group movement (Bischof, 1993). Experiential therapists are concerned with using clients' in-session experiences to produce family growth and change. Experiential therapists steer away from traditional "talking about" conflict and instead utilize active, multisensory techniques to address family problems. Family problems are thought to be caused by lack of awareness of feelings, lack of ability to express feelings, rigidity in responding to problems, and denial of impulses (Walsh, 1993; Nystul, 1993). The goals of experiential therapy are to increase the awareness and expression of feelings, to promote flexibility in response to problems, and to promote spontaneity and playfulness within the family. In addition, this approach to therapy is concerned with uncovering new information by lowering family members' defenses (Goldenberg and Goldenberg, 1995; Walsh, 1993). The overriding goal is not just the reduction of symptoms, but personal and interpersonal growth and change (Walsh, 1993). Four major principles of experiential family therapy are outlined below: (1) the power of
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experience, (2) active, multisensory techniques, (3) affect and anxiety, and (4) spontaneity and playfulness. The Power of Experience An important concept in experiential family therapy is the power of experience (Harris, 1996). The therapist provides the family with new experiences during the session. These different experiences may change the constructs that each family member uses to view the family, its members, or the problem (Connell et al., 1993). Constructs are the sets of internal "rules" that each of us uses to assign meanings to the thoughts and behaviors of others or ourselves. For example, suppose one of my constructs is that patients referred to counseling because of prenatal alcohol exposure are irresponsible. This construct may have arisen from several experiences in which individuals with this indication failed to keep their counseling appointments. Every time a patient coming to discuss prenatal alcohol exposure fails to keep an appointment, I may attribute this to her being an irresponsible person. My interpretation of the patient's actions, as filtered through my construct, is likely to be incorrect as often as it is correct. Changing the constructs operating within a family is likely to change how the family members respond to each other and to the problem (Harris, 1996). For example, suppose a mother and teenage daughter present for genetic counseling, because the daughter has been diagnosed with a dominantly-inherited genetic disorder. Since the diagnosis, mother and daughter have been fighting constantly because the daughter has started dating excessively. Using experiential therapy techniques (see below), it emerges that the daughter feels as though her mother is discouraging her from dating because of a fear that she will then marry and have children who will inherit the disorder. The mother responds that the disorder has nothing to do with her reaction to her daughter's dating. The mother reveals that she regrets marrying and having children at a very young age, and she simply does not want her daughter to make the same mistakes. Uncovering this information changes the construct that the daughter has of her mother. The daughter no longer defines her mother as a domineering woman who wants to interfere with her future, but instead as a mother who simply wants more for her daughter than she had for herself. This change of construct in the daughter's mind may change the way that the daughter responds to her mother when dating issues arise. Also, if part of the daughter's motive for excessive dating was to rebel against her
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mother, a change in construct may even cause the daughter to be more discriminating in her dating habits. Active, Multisensory Techniques The experiential therapist utilizes active, multisensory techniques to allow for a fuller, more intense experiencing of other family members (Bischof, 1993). These techniques catalyze spontaneity, exploration, and communication of feelings (Walsh, 1993). As Vos (1988) stated in her review of experiential therapy techniques, "they've heard it all before, but they've seldom seen it all before," meaning that while most families have verbally stated their problems over and over again, few families have had the opportunity to express their feelings in a nonverbal fashion. Changing the medium within which feelings are expressed may change the meanings of these feelings for family members. In addition, using multisensory techniques helps to make information available to all family members, including children who can be actively involved in experiential family therapy sessions (Vos, 1988). Active techniques, which are often viewed as fun and interesting, also help to sidestep defense mechanisms. Because of this lowering of defenses, participants often reveal thoughts and feelings that had been unexpressed, even within their own minds. To illustrate the power of active, multisensory techniques, I will use the example of a family drawing, in which family members are asked to draw a picture of their family. Imagine a couple who has been referred for genetic counseling. Amniocentesis has revealed that their fetus has Down syndrome, and they are struggling with the decision of whether to terminate the pregnancy. The counselor might ask the couple to make a family drawing of what they think their family will be like if they continue the pregnancy and have a child with Down