ORI GIN AL PA PER
Francesca Fantini • Filippo Aschieri • Paolo Bertrando
Published online: 28 March 2013 � Springer Science+Business Media New York 2013
Abstract In this paper we present a new model of intervention with documented efficacy that combines psychological tests and assessment methods with therapeutic techniques to
promote change in clients. We will discuss Therapeutic Assessment of Children and their
families (TA-C) through the case of a 4-year-old girl, Clara, and her family. Clara’s parents
were distressed by her uncontrollable rage outbursts and feared she might be ‘‘crazy’’. The
treatment helped to shift the narrative the parents had about Clara and give new meanings
to her behaviors. We describe in detail the steps of the assessment and provide a theoretical
discussion of the therapeutic processes involved.
Keywords Assessment � Family � Children � Therapy
Within systemic therapy, skepticism about the tools and methods typical of psychological
assessment has been fostered both by the social constructionist stance that prevailed within
the field in recent year, and by prejudices about the very nature of testing, i.e., the idea that
psychological tests pertain to the domain of naı̈ve realism and tend to give an account of
clients’ problems framed in a positivistic view. In such a context, psychological assessment
is viewed as an effort to measure the ‘‘true reality’’ of clients’ problems, thereby mini-
mizing their own experiences, views, and hypotheses (Brown 1972). While this underlying
philosophy may characterize the traditional approach to psychological assessment, in
recent years new ways have been developed of integrating the tools and methods of the
assessment practice in a therapeutic and post-modern framework. This is the case of
Therapeutic Assessment (TA), a semi-structured form of brief integrative intervention
(Kaslow 2000) developed by Finn and his colleagues (Finn and Tonsager 1992, 1997; Finn
2007) over the last 20 years. TA combines psychological assessment with techniques and
F. Fantini � F. Aschieri (&) European Center for Therapeutic Assessment, Università Cattolica del Sacro Cuore, Via Nirone 15, 20123 Milan, Italy e-mail: firstname.lastname@example.org
P. Bertrando Private practice, Milan, Italy
Contemp Fam Ther (2013) 35:731–744 DOI 10.1007/s10591-013-9265-3
principles of interpersonal and systemic psychotherapy. TA has proved to be effective with
different types of clients such as adult outpatients (Finn and Tonsager 1992; Newman and
Greenway 1997), couples (Durham-Fowler 2010), families with children (Tharinger et al.
2009; Smith et al. 2010), and adolescents (Ougrin et al. 2008). Research has focused on the
effectiveness of TA with different types of problems, i.e., self-harm (Ougrin et al. 2008);
internalizing symptoms, (Aschieri and Smith 2012); externalizing symptoms (Smith et al.
2010); disorganized attachment (Smith and George 2012); and developmental trauma
(Tarocchi et al. in press).
Therapeutic Assessment with Children and Their Families
TA with children and their families (TA-C) involves a suggested series of steps described
in various publications (Aschieri et al. 2013; Smith et al. 2009; Tharinger et al. 2008a; Finn
2007). In summary, after the initial phone contacts, the assessor meets the parents to co-
construct assessment questions that capture their main puzzles and worries about their
child or their relationship with their child (Step 1). By focusing on the parents’ questions,
the assessor aims to involve parents as active participants from the beginning of the
process. Assessment questions are used to build an alliance around parents’ motivations
and goals, and to foster their curiosity about their child. Also, the clear formulation of the
assessment goals as focused on their puzzles and worries has the effect to lower the
parents’ anxiety about the assessment. The assessor also works to gather background
information about the family and uses assessment questions as guides to chose which
themes the parents are open to discuss and don’t find threatening. In fact, besides the
explicit goal of collecting parents’ questions, the assessor also works to build a secure
relationship with them, based on experiences of emotional attunement, collaborative
communication and the repair of possible disruptions (Finn 2012). The creation of a such a
relationship is considered essential for a therapeutic change to occur. The child being
assessed may have his/her own questions too, and these are collected in the second session,
usually scheduled with the whole family. Afterwards, the assessor begins the testing phase
with the child to collect useful information relevant to the assessment questions. The
parents are usually asked to observe test administration or the unstructured activities (i.e.
drawings) that are part of this phase from behind a one-way mirror, over a video link, or
from the corner of the testing room (Step 2). Later, the assessor and parents discuss their
observations and their relevance to the parents’ assessment questions (Tharinger et al.
