Article

The Family Journal: Counseling and

Therapy for Couples and Families

R.E.A.L. Therapy: Rational Emotive 2016, Vol. 24(2) 164-173

ª The Author(s) 2016 Reprints and

Attachment–Based Logotherapy for permission:

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Families DOI: 10.1177/1066480716628626

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1
Laura Lynne Armstrong

Abstract
R.E.A.L. therapy is a novel approach that merges rational emotive and logotherapy techniques in a creative manner for
families. This model teaches skills aimed at enhancing meaning and attachment in the family, building social literacy skills
and personal insight through emotion recognition, and addressing negative thinking patterns through evidence testing. As
traditional ‘‘talk therapy’’ may exclude young children from participating in family psychotherapy, the hands-on activities
presented in this article may serve to engage the whole family in the therapy process.

Keywords
family therapy, attachment, logotherapy, rational emotive therapy, meaning

R.E.A.L. therapy—rational emotive attachment–based developing resilience to, or coping with, mental health con-
logotherapy—is a novel approach for family therapy. It is hol- cerns and suicidal thoughts (Frankl, 1986; Wong & Fry, 1998;
istic, targeting cognitions, emotions, family attachment, and Wong & L. Wong, 2006). Enhancing meaning in therapy is
meaning. Integral to R.E.A.L. therapy is family engagement in transformative in controlling symptoms and forming healthy,
creative activities, as meaningful engagement promotes functional patterns of family interaction (J. E. Lantz, 1982).
mental health and resilience to well-being concerns (L. L. Logotherapy, a meaning-based approach, encourages the
Arm-strong & Manion, 2013; Frankl, 1986). This article inner spiritual resources of creativity, hope, the capacity for
outlines the key tools and techniques, as well as a case study, choice, and the making of responsible decisions in order to
for applying R.E.A.L. therapy to family-based treatment for live a meaningful life (Frankl, 1986; Lukas 1986). A self-
child and youth mental illness. reported meaningful life for children includes the belief that
one has influence over some things that happen in life, self-
esteem, openness to new experiences, and hope for the future
Components and Rationale for R.E.A.L. (Erikson, 1964; Markstrom & Kalmanir, 2001; Search
Therapy Institute, 2009; VanderVen, 2008). In recent randomized
control trials with students, logotherapy significantly
Logotherapy enhanced meaning and pur-pose as well as significantly
Child and youth mental illness has increased 45% between 2006 decreased symptoms of depression in comparison to control
and 2015 (Canadian Institutes of Health Information, 2015).
group participants (Robatmili et al., 2014).
Mental illness that begins before age 25 tends to be chronic, with Logotherapy was developed by Viktor Frankl, an Austrian
substantial negative outcomes, including family difficulties or psychiatrist, for suicidal adolescents and further refined based on
breakdown (Mental Health Commission of Canada, 2010). From his experience in concentration camps. Primary to logother-apy
a logotherapy perspective, these family difficulties—or are the notions that people have the freedom to make choices
challenges to a family’s sense of meaning— can emerge from the under any circumstance and that, with choice, comes
stress of having a child with mental illness (J. Lantz & Harper,
1992a). This existential meaning crisis is filled by the
development of problems and symptoms—creat-ing a family 1 School of Counseling, Psychotherapy and Spirituality, Saint
Paul University, Ottawa, Ontario, Canada
stress response that further compounds child and youth mental
illness (Asarnow, Jaycox, & Tompson, 2001; J. Lantz & Harper, Corresponding Author:
1992b). In popular mental illness treatment models, the concept Laura Lynne Armstrong, School of Counseling, Psychotherapy and
of ‘‘meaning’’ is often ignored in family therapy. Research has Spirituality, Saint Paul University, 223 Main Street, Ottawa, Ontario,
found that a meaningful life is vital for Canada K2J 4E6. Email: larmstrong@ustpaul.ca

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Armstrong 165
Table 1. R.E.A.L. Therapy Thought Record.

Activating events Beliefs (stinky thoughts): shoulds, Consequences (rate feeling 0–10: 0 ¼ Disputes for stinky Effect of new
(situation in musts, awfulizing . . . (I must . . . worst sadness, fear, anger, etc.; 10 ¼ thought evidence on
which ‘‘stinky’’ he should . . . It’s the worst extremely happy, calm, etc.); behavioral (evidence feelings (rate
thought occurs) thing . . . ) consequences against the 0–10) and
thought) behaviors

