Externalizing Children's

“I’m NOT the Problem!” Externalizing Children’s “Problems” Using Play Therapy and Developmental Considerations Brie A. Turns & Jonathan Kimmes

Contemporary Family Therapy An International Journal ISSN 0892-2764 Contemp Fam Ther DOI 10.1007/s10591-013-9285-z

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Author's personal copy Contemp Fam Ther DOI 10.1007/s10591-013-9285-z ORIGINAL PAPER

‘‘I’m NOT the Problem!’’ Externalizing Children’s ‘‘Problems’’ Using Play Therapy and Developmental Considerations Brie A. Turns • Jonathan Kimmes

Ó Springer Science+Business Media New York 2013

Abstract Many children are brought into therapy because parents view them as having a ‘‘problem.’’ Children will often internalize these negative perspectives from others and create an identity based upon these notions. This paper presents a novel way for marriage and family therapists to integrate narrative and play therapy techniques for children and their families. It provides a model that is organized according to Erik Erikson’s psychosocial stage theory to ensure that developmentally appropriate techniques are being utilized. During each stage, an example is provided for further clarification. Keywords Play therapy Narrative therapy Psychosocial stage theory Externalizing

Introduction Children are often involuntary clients (Larner 2003; White 2007) who are brought into therapy by parents who view them as the ‘‘identified patient’’ (Berg and Steiner 2003), stating that the child has something ‘‘wrong’’ with him or her. These children may continue to develop and grow believing that these ‘‘problems’’ are a characteristic of their identity and are immutable. A core aspect of Narrative therapy (White 1995; White and Epston 1990) is to allow individuals to re-write their dominant stories and/or strengthen their useful, but unrecognized, subjugated stories. One technique used to accomplish the aforementioned goals is to help individuals externalize problems from themselves; this creates an identity for the problem and stimulates the process of re-writing their dominant story. Individuals will begin to view instances when they were able to defeat the problem

B. A. Turns (&) J. Kimmes Purdue University Calumet, Hammond, IN, USA e-mail: [email protected] J. Kimmes e-mail: [email protected]

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Author's personal copy Contemp Fam Ther

and recognize new ways to solve the problem. Because children are often viewed as being ‘‘problems,’’ narrative therapy can be a useful technique to remove guilt and shame from children. Play therapy techniques are often implemented when working with children because play is how children communicate (Landreth 2001). Integrating narrative and play therapy allows children to understand and participate in the process of removing the blame and creating a separate identity for the problem. There are limited resources integrating the two concepts (Freeman et al. 1997; Smith and Nylund 1997). Unfortunately, the information provided illustrates how children, rather than therapists, have begun the process of creating a new dominant story. Because children alter their communication and play as they develop, play techniques need to be assigned based on the child’s developmental stage; therefore, integrating Erikson’s (1959) psychosocial stage theory will allow therapists to work with children and adolescents in an age-appropriate manner. Furthermore, the theory emphasizes how an individual’s identity forms and develops. Erikson’s stages are inextricably tied to each person’s narrative; each stage either dictates how an individual’s personal story is written or becomes a part of his or her narrative. For example, the success or failure of the trust versus mistrust stage is based on whether the child reliably gets his or her needs met. Though the child does not typically remember this stage, it influences his or her personal narrative as the outcome of this stage may impact how the child grows to view his or her self and others in relationships. Since each person’s narrative is linked to each stage that is navigated, it follows that Erikson’s psychosocial stage theory could be used as a framework for working through narrative issues in therapy. This paper guides therapists in ways to build on children’s subjugated stories with their families. The model intertwines narrative with play therapy techniques for therapists to utilize with a multitude of children. The model is broken down into four stages, according to Erik Erikson’s psychosocial stage theory. It provides clinicians a way to externalize the child’s ‘‘problem’’ and begin to ask landscape-of-action and landscape-of-identity questions. This paper also provides a framework for how therapists can integrate these techniques outside of the therapy room by involving parents and siblings.