2008b). Different from other systemic collaborative interventions (see, for example,
Teixeira et al. 2011), in TA-C the parents are involved directly as co-assessors, observing
and interpreting their children’s behaviors during the testing. Next the assessor schedules
one or more family sessions, the so called intervention sessions; these represent occasions
to work even more on the systemic aspects of the child’s problem and to work with the
family members on possible new ways of interacting (Tharinger et al. 2008a) (Step 3).
Finally, the assessor meets the parents for a summary/discussion (i.e., feedback) session,
where the main results of the assessment are summarized and discussed (Finn 2007;
Tharinger et al. 2008b) (Step 4). The assessor also gives feedback to the child about the
assessment results in the form of an individualized fable (Tharinger et al. 2008c) (Step 5).
TA-C can be done by one clinician or by two, depending on the presence of a colleague
trained in the approach and on the financial aspects of the assessment. Clearly, one of the
main advantages of working with a co-therapist is that during the testing phase, while one
clinician works with the child, the other can stay behind the one-way mirror with the
732 Contemp Fam Ther (2013) 35:731–744
parents. There, the second clinician can support the parents emotionally and begin com-
menting with them on what is happening in the assessment room with the child.
A recent review of the research on TA by Finn et al. (2012) revealed fewer empirical
studies supporting TA-C than TA with adult clients. However, the results available so far
are promising. An aggregate group study by Tharinger et al. (2009) assessed the overall
effectiveness of the TA-C model with 14 families with preadolescent children referred for
emotional and behavioral problems. The study showed that TA-C reduced symptoms in
both parents and children, increased communication and positive emotions, and decreased
negative emotions and conflicts within the family. Also, participants reported high
engagement in the assessment and satisfaction with the services. Tharinger and Pilgrim
(2012) studied the effect of giving feedback to children through an individualized fable at
the end of a standard neuropsychological assessment. The addition of this single step of
TA-C increased children’s sense of learning about themselves, and children who received a
fable rated their relationship with their assessor as more positive and the assessment
process as more collaborative than did children in the control group (who also received a
fable, but after the study was completed). Children who were given fables also perceived
that their parents learned more about them because of the assessment. Also, the parents of
the fable group reported a more positive relationship between their child and the assessor, a
greater sense of collaboration, and higher satisfaction with the assessment compared to the
control group. Smith et al. (2009), using a repeated measures single-case design, showed
the effectiveness of TA-C with a family referred for their child’s conduct problems. Last,
using a replicated time-series design, Smith et al. (2010) found that TA-C promoted change
in families at different points during the process, suggesting that different families are
receptive to different aspects of the approach. The clients of this latter study repeatedly
completed individualized rating scales to track symptomatic change during the treatment.
Such scales are a powerful tool to evaluate the effectiveness of an intervention, to involve
the clients in the research process, and to help clinicians evaluate their own practices
effectively (Kruger 1999). In addition to these empirical studies, a number of clinical
reports on TA-C have been published that illustrate its application in schools (Tharinger
et al. 2007), university clinics (Hamilton et al. 2009; Smith and Handler 2009), private
practice (Finn 2007; Handler 2006), and community clinics (Guerrero et al. 2011).
The current paper illustrates the structure of TA-C and some of the therapeutic pro-
cesses involved through the case of Clara and her family.
Case Example: Clara and her Family1
Clara was a 4-year-old child referred to the European Center for Therapeutic Assessment
together with her parents by her neuropsychiatrist. The reason for the referral concerned
Clara’s frequent rage outbursts, during which she screamed at the top of her lungs, threw
herself on the ground, and cried uncontrollably.
The case was assigned to Francesca Fantini and Filippo Aschieri who contacted the
neuropsychiatrist and collected the following background information. At 9 months of age
Clara suddenly showed symptoms of a neurological illness, for which the diagnosis is still
1 The clients’ names and all potentially identifying information have been altered to disguise the clients’ identity. Additionally, the clients provided explicit permission to write about their TA in de-identified form.