responsibility (Frankl, 1986). Another key tenet is that life has underlying these feelings include (1) shoulds, (2) musts, and
meaning under all circumstances and that each person must (3) awfulizing (catastrophic) thinking. Like in cognitive–beha-
discover the meaning potential of each situation (Frankl, 1986). vioral approaches, such thinking is addressed scientifically
Logotherapy is therapy through meaning (Frankl, 1986). The goal through examining activating events, beliefs, consequences,
of a logotherapy approach to family treatment is to help parents disputes for ‘‘stinky’’ thoughts, and effects (on feelings and
and children uncover, discover, and make use of meaning behaviors; see Table 1). RET is simpler than Beckian
opportunities in family life (J. Lantz & Harper, 1992a). Children cognitive approaches, as family members only have to
are generally able to experience fewer impe-diments in finding remember three types of irrational (stinky) thoughts in RET
meaning than adults (J. E. Lantz, 1982). instead of numer-ous cognitive distortions. Attitude changing
Pathways to meaning include (1) creating a work or doing a is also a compo-nent of logotherapy but is fairly unclear in the
deed (e.g., creating something for others, valued work), (2) literature: A grafted RET approach provides a more replicable
experiencing something (e.g., engagement in valued activities, means of addressing problematic thinking in family therapy.
experiencing nature), (3) encountering someone (relationships
with others), and (4) choosing our attitudes (thought changing). Creativity and Attachment Building
Tools to uncover meaning in logotherapy include dereflection,
paradoxical intention, and Socratic dialogue. Dereflection Encouraging creativity, or being playful, in family therapy is a
involves directing a person’s attention away from the problem key ingredient in attachment building among family members
toward something engaging or valued. Dereflection is not meant (Creed & Kendall, 2005; Gil, 1994; Walter & Petr, 2006).
to be ‘‘avoidance,’’ as avoidance is known to enhance symptoms. Attachment injuries can occur through family difficulties
Rather, it involves using a helpful tool to step back from an adjusting to child illness or mental illness, damaging secure
emotionally overwhelming ‘‘cliff edge’’ to have the strength to relationships (Cloutier, Manion, Walker, & Johnson, 2002).
face the important issue or thought pattern head-on. Dereflection Play therapy provides opportunities for ‘‘mutual attunement,’’
is meant to help clients emotionally de-escalate, so that they are which is central to the development or reestablishment of pos-
able to connect with the moment to address thinking that led to itive, secure attachments (Malchiodi & Crenshaw, 2014).
the cliff edge or connect with an experience that is perceived as When family members participate in, or listen to, arts-, story-,
meaningful. Paradoxical intention is the opposite of avoidance: or play-based therapeutic activities together, thoughts and
exposure, but using a deliberate attempt to evoke humor. feelings are engaged in a hands-on, multisensory manner (Gil,
Logotherapists also use metaphors and story-telling, along with 1994; Lowenstein & Sprunk, 2010). Deeper communica-tion
Socratic dialogue to stimulate critical think-ing and to illuminate than in traditional talk-based therapy can be unlocked, as
ideas. creative activities move therapy from the intellectual, cerebral
world of adults to the world of imagination and creativity
familiar to children (Bailey & Sori, 2000). Play is the
Rational Emotive Therapy language of children (Gil, 1994). Moreover, ‘‘talk’’ therapy
Rational emotive (behavior) therapy (RET) is a primary com- can be lim-ited with very young children due to their stage of
plement of logotherapy (Hutchinson & Chapman, 2005). It is an language development, marginalizing them in family therapy
active-directive, empirically based approach to psychother-apy (S.A. Armstrong & Simpson, 2002; Johnson & Thomas,
developed by Albert Ellis (2004). The goal of RET is to enhance 1999). Hands-on activities acknowledge the developmental
critical thinking and problem-solving skills, showing the family levels of all family members and allow for even young
how the misinterpretation of events is causing prob-lems. RET children to actively participate in family therapy sessions (S.
teaches more rational ways to interpret situations. Like A. Armstrong & Simpson, 2002).
logotherapy, in RET, people are responsible for their own well- There is a body of research to suggest the benefits of a hands-
being and the use of humor to overinflate concerns is a key on, artistically or technologically enhanced, multisen-sory,
teaching tool. The primary tenet of RET is that what we think experiential learning approach (Malchiodi, 2005). In par-ticular, a
leads to how we feel, and that feeling will last as long as we have multisensory approach to therapy enhances authentic, effective
irrational thoughts (for families with younger children, a more dialogue because it taps into people’s different verbal, visual, or
child-friendly way of phrasing ‘‘irrational thoughts’’ may be tactile learning and expressive strengths (Malchiodi, 2005).
‘‘stinky thoughts’’). Anger, sadness, and fear mask the basic Whether through art, play, music, movement, enact-ment, or
experience of pain and pleasure. Irrational beliefs creative writing, incorporating creativity into therapy