Narrative Therapy Narrative Therapy (White 1995, 2007; White and Epston 1990) hinges on the notion that problems are caused and sustained due to beliefs about problems that are rooted in the use of language. Narrative therapists believe that there is no one objective reality, meaning that how a family should function, identify, and solve its problems are all subjective—there are numerous ways to view reality (White 2007; White and Epston 1990). Problems begin to arise when an individual or family view a problem from only one, myopic perspective, rather than from numerous alternatives. White and Epston (1990) argued that when clients are unable to recognize alternative beliefs of reality and, by extension, alternative beliefs regarding their identity, they are prevented from finding new ways to solve their problems. Narrative therapy was based on the assumption that there are two kinds of ‘‘stories’’ that an individual utilizes to interpret events and experiences: dominant stories and subjugated stories. A person’s dominant stories are a set of beliefs that he or she believes about his or her surrounding environment– the person’s main view of ‘‘reality.’’ This dominant method of viewing the world gives the individual a way to attribute meaning to events and experiences (White and Epston 1990).

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An individual’s subjugated stories are alternate views of reality which the person does not typically use in perceiving his or her world and experiences. According to White and Epston (1990), a client comes to therapy because he or she continues to view experiences in the world using his or her ‘‘dominant story’’ when this lens is no longer effective. Therapy, hence, involves shifting from the old, ineffective dominant story to a new, effective subjugated story until the subjugated story becomes the dominant story. The technique of ‘‘externalization’’ is one way in which this goal is accomplished. Narrative therapists believe that, instead of telling clients how to solve their problems, it is better for clients to discover solutions to their problems (White and Epston 1990). By therapists promoting the notion that client’s solutions are superior to the therapist’s, the client is permitted to find more effective solutions for his or her current and future problems. The client will begin to view him or herself and his or her problem differently than he or she had before. The client will also not rely on a professional to solve his or her problems—which further empowers the client. Techniques in Narrative Therapy The three techniques that will be discussed in this paper are going to be adapted in the model to the appropriate developmental stage. Externalizing ‘‘Many people who seek therapy believe that the problems of their lives are a reflection of their own identity, the identity of others, or a reflection of the identity of their relationships’’ (White 2007, p. 9). For this reason, one of the most popular techniques of narrative therapy is the externalization of the problem from the client. Externalization is the process where a client begins to attribute problems that he or she experiences to external factors (Carr 1998; White 2007). When a client is able to attribute the problem to an external entity, as opposed to something that is a part of his or her identity, the client can begin to defeat the problem. Externalizing a problem in children cases is vital because often times family members attribute the problem to the child (White and Epston 1990). To begin to externalize a problem, the therapist can either directly ask the child to name the problem or simply re-circulate the language the child uses to describe the problem in response to the therapist’s questions (Ramey et al. 2009). Subsequent questions may help the child more fully describe the problem; the questions may investigate when the problem is typically present or what the problem looks, sounds, and feels like (Freeman et al. 1997). The therapist may also assist the child in making associations between the problem and the consequences of the problem; for example, the therapist might ask about how the problem gets in the way of things that the child likes to do. In addition to solidifying the problem as a separate entity from the child, this process also provides an opportunity for the child to explore how the problem influences his or her behavior, relationships, and overall wellbeing. Once children are able to view the problem as separate from them, they can begin to identify instances when they had control over the problem; consequently, the useful ‘‘subjugated stories’’ are identified and fortified. Furthermore, the externalization process allows for novel and productive conversations regarding alternatives for taking action against the problem (White 2007). Within family systems, the process of externalizing