Contemp Fam Ther (2013) 35:731–744 733
unclear. Basically, the symptoms were very strong tremors all over her body that prevented
Clara from controlling her movements and even from standing and walking. Clara was
hospitalized and had to have several invasive medical tests. Through medications and
physical therapy the child recovered a great deal, but she still had some tremors at the time
of the assessment. A year before the assessment Clara began having anger outbursts, which
didn’t seem directly connected to the neurological problems.
Clara’s parents, Maria and Jorge, came from El Salvador and were illegal immigrants in
Italy for 7 years. When Clara got ill they had a great deal of difficulty accessing Italian
public health services. After a while, they were eventually able to get a residence permit
for the entire family because of Clara’s illness. Both parents had previous partners in El
Salvador and other children there, to whom they regularly sent money from Italy. In a
meeting alone with the neuropsychiatrist, Maria hinted that she had a history of neglect and
violent treatment as a child and had been beaten often by her former husband. The neu-
ropsychiatrist found her reticent to tell more details about her past. Maria also intimated
that Clara’s father had been beaten and neglected as a child too.
After presenting the case to us, the neuropsychiatrist agreed that Clara’s family might
benefit from a TA, and we were able to offer this to them for free, due to their limited
financial resources. Then the neuropsychiatrist gave Maria and Jorge our contact number,
and they phoned to schedule the first appointment.
Step 1: Meeting with Clara’s Parents
At the beginning of the first session, we oriented Maria and Jorge briefly to the Center.
Filippo Aschieri had previously talked on the telephone with Maria giving her some
information about the assessment, and we took more time to help both of them understand
the main points of the informed consent they had to sign. After summarizing for them the
content of the form and asking for questions, Maria and Jorge began to silently read it for
several minutes, during which time their (and our) anxiety was clearly palpable in the
room.2 We then started to talk about why they where seeking help for Clara. Maria and
Jorge were fairly fluent in Italian, although they made grammatical mistakes and some-
times used a few Spanish words in their speech. Nevertheless, it wasn’t at all difficult to
talk to them, and we could understand and communicate very well with each other.
Maria and Jorge posed the following questions to guide the assessment:
1. Why does Clara react so crazily and get angry?
2. Are these just tantrums or is it a psychological problem?
3. How can we help her to control herself better?
While collecting background information about these questions, we began to understand
how distressed and puzzled both parents were about Clara’s outbursts and how bad they
felt about not being able to successfully manage them. While inquiring about the second
question, we also began to notice an underlying conflict between them concerning the right
way to deal with Clara: Jorge tended to see Clara’s outbursts ‘‘just as tantrums,’’ and so he
2 In retrospect, we think that encouraging them to take time to read the informed consent before signing it was an important part of the process. In fact, it implicitly communicated them that they were in control of the assessment and that we were working with their permission (Falicov 1988; Grimes and McElwain 2008). Sensitivity to cultural and power-related issues is a prerequisite to working effectively with immigrant clients (Horst at al. 2012). This episode was particularly important given their previous experience (that we came to know about later) of being cheated by Italians in positions of authority (e.g., an attorney who took their money to help with a residence permit but didn’t do what he was supposed to do).
734 Contemp Fam Ther (2013) 35:731–744
often reacted by yelling at Clara and being very strict. This frequently led to escalations
and big scenes where Clara threw herself on the ground crying very loud. He also accused
Maria of generally being too permissive with the child. Maria instead was worried about
Clara’s having a serious psychological problem, and therefore she tended to be more
permissive with her, especially when Clara was beginning to get angry. Maria also con-
fronted Jorge about his authoritarian way of dealing with their daughter. Such conflicts
have been addressed by classical family therapy authors in terms of family triangles and
triangulations, and have been described from different vantage points. Bowen (1978)
considered the triangle as a natural feature of any human system, albeit possibly disad-
vantageous, whereas strategic and structural therapists, such as Haley (1959) and Minuchin
et al. (1978), saw some forms of triangulation—especially triangles involving a parent/
child alliance against the other parent—as potentially pathogenic. Also, feminist therapists
have described such triangles as gender-based roles (Goldner 1988; Hare-Mustin 1987). In
TA-C such disagreements are transformed into questions, which helps the couple ‘‘con-
tain’’ the conflict and brings in curiosity. This tactic seemed to work well with Jorge and
Maria, and they seemed noticeably calmer after we paid attention to and gave voice to their
different points of view through the questions. TA-C also addresses such triangulations
throughout the assessment, by attempting to find common ground between parents when
constructing the new family narrative.