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166 The Family Journal: Counseling and Therapy for Couples and Families 24(2)

engages the whole person, affects the brain, and leads to better listening to music, talking to a friend, taking a bath, etc.). These
memory for therapy concepts, self-discovery, and change (Mal- activities may also be helpful when parents argue. If they think
chiodi, 2005). In R.E.A.L. therapy, RET and logotherapy activ- that they are going to say something regrettable, then they can tell
ities are presented in a play, hands-on manner to enhance their partner that they need a brief time out and will be back to
attachment and child engagement. R.E.A.L. therapy is, there-fore, resume the discussion following their chosen activity. These
meant to foster family intimacy and interconnectedness through activities ‘‘dereflect’’ from problems and can facilitate helpful,
building antidotes to the three poisons of suffering: meaningful discussions and avoid hurtful statements.
disconnection, meaninglessness, and the despairs of an irra-tional
(stinky) thought process.
Dereflection: Pasta Dance
Humor is often a key element in healing (Frankl, 1986). When
R.E.A.L. Therapy Tool Examples an entire family engages together in the pasta dance dereflec-
Dereflection: Distraction Activity Game tion activity, it usually results in shared laughter. For home-
work, when feeling tense after a difficult day, family members
As noted, dereflection is not meant to be a pathway to avoid- practice the pasta dance together or use other dereflection
ance. One must step back from the cliff edge in order to exam- exer-cises (e.g., diaphragmatic breathing—‘‘belly balloon’’
ine it rationally, without overwhelming feelings getting in the breath-ing or imagery). R.E.A.L. therapists can use the
way. Through dereflection, clients can de-escalate and ask following script and carry out the activity with the family to
themselves, ‘‘How am I right now?’’ they can notice the feel- model the actions for them:
ings as they happen and gain awareness of whether the
situation is calling on them to make a choice: A choice for
Stand comfortably and imagine that you are a long piece of pasta.
new, mean-ingful actions or new thinking that can help them Hop into the pot of boiling water (everyone hops forward). Feel
stay away from the emotionally overwhelming cliff edge. A yourself bounce around in the boiling water, hopping around the
choice in response to the question, ‘‘Is this who I want to be in pot. As you bounce around and begin to cook, notice yourself
this moment?’’ becoming softer (everyone dances around with their bodies
For the dereflection, distraction activity game, a therapist can becom-ing more and more relaxed). Softer. Softer. Finally, you’re
choose any game that takes less than a minute to play. Therapists cooked and you feel yourself gently falling down onto a plate (sit
practicing a R.E.A.L. approach can use a card game like ‘‘snap’’ softly back in therapy chairs). You feel yourself let go entirely of
whereby clients say snap or slap a card in the center of the table the hardness in your soft, relaxed state.
when they see pairs as two cards are flipped. Once the deck of
cards runs out, the player who has the most cards wins (the
therapists makes sure the client wins). For this exercise, therapists Dereflection: Imagery
have one member of the family volunteer to play with the
therapist to avoid the possibility that some people may have a A therapist following a R.E.A.L. approach can have family
decrease in happiness if they were to lose the game against members create a dereflection image to use when feeling tense.
another family member. Prior to playing the game, the volunteer Specifically, therapists have family members collectively
family member is instructed to think about a really bad day. describe a relaxing scene or favorite family memory that uses all
When he or she is thinking about this bad day, the therapist gets five senses, if possible. Scenes have included being on a beach,
him or her to rate feelings from 0 (feeling bad) to 10 (feeling walking in a forest, driving in the country, petting a cat, lying
good). Following this rating, we play the game. The client is under warm covers, and so on—whatever image is most relaxing
asked to rate their feelings again after completing the game. or enjoyable for the particular family. Following the detailed
Clients and observing family members are usually sur-prised at description of their scene, if family members agree that they
how feelings changed following the very brief game. In a enjoy art, therapists then have them draw their dere-flection
R.E.A.L. therapy script, the therapist can say, image to use as a reminder cue before they practice using
imagery. Between sessions, therapists can also create a
Sometimes even doing very brief activities can make us feel a lot personalized guided imagery audio recording for the family,
better. Sometimes these activities just make us feel a little bit using their words and their description of the scene. Clients have
better. Strong feelings are like standing at the edge of a cliff. indicated that having the audio recording, at least initially,
When our toes are at the edge of a cliff, we can’t think clearly. facilitates their ability to use imagery in order to cope with
These activities can be enough to calm us down a little bit and stressors or to calm down, until the use of imagery becomes more
bring our toes away from the edge of the cliff so that we can think automatic. The recording and the drawing provide an activity that
more clearly. the family can practice together.

