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DOI: 10.1002/jclp.22998 CLINICAL CASE REPORT The use of cinematherapy to illustrate systemic resilience Christie Eppler1 | Jen Hutchings2 1Couples and Family Therapy, Seattle Abstract University, Seattle, Washington, USA 2Marriage and Family Therapist, Private Resilience is the process of coping with and overcoming Practice, Rockford, Michigan, USA adversity, finding purpose in the face of suffering, and preparing for the future with a focus on interconnections Correspondence and personal strengths. Being resilient is the ability to Christie Eppler, Couples and Family Therapy, flourish in the face of trauma or hardship. The traits and Seattle University, 901 12th Ave, PO processes of resilience are woven throughout the film Little Box 222000, Seattle, WA 98122‐1090, USA. Miss Sunshine. As characters deal with suffering, they also Email: [email protected] embody systemic strengths, which align with the current resilience research. This paper explores the use of cine- matherapy to illustrate concepts of resilience in systemic therapy and in training relational therapists. KEYWORDS cinematherapy, film, resilience, systemic therapy 1 | INTRODUCTION Little Miss Sunshine (Dayton & Faris, 2006) is an indie‐comedy film that depicts a White, lower‐middle‐class family who travels to California to enter 7‐year‐old Olive into a beauty pageant. The characters are presented as troubled, yet as a family they are resilient. During their time on the road to the pageant, the family faces difficulties such as economic hardship, death, medical diagnoses, and interpersonal conflict. However, the film ends with a cohesive and supportive family dancing to the song, Superfreak, as pageant attendees look on aghast. Using the example of Little Miss Sunshine, this paper explores the use of film to identify traits and processes of systemic resilience, as an intervention in systemic clinical practice to strengthen relationship resilience, and as a tool to teach systemic therapists about systemic resilience. Resilience is the process of coping with and overcoming adversity, finding purpose in the face of suffering, and preparing for the future with a focus on interconnections and personal strengths (Grotberg, 2003; Walsh, 2006). Being resilient is the ability to flourish in the face of trauma, hardship, or the inevitable adversities of life; it is a “fluid process that evolves over time” (Becvar, 2013, p. 52). DeHaan, Hawley, and Deal (2013) operationalized family resilience in terms of both processes (e.g., navigating trauma experiences throughout the family life cycle) J Clin Psychol. 2020;1–9. |© 2020 Wiley Periodicals LLC 1

2| EPPLER AND HUTCHINGS and traits (e.g., positive outlook). Although certain factors may increase the ability to thrive, the complexity of individuals, families, and their social environments prohibit predicting patterns of causality that determine resi- lience (Ungar, 2013). The majority of resilience literature indicates that having significant, supportive relationships contribute to individual and family flourishing. The extant literature indicates that viewing a film has the potential for a significant impact on the viewer. The use of film can be helpful in clinical work with clients in a therapeutic outpatient setting (Berg‐Cross, Jennings, & Baruch, 1990; Calisch, 2001; Dermer & Hutchings, 2000; Eppler, 2018; Hesley & Hesley, 2001; Hockley, 2015; Lampropoulos, Kazantzis, & Deane, 2004; Marsick, 2010; Schulenberg, 2003; Sharp, Smith, & Cole, 2002) and with specific presenting problems such as grief (Izod & Dovalis, 2015; Neimiec & Schulenberg, 2011). Films provide a shared language or story between clients and therapists, which can lead to cocreating metaphors or displaced conversations (i.e., describing a personal scenario through the perspectives of someone else; Kalter, 1990). Movies can also provide a way to externalize problems, allowing them to be viewed through a different lens or perspective, and facilitating the exploration of different coping options (Orchowski, Spickard, & McNamara, 2006). The film can normalize experiences and help clients feel like they are not the only ones struggling. Niemiec and Wedding (2008) recommended watching certain films to promote resilience. They named three criteria for films to be classified as positive psychological movies: (1) the movie has at least one research‐ based strength depicted, (2) there is an obstacle that the character with the strength overcame, and (3) the movie's tone is uplifting. The authors indicated that watching the movie could elevate mood and influence values, although Bergsma (2010) questioned their claims based on the lack of empirical data and lack of methodological rigor related to the proposed classification system. Bergsma and De Greef's (2009; as cited in Bergsma, 2010) small study found that the interplay between watching a film and the effect on the viewer was unpredictable. A movie could be sad yet meaningful for a reason unknown to the viewer. In other words, movies may evoke difficult feelings yet be inspirational and facilitate viewers' deeper understanding of themselves. For couples and family therapists, the film can be used as an intervention in systemic treatment. Eğeci and Gençöz (2017) found that the benefit of using movies to facilitate change for relationship problems lies not in the viewing of the movie but in the discussion after the viewing. These