Toward the end of the session, before scheduling the following appointment, we asked
Maria and Jorge if they had any further question about us or about the process of the
assessment. At that point, Maria and Jorge seemed to be more at ease and Maria disclosed
that this experience was new for them and she felt a little bit embarrassed. This was the
exchange that followed:
FF What do you find the most embarrassing?
M everything… it’s the first time we’re talking about our problem with anybody, because we don’t talk about this with our friends, it stays between us… and moreover we are immigrants, so, maybe, I don’t know…
FF Are you worried that we could misinterpret something because you’re immigrants?
J No… but maybe it’s difficult to understand… maybe here there’s a behavior and instead, in our country… if we were in Salvador Clara’s behavior wouldn’t matter for us, you know? …Because she could either get angry or not, but nobody would tell you how to take care of your child. Instead here sometimes it’s uncomfortable. One
time Clara was bad and Maria had to spank her and people were staring at us but …
Jorge then went on to recount many examples of their taking good care of Clara.
FF I absolutely don’t think that you’re not good parents because you’re from a different
country and maybe you have different customs… and I’d like to ask you, because it’s true that we come from different cultures, that for us it would be very useful if you
could teach us what’s maybe normal for you and that maybe for us might seem
unusual. So every time you think you see things differently because in El Salvador
it’s different, please stop and teach us because we need to learn this from you to be
able to work together
After this exchange, Maria and Jorge began disclosing many experiences they had of
being discriminated against by Italians, and we could talk about how difficult it was
currently for them to trust other people. Jorge also began to talk about how previous life
experiences in El Salvador had affected their ability to trust others, but Maria stopped him.
She didn’t want to talk about her past.
Contemp Fam Ther (2013) 35:731–744 735
This is what followed:
M (Looking at her feet) Because we are not normal… we are surrounded by people who have nice families…
J They are just lucky, it’s not a matter of being normal
[Maria looks down and begins to cry]
FA This… look at me [leans to catch Maria’s eye] I’d like to tell you that there’s no… M Sorry. That’s why I don’t want to talk about my past, you know?
FA Yes, and that’s ok. And today, there’s nothing we talked about that makes me think
that you aren’t normal, nothing
M It’s not a big deal, I’m like this, don’t worry
FA No, I’m worried, absolutely. It’s very important that you take this in. I’m just seeing
two people who are having a lot of difficulty keeping going in a very complicated
situation, very difficult. This is what I saw today
M Ok. (Seems calmer and raises her eyes.)
J This is what I always say, we were just not as lucky as other people, that’s all. That’s
why we protect our daughter. Maria and I surround her and don’t let anybody get
near her, you know? Maybe in the meantime we are doing something wrong and our
child is expressing it, you know?
FA Maybe, today we don’t know. We’ll see
FF We’ll talk about it
At that point, everyone’s emotions seemed to be settled down and Jorge told us that
before entering the Center, right in front of the door, they had talked about turning back
and going home. He told us that Maria especially was worried that they would be mis-
understood by us. Maria’s last comment in the session was: ‘‘One test passed.’’
Step 2: Projective Drawings with Clara While Parents Observe Behind the One-Way
In the second session we initially met Clara and her parents together. She was a cute little
girl who talked easily with us and very quickly agreed to stay alone in the room with
Francesca Fantini. We explained to Clara that her parents would be watching from behind
the one-way mirror and we showed her the room where they would stay. We played for a
few minutes, testing the ‘‘magic properties’’ of the mirror and checking if her parents could
see her waving at them. Then Clara and Francesca Fantini sat down, while Maria, Jorge
and Filippo Aschieri took their places behind the mirror.