In session, family members then generate a list of 5–10 very

Paradoxical Intention: Fear Charades
brief, enjoyable ‘‘time out’’ distraction activities that can help
family members feel better or calm down when angry, sad, or Paradoxical intention is intended primarily for anxiety, insom-
worried (e.g., going for a walk, playing a brief game together, nia, or sexual dysfunction (Frankl, 1986). Regarding fears,

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Armstrong 167

when family members attempt to avoid the things that they thinking something will cause something to happen (e.g., if I
fear, the fears grow bigger. In paradoxical attention, clients try think I will eat that food that I’m allergic to, when faced with
out the things they fear in an ‘‘over-the-top’’ manner to evoke it, I worry that I will end up eating it). For this exercise in
humor. To provide initial exposure in session when family family therapy, a therapist taking a R.E.A.L. approach might
members experience many fears, and to begin decreasing the have clients stand about 1 m from a wall and say, ‘‘I can’t
fears, family members can play ‘‘fear charades.’’ In session, touch this wall.’’ The therapist can ask them to keep repeating
family members acting out the things that they fear in a I can’t touch this wall as they move closer and closer to the
playful manner, while other family members guess the acted wall. Finally, even though they are saying, I can’t touch this
feared situation or object. wall, they find themselves touching the wall. The therapist
then asks, ‘‘What just happened?’’ Clients indicate that they
touched the wall. In response, the therapist can note,
Metaphors Fostering Teaching,
Learning, and Socratic Dialogue Even though you told yourself that you can’t touch the wall, you
The following metaphors are used to illustrate logotherapy touched the wall. This shows us that we don’t have to act out on
concepts, foster Socratic dialogue, provide a visual our thoughts. A thought is just a thought. We have a choice
demonstra-tion, or highlight the relationship between RET whether to listen to our thoughts or whether to choose a different
irrational thoughts (stinky thoughts—shoulds, musts, and action in response.
awfuling think-ing) and feelings:
In relation to the food example, just because a client is
Pink elephant. The pink elephant exercise serves to teach clients worried that they are going to eat the allergens on the table in
why telling themselves such things as ‘‘not to worry about [x],’’ the room, having the thought does not mean that they have to
or ‘‘I must go to sleep,’’ or ‘‘I must not have this thought’’ are not act on that thought. This experience can then be explored in
helpful. It also demonstrates the value of dereflection or relation to the clients’ specific thoughts that are affecting the
meaningful engagement. Before teaching clients dereflection, family unit. To further enhance family learning, the therapist
mindfulness, or distraction tools, a therapist taking a R.E.A.L. could discuss what the client could do or think differently in
therapy approach can use the pink elephant exercise to explain this situation and then repeat the ‘‘thought is just a thought’’
the value of these tools in a creative, hands-on manner. More activity to incorporate those changes. For example, negative
specifically, the therapists asks family members to visualize a self-talk could be substituted with something positive, such as
pink elephant in the room. We agree on whether he is big or little, ‘‘When I get close to touching the wall, I can choose to get a
his ears are up or down, his trunk pointing is up or down, and glass of cold water (or call a friend, take a walk, etc.).’’ The
whether his tail is long or short. Once we have agreed on his dereflection activities discussed previously can be used in
features, the therapist says, ‘‘I’d like you to see this pink conjunction with this exercise.
elephant, really see the elephant. Can you see him?’’ (pause).
‘‘Now I’d like you to stop thinking about the pink elephant. Stop Left foot. In order to illustrate the connection between our
thinking about him . . . .. What are you thinking about?’’ The vast thoughts and our feelings, for attitude changing/thought chal-
majority of the time, family members indicate that they are still lenging, in a creative manner to engage clients, the left foot
thinking about the pink elephant. The therapist then goes on to exercise can be used. The following is the left foot script:
say, ‘‘I’d like you to notice your feet on the floor, the
hardness/softness of the chair beneath you, notice what your Imagine that I get up to go get my cup of coffee. As I’m going
hands are doing, notice the colors of the walls around the room . . across the room, I step on your left foot. What do you feel?
. ’’ (pause). ‘‘What’s going on for you right now.’’ Clients (Clients respond ‘‘pain’’ or oww’’).
typically respond that they are thinking about their chair and the How long do you think that feeling would last? (Clients typically
room and are then asked what happened to the pink elephant. respond, ‘‘a short time’’).
Clients smile and respond that he went away. Therefore, the
therapist indicates that dereflection or other engaging distraction Now as I’m walking back across the room to my seat, I step on
activities, rather than telling ourselves not to worry (etc.), can that same foot again. What do you feel? (Sometimes clients still
say ‘‘pain,’’ other times they respond with an angry statement.
help turn our negative thoughts into back-ground noise. For the
Keep repeating this exercise until clients come out with an angry
rare client who stops thinking about the pink elephant when the
—or sad—response beyond pain).
therapist tells them to stop thinking about the pink elephant, the
therapist can ask them what they are focused on. Generally, they How long do you think that feeling would last? (When clients
are already using a preexisting good dereflection tool and the move from a pain response to an angry or sad response, they
therapist can highlight this as a key strength. generally say that the feeling will last quite a bit longer).

