Therapeutic exercises for couples and families: Royal Flush and beyond

¶ … family counseling requires a broad and diverse set of tools and techniques. Those tools and techniques should be adaptable to suit the needs of each family, individuals within that family, and also the contextual or environmental variables that impact families. Using a wide range of exercises and interventions, therapists can provide effective and evidence-based practice, as well as offer ongoing assessments and maintenance.

Techniques and exercises that may be particularly useful for families and couples include the Royal Flush exercise for families with young children, the family-based school interventions for children with behavioral or academic performance problems, and the "altering the abyss" exercise for couples. Each of these exercises is rooted in fundamental family practice theory, and each can also yield measurable outcomes that improve the efficacy of the treatment.

Royal Flush

The "royal flush" technique is named as such because it uses picture cards, similar to those used in card games. The exercise can be used regularly, and involves simply arranging the picture cards spatially. Because it is relatively straightforward, the exercise can be repeated throughout ongoing therapy to provide measurable assessments of change. Because it connotes game play, this exercise can be useful for families with young children. The goal of the Royal Flush technique is to assess family structure, and understand how individual members of the family might perceive that structure differently.

It is important to understand the family's structure because family structure is empirically linked to several tangible outcomes. For example, there is a proven association between family structure and the children's academic and social development, and between family structure and the child's overall well-being (Thompson & McLanahan, 2012). However, family structure is also connected with cultural norms. The therapist's role in the Royal Flush is not to make judgments about the family structure or recommend changing it, but to simply help the family understand their own structure, and recognize their roles within it. In fact, one of the core strengths of the Royal Flush method is that it can be especially useful for extended families and larger households, which are common among many ethnic groups. The awareness of structure may help illuminate dysfunctional relationship patterns in a culturally appropriate manner.

With a better understanding of family structure, the therapist can apply what has been learned from the Royal Flush towards specific recommendations for change. The information gleaned from the Royal Flush technique can reveal gender interactions and norms in the family, and can help each family member "locate" themselves in the family structure, and become more aware of their roles and how they might want to change those roles. Concrete and measurable outcomes linked to the Royal Flush would include shifts in the balance of power in the family over time, and changes in self-perception over time.

The Royal Flush technique is grounded in several theoretical viewpoints including symbolic interactionism and family structure theory. Rooted in John Dewey's social psychology and Blumer's research that followed, symbolic interactionism suggests that "human beings are best understood in a practical, interactive relation to their environment," ("Symbolic Interactionism," n.d.). The arrangement of the cards is not inherently meaningful; what is meaningful are the attributes, emotions, and thoughts ascribed to those relationships. In other words, individuals in the family co-create their own family structure. The roles and relationships formed in the family are meaningful insofar as the people continue to play out their roles and project their expectations on other people.

Altering the Abyss

Not all families have children, and even when they do, the children may be grown or have little bearing on the more pressing issues facing the integrity of a couple. "Negative couple interactions" can be worked out with exercises like "Altering the Abyss," (Brimhall & Gardner, n.d.). The "Altering the Abyss" exercise help couples identify and articulate the negative communication patterns and cycles they have fallen into, recognize their role and responsibility in the negative patterns, recognize and express their perceptions of the other persons' role, and replace any negative or dysfunctional patterns with positive ones. The theoretical grounding for Altering the Abyss comes from emotionally focused therapy and externalization theory, all of which delve into the deeper emotional and cognitive patterns impacting external behaviors and communication styles. The advantage of Altering the Abyss is that through externalization, negative patterns like blame are minimized. Acute conflicts are also dissipated, allowing the couple to recognize the bigger picture and the patterns rather than focusing on minute details. Using specific exercises and techniques like the circular pattern diagram recommended by Brimjhall & Gardner, n.d.), the couple and the therapist work over a period of time to map out difficult emotions and resolve conflict.

One of the drawbacks or limitations with the Altering the Abyss technique is that it precludes the therapist from using it in any situation where abuse is suspected. It may also prove challenging for some participants and can take a long time to complete the therapy. Measurable outcomes are more subjective than quantitative in nature, but include the therapists' observations of the couples' interactions as well as subjective or self-reports from the individuals.