As is often done in TA with children, we began by asking Clara to draw. Francesca
Fantini asked Clara to draw a person and she initially ignored the request and drew a sun.
Afterwards she drew a red child and a blue child. When asked, Clara said they were both
sad because their friends didn’t want to play with them. Behind the mirror both parents
were surprised and told Filippo Aschieri ‘‘It’s the first time she has used the word sad in
her life… we didn’t even know she knew what it means.’’ Other variously colored children were then added to the drawing and each one was sad. At a certain moment, Clara pointed
her finger to each child saying, ‘‘this is me, this is me, this is me.’’ Afterwards Clara drew a
scary monster that was threatening a baby in a castle. The monster had blood around its
mouth, but she and Francesca Fantini worked together to draw a cage around the monster.
Behind the mirror, Maria and Jorge associated the monster’s blood with Clara’s early
hospitalization and said that since that time Clara was very scared of blood. By the end of
the drawing Maria commented: ‘‘I didn’t think you could talk that much with a 4-year-old
736 Contemp Fam Ther (2013) 35:731–744
child’’. Clara’s third drawing was of a dragon spitting fire at all the other animals and
feeling good about it.
After the session with Clara we talked with Maria and Jorge about their observations.
They were very surprised about Clara’s being so focused on sadness in the first drawing;
they didn’t perceive her as a sad child at all. We began to discuss that, as for the dragon,
she probably felt better when she was aggressive. We also began to discuss their associ-
ations to the blood Clara drew on the monster and her early experiences in the hospital.
Maria and Jorge told many sad stories, for example that at one point Clara was in so much
pain all over her body that they couldn’t even touch her. We discussed how traumatizing
that experience had been for Clara, and for them as well, and how such experiences have
the power to sensitize children and make them less able to manage strong emotions.
Because of Clara’s young age, we didn’t have a wide choice of standardized tests to use.
For this reason, and considering how well she expressed herself through her drawings, we
decided to ask her to draw during the following session also. Something very important
happened at the end of that session. When Francesca Fantini called Maria and Jorge into
the room and Clara realized the session was ending, she became distressed and started to
cry, complaining that she wanted to go on drawing. Maria seemed to freeze and whispered,
‘‘She’s going to blame me.’’ Then, Francesca Fantini came back to the drawing table with
Clara and began mirroring her sadness about the imminent separation, but was nonetheless
gently firm about the session needing to end. She asked Clara to help her put the pencils
back in the box and Clara slowly calmed down, put the pencils in the box and then went
away with her parents. We hypothesized that Clara seemed particularly distressed about
separations, but was able to quickly reorganize herself when her emotions were mirrored
and contained. This was consistent with what Maria told us, that Clara got often angry at
her when she brought her to school. It also seemed apparent that Maria and Jorge did not
know how to mirror and contain Clara’s emotions, and in fact were frightened by her
anger, perhaps because of their traumatic pasts.
Step 3: Family Intervention Session
As a result of the testing with Clara, the discussions with Maria and Jorge, and our
observations, we made the following tentative case formulation:
(a) Clara’s sensitivity and her developmental needs were probably stirring up unresolved
issues of her parents (i.e., sadness/depression, dependency needs and traumatic
memories), and Clara’s anger might help her parents feel more alive and distract them
from their own depression and past trauma. By directing their energy towards caring
for Clara and giving her everything they never had, Maria and Jorge could also
manage their grief about their own deprived upbringings.
(b) Some important developmental needs of Clara didn’t seem to be met. She needed to
be supported emotionally and helped to make sense of her emotions, and instead her
sadness wasn’t recognized and her frustration and anger, more on the surface, were
responded to with explosive anger by her father or with freezing or overindulgence by
her mother. Moreover, Clara’s needed to live in an environment where limits were set
without scaring her.
(c) Clara’s difficulties could be framed in the context of her being a medically
traumatized child and her parents having traumatic backgrounds that kept them from
responding in the best ways to her difficulties.
