Filial Therapy: What It Is & How It Works

What Is Filial Therapy?

Filial therapy, also known as filial play therapy or child-parent relationship therapy (CPRT), is an evidence-based form of psychotherapy. It incorporates aspects of both family therapy and play therapy to help kids 3-12 years old deal with emotional, behavioral, attachment, adjustment, and self-esteem issues. By teaching parents skills to practice during playtime, they learn to become the “primary change agents” for their children.¹

Bernard Guerney and his wife Louise, both psychologists, founded filial therapy in the 1960s after seeing the limited number of treatment providers for children. With that, they realized that parents themselves can be properly trained to interact with their kids in a way that yields positive outcomes. As the child communicates their feelings through play, the parent understands them better and tunes in to their needs.

It may seem like the child is the only one who benefits from filial therapy, but the reality is that everyone involved experiences positive changes. This includes increased empathy on the parent’s part, the child feeling more comfortable expressing their concerns, a reduction in the child’s problematic behaviors, and healthier boundaries within the family. Based on qualitative studies, parents who received training reported an increased awareness of their kids’ needs and feelings.²

Filial Therapy Techniques

Filial therapy techniques include structuring, empathetic listening, child-centered imaginary play, and limit setting. Note that these techniques are taught to parents by a registered play therapist or trained filial therapist. Learning may involve group discussions with other parents, role-playing, using videos to demonstrate techniques, and getting feedback to help a parent reflect on their play sessions with their children.³

Strategies used in filial play therapy are non-directive, which means that the child is free to choose how they express themselves in play as long as they feel comfortable. While the child takes the lead, the parent, in turn, listens and reflects without passing judgment.

Here are the four primary filial therapy techniques used in sessions:

1. Structuring

Structuring is one of the most basic skills parents learn. It involves the parent designating an area for the child to play. While parents provide them with toys, such as puppets, stuffed animals, masks, dollhouses, and art supplies, they also let their children know that they can pick and interact with whatever toys they like.

Structuring aims to ensure that the parent and child have an environment or space where therapeutic interactions happen. Furthermore, letting kids take the lead during play sessions will encourage them to be engaged in the process instead of avoiding it.

2. Empathic Listening

During empathic listening, a parent gives full attention to their child. They closely observe the child’s body language, facial expressions, and tone of voice. Unlike typical social interactions, empathic listening is a special skill in that it involves showing unconditional acceptance. When parents set aside their own judgments and avoid giving suggestions, kids feel understood and accepted, which allows them to release their emotions.⁴

Based on what their child is saying or how they’re acting during play, the parent can then reflect and try to understand what the child is going through. For example, a child who’s always angry may lead some parents to believe that they’re being disobedient (and other parents blame themselves too), but the child is actually experiencing a difficulty that caused them to behave this way.

3. Child-Centered Imaginary Play

The child is allowed to take the lead, meaning that they are free to choose which toys to use, characters to portray, as well as their scenarios (e.g. in the classroom, hospital, grocery store, office, at the dentist or vet, or in a tea party). Always keep in mind that as a parent or caregiver, your only role is to observe and respond to them in a non-judging way.

Child-centered imaginary play aims to create a safe atmosphere, which allows for creative expression. It provides plenty of opportunities for children to exercise their creativity and learn problem-solving skills. Research also suggests that when play is accompanied by a nurturing presence, it promotes coping and resilience.⁵

4. Limit Setting

Another one of the key filial therapy techniques parents learn is setting boundaries. Although kids are empowered to be in control of their play scenario, certain limits need to be communicated by parents. Before the filial therapy session starts, you can, for example, remind your child that destroying toys, hitting or throwing toys at you, and climbing or jumping on the furniture is not allowed.

Limit setting aims to promote safety and prevent potential hazards. Telling your child in a firm and calm way that showing aggression is forbidden and explaining the reason behind it will increase their cooperation. It’s also a helpful way of teaching them the importance of respecting other people and property.

What Can Filial Therapy Help With?

Filial therapy can be used as part of a bigger treatment plan or as a primary approach for families with kids who are having mental health problems. Children who are consistently acting out, have experienced trauma or been abused, have emotional regulation issues, dealing with loss (e.g., death or a loved one or divorce), or have a developmental disability can benefit from filial therapy.

There are instances when filial therapy can be used as a preventive approach for kids whose problems have not yet been identified. Regardless of whether it’s used as treatment or prevention, the methods involved in filial therapy remain the same.