authors found that clients may have a variety of processes while viewing movies, including identifying with characters who have similar problems and learning new behaviors based on how the film resolves crises. One of the most salient benefits of viewing films within a therapeutic setting is the potential for increasing empathy among partners—that is, helping clients view issues from the perspective of their partner, and identifying their own responses during interactions. Ballard (2012) described the use of cinematherapy as an intervention to help families move beyond the feeling of “stuck” when approaching a new developmental family life cycle stage, such as leaving home as a single young adult to transitioning to the joining of families through marriage as a new couple. Turns and Macey (2015) described the use of cinematherapy with families, using concepts from narrative family therapy. They used the children's film, Wreck‐It Ralph, to externalize the problem, or remove the problem from the identified client and make it an entity the family can transform. Instead of naming Ralph as the bad guy, the family and therapist discuss how another character, a tarantula, influences Ralph to wreck‐it, or make bad choices. The clinical discussion explores how the family collectively and individually stop their own tarantulas from creating similar problems. In a related vein, Eppler and Latty (2002) employed two films in systemic treatment, Stepmom and Mrs. Doubtfire, to engage divorcing families in the dialog. They explained that a therapist could show a clip from Stepmom where the parents talk to their children about separating. After viewing the clip, the therapist would facilitate a discussion with the clients about what worked for the film's family. How were the clients' experiences the same or different? What would the clients like to happen next as they communicate about changes in their family?

EPPLER AND HUTCHINGS |3 2 | SYSTEMIC RESILIENCE DEPICTED IN LITTLE MISS SUNSHINE Multiple therapeutic models define systemic resilience or characteristics of families who are able to thrive in the face of complex problems. Walsh's (2006) model of family resilience names five characteristics: (1) making meaning from adversity, (2) having a positive outlook and a sense of purpose, (3) being connected and having mutual support and respect, (4) mobilizing resources by reaching out to kin and finding work/life balance, and (5) communicating clearly and solving problems collaboratively. Another systemic model, The Circle of Courage, sees resilience as four equal quadrants within a circle: belonging, mastery, independence, and generosity (Brendtro, Brokenleg, & Van Bockern, 1990). Each quadrant must be in harmony with others and no one element can be bigger than the other. Resilience is promoted through a synthesis of belonging to a community, achieving goals and having a sense of accomplishment, accepting responsibility and participating in decision‐making, and offering the best to others. In career counseling research related to resilience, Mitchell, Levin, and Krumboltz's (1999) planned happenstance model identified curiosity, persistence, flexibility, optimism, and risk‐taking as sources of resilience. These factors supported clients when they made significant career transitions. These are but a few of the multiple theories that identify strengths, assets, and sources of resilience. As noted earlier, Little Miss Sunshine's characters struggle with multiple stressors including financial concerns, depression, suicide ideation and behavior, substance abuse, and loss of dreams (i.e., all of them experience a loss of hopes and dreams of some kind). Yet together the family embodies traits of resilient families. The dad, Richard, is a motivational speaker who sees the world in terms of winners and losers and has a motivational plan for success. The mom, Sheryl, says she is prohonesty, but is perplexed when confronted with meaningful dinner table conversation. Sheryl's brother, Frank, a Proust scholar, had recently attempted suicide and is recovering from a failed relationship with a former student and a significant career disappointment. Richard's father, Grandpa Edwin, lives with his son after being kicked out of a retirement home and is coaching his granddaughter, Olive, to perform a dance routine for the local beauty pageant. Olive's brother, Dwayne, has taken a vow of silence until he is accepted into the Air Force. Amidst the personal and familial hardships, each character displays strengths and the family comes together to form a caring and cohesive unit. In an early scene, there is a dinner table conversation that does not go well. Soon after the family leaves for the pageant, their yellow VW bus breaks down and they have to push it to start it while it is in third gear. Throughout the film, there are glimpses of the family working together to make it to the pageant on time. Grandpa passes away in his sleep, yet the family keeps traveling. When Olive is dancing solo on the pageant stage, the family notices the crowd's judgment and joins her to dance together to the song, Superfreak. The family thrives in the face of adversity. Scenes from Little Miss Sunshine illustrate the three models of resilience defined above: Walsh's (2006) foundational model of process‐based, systemic resilience; Brendtro et al.'s (1990) Circle of Courage model, de- veloped by theorists and clinicians from Indigenous backgrounds, that