Contemp Fam Ther (2013) 35:731–744 737
(d) The split that existed between Jorge and Maria about the best way to handle Clara’s
tantrums represented their own difficulties integrating the firm and caring parts of
themselves. They each tended to hold a single part of this dilemma and to become
polarized. In fact, each had a part of the truth and they needed to balance their
approaches both within and between themselves.
The main goal we had for the family intervention-session was to help Maria and Jorge
focus on Clara’s sadness and give an attuned and comforting response to it. Therefore, we
planned to ask Clara to draw people again, and we hypothesized that they would be sad.
We planned to involve Maria and Jorge in the drawing, helping them be attuned to Clara’s
emotions, much as they had seen Francesca Fantini doing in previous sessions.
However, when the family entered, Clara immediately said with a scared face, ‘‘Yes-
terday I saw a monster.’’ We asked her about the monster and then we asked her to draw it.
The monster soon became a sad monster, then a sad father-monster, and afterwards was
followed in the drawing by a mother and daughter. Clara said they were all sad. We tried to
ask her more about them, but she wasn’t able to say much more than that they were very
sad and were crying. We then tried to involve Maria and Jorge in helping to give meaning
to the sadness of the mother and the father in the drawing. Jorge said he didn’t know the
reason and he didn’t talk much during the session. He did notice that listening to Clara
talking about sadness made him feel sleepy. And Clara seemed very tired too. Maria told us
that Clara was probably misunderstanding: ‘‘She thinks we’re sad, but we are worried
because of our jobs’’ and turned the conversation to their job worries. But at the end, Maria
said that probably they had underestimated Clara, and that she was like a sponge absorbing
what was happening in the family.
After this session we felt the need to have another meeting with the Maria and Jorge
alone to process what happened during the intervention session and before moving to the
summary/discussion session. During that meeting Maria and Jorge opened up, talking
about their own sadness. Jorge often felt he was not a good husband and father, because he
wasn’t able to give Clara and Maria a wealthy life and couldn’t afford to bring Maria’s and
his other children to Italy. When all the problems and worries became too heavy, he
sometimes prayed to God to ‘‘take him away.’’ Maria felt trapped, she didn’t want to go
back to El Salvador, because of the money she could earn in Italy and send to her children
and because of Clara’s medical treatments; but, she didn’t like her life in Italy. She said she
thought she had suffered for a long time with depression. We also discussed how both
Jorge and Maria had become very skilled at dealing with their feelings of sadness alone and
didn’t yet know how to be supports for each other.
Step 4: Summary/Discussion Session with the Parents
Maria and Jorge arrived at the summary discussion session visibly relaxed. We began by
thanking them for all the work they did and the efforts they put in overcoming the initial
shyness and embarrassment. We then moved to discussing the answers to their questions.
We stressed once again the influence of the medical trauma on Clara’s ability to deal with
emotions and underlined that we didn’t think Maria and Jorge were the cause of all of
Clara’s problems. Maria and Jorge told us how relieved they were to know this and how
scared they were at the beginning of the assessment that we would judge them. We then
discussed how Clara’s sensitivity made her feel the tension in the family, the sadness and
the worries of the parents, and how part of her distress was probably related to these
factors. Clara’s parents agreed that at that time they were too overwhelmed by daily
738 Contemp Fam Ther (2013) 35:731–744
stressors, too involved in the conflict over the management of her outbursts, and too
distressed by their past traumas to hold and effectively contain Clara’s needs. Among those
needs, Clara particularly needed help in making sense of her emotions and the emotions
she sensed in her parents. We also discussed how during the assessment, Clara’s behavior
and the climate in the family had changed, and Maria and Jorge described how they had
come to see their daughter differently. Jorge was more available to listen and talk to Clara
since he understood that her outbursts where not ‘‘just tantrums.’’ Maria was trying to be
firmer with Clara; she admitted that previously (a) her desire to be a better mother to Clara
than her own mother had been to her and (b) the tiredness she felt from managing the many
problems in their lives sometimes led her to be inconsistent in setting limits. Finally, we
discussed how important it was for Maria and Jorge as parents to learn how to share their
own sadness with and support each other, and so we recommended more therapy sessions
for them with and without Clara.