syndrome. Asking them to express their feelings in a different way (i.e., through pictures rather than words) may extract "unspeakable" information. Suppose the father draws a picture in which their child with Down syndrome is lying in bed, as the rest of the family stands around the bed, frowning. The house is surrounded with dark clouds. The counselor might ask the father to describe what he is portraying in the picture. He may have had difficulty expressing his feelings verbally, but when he is faced with describing his picture, hidden feelings may emerge. Family drawings can be used to uncover new information in a variety of ways. Family members may be asked to draw a picture of their family doing something together, fighting, or solving a problem. In addition, they may be asked to draw a picture of what they wished the family could be
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like (Bischof, 1993). Each of these variations may introduce slightly different information. However, the important themes underlying the conflict, such as "I can not raise a disabled child" or "My husband will not accept my diagnosis" are likely to be extracted from virtually any family drawing scenario. Other techniques commonly used in experiential therapy are role plays, the Kvebaek technique, family sculptures, continuums, and the "empty chair" technique. Role plays are skits in which each family member plays either themselves or another person in enacting a family scenario, such as a problematic incident. Role reversals, in which two conflicting family members play each other, are often especially useful for gaining an understanding of how family members view one another and in getting at new solutions to old problems. The Kvebaek technique involves the use of a chess-like board and pawns representing family members, who are asked to place their pawns on the board to indicate the closeness, distance, conflicts, and loyalties existing between family members (Bischof, 1993). For instance, suppose the mother of a family places her pawn in the middle of the board, indicating her centrality in the family. Her daughter, who has spina bifida, places her pawn on a corner square as far away from her mother as possible. This may indicate a feeling of distance. Another, unaffected daughter may place her pawn on the same square as her sister's pawn. This could indicate a feeling of closeness or of competitiveness between the sisters. A discussion of why the mother and daughters placed their pawns where they did may clarify how they see their roles within the family as well as how they cope with the daughter's disability. Family sculptures are similar to family drawings in that they are pictorial representations of the way in which the family interacts. Instead of drawing a picture of the family on paper, a family member is asked to physically arrange the other family members to make a sculpture that represents the family (Nystul, 1993). The therapist may ask each family member to make their own sculpture and then discuss why each of them arranged their family members as they did. The therapist may manipulate the sculpture and gauge the reactions of family members to the new sculpture (Vos, 1988). The empty chair technique is one in which an individual speaks to an empty chair as though it was occupied by a family member (Vos, 1988). This technique can be used to enable a family member to freely express his or her feelings to another member of their family with whom there is some conflict. The person "in" the chair may or may not be present in the session. Speaking to the empty chair allows an individual to express feelings and concerns freely and safely, with no risk of interruption or angry re-
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sponses. If the individual "in" the empty chair is present in the room, s/he gets the opportunity to hear the other person's feelings, perhaps for the first time. An "empty chair" may also provide a practice session for a face to face discussion, with the individual modeling for himself or herself how such a discussion might be conducted. For example, suppose a patient has been found to carry a fragile X premutation and expresses her worry about sharing this result with her sister. The counselor might suggest that the patient pretend her sister is sitting in the empty chair. The patient could then practice sharing her carrier status with her sister until she feels comfortable enough to divulge the information in person. A therapist using continuums utilizes the therapy room as a scale, with each side of the room representing one extreme of the scale. The therapist names a dimension for the scale to measure, such as power. In this case, one side of the room would represent omnipotence, and the other side of the room would represent powerlessness. Each family member would be instructed to stand at the place on the continuum corresponding to the amount of power they felt they had (Bischof, 1993). In a genetic counseling setting, continuums could be used with a couple having difficulty deciding whether to pursue prenatal testing. The dimension of the scale might be "desire to have an amniocentesis." Each member of the couple would be asked to stand at a point on the scale which corresponded to the strength (or lack) of his/her interest in amniocentesis. For clients who are very uncomfortable physically moving around the room, the continuum could be drawn on a sheet of paper. Affect and Anxiety Experiential therapists believe that affect is therapeutic and growthproducing (Bischof, 1993). Affect can be