includes both traits (e.g., belonging) and processes of resilience (e.g., harmony); and Mitchell et al.'s (1999) planned happenstance model that focuses on individual traits that can be applied both to individuals and family systems. Table 1 shows specific examples of resilience in the film, Little Miss Sunshine. The left column lists the time of the scene, the second briefly describes the event and the next three list constructs from the respective resilience model that applies to the scene. To create the table, the authors watched the film independently. Then, they created a list of scenes they determined to show resilience. Finally, they met to discuss which resiliency constructs best fit the scene. The authors discussed the alignment between the scene and the resilience model's constructs until consensus. For example, the first entry shows the family's decision to drive to California and pursue Olive's dream of becoming Little Miss Sunshine in spite of the obstacles (Frank's recent suicide attempt, Dwayne's resistance and vow of silence, financial stressors, drivers who can drive the van). In a quick decision, the family finds ways to negotiate and compromise to support Olive even though it creates a potential hardship for them all. This example demonstrates concepts from all three resilience models. Per Walsh (2006), they have a positive outlook, sense of purpose, are connected, demonstrate mutual support, mobilize their resources by reaching out to kin and finding a work/life balance and solve problems collaboratively. They align with the Brendtro et al. (1990) concepts

T A B L E 1 Models of resilience illustrated in Little Miss Sunshine 4| Little Miss Sunshine Models of resilience Walsh (2006) Time Scene Brendtro et al. (1990) Mitchell et al. (1999) 17:30 The decision to go to the Little Miss Sunshine Positive outlook, sense of purpose, connection, Striving towards generosity Flexibility, optimism, risk‐ pageant mutual support, reaching out to kin, finding work/ and belonging taking life balance, collaborative problem solving 27:00 Family eating ice‐cream in support of Olive during Respect, connected, mutual support, reaching out Generosity, belonging Flexibility, optimism criticism, judgment from father to kin 31:38 Family pushes van and “no one is left behind” Connected, mutual support, reaching out to kin; Belonging, mastery, Persistence, flexibility, risk‐taking solving problems collaboratively generosity 40:50 Grandpa says to Richard, “You took a big chance Making meaning of adversity, positive outlook, Belonging, generosity Risk‐taking and it took guts and I'm proud of you” after connected, respect, clear communication Richard loses the book deal Multiple Grandpa's support of Olive's dream Positive outlook, sense of purpose, connected, Belonging, mastery, Curiosity, persistence, scenes mutual support, respect, reaching out to kin independence, generosity optimism, risk‐taking 51:22 Sheryl prepares the family for the possibility of Making meaning of adversity, positive outlook, Belonging, generosity Flexibility, optimism Grandpa's death, “I know he loves both of you very connected, mutual support, respect, clear much. If God wants to take him, we have to be communication ready to accept that, ok?” “Whatever happens, we are a family. And what's important is that we love each other.” Frank puts a hand on Sheryl's knee. Dwayne writes a note to tell Olive to “Go hug Mom” 56:30 Richard's insistence to move on verses giving up so Sense of purpose, connected, mutual support, Mastery, independence, Persistence, flexibility, they can make it the pageant. Family bonds solving problems collaboratively generosity risk‐taking together to load up Grandpa's dead body in the van EPPLER AND HUTCHINGS 1:05:50 Dwayne discovers that he's color blind, cannot be a Connected, mutual support, respect Belonging, generosity Curiosity, persistence, pilot and panics. Olive follows him and puts her optimism arm around him with her head on his shoulder. Dwayne decides to go, carries her up the hill

T A B L E 1 (Continued) EPPLER AND HUTCHINGS Little Miss Sunshine Models of resilience Walsh (2006) Time Scene Brendtro et al. (1990) Mitchell et al. (1999) Independence 1:26:10 Concerns about Olive's participation in the pageant. Making meaning of adversity, sense of purpose, Persistence, flexibility, Final scene risk‐taking Male adults want to protect Olive. Sheryl respect, clear communication encourages them to “let Olive be Olive” Family all dancing to Superfreak in spite of judgment Connected, mutual support, solving problems Belonging, mastery, Persistence, flexibility, from pageant onlookers collaboratively independence, generosity optimism, risk‐taking |5