Step 5: Feedback to Clara
In the following session we met with the whole family to read Clara the fable we had
written to give her feedback. The title of the fable was ‘‘CARLA, THE LITTLE DRAGON’’. Here is an excerpt.
‘‘One upon a time there was a little dragon named Carla who lived in a cave near a
forest with her mom and dad […] Even though she was only 4 years old, she had had a very difficult life. When she was very little she got a very bad illness that made her tremble
all over her body […] Her parents had a very difficult life too. They came from a far away land to find a better cave to live in […] but during the trip they had forgotten the words to speak about emotions and so they couldn’t teach them to Carla when she was born. So,
when Carla felt that something was wrong at home, when her dad was sad or her mom was
worried, or when Carla felt bad, she was confused and didn’t know the words to talk about
this. Every time this happened, she felt something burning inside her and suddenly she
began spitting fire out of control, burning things even when she didn’t mean to […] Mom and dad were worried, they didn’t know why Carla spit fire all the time. So they decided to
speak to two wise owls that lived on a tree in the forest […] The two owls met Carla, asked her to draw while her parents watched her through a magic mirror […] Finally, the wise owls said to Carla: ‘You are not a bad dragon. Little dragons learn to control their fire when
they learn the words to talk about their feelings, but your parents couldn’t teach you such
words. They forgot them. That’s why you can’t control your fire. You and your parents
have to go to a place where dragons are trained to speak about feelings […]’. That afternoon Clara and her parents came back to their cave, and Clara felt a little bit lighter
and hopeful that she could also learn to control her fire. And what happened next?’’
Case Development After the TA
A few weeks after the end of the TA we had the chance to speak to the neuropsychiatrist,
who updated us about the fact that Maria and Jorge had decided to go back to El Salvador
and marry each other. (They had been together for many years without marrying.) Then,
several months later we scheduled a follow-up session with the family, but Maria was the
only one to show up. She told us that things were much better with Clara, but that Maria
and Jorge where having a lot of couple problems since they had gotten married and were
thinking about separating. That session was followed by an individual session with Jorge
who also appeared very distressed. Since then, we have started bi-weekly couples therapy.
Contemp Fam Ther (2013) 35:731–744 739
Maria and Jorge still live together and are working hard to overcome their individual and
couple struggles, related to tolerating intimacy and to dealing with their early traumatic
Therapeutic Processes in TA
Considering Clara’s TA from a systemic perspective, it is possible to highlight the fol-
lowing therapeutic processes:
1. Establishing a safe attachment relationship with clients (Byng-Hall 1999): collabo-
rative communication, emotional attunement, and repair of disruptions are among the
basic processes for the assessors to validate parents’ sense of self-efficacy, to foster
parents feeling like experts about themselves and their child, and to promote a secure
attachment with assessors as a prerequisite for their self disclosure and therapeutic
2. Hypothesizing (Cecchin 1987): TA-C requires a recursive redefinition of systemic
case-formulations according to the phase of the assessment and to the amount of
information collected about the child/family struggles. The course of the assessment
depends upon the case formulation, and the semi-structured format of the assessment
aims to adapt the techniques to the current needs of the family system. Assessors share
their hypotheses with clients (Bertrando and Arcelloni 2006) but in doing so try to
protect the family from the most emotionally overwhelming information contained
therein. Such information, called Level 3 information in TA (Finn 2007), is discussed
with specific emotionally supportive techniques so that it can be processed and used
adaptively by the family. In Clara’s family, the assessors’ case conceptualization
integrated progressively the social and psychological consequences of migration of the
parents with Clara’s depressive and sad feelings and finally with the post-traumatic
aspects of her parents’ functioning.