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problems also unites family members as they work toward solving the problem (White and Epston 1990). Landscape of Action Questions Landscape of action questions were developed in order to assist clients to identify occasions in which they had control over their problems, also called ‘‘unique outcomes’’ (White 2007). These questions follow the clients’ ability to externalize the problem from themselves. Once clients are able to recognize the times in which they successfully overcame their problems, they are encouraged to increase those behaviors (White 1995). Therapists, inevitably, become the observers and students as to how the clients defeated the problems—placing the clients in the expert role. Therapists should ask clients what they were doing when the problem was not present. Many clients may not be aware of times when they were able to solve the problem. In these instances, therapists should assign clients to try to observe times when they are successful at overcoming the problem (White and Epston 1990). Landscape of Consciousness Questions White (2007) believes that once clients are able to identify and implement their own solutions, therapists are able to move onto landscape of consciousness questions. These questions help clients recognize their competence at managing their own problems. Clients begin to see themselves differently because these questions focus on the clients’ positive aspects of their identity within the process of solving their problems (White 1995). When therapists point out the positive aspects of the clients, it does not carry as much weight as if the clients were able to identify their qualities themselves. An example of these questions include: ‘‘What do you believe your ability to fight the problem says about you?’’

Play Therapy Gil (1994) claims that children are an essential part of the family and should not only be included, but be active participants during family therapy. Gil describes play as the fundamental element for actively involving children in therapy because it is what children do best. Playing during the therapeutic process is vital because it is how children feel the most expressive, competent, and playful. Families are given the opportunity to experience happiness, pleasure, and fantasy while expressing their thoughts and feelings about their world (Ruble 1999). A therapist who utilizes play during treatment shows children and parents that therapy belongs to the child and that the child is worth spending time with (James 1989). The integration of play with family therapy did not arise until the 1990s (Gil 1994; VanFleet 1994). VanFleet (1994) held the belief that play is a vital element of child development and is therapeutically beneficial to treatment, and that child-centered play therapy is linked to positive child outcomes. Children are often involuntarily clients; brought by parents who have defined their problem and decided that their child needs professional help (Berg and Steiner 2003; Larner 2003; White 2007). Berg and Steiner (2003) make note that most children do not fully understand the concept of therapy, why they are being brought to therapy, or what their parents or therapist expects from them. Play therapy allows children to use play as a medium through which they may express their

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feelings as well as seek mastery of conflicts (Landreth 2001). Play therapy is an opportunity for therapists to assuage children’s fears while engaging them in therapy by using toys, dolls, sand trays, crayons, puppets, toy animals, and a variety of other items.

Erik Erikson’s Psychosocial Stages Erikson (1950, 1959) developed the psychosocial stage theory that was based upon Freud’s theory of psychosexual development. Erikson approved many of the basic ideas of Freudian theory such as, the psychological structures, the unconscious and conscious, and the psychosexual stages. However, Erikson expanded upon Freud’s theory by creating eight psychosocial stages that individuals travel through during their lifespan and also by researching the development of identity. Each stage that an individual passes through can have a positive or negative outcome. It is ideal that each individual has a higher ratio of positive rather than negative outcomes while experiencing each individual stage throughout his or her life. For example, Miller (2001) stated that an individual needs to know when to trust or mistrust but, overall, should have a trusting attitude towards individuals in his or her life. Erikson believed that one of the key themes of life is an individual’s pursuit for identity—meaning that, identity is believed to be the understanding and acceptance of the self and one’s society (Erikson 1959). Individuals are continuously asking themselves the question, ‘‘Who am I?’’ and will create a different answer during each of Erikson’s stages. Ideally, an individual’s sense of identity is re-confirmed at the end of each stage. The earlier forms of identity will enhance the later forms. According to Erikson (1959) there are eight stages that every individual travels through during their lifetime. This model is going to cover four of those stages: autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, and identity versus role confusion; which covers the approximate ages of 2–18. During the autonomy versus shame and doubt stage (ages 1–3), children attempt to assert their independence without experiencing too many failures that may have a negative impact on self-esteem. In the initiative versus guilt stage (ages 3–5), children work toward developing confidence in their ability to make decisions and execute plans. As children begin to read, write, and spend more time with their peers and teachers, they enter the industry versus inferiority stage (ages 5–12). If children feel that their initiative is being reinforced, they gain a sense of competence. In the last stage, identity versus role confusion (ages 12–18), children continue to become more independent and their bodies take on a significant change. Children navigating this stage are attempting to develop a stronger sense of self as they enter into adulthood. Because identity development does not occur at one specific time for every individual, the authors want to stress that the ages given are approximations. Therefore, therapists need to be sensitive to each child that they treat.