defined as a verbal or nonverbal expression of feeling. The active, multisensory techniques employed in experiential family therapy often increase the level of affect in the room. This increase in affect is frequently coupled with an increase in anxiety. Because this emerging anxiety is difficult to tolerate, families mobilize their resources for change in an effort to relieve it. For example, suppose a brother and sister come in to discuss a family history of cystic fibrosis. They have recently lost a sibling to the disorder, and it becomes evident that they have some unresolved feelings about their deceased sibling which they are not expressing verbally. An experiential family therapist might suggest the use of the Kvebaek technique. The therapist asks each sibling to place their pawn in relation to the piece representing their deceased sibling. Both the brother and sister place their pawns
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far from the deceased sibling, but close to each other. This may be the first time that they have allowed themselves to express the distance that each felt from their sibling. Having finally done so may cause an immense amount of anxiety, guilt, sadness, or anger. Because this new situation is difficult to "sit with," the siblings may now be mobilized to explore why the feelings of distance existed so that the guilt, sadness, and anger can be worked through and the unsettling anxiety relieved. Spontaneity/Playfulness In experiential family therapy, techniques flow from the moment; they are not pre-planned (Connell and Russell, 1987). Although an experiential therapist may have a repertoire of techniques, he or she does not go into a session planning to use any particular technique. The therapist is intuitive and spontaneous in choosing techniques. In addition, the therapist encourages the family to be spontaneous and to have fun with each other. Fostering such a "free" environment adds to the new experience of the family in the session and helps to lower family members' defenses, allowing new information to emerge (Bischof, 1993; Connell and Russell, 1987). For example, suppose a couple came for counseling because of advanced maternal age. The couple is conflicted about whether to have an amniocentesis. She is worried about the miscarriage risk, but he thinks that risk is too small to be concerned about. The discussion goes around and around, with no decision in sight. An experiential family therapist may suggest that the couple switch roles and continue the discussion. Asking them to switch roles may uncover new information and increase the couple's understanding of one another. Asking the couple to be spontaneous and do something unusual may also lower their defenses, and allow them to speak more freely about their feelings. They may even have fun with this opportunity to "play" each other. The experiential therapist would not discourage this playfulness. The couple's enjoying of each other during the process of making this difficult decision may result in their increased motivation to work together to reach a compromise.
CASE PRESENTATION I will now briefly describe a case that I observed at a genetics clinic held in large urban hospital. A 7-year-old boy, "David," had been diagnosed with autism at the age of four. David had delays in cognitive, speech, and social functions and spoke about 15 words, all characteristic of autism
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(Autism Society of America, 1996). David also exhibited other autistic features, such as repetitive clapping behavior and self-injurious behavior, at times wringing his hands violently. David's neurologist referred him to the genetics clinic to rule out a genetic syndrome as the cause of his autism. There are several genetic syndromes in which a subset of affected individuals have autism or autistic-like behaviors, such as basal cell nevus syndrome, fetal alcohol syndrome, fragile X syndrome, Noonan syndrome, Sotos syndrome, tuberous sclerosis, velocardiofacial syndrome, and Williams syndrome (Swillen et al., 1996). David was the product of an uncomplicated pregnancy and delivery. His developmental milestones were normal until between the ages of 2 and 3 years, during which time his parents began to worry about his speech delay. All of his tests were normal, including chromosome analysis and fragile X testing. David arrived at his appointment with his father, Anthony. The medical geneticist and I showed David and Anthony into the counseling room and proceeded to take a family history. The family history was unremarkable with the exception of two monozygotic male twins, who were David's maternal first cousins-once-removed. One of the twins was autistic, and the other had unspecified learning disabilities. David's physical exam showed a variety of minor abnormalities, including brachycephaly, prominent ears, strabismus, and upward-slanting eyes. He had a thin vermilion, flat philtrum, oligodontia (upper central and lateral incisors missing), a high-arched palate, a small penis, curved toes, hypoplastic nipples, and broad proximal interphalyngeal joints. The last finding was especially perplexing, and we asked that Anthony take David to radiology for hand X-rays. We were not sure if the finding was clinically significant or merely a consequence of his hand-wringing. During the history-taking portion of the session, David was fidgety and kept reaching for the telephone and the stethoscope, but in general was well-behaved. However, when the physical examination began, he began to scream and cry. A typical feature of autism is a misprocessing of sensory stimuli, which causes many children with autism to dislike being touched (Autism Society of America, 1996). David may have disliked the physical contact, or perhaps he had just learned to resist exams and doctors. We managed to distract him with movement and noises enough to perform a full physical exam. However, once the exam was done, it was evident that it was time for Anthony to take David home. Therefore, this was a short session, mostly involving information gathering, and we did not have an opportunity to fully explore psychosocial issues. Throughout the session, Anthony's speech and behavior revealed that he was clearly frustrated by the fact that the cause of David's autism was