3. De-triangulating the identified patient (Fulmer et al. 1985): joining the parents’ initial
agenda, and focusing on their concerns for their child often allows parents to become
less defensive. The more parents feel respected and engaged as valuable co-observers
and co-assessors in defining the reasons for their child’s problems, the more they can
start considering their own role in shaping or sustaining them. Respecting the parents’
initial agenda, and focusing on Clara’s behavioral problems helped Maria and Jorge
becoming more open. In this way they could begin considering their own role in
Clara’s problems. By the end of the assessment, Clara’s parents had begun to realize
how important it was for Clara that they address their own psychological and relational
4. Co-editing a new narrative for the family (Manfrida 2008): reflecting upon the child’s
behavior problem in a circular manner during the initial sessions, observing the child’s
behaviors while completing the testing or the other unstructured activities (i.e.
drawings), and trying to connect this information with the initial assessment questions
helps parents become engaged in observing and reflecting upon the narrative
discrepancies in their story about their child’s problems. The summary/discussion
session, the feedback letter for the parents, and the fable for the child provide a new
and coherent narrative for the family, in which both parents and child can find new
understandings of their previous problems and act upon corrective scripts (Byng-Hall
1991; Dallos 2006). In Clara’s case, the initial family narrative included an
incomprehensible ‘‘bad’’ child that tried to shame two powerless parents, who in
740 Contemp Fam Ther (2013) 35:731–744
turn felt as inadequate as they perceived their own parents had been with them. The
new co-edited narrative included the influence of the parents’ past traumas on Clara’s
troubles. Their depressive feelings and Clara’s sensitivity were interacting, making it
hard for the family to cope with daily stressors and demands. However, the new
narrative highlighted also how different Maria and Jorge were compared to how their
own parents. This helped them decrease shame and build a stronger sense of self-
esteem and sense of agency. Also, before the assessment, the parents struggled to ask
for help, as they felt ashamed about their problems. In the newly developed story,
asking for help was framed as a positive experience, in as much the assessors actively
counteracted shame and addressed the parents struggles, while also respecting the
timing and pace of change and the cultural and contextual influences on asking for
help (Mirecki and Chou 2012).
We believe this case history illustrates how the use of tools and methods typical of a
psychological assessment within the context of TA-C can promote and foster new views
and emotions in our clients’ families, when framed into an attachment based, intersub-
jective framework. This happens, first, because the TA-C format establishes a positive
therapeutic relationship, on the one hand emphasizing the scientific nature of tests and
other psychological tools (Aschieri 2012, 2013), and, on the other, creating a dialogical
stance between assessors and family members (Bertrando 2007). This in turn enables
family members to become active partners in the construction of different hypotheses
about the presenting problems and the possibility of overcoming them. In this way,
changes may happen both on the family structural and narrative level, as we have seen in
TA-C shows us that in family therapy there is no instrument that should be proscribed
from use for epistemological reasons. Psychological tests can become part of an active
reflective process that involves both family members and assessors/therapists in the con-
struction of new, hopefully better, meanings for family life. For this reason we believe that
family therapists could effectively introduce in their practices the use of tests as structured
occasions to open up a dialogue on relevant themes for the families they meet in therapy.
Especially when working with families with children, tests represent means for children to
express more easily their difficulties and struggles through images, stories and behaviors
rather then by talking directly about them. Also, allowing parents to observe their chil-
dren’s testing is a powerful tool to increase parents’ awareness of their children’s diffi-
culties and an occasion to develop more systemic and circular explanations for those
This case illustration possesses limitations intrinsic to clinicians’ reporting of their own
practices. Research has showed therapists’ tendency to overestimate their effectiveness
with clients (Kruger 1999). We are aware that more empirical research on TA-C is needed
to (a) evaluate its overall effectiveness with different kinds of clients, (b) provide data
about how the various steps and therapeutic processes involved work, (c) compare the
therapeutic processes implied in TA-C with well-established manualized family therapy
approaches (Pote et al. 2003), and d) provide useful data to help clinicians in their everyday
clinical work (Stratton 2007a, b). In this regard, the use of repeated measures single case
studies or replicated single case studies (Smith 2012; Tarocchi et al. in press) seems
Contemp Fam Ther (2013) 35:731–744 741
promising, as it allows clients to have an active voice in defining the quality of the therapy,
while tracking moment-by-moment changes in the clients’ symptoms.
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