Filial therapy can help with the following conditions:

• Anxiety
• Attachment issues, such as an anxious attachment
• Childhood trauma, such as adoption trauma
• Abuse or emotional neglect
• Attention-deficit/hyperactivity disorder (ADHD)
• Conduct disorders
• Depression
• Oppositional defiant disorder (ODD)
• Psychological issues that result from a chronic illness

Examples of Filial Therapy

What’s great about filial therapy is that it can be adapted to address different conditions or situations. For a child who’s grieving the loss of a parent, filial therapy would likely involve the child reminiscing about the deceased parent and creating a memorial using play dough to remember their fun times. During each session, the remaining parent and child can process the loss together.

Here are a few examples of what filial therapy could look like:

Filial Therapy for a Child With ADHD

When applied to children with ADHD, filial therapy will likely include board games (which help with focus, planning, and memory skills), puppets (to act out different scenarios, allowing them to redirect their emotions), and hula hoops (to help the child calm down). Whether a child has received an ADHD diagnosis or they’re showing ADHD behaviors, play has been shown to improve symptoms of inattentiveness, hyperactivity, and impulsiveness.⁶

Filial Therapy for a Child With Social Anxiety

A child with social anxiety is reluctant to meet or hang out with other kids and avoid situations where they’ll be the center of attention. Therefore, filial therapy would be geared towards helping the socially anxious child feel validated, play out their anxieties, and prepare themselves for new situations. Relevant toys to include are stuffed animals, pretend play sets (such as doll houses and doctor kits), and art supplies.

Note that while storybooks covering social situations may be helpful for children with social anxiety, they’re not typically recommended in filial therapy since they direct the child’s play.³

Filial Therapy for a Child With Trauma

For a child who has PTSD, filial therapy can help uncover potential trauma triggers as well as co-morbid problems (e.g., ADHD, anxiety disorders, and mood disorders).⁷ In a filial therapy session, a child gets plenty of opportunities to express their perceptions of the traumatic experience.

Research shows that combining play therapy with trauma-focused cognitive behavioral therapy (TF-CBT), another evidence-based treatment, can increase the child’s coping skills and build resilience.⁸

Filial Therapy for a Child With Autism

An experimental study involving 32 children with autism showed that filial therapy increased parents’ acceptance of their children and lowered parenting stress.⁹ During filial therapy, a child with autism will likely engage in repetitive play, such as lining up mini toy cars or repeating the same phrase. Whereas other kids do role-playing, pretend play, or take turns, those with autism do not. When applying filial therapy to ASD, it’s important to carefully consider what the child likes, which will likely involve sensory toys and weighted stuffed animals.¹⁰

Benefits of Filial Therapy

Besides the fact that filial therapy has been extensively researched, it’s considered to be a culturally sensitive approach. This is one of the reasons why families of different backgrounds would benefit from filial therapy to improve parent-child relationships and reduce the child’s problematic behaviors.¹¹

Filial therapy can benefit a child by:

• Increasing awareness of their emotions
• Improving self-esteem
• Increasing feelings of safety and acceptance
• Teaching age-appropriate coping skills for kids
• Improving social skills
• Enhancing conflict resolution skills

Filial therapy can benefit the parents by:

• Increasing the bond with their kids through play
• Becoming more attuned to their child’s needs
• Understanding why their child behaves the way they do
• Teaching how to set healthy limits in a way that’s gentle and age-appropriate
• Empowering them to take an active part in their child’s healing process
• Helping to reduce parental anxiety

Is Filial Therapy Effective?

Filial therapy is effective for a wide range of problems affecting children because it capitalizes on play, which is a child’s natural language, and engages parents in the process.¹² Also, it is both developmentally sensitive and culturally sensitive, which increases effectivity. As more and more professionals utilize filial therapy, the more it is empirically supported and validated as an evidence-based treatment.¹³

Research shows that filial therapy is particularly effective for single-parent families, families that have experienced trauma at the same time (due to natural disasters or violence), and children who are being effected by divorce or a loss.^{14, 15}

Criticisms of Filial Therapy

Filial therapy is not a one-size-fits-all. Since a parent needs to be present in all therapy sessions, filial therapy can be challenging for those who are overwhelmed with hectic schedules. Another concern is that although filial therapy is culturally sensitive, it is possible that a therapist’s practices may not align with a family’s beliefs. Therefore, a competent therapist should take time to learn the background of the family they’re working with.

Is Filial Therapy a Good Fit for You & Your Child?

Filial therapy is a good fit for most issues affecting children, especially if these issues are preventing you from having a healthy relationship with your child. It’s also appropriate for parents who have the desire to play an active part in their child’s recovery.