Isn’t it interesting. I did the same thing to you [X number of] times.
Can’t touch this wall. The ‘‘can’t touch this wall’’ exercise may The situation was the same, but you reacted differently the last time
be helpful for clients who make the irrational deduction that than you did the other time(s). You said (whatever the clients’
statements were). What’s causing you to feel different? It’s not

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168 The Family Journal: Counseling and Therapy for Couples and Families 24(2)

the situation that’s different. I would suspect that the last time therapist can then deal four cards to each player including
thoughts got in your head. As long as you have those thoughts, you’re oneself. Pairs that people hold in their hands initially do not
going to continue to be (angry/sad). Those thoughts (e.g., she should count as pairs—only count pairs if a card is received from
have been more careful: anger/what did I do to deserve this: sadness) another player. Players take turns asking each other such
block the brief, short-lived, natural emotions of pain or joy in things as, ‘‘do you have sad?’’ If the other player has the
different situations. Our negative feelings of anger, sad-ness, or worry requested card, then he gives one such card to the player who
will last as long as we continue to have negative thoughts. If we can
asked for the card. Upon receiving a matched pair of cards,
change our thinking, then we can change the way we feel. At certain
the person names a situation in which they might feel that
times, we want to feel emotions such as grief following loss or fear in
emotion and why. R.E.A.L. therapists may then ask the family
dangerous situations, but other times we want to be able to have
control over our difficult feelings and we can do that by changing our
what other emotion someone else might feel in that same
thinking or our behaviors.
situation and why. Whenever the therapist receives a matched
pair, he or she could discuss a situation in which some people
might feel that emotion, rather than self-disclosing. The
family is still asked what other emotion someone else might
Ernie and Bert. In order to further highlight for families the
feel in the same situ-ation that was discussed by the therapist.
relationship between thoughts, behaviors, and feelings, as well
To be more poignant, situations relevant to information
as to explore the fact that two people can feel differently in
already learned from the family may be helpful.
response to the same situation, therapists can use an Ernie and
Bert story: If someone asks for a card from another player who does not
have such a card, the other player says go fish and the asking
Ernie and Bert both fail a math test at school. They both feel sad person must pick a card from the top of the draw pile of
about failing. Shortly after getting the test results back, their friends remaining cards. Pairs of cards are placed in front of the player
invite them out to have cake and ice cream while watching a baseball who discusses them, removed from one’s hand. The game ends
game. Ernie agrees to go with his friends, despite feeling sad about when either one person is out of all of their cards or when all but
failing. Bert doesn’t feel like going out, so he just heads home. At the one player is out of all their cards, depending on how fast the
end of the day, Ernie is feeling much better, since he had such a good game has progressed (therapist’s discretion). For home-work,
time with his friends. He also has figured out where he went wrong clients may be asked to each identify a feeling that they had,
on the math test and thinks about what he might be able to do in order name the situation in which they had that feeling, suggest what
to pass the next test. At the end of the day, Bert, who sat at home led to that feeling, and note how and why someone else might
moping all day, is feeling even more miserable. He thinks that it’s the feel differently in the same situation. Family members are asked
end of the world that he failed the test and that he’ll never graduate to collaborate on this at-home exercise.
from school, and he will never get a job that he wants when he grows
up.
Challenging Stinky Thoughts: Crown of Thoughts
As you can see, both Ernie and Bert experienced the same negative
situation, but they acted differently and they thought differently about To carry out a thought record visually, family members can make
it. Therefore, they felt differently at the end of the day. paper crowns to wear. On colorful post-it notes, parents and
children write down their stinky thoughts and then stick those
post-it notes to their crowns on their heads. When wear-ing their
thoughts, family members visually demonstrate the feelings that
Feeling Recognition: Enhancing Emotional Literacy
go along with those thoughts by making the facial expressions.
In the R.E.A.L. therapy model for families, emotions are help- They also walk around with the negative thought post-it notes
ful biological ‘‘alarm’’ bells. They alert clients as to whether and mumble aloud what their negative thoughts are. Following
they are having a helpful feeling (e.g., sadness in response to this, the family discusses what this was like for them to do this
grief) or whether there is an irrational belief (a stinky and to hear others’ negative thoughts. Stinky thoughts can then be
thought), when a false alarm is going off. In order to change challenged through evidence testing to derive a new, healthier
one’s think-ing, a clear insight into one’s emotions, as well as way of thinking about the situation. The new, healthier thoughts
the potential emotional experience of family members to build can then be pasted to the crown, taking off the old thought.
attachment, is necessary. Family members subsequently make the feeling faces associated
To enhance emotional literacy in family members and emo- with these new thoughts that they are wearing and wander around
tion language use, a therapist can create emotion cards. This saying these new thoughts aloud. Following a debrief with the
game is a variation of ‘‘go fish.’’ The six basic global feelings are family about this experience, all of these thoughts and feelings
happy, sad, fear, anger, surprise, and disgust. In PowerPoint or are written on a thought record (i.e., Table 1). For homework,
Word, the therapist can create a deck of 36 cards. More each family member uses the thought record to write down a
specifically, set the slides or page size to 8.5 11 landscape and situation that triggers stinky thoughts and feelings. Parents and
insert six 2 3 tables that fill six pages. Fill each of the tables with children work together to challenge those beliefs and derive, and
the six basic emotions, print the six pages and paste them onto write down, new healthier thoughts and feelings in those
card stock, and then cut out the 36 cards. The situations. If motivated, family