Justification for Use of Narrative and Play Therapy, and Erikson’s Theory Many parents feel that their children’s behaviors and attitudes are a characteristic of their children—which is unable to change (White 2007). In turn, children receive messages suggesting that they are the problem, rather than viewing the problem as an external entity. By implementing narrative therapy techniques, therapists are able to help children and their families separate the problem from the child through externalizing conversations. Children

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will no longer be the problem, but they, along with other family members, will be able to engage in a relationship with the external problem (White 2007). This will remove feelings of ridicule and blame from children and open-up the parent–child relationship to a healthier, more collaborative connection. As mentioned above, children are often brought into therapy, without any prior knowledge as to why or what the therapeutic process consists of, by parents who would like their child’s behavior and attitude to change (Larner 2003). Play therapy techniques are utilized to engage children in therapy by employing various methods that are geared for children and adolescents. When parents are explaining the child’s behavior in therapy, the room can become full of guilt, shame, and loneliness for the child. To avoid children feeling blamed and ridiculed by others, narrative and play therapy will allow children to use their imagination with family members to pull the ‘‘problem’’ outside of them and then defeat the problem. Children may be unable to communicate with parents and therapists by speaking to them like adults; instead, children tend to communicate more effectively through play. Depending on the age of the child, they will play or communicate in very diverse ways (Berg and Steiner 2003). Erik Erikson’s theory allows us to break down children’s age ranges to implement the best skills to communicate with the individual child. As stated previously, a key aspect of Erikson’s theory emphasizes the development of an individual’s identity. Inevitably, Erikson’s stages are intertwined with each individual’s narrative. Every stage an individual experiences will either guide how a person’s story will be written or become a part of his or her narrative. Although there have been published resources integrating the use of narrative and play therapy (Freeman et al. 1997; Smith and Nylund 1997), nothing has been written providing therapists with consistent tools to utilize in the therapy room. In these resources, therapists take a non-directive stance when externalizing problems. These resources have also neglected to discuss ways therapists can inform parents regarding the continued use of externalization of problems outside of the therapy room. There is also a lack of published material that breaks narrative and play therapy techniques into age groups. This model not only breaks down, in four age-related sections, ways that therapists can begin to externalize problems from children, but it also demonstrates how therapists can teach parents to continue using these tools at home.

Therapeutic Suggestions Working with Families to Decrease Pathologizing and Increase Child’s Subjugate Story Families and Toddlers (Approximately 1–3 Years) The conflict between 1 and 3 years of age, autonomy versus shame and doubt, is positively resolved when parents are able to provide their child with adequate guidance and reasonable choices. Parents need to make note that they are not criticizing the child when he or she fails at a task. If parents are over-controlling and critical, the child may doubt his or her ability to control his or her impulses and may likely feel shameful; consequently, the child could fear his or her ability to act on his or her own. Parents who speak to their child in a manner that brings shame and guilt to the child’s personality and personhood will likely complete this stage in a negative manner. Therapists