6| EPPLER AND HUTCHINGS of striving towards generosity (i.e., supporting Olive) and they come together as a community (e.g., they create belonging). This scene highlights flexibility, optimism, and risk‐taking which are constructs from Mitchell et al. (1999). The table captures traits of resilience; however, the processes of resilience are harder to depict. Throughout the arc of the film, Richard moves from categorical, black‐and‐white thinking (e.g., people being either winners and losers) to a more inclusive view of support, adaptability, and success. Frank evidence a similar progression. At one point in the film, Frank chastises Olive for ordering ice‐cream for breakfast while explaining that skinny girls would not eat fattening food. The rest of the family supports Olive by enthusiastically digging into the dessert. Frank resists the ice cream, but by the end of the film, Frank willingly joins the family dancing on stage, exhibiting a more flexible and adaptable side of himself while supporting the family. The resilience constructs above are not representative of all facets of flourishing. The film has examples of humor, which is not represented in the models presented above but have been explored within the larger body resilience research (Cann & Collette, 2014). In one example, Frank jokes that he is a Proust scholar as he pushes the van. Likewise, Grandpa is a humorous and complicated character. The viewer may develop compassion for his antics when they learn of his history of combat. While trauma‐informed care and compassion are not specific to resilience models, they share an ethos of empowerment and healing. Even if the viewer has compassion for Grandpa, his support of Olive and her dream of dancing may be problematic. While one interpretation of this scene focuses on mutual support and thus aligns with traits of resilience, helping his young granddaughter with an adult‐themed dance routine may be troublesome considering the potential for objectification and embarrassment in front of the pageant audience. This is one example of the importance of including development, social location, and context when examining sources of resilience. The Circle of Courage (Brendtro et al., 1990) prioritizes the importance of harmony among the four compo- nents of resilience, yet each scene does not contain evidence from each quadrant. However, throughout the movie, the characters and family demonstrate harmony among the components of independence, mastery, generosity, and belonging. The table indicates fewer observations of independence, yet that is not to suggest that there are no other scenes that highlight a character's independence. Another analysis of the film with the goal of identifying scenes of independence might well provide additional examples of a character's ability to set goals and take responsibility (i.e., indicators of independence). The movie reinforces the premise that resilience is not being problem‐free; rather it is the process of working together to find strengths, meaning, and support (Walsh, 2006). After some early trip struggles, the family's van bypasses the exit to Carefree Highway. The family may not be carefree, but they are bolstered by resilience traits and processes that strengthen their family system. 3 | CLINICAL IMPLICATIONS Assigning movies or watching clips in session can be used to help clients identify strengths and apply what works for the film's characters to their own lives. Using established protocols (see Dermer & Hutchings, 2000), the clinician would take a strength‐based approach to analyze films. Viewing a movie through the lens of resilience can help heal families by having them look beyond their frustration and self‐perceived negative traits. Often, families can get stuck in a “right” way of doing things. The use of cinematherapy allows them to see other options outside their daily patterns. Viewing a system through a resilience lens encourages the recognition that even small changes to the system can contribute to large changes overall. An example in Little Miss Sunshine involves the characters' use of physical touch, often in small, subtle ways when there are no other words to say to each other when they are disappointed or frustrated. It appears that the simple act of an encouraging touch feels supportive and encouraging to family members when they feel discouraged or stuck. Using film as an intervention in systemic therapy, the therapist and clients may explore what helped the film's family to cope, move forward, and thrive. Clients and therapists could discuss how viewing systemic resilience in films creates awareness of strengths or resilient traits in the clients' own lives. For example, after watching the Little Miss Sunshine scene where Olive comforts her brother, the therapist might inquire: What nonverbal behaviors in your family

EPPLER AND HUTCHINGS |7 are used to express support or care? Or, after the family watches the movie, a clinical session could focus on each client's dreams or goals. To each family member, the therapist might ask: What is one surprising thing you wanted to do when you were 7 years old (Olive's age)?; How did your family help you with this dream, even if the task itself was not accomplished?; In what ways are your family members “superfreaks”?; What do you appreciate about your family members that others may not get?; To what extent and how do you express this appreciation?; What makes your family different or unique?; When was a time when you were proud of your family?; How do you support each other with helping or giving advice?; How do each of you express your needs or true self without words?; When did you take a small risk in asking something from your family and how was that received?; Were you surprised by the outcome? It is important to consider clients' intersecting social locations to provide culturally‐attuned therapy (McDowell, Knudson‐Martin, & Bermudez, 2018). In many ways, the family in Little Miss Sunshine represents the dominant culture (White, nonimmigrant), yet several characters represent minoritized populations: Frank is gay, Dwayne has vision problems, and Grandpa is an older adult. While the film passes the Bechdel test (Erigha, 