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undetermined. He noted that every laboratory test was normal, but David obviously was not. He asked us why no one could figure out what was causing David's problems. Another source of his frustration was the discrepancy between what David could understand and what he could express. Anthony described David as "smart" several times and cited as evidence David's ability to respond correctly to directions to get a Sprite vs. a Coke from the refrigerator. While David was unable to express even his most basic feelings and desires, he was able to understand the difference between Sprite and Coke. At points throughout the session, it seemed as though Anthony was trying to prove to us how "smart" David was. Anthony tested him by instructing him to touch various parts of his face and to remove his own shoes. David failed to perform these tasks, which seemed to cause even more frustration for Anthony. Anthony also stated that he felt frustration for David, because David could understand so much but express little in return. Toward the end of the session, Anthony suddenly stated, "You know, these things (autism) break up marriages, Doctor." Unfortunately, the issue was not pursued, but it left lingering questions in my mind. Why had he brought that up? During the family history, he had reported that he was married to David's mother, Janine. A few weeks after the session, I called David's house to inquire about the hand X-rays, because there was still no radiology report in the hospital's computer system. No one was home, and my suspicions about Anthony's comment were renewed when I heard that the answering machine recording was a woman's voice saying, "I am not home right now." Of course, there could be other explanations for his comment and for the recording, but the instances were enough to leave me wondering about the state of their marriage.
APPLICATION OF EXPERIENTIAL FAMILY THERAPY TECHNIQUES TO A HYPOTHETICAL SECOND SESSION In order to illustrate three experiential family therapy interventions: family drawings, "empty chair" technique, and continuums and their potential applicability to genetic counseling, I will portray Janine, Anthony, and their speculated conflict in simplistic terms. For the purposes of this article, I will hypothesize that Janine feels Anthony is preoccupied with finding a diagnosis for David, at the expense of ignoring his role as a husband and father. Meanwhile, Anthony feels that Janine does not care about David's well-being because she is not as concerned with finding a diagnosis. Suppose that, a few weeks after the first session, we meet again with this family to discuss the progress made in arriving at a diagnosis for David
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and what our next steps might be. This time, we request that Anthony, David, and Janine all attend the session. We greet them and show them into the counseling room. Anthony immediately asks whether we have found a diagnosis. We admit that we have not. This sparks off the following possible argument between Anthony and Janine: J:
A: J: A:
Well, Anthony, are you satisfied? Another shot in the dark! And I took a day off of work to come here. Anthony is on a mission to find a diagnosis for David. He's crazy...he doesn't care about anything else. He's either reading about some new treatment or dragging David to some new doctor. He's never therefor us anymore as a husband or a father. I couldn't take it anymore, so... So, you kicked me out of the house—isn't that a fine way to break up a family!! We haven't been a family for a long time. At least I care about our son...you couldn't care less about finding out what is wrong with him.
At this point in the session, after listening to Anthony and Janine angrily arguing with each other, the counselor might decide to try an experiential approach: GC: It seems like you two are so angry with one another. I want to try something with you that might seem a little crazy or weird, but that I think might help us get to the heart of what's going on in a calmer way. Are you willing to give it a try? A: Sure, I'll try anything to resolve this. Janine? J: OK..Whynot? Intervention #1: Family Drawings GC: OK, I'm going to give each of you a piece of paper, and I want each of you to draw a picture of your family as you see it. I want you to represent yourselves with circles (Vos, 1988). So, each of you, when you're done, will have three circles drawn. OK? [Anthony and Janine draw their pictures.] GC: All set? Let's see what each of you has drawn. A: Here's mine (Fig. 1). GC: Why did you draw your picture the way you did? A: Well, I want to be with my son, but my wife is standing in my way; she has kicked me out of our home, and now I can't be with David. GC: Why isn't your wife's circle connected with David's?