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Armstrong 169

members can continue to use their crowns at home for this preferences. Amy had little awareness of others’ feelings and
exercise or simply use the thought record. the impact of her behavior on their feelings.
Although Kyler did not meet full diagnostic criteria for
Problem Solving: Comics obsessive-compulsive disorder, he exhibited a number of
obsessions. For example, he would not drink out of a blue
To help family members problem solve, and to move clients from cup, as he feared contamination with germs, given that it was
‘‘stuck’’ situations, therapists following a R.E.A.L. approach can once left out with milk while on a family vacation. He washed
predraw stick figure comics relating to their cur-rent issues. The his hands and bathed far longer than his parents thought
therapist can choose issues that are problematic patterns of reasonable (i.e., 4 min hand washing instead of the public
behavior for the family. On blank faces and empty thought health recommendation of washing as long as the ‘‘happy
bubbles, family members are asked to draw their feel-ings and birthday’’ song duration), as he was concerned about
thoughts in relation to this situation (Where does this situation cleanliness. These fears seemed to emerge following a
lead you?). Typically, they will draw their current sequence of misinterpretation or overinterpretation of a comment that his
thoughts, feelings, and behaviors that leads to a ‘‘stuck situation,’’ parents had made (e.g., ‘‘Make sure you use soap to get
which can be enlightening for them. Follow-ing this, another clean’’).
copy of the same situation is presented and family members
Jennifer’s fears predominantly revolved around health or
generate new, more helpful thoughts or state-ments, and therefore
safety, primarily stemming from the time that she became per-
feelings, in this same situation or to prob-lem solve a new way of
manently deaf in one ear as a child following an illness. In
behaving. Family members draw the new behavior in the blank
front of her children, she would ‘‘google’’ symptoms if
panel provided (for an example, see Figure 1). For homework,
anyone expressed a concern. Ben, the father, had successfully
clients can be sent home with addi-tional simple comics produced
received previous treatment for alcoholism as well as
by the therapist related to their present concerns in order to solve
symptoms of depression and anxiety. Prior to his own
problems together.
individual treatment, Ben indicated that he worked long hours
and was relatively absent from his family. Over the past year,
Relapse Prevention: Radio Show he had been trying to build closer relationships with his wife
and children. He wanted to continue building a strong
To highlight all of the therapy tools used across R.E.A.L. ther-apy
attachment relationship with his family as well as address
family sessions, R.E.A.L. therapists may use a hands-on way to
their anxiety through a R.E.A.L. therapy approach: Enhancing
test learning. More specifically, the therapist could set up a
meaning through giv-ing, creating, experiencing with one
microphone and encrypted (password protected) computer to
another, and cultivating helpful attitudes.
record the final session as a mock radio show. Free programs
such as Audacity can be used to record on a Mac or Windows
computer. During the session, the therapist pretends to be dif-
ferent ‘‘call-in listeners.’’ Family members are the ‘‘experts’’ who Session 1 (Following the Intake Assessment Sessions):
answer the call-in questions. When the therapist drama-tizes call- Full Family
in listeners’ questions, the family experts are asked about how to
address issues that are the same as the issues that the family had – Storytelling highlighting the family’s values and positive
faced. Family members describe new ways of thinking, acting, or experiences presented during intake to dis-cuss
other ‘‘tools’’ that were helpful for them. Following the ‘‘meaning strengths’’ to build upon during therapy.
recording, the therapist can make a copy for the family to keep
and review if similar difficulties emerge in the future (e.g., by – Introduction to the concepts of choice and responsibil-ity:
saving to a flash drive or burning to a CD). Discussion of emotions as ‘‘fire alarm bells’’ that tell us
of a real threat or reasonable emotion (i.e., grief) versus
alarms that highlight our need to choose respon-sible
action; attending therapy in response to family distress
Clinical Case is such a choice.
Amy, a 10-year-old girl, and Kyler, an 8-year-old boy, pre- – Ernie and Bert metaphor was used to describe how two
sented with their parents for family therapy. Amy was exhibit- people can feel differently in the same situation to
ing symptoms of generalized anxiety, as was her mother, intro-duce emotional literacy concepts.
Jennifer. Amy was afraid of falling asleep in her own room – Given difficulties with emotional literacy, and to develop
and had been sleeping in her parents’ bedroom for several emotional language, engage family in emo-tional
years. She also feared failure and would not try difficult literacy card game.
home-work. Most evenings, when given difficult homework, – Homework: Identify a feeling, name the situation in
she would whine and raise her voice until her parents would which they had that feeling, and suggest how and why
com-plete the homework for her. At least once per week, Amy someone else might feel differently in the same
would cry and raise her voice until she was given her choice situation; family members were asked to collaborate.
of family game or restaurant over other family members’