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should teach parents how to communicate differently with their child, in a way that clearly separates the problem from the child’s identity. This change in communication will assist children to positively accomplish this stage and move toward autonomy. Parents who are critical and blame the child for his or her efforts will raise a child who does not have confidence in his or her abilities or him or herself. To foster a therapeutic setting that promotes praise and encouragement rather than blame and guilt, therapists needs to actively educate parents about the negative repercussions of blaming and criticizing children and their behaviors. Instead of placing blame on children and endorsing, ‘‘The child’s behavior is wrong,’’ it is helpful to give the problem, or behavior, its own entity. Externalizing In order to give the problem its own identity, young children often need something tangible to look at and speak to. Therapists should utilize dolls, puppets, and toy animals to begin an externalizing conversation. Many toddlers enjoy coloring, painting, drawing, and playing with clay. Therapists can ask the child to either make, paint, color, or choose (if it is a doll or animal) what he or she believes the ‘‘problem’’ looks like. Therapists are encouraged to use any craft material that will allow the child to create the ‘‘problem’’ and how he or she sees it. Items such as construction paper, pipe cleaners, glitter, stickers, and string can all be implemented however the child sees fit. The child and parent will begin to speak about the problem as separate from the child. Therapists should let the child name the ‘‘problem’’ in order to use language that he or she feels comfortable with and will use in the future. These activities will allow the child to utilize his or her skills and imagination and encourage autonomy. The therapist can ask questions to build on the identity of the problem. If, for example, the problem was named ‘‘Angry Alligator’’, the therapist might ask questions such as ‘‘When does the Angry Alligator come out the most?’’ or ‘‘What does the Angry Alligator sound like?’’ The therapist can also ask about what happens after the Angry Alligator comes out; this kind of question helps the child to make the connection between the problem and the outcomes of the problem. The therapist and parents can begin to play with the ‘‘problem’’ that the child has created. Playing with the item the child created will promote the notion that the ‘‘problem’’ has its own identity rather than it being a characteristic of the child. Therapists can then begin to ask questions to the child and his or her parents about times that the child has been able to overcome the problem (landscape of action) and what that says about the child (landscape of identity). For example, after letting 3-year-old Suzy create ‘‘Grumpy Gus,’’ the angry creature that crawls inside of her when she does not receive a toy she wants, the therapist began asking her parents about times that ‘‘Grumpy Gus’’ was not angry and times that Suzy was able to defeat Gus. Often times, the child will begin to engage in the conversation after observing his or her parents and therapist. Toddlers are likely to be quieter in session due to the unfamiliarity, but therapists should remind parents that when they speak differently about the problem, the child will begin to see him or herself and act differently when discussing the situation. To continue externalizing the problem outside of therapy, the therapist can allow the child to take the item that he or she created home. When parents notice the ‘‘problem’’ arise, they can have the child grab the item so they can all sit down and play with the item and, together, think of ways to make the problem go away. The child will begin to notice

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the shift in blame and will begin to interact with his or her parents in a positive manner until the problem dissolves. Parents can have the item sit on a popular shelf in the home and occasionally bring up conversations with the child encouraging and congratulating them for not allowing the problem to bother them. Because this is a time when children need to be encouraged by their efforts, parents should reward their child for his or her efforts—even if the child could not defeat the problem. Families and Preschool Aged Children (Approximately 3–5 Years) ‘‘Being firmly convinced that he is a person, the child must now find out what kind of person he is going to be’’ (Erikson 1959, p. 74). The next stage that children enter, as described by Erikson (1959), is initiative versus guilt—a time where children begin to identify with their parents. During this time, children begin to take more initiative in carrying out ideas, activities, plans, and decisions that they have established. Children master this stage when parents are able to provide room and encouragement for the child to engage in their activities—children will develop a sense of security and initiative in their identity. If parents are controlling or demean their child’s initiative, then their child will develop a sense of guilt (Erikson 1959). Erikson (1950, 1959) stated that children utilize play as a way to learn about themselves and their environment. Children will begin to imagine and act out family situations and popular occupations, such as police officer, doctor, firemen, teacher, and president. Parents who are overly protective of their child will instill the concept that the child is not capable or should not be engaging in such activities. The child will feel a sense of guilt, blame, and shame for his or her effort. Therapists need to emphasize to parents that this is an age where encouragement is essential and should provide the child situations that foster the child’s decision making skills. Externalizing In order to externalize a problem from a child who is in this stage, the therapist needs to continue playing in a manner that is familiar and comfortable with the child. First, the child is encouraged to come up with a name for the problem, and the child is also asked to draw a picture of the problem. In addition to asking general questions about the problem, the therapist should inquire about what kinds of things the problem is afraid of or weakened by. These questions are aimed at allowing the child to find out how to best battle the problem. Because this is a time for children to begin acting out roles, scenes, and careers, the therapist should have the child act like the ‘‘arch-nemesis’’ of the problem. By using dressup material, such as dresses, capes, costumes, hats, shoes, face paint, masks, and other accessories, the child is able to dress up like a hero to defeat the ‘‘problem’’ that is intruding in his or her life. The therapist should encourage parents to compliment the child and encourage his or her creativity in the therapy room. The therapist and parents are also able to dress up with the child to be his or her side-kick. While the child is dressed like the hero in the therapy room, the therapist can ask each family member about events when the child has been able to conquer the problem, while recreating the event, (landscape of action) and give descriptions about what that says about the hero, or child, (landscape of consciousness). For example, 5-year-old, Timmy came into therapy because he was bullying his little sister. The therapist asked Timmy to dress up in a costume in order to slay the problem.