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Fig. 1. Anthony's family drawing.
Fig. 2. Janine's family drawing.
A:
Because I don't feel like she wants to be connected with him. She does a good job taking care of him, I guess, but she doesn't want to be involved in figuring out what's going on with his autism. GC: Janine, what do you think about what Anthony drew? J: I feel badly that he feels cut off from David. I didn't want that to happen. I just couldn't stand it...the constant attention to the autism and not to the David inside. Anthony, I love David very much...he and I are connected. GC: Janine, let's see your picture (Fig. 2). J: Here are David and I, connected as mother and son. There's Anthony, off to the side, preoccupied with diagnosing David, and meanwhile ignoring David and me. A: Well, I do spend a lot of time away from Janine, reading and stuff like that—about autism. But, I spend time with David, everyday while Janine is at work. GC: How do you feel about Janine's drawing? A: I feel really hurt to be put off to the side like that. I'm only trying to help my family by doing the things I do. I love them both so much...
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GC: Now, we have an idea how you see each other.,.I want you to try the same exercise again—only this time, draw what you'd like your family to look like. [Anthony and Janine draw their pictures] GC: OK, let's see them at the same time. J: They're the same (Fig. 3 and 4)!! GC: Well, that says a lot...it looks like you both want the same things. What is one small thing that each of you could do to make that picture happen? J: Well, I guess I could be more supportive of Anthony and come to some of these appointments—the necessary appointments—with him and David. I want to show him that I really do care about David's progress and I would like to find some answers, too. A: I'd like that...I think David would, too. Sometimes, he gets scared at the doctor's, and I'm not always good at calming him down. I
Fig. 3. Anthony's "ideal family" drawing.
Fig. 4. Janine's "ideal family" drawing.
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guess I could cut down on the number of doctors and appointments. I know I go overboard. I just feel so frustrated. Me too. For the first time in a while, I feel like we're in this together.
In this example, the process of drawing and discussing family pictures produced remarkable changes in both Anthony's and Janine's constructs. Janine had interpreted Anthony's pursuit of a diagnosis as serving to distance himself from the family. Her construct was challenged when she learned that he was hurt and surprised to be portrayed that way. In actuality, Anthony desired more intimacy with Janine and David. Anthony had viewed Janine as not caring about David because of her lack of interest in a diagnosis. He also saw his separation from Janine as her effort to keep him apart from David. These constructs were challenged in the discussion of the drawings, when Janine stated her love for David and her desire for Anthony and David to have a close relationship. The process of seeing each other's feelings rather than hearing them forced Anthony and Janine to confront their roles within the family, and how those roles affect David. For each, seeing their spouse's view of them raised their level of affect as they realized that there was some truth to the other's drawing. The discussion of the drawings increased the understanding that each had for the other. The second drawing exercise, in which they drew how they would like the family to be, solidified that understanding by dramatically illustrating that despite their arguing, their goals were the same. Neither was as alone as they had felt. Another approach that might have produced a similar outcome is family sculpture. A family sculpture would allow Janine and Anthony to "draw" their pictures using each other, rather than pen and paper. Sculpting may have an even greater affective effect because, in addition to stimulating the auditory and visual senses, it incorporates a third sense—kinesthetic. For instance, if Janine was to move Anthony into the corner of the room, facing away from her and David, Anthony's affect may have intensified even more than if the same image was depicted in a drawing. However, in this case a drawing may have been a better choice than sculpting. Because of his condition, David may have objected to being physically maneuvered for a sculpture, and is unlikely to have been cooperative. However, his lack of cooperation may provide a poignant symbolization of Anthony and Janine's failed efforts to reach him. Another consideration in deciding between drawing and sculpting techniques is which family members are present at the session. A drawing would allow nonpresent family members to be in the picture and may be more effective if key family members are not present. A final consideration is the comfort level of the family. Some families
