psychological tests and assessment methods with therapeutic techniques | Cheap Nursing Papers

psychological tests and assessment methods with therapeutic techniques

ORI GIN AL PA PER

‘‘Is Our Daughter Crazy or Bad?’’: A Case Study of Therapeutic Assessment with Children

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: filippo.aschieri@unicatt.it

P. Bertrando Private practice, Milan, Italy

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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

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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

The Referral

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.

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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).

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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.

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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

Mirror

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

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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.

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(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

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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.

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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

experiences.

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

change.

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

difficulties.

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

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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).

Conclusions

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

this case.

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

problems.

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

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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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