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170 The Family Journal: Counseling and Therapy for Couples and Families 24(2)

Figure 1. Problem-solving comics.

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Armstrong 171

Session 2: Full Family completion,’’ and ‘‘blue cup drinking’’ behaviors with
tokens for shared activities with parents—such as
– Reviewed homework.
choice of family game, choice of family television
– Pink elephant in the room metaphor used to teach about program for an evening).
dereflection.
– Dereflection tool presented: Distraction activity game to Session 7: Full Family
help Amy de-escalate when feeling angry; also to help
– Reviewed homework
both children and Jennifer turn focus from anxiety-
provoking thoughts to brief, meaningful pursuits; de- – Further dereflection strategies for anxiety: Pasta dance,
escalate to gain the strength to eventually be able to imagery, and belly balloon breathing (diaphragmatic
turn toward anxious thoughts, analyze them, and breathing).
change them (when they learn the future tools). – Fear charades for initial exposure to fears, humorous to
reduce intensity of fears.
– Homework: Try out dereflection activities discussed; rate
feelings before and after. – Homework: Continue daily practice of dereflection stra-
tegies at home, use of dereflection when anxious, mon-
Session 3: Full Family itor effect on anxiety (before and after); use helpful,
previously learned thought-changing and problem-
– Reviewed homework. solving strategies following decrease in anxiety after
– Left-foot metaphor to socialize the family to the connec- using dereflection.
tion between thoughts and feelings.
– Further discussion of emotions as ‘‘alarm bells’’—bio- Sessions 8–13: Individual Sessions With Each Child
logically relevant or alerting us to shoulds, musts, or
– Reviewed homework
awfulizing thoughts; feelings alert us to a ‘‘meaning
potential’’: we can choose our attitude! – Problem-solving comics to reach meaningful outcome
– Crown of thoughts activity to replace stinky thoughts rather than current negative outcomes (avoidance or
with more helpful, rational thoughts; write on thought impacting others negatively: Amy); comics and further
record. crown of thought exercises also used for stinky versus
helpful thoughts for anxiety-provoking situations
– Carry out thought record homework collaboratively (Kyler).
(activating event, belief, consequences, disputes for
stinky thoughts, and effects on feelings and behaviors) – Exposure homework, using dereflection tools to calm
using stinky thoughts experienced during the week. down before and during exposure; monitoring mood
before and after exposure to fears.
Sessions 4, 5, and 6: Parents Alone
Session 14: Parents Alone
– Reviewed homework
– Assess progress; therapeutic goals met.
– Socratic dialogue, psychoeducation, and problem-solving
– Troubleshoot minor problems.
regarding ‘‘googling’’ and exhibiting other anx-ious
behaviors around children, giving in to demands Session 15: Full Family
(homework and sleeping arrangements).
– Discussed meaning of deafness for Jennifer: She had – Relapse-prevention radio show.
been studying music at university when she lost her
Outcome
hearing in one ear; music became monophonic and lost
its pleasure; devastating for her; pursued computer sci- Jennifer and Ben appeared to develop a meaningful, secure
ence instead; meaning: Jennifer would not have met her attachment relationship with their children. Amy became aware
computer scientist husband if the illness resulting in of her own and others’ feelings and was respectful of others’
deafness had not occurred. Old attitude: ‘‘This was the needs. She expressed her feelings in a calm manner and no longer
worst thing that ever happened to me as I cannot enjoy exhibited emotional outbursts at home. She was willing to try
music anymore the way it used to move me.’’ New tricky homework and would ask her parents questions when stuck
attitude: ‘‘Sometimes when a door closes, a window but would no longer ask them to do her homework for her. By the
opens and good things can happen. Even illnesses that final session, Amy was sleeping in her own room, with the
result in bad things can change a person’s life for the exception of a night that she was feeling ill. Kyler was able to use
better in many other ways.’’ his dereflection activities and helpful thinking to address his
– Thought records for health-related and safety fears (min- fears. He was no longer worried about blue cups, lengthy
imal concerns after new, meaningful attitude toward ill- washing, or other initial concerns. Although Jennifer still
ness and deafness). experienced some health-related anxiety when her children
– Homework: Try the discussed new problem-solving indicated unfamiliar symptoms, she no longer expressed these
strategies for child’s demands or exposure behaviors worries to her children. She also noted that her anxiety was
(e.g., rewarding ‘‘sleeping in own room,’’ ‘‘homework significantly reduced from initial levels, as she