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are self-conscious about participating in these techniques, and they may be more comfortable drawing rather than sculpting. In many cases, children in the family could also be involved in drawing activities. However, in this case, it is unlikely that David would have been able to participate in the exercise. Another caution in using this technique (or any experiential technique) with children, especially autistic children, is that the inferences and connections that make sense to adults may not apply to children. For instance, suppose David understood the instruction to draw his family and was able to produce a recognizable picture of his father standing far away from himself and his mother. Does this mean that David agrees with Janine that Anthony is disconnected from them, or did David just happen to draw his father at the edge of the paper? Does distance on paper correlate with emotional distance in David's mind, as it might in our minds when we interpret these drawings? Consider the drawing of a child with Williams syndrome, a genetic condition in which affected individuals have unusual spatial perceptions. One would have difficulty in determining whether a disjointed drawing done by a child with Williams syndrome was representative of an undesirable family environment or simply a manifestation of the child's disorder. Intervention #2: Empty Chair Technique GC: Janine, I want you to pretend that Anthony is sitting in this chair. I want you to tell him how you feel and what you need from him. You may feel a little silly doing this, but think of it as your chance to tell Anthony everything you've been wanting to tell him. He can't argue with you or interrupt you...he can only listen. Are you ready? J: [talking to the empty chair] Anthony, I feel alone. I feel tike you are never there...I mean, you're there, but you're either reading some medical journal or speaking with the autism society or getting ready for a doctor's appointment. You're so focused on David as a patient that you seem to have forgotten that he's your son! He needs more of you. I need you, too. I need a husband. Talk to me about something besides David's last appointment or his next one. I miss you...don't abandon me. I don't want to live apart from you, but something has to change. A: Wow! You need me? Why would you need me? I'm a failure as a father and a husband. I can't take care of my famify...I can't do anything for my son, no matter how hard I try. I'm so frustrated not to be able to help him. J: So am I.
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A: J:
You are? I thought you were against finding outside help. I'm not against it, Anthony...you're just so for it, that if I don't balance you out, you'll go even more overboard than you do! A: Hmm...I was afraid you just didn't care...it felt like I didn't know you anymore, J: That's how I feel. I want to know you again. Here, the empty-chair technique has allowed Janine to express her feelings without fear of backlash. Janine presented her case without interruption, possibly for the first time. The information that emerged was new to Anthony and provided a topic for discussion and new understanding. In addition, some of the information may have been new to Janine, who may never have expressed her feelings before, even to herself. However, although Anthony could not counter her arguments or interrupt her while she was speaking to the empty chair, Janine knew that he was listening. Because of this, she may censor her speech somewhat. Another way in which this technique might have been useful is if the counselor had asked either Janine or Anthony to pretend that David was in the empty chair. This would provide them with perhaps their first opportunity to express their feelings to David as though he could truly understand them. They may share their frustration about not being able to reach him, their sorrow that he has to live his life as an autistic child, or their fear that he does not love them because he does not express it. The empty chair technique could even be used to provide an opportunity to explore how David might respond. Suppose Janine is speaking "to" David in the empty chair. She could role play his part, as well, and respond to what she says. For instance, suppose Janine expresses "to" David the guilt she feels that he must live his life as an autistic child. She then role plays how she thinks David might respond, if he could, to her statement. Playing him, she may say, "I blame you for my condition; I hate you for having me." Expressing this fear may start the process of exploring her (and likely Anthony's) feelings of guilt. Part of this exploration might involve the counselor asking Janine to role play David forgiving her and Anthony and expressing his love for them. A caution in having Janine and Anthony speak to David as though he was in the empty chair is that one does not know how much the real David, if he is in the counseling room, would understand. He may become confused or scared upon hearing his parents speaking to "him" in unfamiliar terms in a strange situation. Also, Janine and Anthony may be reluctant to even pretend to express any negative feelings about David, regardless of whether or not David was in the room. A possible way to avoid this discomfort might be to place "autism" in the empty chair, thus making the
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diagnosis the target of any negative feelings instead of the child. Anthony and Janine may then feel more comfortable exploring their anger and sadness. David would also be less likely to understand this more abstract scenario, and he probably would not interpret what his parents say as being directed toward him. One can also use the empty chair technique to bring family members who are not present into the room. Suppose that Anthony stated that one of the factors feeding into his desire to help David so much is that Anthony never felt that his own father loved him. The counselor could ask Anthony to "empty chair" with his father in the chair. This would allow Anthony to express his feelings "to" his father. Because his father is not present, Anthony will most likely be comfortable enough to speak freely, without censure. Intervention #3: Continuums