On the other hand, filial therapy is not ideal if a parent has a serious mental illness that would interfere with therapy outcomes. Parents who are unwilling or too overwhelmed to commit to the whole process might benefit from another type of therapy. Another contraindication is if the parent happens to be the perpetrator of the child’s abuse.

Here are a few things to consider when determining if filial therapy is right for you:

• The specific concern or issue your child is experiencing which requires proper assessment
• Your relationship with your child
• Your commitment to consistent participation in your child’s play sessions
• The availability of a qualified filial therapist in your location
• Your openness to receiving feedback from the therapist and other parents in group sessions
• Whether filial therapy fits your budget

What Is the Cost of Filial Therapy?

The average cost of filial therapy is $100-$200 per session, but the cost varies across treatment providers. Other factors that may affect the cost include location, the format being used (group setting or multiple family groups vs individual families), the treatment timeline, and session length.

Does Insurance Typically Cover Filial Therapy?

Filial therapy can be covered by insurance, depending on whether your health insurance plan includes mental health benefits. Note that some insurance plans that include therapy coverage specify “family therapy” and “play therapy” but not “filial therapy.” You can contact your insurance company to learn more. Keep in mind that a referral from a professional and a medical diagnosis will likely be required, plus a referral to get coverage.

Speaking of coverage, find out if your therapist of choice accepts your insurance and how many sessions will be covered. It will also help to check for in-network providers if your insurance plan has them to reduce out-of-pocket costs.

What to Expect During Filial Therapy Sessions

Filial therapy begins with an initial assessment and a demonstration of what typical child-centered play sessions would look like. Parents then start their training phase involving mock play sessions in which parents get to practice the 4 filial therapy techniques — structuring, empathic listening, child-centered imaginary play, and limit setting.

As parents feel more confident in conducting the play sessions, they can start doing them at home on a weekly basis and do video recordings of these sessions for feedback from the therapist. When it comes to session length, each session may take less than an hour or longer depending on the child’s attention span. Some families benefit from 10-15 sessions, while others may require more. Sessions occur over a period of 3 months to 1 year.

During a filial therapy session, the following may occur:

• Initial filial therapy activities involve the therapist discussing the current problem and the entire therapeutic process. The therapist also models play sessions with the parents observing the therapist.
• The parent starts conducting play sessions with their child, and the therapist supervises the sessions. The therapist usually stays in a viewing room so that the parent and child can interact without the child feeling interrupted by the therapist’s presence.
• Sessions 6-10 and beyond will likely be done at home, and these play sessions are structured similarly to office sessions. All play sessions will be video recorded and reviewed by the therapist, who then identifies signs of progress and areas for improvement.
• During each session, the parent avoids making suggestions on how their child plays, criticizing, praising, and interrupting.
• Post-session discussions with the therapist and other parents (within a small group) are kept positive. While the therapist identifies things that a parent may have missed during play, suggestions are provided in a gentle and reassuring manner.

How to Find a Filial Therapist

A highly convenient way of finding a suitable filial therapist is by searching through an online therapist directory or online therapy platform. Alternatively, you may ask for recommendations from relatives, friends, or other parents you know whose children have undergone therapy.

What to Look For in a Filial Therapist

Even after getting referrals, it is important to take the time to find a therapist that is the right fit for your child. Most certified filial therapists have had 2 years of post-master’s experience. They possess unique qualities that enable them to successfully help families, such as compassion, cultural competence, and a non-judgmental and non-directive attitude.

Here are a few questions to ask a potential filial therapist:

• Have you worked with families of children my child’s age?
• How many years have you been doing filial therapy?
• What is your payment structure? Do you accept insurance?
• What is your approach to dealing with challenges that occur in the middle of filial therapy?
• What will happen during each filial therapy session? How long does a session typically last?
• As a parent, what will my involvement in filial therapy sessions look like?
• Can you tell me more about the potential results of filial therapy or successes from your previous clients?

In My Experience

I believe that Filial therapy would be a good approach for younger kids presenting with emotional dysregulation and behavioral issues. Kids ages 2-7 who undergo parent-child interaction therapy (PCIT), which involves broader techniques and also improves a child’s behavior and parenting skills, also get to experience the benefits of filial therapy through play.

Whereas other therapies focus on the child or adult as the client, filial therapy focuses on the “relationship” between the parent and the child. By helping this relationship, the child doesn’t only experience a reduction in their symptoms, but they also develop a sense of who they are and what they’re capable of.