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Timmy, first, described and drew a picture of the ‘‘Bully Dragon’’ and then dressed up as a white knight which needed to protect his family from the dragon. Timmy’s therapist, mom, and dad dressed as armored guards to protect the dragon from escaping the therapy room and bullying others in the building. The therapist can then teach the parents that when they recognize the problem interfering in the child’s life, it is beneficial to gently tell the child what they recognize and ask the child if he or she would like to dress up as the hero in order to make the problem go away. Parents and siblings are able to dress up as the sidekicks at home in order to help the child defeat the problem. Parents are encouraged to reward their child appropriately when the child is able to defeat the problem and it is no longer affecting the child or the family. Families and School Aged Children (Approximately 5–12 Years) Entering the fourth stage, industry versus inferiority, Erikson (1959) described this time as the ‘‘industrial age’’ where children enter into the world of work and knowledge. The underlining theme becomes ‘‘I am what I learn’’ (Erikson 1959, p. 82). Children begin to no longer place energy into make-believe but rather into realistic accomplishments, usually school related tasks. The stage is positively resolved when children have successful experiences when completing tasks and are encouraged and rewarded for their accomplishments. If children are punished or receive extremely negative feedback for their efforts, children will develop feelings of inferiority towards their capabilities (Erikson 1959). The large event that takes place for the child is entry into school. Children will begin to take pride and be motivated by classroom assignments and tasks. Parents will need to provide proper encouragement and guidance for children while they begin to focus on homework and class work. Peers also become a larger part of children’s lives during this time. If children have received the message that they are unable to do things well, then they will feel inferior to their peers. Overall, in this stage children are looking to accomplish a positive but realistic self-concept, pride in accomplishments, cooperative participation with peers, and moral responsibility (Erikson 1959). Externalizing As stated above by Erikson (1959), this is a time that emphasizes the theme, ‘‘I am what I learn,’’ for children. Because of this theme, therapists need to emphasize to parents how the problem is not a part of the child, so the problem was not something that was learned— rather it is happening to the child and interfering with his or her life. Fostering the idea that the child has learned positive characteristics and attributions should be highlighted. Discussing and complementing the child on learning more helpful, positive behaviors will reinforce the belief to the family that the problem is not a characteristic of the child. For a therapist to externalize a problem for a child in this age group, he or she needs to evaluate if the child is more inclined to focus on realistic accomplishments or makebelieve. If the child is still responsive to imaginary play, implementing an activity from one of the beginning two stages will be adequate. The therapist needs to ensure that he or she is sensitive to each child’s psychological development. If the child is becoming more geared towards realistic expectations and goals, the therapist can begin externalizing problems in the following manner. To externalize the behavior for a child who is in Erikson’s fourth stage, the therapist should have the child draw cartoon strips that involve the child and the problem. The