Creating Rituals for Couples Coping with Early Pregnancy Loss

Because of its high level of specificity, the Thomas (n.d.) recommendations for creating rituals for couples coping with early pregnancy loss may not be helpful for my practice. The exercise is used when couples have experienced miscarriage and the related trauma and stress the experience entails. Rituals involving symbolic items and ceremonies may be helpful because, as Thomas (n.d.) points out, most couples suffer silently. They do not enjoy public support in the form of a funeral or other ritual that might help the grieving process. Without the help of a ritual, the couple may have trouble expressing their emotions or receiving support from friends. Exacerbating the stress could be a sense of failure and shame at the loss. Therefore, this technique is worth mentioning as an adjunct for couples who have gone through the trauma of early pregnancy loss.

Miscarriage can lead to breakdowns in communication within the relationship and occasionally leads to the dissolution of relationships. Therefore, this technique has the advantage of providing targeted assistance for a specific type of crisis and encourages both members of the couple to face the difficult issues ranging from anger and blame to self-hatred and depression.

The technique is based on symbolic-experiential therapy, which permits a degree of externalization that can help deflect blame (Thomas, n.d.). The rituals can be tailored to suit the needs of couples from different ethnic backgrounds or same-sex couples, another advantage to this technique. Moreover, ritual offers the potential for ongoing reflection and the therapist can return for assessment and the acquisition of measurable outcomes such as scores on psychological testing, if those tests were being used.

Speak Softly and Carry a Big Stick

Named after the famous quote from President Theodore Roosevelt, the Speak Softly and Carry a Big Stick method may be useful for some family scenarios. One of the notable advantages of this exercise is that it can be used as a "homework" assignment that families end up turning into common practice in their homes (Hertlein, n.d.). The theoretical underpinnings for Speak Softly and Carry a Big Stick derives from social constructionist theory and feminist theories. Social constructionist theory shows how individuals construct their identities, and gender roles and norms are a huge part of that social construction of identity (Gergen, 1985). The Speak Softly and Carry a Big Stick method involves the simple technique of formalizing communication via the use of a "talking stick." Like the conch shell in Lord of the Flies, the talking stick gives the floor over completely to the person talking. Interruptions are forbidden, and this especially helps persons who are prone to self-effacing communication methods. The method may be useful in patriarchal households, particularly when there are cultural constraints on communication styles and gender roles. The disadvantages to the Speak Softly exercise is that it needs to be combined with systematic insight into the problems the family faces. This method helps the therapist to listen more closely to the concerns of each family member, but it does not offer a program for change. However, the therapist can create specific and measurable outcomes related to communication. The therapist can observe shifts in communication style with observation or video recording, and encourage the family to practice more egalitarian methods of interaction.

Family Stress Balls

Family stress balls are used as part of a stress reduction program. They are based on the principle of externalization, but they also provide the additional bonus of a physical stress release. Viers (n.d.) recommends that families make their own stress balls instead of purchasing them, for additional therapeutic benefit. Designing one's own stress ball may also confer a sense of empowerment, and can also be a fun activity for the family. Therefore, the Family Stress Balls exercise has distinct advantages in its ease of use and flexibility. It is similar to the Speak Softly and Carry a Big Stick method in that it is something that families can practice on their own, even after formal therapy sessions have ended.

The American Psychological Association (2015) recognizes that the majority of parents experience stress related to parenting duties, and that effective stress management is critical for family health. Stress management is also important for the emotional outcomes of the child. Externalizing stress helps children and parents prone to bottling up their emotions. However, the family stress balls cannot substitute for actually having difficult conversations. "Having regular conversations can help a family work together to better understand and address any stressors children are experiencing," (American Psychological Association, 2015). The stress balls should be used as an adjunct to therapeutic interventions and not as a sole intervention, similar to the Speak Softly and Carry a Big Stick method and even the Rituals for Couples who have suffered from miscarriage. Specific and measurable outcomes for the family stress balls are possible, especially when biological markers for stress have been identified prior to the intervention, during, and after the technique has been employed over a long period of time. For example, blood pressure, weight changes, and self-reports of well-being can be measurable outcomes.