GC: I want you to pretend that this room is a scale. This side of the room is one extreme, and that side of the room is the other extreme. I'll name the dimension that the scale is measuring, and each of you will walk to the place where you "belong" on the scale. The first dimension is control. Stand on this side of the room if you feel in complete control over what happens—in your marriage, with David, in your life—and stand on that side of the room if you feel like you have no control over what happens. [Janine and Anthony both walk to the "no control" side of the room.] J: 7 don't know why he's standing over here. He is in complete control. He determines everything about all of our lives. He says which doctors David goes to, which school he attends, how we spend our time... A: 7 have no control over what happens! If I had any control, David wouldn't be this way. I try to make things better for him, and nothing works. I have absolutely no control at all. I'm helpless. J: I feel like I have no say in David's life...I'm helpless, too. GC: Let's try one more of these scales. This time, stand on this side of the room if you have a very strong commitment to your marriage and stand on the other side if you have a very weak commitment to your marriage. [Janine and Anthony both walk to the "strong commitment" side of the room.] J: Lately, I've been feeling like you didn't care about us.
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A: I always care about us...all of us. I was afraid you'd walk to the other side. J: It's good to see we're still on the same side. Like family sculptures, continuums provide the family with kinesthetic as well as auditory and visual input. In the example above, as they walk to the "no control" end of the first continuum, Janine and Anthony both acknowledge that they feel out of control. It appears that this is the first time that each of them has realized that the other person feels helpless, too. Each had thought that their spouse was firmly in control. After Janine and Anthony had both walked to the "no control" side of the room, the therapist could have asked where each of them would place David on the control continuum. Suppose that they both placed him on the opposite side of the room. In this instance, performing this exercise might have caused them to realize, perhaps for the first time, the control that David has over both of their lives. The "commitment to the marriage" continuum indicates, as the second set of family drawings did, that their goals are the same. Despite their arguing, they both want the marriage to succeed. Their affect around learning this may be more intensified with this technique than with the family drawing, because of the physical nature of the continuum technique. Walking together to the "committed" end of the continuum may reinforce their feeling that they are a couple. The physical aspect of this technique also introduces a fear of abandonment that Anthony expresses when he says "I was afraid you'd walk to the other side." The anxiety that each experiences, as they fear the other will walk to the "no commitment" end of the continuum, may cause them to more intensely experience their union when each of them realizes that their spouse wishes to stand by them, physically and emotionally. Of course, this brief counseling intervention is unlikely to be sufficient for a couple facing serious marital problems, and the counselor may wish to accompany this continuum with a thoughtful referral for longer term couples counseling.
APPLICATIONS TO OTHER GENETIC COUNSELING SETTINGS Throughout this article, I have attempted to emphasize the many potential applications of experiential family therapy techniques to genetic counseling. However, two common genetic counseling settings have not been mentioned in my examples, and I would be remiss not to do so here. These two settings are: (1) cancer counseling, and (2) support groups. In a cancer counseling setting, experiential techniques could aid clients in
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making decisions about genetic testing. For example, the counselor could ask a client considering breast cancer predisposition testing to draw a picture of her family's reaction to her receiving a positive (or negative) BRCA1 result. Role plays might be used to allow clients undergoing genetic testing to practice how they will inform family members of their results. These techniques could also be used to encourage the expression of feelings surrounding a diagnosis. For example, the counselor could ask a patient to do an "empty chair" with breast cancer or with an affected relative. Because of the wide range of support groups facilitated by genetic counselors, I will attempt to illustrate applications to only two types of support groups: termination support groups and sibling support groups. In a support group for couples who have elected to terminate a pregnancy in which a genetic abnormality was discovered, role reversals between partners could be very helpful in eliciting their feelings about the experience and to explore which stage of grieving each is at. Role plays could also aid in exploring the decision of when (and whether) to attempt another pregnancy. In a support group for siblings of individuals with a genetic disorder, the empty chair techniques may permit healthy siblings to express their feelings to their affected siblings. In a sibling support group that includes young children, puppets could be used to role play family situations. The use of puppets is an experiential technique that aids in exploring the feelings of young children, who are not mature enough to engage in more sophisticated techniques such as continuums and empty chairs.