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therapist should have the child draw themselves and the problem—however they believe the problem looks—interacting throughout the day. For the first scenario, the therapist should have the child draw him or herself next to the problem. This will begin to show the child that the problem is a separate entity. The second scenario should consist of times when the problem has affected the child’s life with peers or family—furthering the belief that the problem is affecting the child, rather than something the child learned. The third scenario should be an occasion where the problem has affected the child’s school work or home-life. Under each scenario, the therapist can ask the child to describe what he or she has learned about him or herself when the child had the encounter with the problem. If the child is uncomfortable with drawing, the therapist could ask the child to cut-out words or images from magazines, books, and other printed resources that represent each scenario and create a collage. Pictures of the child and his or her loved ones and friends can also be utilized. Each collage will be used in place of each cartoon scenario. To begin asking landscape of action questions, the therapist can continue the drawing or collage activity and have the child draw or create instances when he or she was able to prevent the problem from affecting his or her life. The therapist can also encourage the parents to participate by asking them to also identify instances in which the child was able to overcome the problem; this allows the parents to have a positive, strengthening impact on the child’s subjugated story. The therapist should ask the child what they have learned in the past that has helped them to defeat the problem. Under each scenario or collage the therapist can ask what the child and parents believe this says about the child’s attributes and character. In order to ensure that the child is not developing feelings of inferiority, parents and therapist should make sure they are rewarding the child for their participation and accomplishments. To this end, therapists need to continue to psycho-educate parents about appropriate rewards and punishments. Rewards for children need to be age-appropriate and individualized to each child. For example, one child may desire a new video game while another child may want to spend more time with his or her parents. Ten-year-old, Jessica, wrote several scenarios about her and the problem, ‘‘Hyperactivity.’’ During the first scenario, Jessica drew what she believed ‘‘Hyperactivity’’ looked like. She then drew events in her life where ‘‘Hyperactivity’’ affected her while she was trying to learn in school. Jessica wrote under the descriptions that she learned that she ‘‘cares about other people’’ because she becomes upset when ‘‘Hyperactivity’’ distracts others in class and ‘‘Hyperactivity’’ has taught her how she can be more considerate instead of disturbing others while they are trying to focus. Jessica’s parents informed her teacher of the techniques and during each art class Jessica’s teacher encourages her to draw events when she defeated ‘‘Hyperactivity.’’ Families and Adolescence (Approximately 12–18 Years) The last stage that this model will cover is stage five, identity and repudiation versus identity diffusion. Erikson (1959) stated that if children are able to integrate their identities, and roles from previous stages, they successfully accomplish this stage. If a child is not able to incorporate them, they will face identity diffusion. Erikson (1959) believed that in complex societies adolescents experience an identity crisis—where children sift through characteristics that define the self in early stages and combine them with new emerging identities. If society limits the child’s choices he or she can seem directionless and ill prepared for adulthood challenges. Identity is a major personality achievement for young adults at this time (Erikson 1950). Children are becoming more independent during this stage and begin to think more