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172 The Family Journal: Counseling and Therapy for Couples and Families 24(2)

reframed her own illness history in a meaningful, positive family living (Fulkerson et al., 2006). Creative tools in
man-ner. Both Jennifer and Ben reported increased feelings of therapy can, therefore, provide a model for such at-home,
par-ental competence and problem-solving ability. They noted attachment-building parent–child activities. Shared creative
an enhanced sense of meaning in their life, due to improved family activi-ties are one foundation for the development of
parent–child relations. The family was also meaningfully meaning and purpose (Frankl, 1986). Therefore, it would
engaged in activities collaboratively decided by all members, seem that creative activities should regularly be incorporated
as demands by Amy were no longer present. into family therapy in order to fully meet client needs, better
engage children who may feel excluded from therapy, and
make the sessions meaningful.
Implications
The key goal of R.E.A.L. therapy with families, applying
The list of activities and discussion tools presented here is not skills in meaning-enhancing, creative ways, is to develop the
an exhaustive list of possible creative options to use in antidotes to the three poisons of suffering: Move from (1) dis-
R.E.A.L. family therapy. The hope is that the reading of this connection to (re)attachment; (2) meaninglessness to fostering
article will stimulate further thought and creative applications meaning by engaging families in activities that enhance crea-
integrated into rational emotive and logotherapy techniques tivity, experiencing, attitudinal change, and giving; and (3)
for children. irrational (stinky) thoughts to rational, healthy ways of
Logotherapy, in particular, as well as creative structured play thinking that do not cloud the experience of pain, pleasure,
activities, is often discussed outside mainstream therapy and meaning. Given the importance of values, meaning,
literature. In comparison to other species, human lives are shaped engaging all family members, and addressing thinking, it
by values, purpose, and the search for meaning. Outside of the seems critical for family therapy to begin incorporating and
logotherapy movement, Carl Rogers (1964) also recog-nized that investigating the use of a R.E.A.L. approach: creative,
distress occurs when there is a discrepancy between one’s values meaningful, whole person, whole family.
—that which one would find meaningful—and one’s current
behavior. Reducing this discrepancy, living one’s values,
Acknowledgment
minimizes distress (Rogers, 1964). Logotherapy goes one step
beyond living one’s grand values to reframing even traumatic I would like to acknowledge the past educators who inspired my use
situations in helpful, meaningful ways and looking for small of creative activities in family therapy and who taught me some of
these tools. In particular, I would like to thank Dr. Jane Ledingham,
meaning potentials in everyday life (Frankl, 1986). Despite
C. Psych., Dr. Ian Manion, C. Psych., Dr. Jean Grenier, C. Psych., Dr.
logotherapists’ and Rogers’ recognition about the importance of Brian MacDonald, C. Psych., and Dr. Simon Davidson, M.D.
values or meaning, corresponding with the dearth in the research
literature, mainstream treatment often continues to ignore
meaning, resulting in a key gap in service delivery. R.E.A.L. Declaration of Conflicting Interests
therapy fills this gap and blends meaning with a mainstream, The author(s) declared no potential conflicts of interest with respect
evidence-based approach. To date, a pilot study of a R.E.A.L. to the research, authorship, and/or publication of this article.
approach has been carried out through the D.R.E.A.M. program
—Developing Resilience through Emo-tions, Attitudes, and Funding
Meaning (L. L. Armstrong, 2015). Using a R.E.A.L. approach for
The author(s) received no financial support for the research, author-
mental health education with young children, the D.R.E.A.M.
ship, and/or publication of this article.
program implements the majority of these activities in a
classroom setting. Compared to a control group, these tools were
found to significantly enhance mean-ing—hope, self-esteem, References
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