CONCLUSIONS I have reviewed the principles and goals of experiential family therapy, an approach that utilizes active, multisensory techniques to elicit change and growth in the family system. The three examples of experiential interventions—family drawings, "empty chair" technique, and continuums—illustrate how experiential techniques can be applied to resolve family conflict in the context of a genetic counseling session. These techniques, which draw upon nonverbal senses and lower defenses, are an innovative and efficient way to explore emotional and sensitive issues, such as illness and pregnancy termination, with clients. Experiential techniques are especially useful when traditional verbal communication proves to be ineffective, as in the case of Anthony and Janine, in which emotions were elevated and intense (Vos, 1988). It is likely that strictly verbal interventions would have only resulted in an angry rehashing of the same negative comments. Experiential techniques are also likely to be helpful in the opposite situ-
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ation, in which there is no verbal expression of emotion, and the counselor needs some means of eliciting feelings (Vos, 1988). Experiential techniques can be useful to genetic counselors. As the time allotted for each session continues to decrease, our repertoire of counseling strategies must expand in order to maximize their efficacy. We do not have the option of repeating ineffective strategies. However, some may ask whether there is time to incorporate experiential techniques, which can be time-consuming, into our busy clinical practices. Certainly, there will not be time for these techniques in every counseling session, nor would it be appropriate to try them with every client. When and with whom to use them must be left to the discretion of the genetic counselor. However, I believe that even counselors in a busy clinic setting can find a place for experiential techniques in their practices. When these techniques are used appropriately, even in the context of a brief session, they may stimulate discussion and motivate family members to resolve conflict. Clients can even be encouraged to try a technique, such as a role play or an empty chair, at home if there is not enough time to do so during the session, or they could be asked to return for a follow-up visit, if possible. I believe that genetic counselors can (and should) immediately begin to introduce some of the experiential tools described in this article into their counseling sessions. For those counselors who are interested in receiving more information or training in experiential therapy, the psychology department at your local college or university may be able to assist you. In addition, many cities have psychotherapy resource networks that can help you to locate educational opportunities in the field of experiential therapy.
ACKNOWLEDGMENTS I would like to express my appreciation to Annette Kennedy, PsyD, and Kathryn Spitzer Kim, MS for their thoughtful suggestions and critical reading of a draft of this manuscript.
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Connell GM, Mitten TJ, Whitaker CA (1993) Reshaping family symbols: A symbolic-experiential perspective. J Marital Family Ther 19(3):243-251. Goldenberg I, Goldenberg H (1995) Family therapy. In: Corsini RJ, Wedding D (eds) Current Psychotherapies (5th Ed). Itasca, IL: F.E. Peacock Publishers, pp. 363-364. Harris SM (1996) Bowen and symbolic experiential family therapy theories: Strange bedfellows or isomorphs of life? J Family Psychother 7(3):39-60. Nystul MS (1993) The art and science of counseling and psychotherapy. New York: Macmillan Publishing Company, pp. 223-224. Swillen A, Hellemans H, Steyaert J, Fryns J (1996) Autism and genetics: High incidence of specific genetic syndromes in 21 autistic adolescents and adults living in two residential homes in Belgium. Am J Med Genet 67:315-316. Vos B (1988) Guidelines for selecting experiential techniques in family therapy. Family Ther 15(2):115-131. Walsh F (1993) Conceptualization of normal family processes In: Walsh F (ed) Normal family processes, New York: The Guilford Press, pp. 41-43.