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seriously about relationships, careers, and independence away from their family. Parents should encourage children to pursue areas that the child is interested in and spend time with the child researching various careers that interest the child. Externalizing To externalize a problem at this stage, therapists need to first assess the communication level of the child. Teenagers at the beginning of this stage are likely to want to communicate in different ways than adults. Conversely, teenagers at the later end of this stage will likely want to engage in conversations with minimal play techniques. The therapist also needs to assess the different careers that the child is interested in pursuing. For individuals in this age group who are geared towards their careers and taking the proper steps into adulthood, therapists have the option of externalizing the problem in a more adult manner than the previous stages. As Erikson (1950) averred, many individuals in this stage are concerned about their careers, relationships, and independence. A therapist should externalize a conversation by having the young adult complete two writing exercises. For the first exercise, the teen should explore his or her career aspirations, going into depth regarding the steps required for him or her to reach one or several career goals. The second writing exercise involves the teen writing a letter to the problem pretending he or she is 10 years older looking back at the problem. The individual is able to name the problem anything that he or she would like. The teen can write to the problem explaining how the absence of the problem has benefitted him or her in his or her life and achievements and how his or her identity has overpowered the problem. This activity will allow young adults to no longer feel that the problem is a part of them because they will no longer have the problem in the future. Therapists and parents can also write letters to the externalized problem regarding how they have seen the teen grow and develop without the problem and how they view the individual’s identity without it. To begin asking landscape of action and landscape of identity questions, the therapist can ask each family member how the teen has overcome the problem in the past and write short excerpts to the problem explaining how this event added to the teenagers identity. Therapists can have parents keep all of the letters and excerpts in an envelope at home for the child to read whenever he or she would like. Therapists can also have teenagers keep a journal and continue to write to the problem anytime it begins to interfere in the individual’s life. Parents should be encouraged to consistently check-in with their child and ask if they would like to discuss any journal entries. For example, 16-year-old Justin, who was brought into therapy by his mother, was asked to engage in both of the aforementioned writing exercises. He wrote several pages regarding his goal to become a movie director. He described how, among other things, he would need to attend film school and intern at a movie studio to reach his ultimate goal. Justin was also asked to write a letter to the ‘‘problem’’ from 10 years into the future. While Justin wrote a 3-page letter to the externalized problem, underage drinking, he decided that he wanted to call it, ‘‘The Good Life.’’ Justin’s letter consisted of him discussing how happy he was with the decision that he made to no longer drink with his friends because he would not have been accepted into college and later received a job if ‘‘The Good Life’’ continued to affect his schoolwork. Justin also listed how the positive aspects of his identity have overpowered ‘‘The Good Life.’’ Justin’s mother read her letter aloud and thanked the problem for leaving Justin alone so he was able to accomplish his dreams and goals.

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Discussion By using play to externalize problems with children and their families, therapists can create distance between the problem and the children’s identities. Subsequent landscape-of-action and landscape-of-identity questions allow children to fill the space that is created between the problem and their identities with possibilities and novel solutions. Empowering children and their families through externalizing problems allow for new solutions to emerge and individuals’ identities to take new shape. Undoubtedly, however, the way the therapist chooses to facilitate the process of externalizing the problem can influence the outcome of therapy. Tailoring externalizing interventions, landscape-of-action questions, and landscape-of-identity questions to fit children’s stages of development will benefit children as they navigate through Erikson’s stages. Though the proposed interventions are research based, they have not yet been empirically tested. Research exploring this approach to treating children and their families must be conducted before the model can be proven effective. Therapists need to continue to assess each child’s individual development to ensure that appropriate interventions and skills are being utilized. All children are not going to develop and move through Erikson’s stages during the same time or in the same way. It is evident, then, that therapists must remain sensitive to the uniqueness of each child throughout therapy. The approach to therapy proposed in this paper is not meant to address all of the reasons why parents bring their children to therapy. For example, the narrative approach to play therapy may not be conducive to therapy for a child who is struggling with the chronic illness of a parent or an unexpected death in the family. The narrative approach to play therapy may be most effective in addressing problems that seem to stem from the way a child views himself or herself. The therapist must assess each child, family, and the presenting problem in an effort to determine if the narrative approach to play therapy would be useful in therapy.

Conclusion The integration of narrative and play therapy techniques allow clinicians to begin to externalize children’s ‘‘problems.’’ Externalizing the problem from children will allow them, and their parents to no longer view themselves as maintaining these negative characteristics. Children will likely start to enjoy defeating the problem while being given the opportunity to bond with their therapist and family members. Allowing children to communicate in an age-appropriate manner will allow them to feel more comfortable, engaged, and important during the therapeutic process. Erikson’s (1950, 1959) theory emphasizes the development of a child’s identity and how not completing one of the stages in a positive manner can negatively impact the child’s self-esteem, self-efficacy, and identity. This paper guides therapists on how to direct children and parents away from negatively impacting a child’s identity and promoting a positive identity full of selfpromoting characteristics. Acknowledgments The authors would like to thank Joseph Wetchler, Ph.D. and Lorna Hecker, Ph.D. for their continued guidance and support.

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