2015), a feminist critique that assesses if a film has two named female characters who talk to each other about something other than a man, it does not pass the DuVernay test (Logan, 2016), a metric to assess a film's racial diversity. To pass the DuVernay test, films must present minoritized characters as dynamic and fully‐realized. While Little Miss Sunshine's social worker is Black and other pageant contestants are racially and ethnically diverse, they are thinly written supporting characters and not featured players in the film. When choosing films to promote client resilience or to teach about systemic resilience, one must consider the representation and avoid stereotypes (Cappiccie, Chadha, Lin, & Snyder, 2012). Since clients come from diverse backgrounds, it is crucial to understand our clients to assign a film that is a good fit. For example, a family with clear evangelical Christian expectations may feel resistant to certain content in movies. In some cases, these negative reactions can be used for therapeutic work, but for others, it could feel offensive and get in the way of the therapeutic relationship. In this example, Little Miss Sunshine, an R‐rated movie, has content that may be considered irreverent or offensive to some clients. 4 | USE OF FILM TO TEACH SYSTEMIC RESILIENCE The use of cinematherapy can be a teaching tool for students (Conti, Clari, Carignano, Saccà, & Garrino, 2019). For example, Datta (2009) and Hankir, Holloway, Zaman, and Agius (2015) used film to introduce psychiatric topics to medical students. In both cases, students reported overall satisfaction with the integration of film in their edu- cation and an increased understanding of mental health diagnoses. The authors of this article use film in an academic setting to train future graduate‐level couples and family therapists. In a psychopathology class, students are invited to explore issues of mental health and the effects of their struggle on relationships and systems around them using a film that they have chosen. There are several options to locate films that aid in identifying resilient traits. One of these resources (Zur & Wolz, 2015) provides an updated, extensive list of movie options for students to choose from. Although they do not specifically provide a category titled resilience, they provide headings for categories of aspiration, authentic self, courage, determination, dreams/inner guidance, forgiveness, human spirit, inspiration and hope, risk, spiritual awareness, and transformation. Students are asked to identify diagnoses, differential diagnoses, and comorbidity in the characters in the film. They are also asked to describe the historical context in which the film was set and to critically examine stereotypes and the ways that these may contribute to the stigma of mental health issues in society. Finally, they are prompted to identify the systems that show up in the film with specific attention to multiculturalism and spirituality. The ensuing classroom discussion inevitably helps students to see their clients and future profession in a hopeful way, amplifying options for clients to continue to grow in spite of the struggles that they encounter. Using film holds the potential to help students understand systemic resilience. In the present authors' ex- periences, when asking about client strengths, one of the first responses from students is that the clients show up

8| EPPLER AND HUTCHINGS to the session. Students often have a difficult time observing clients' sources of resilience, or how clients cope, maintain, and transform during difficult times. To create a nuanced understanding of systemic resilience, films can be assigned as homework to be watched before class discussion or clips can be shown in class. After viewing the clip and noting the social locations of the characters, students could brainstorm the family's resilient traits and their processes of resilience (e.g., how they adjusted their coping mechanisms over time). Course discussions might have students analyze the resilience of each of the models assigned to them (e.g., Walsh's model or the Circle of Courage Model). Having a shared language for students to explore what worked when families overcame adversity may support students in becoming strength‐based systemic therapists. 5 | FUTURE DIRECTIONS A major critique of implementing a resilience‐focused approach in treatment is that it has the potential to minimize problems (Becvar, 2013). Fostering strengths is not a stand‐alone approach, rather it is one that can be integrated into evidence‐based systemic treatment. To maximize the value of resilient‐focused cinematherapy, empirical research is needed. There are multiple questions that researchers could profitably investigate. For example, Do other viewers see the same concepts of resilience as the present authors do throughout the film?; Do people from various cultural locations perceive these scenes differently?; Is using cinematherapy to strengthen client resilience or student application of resilience effective? Using cinematherapy to introduce concepts related to resilience may be helpful when working with clients as well as students on both the graduate and undergraduate levels. The expansion of cinematherapy to work with systems, including couples, families, and other relationship types, provides even more options for interventions with client systems. Both therapists and faculty can use the integration of resilience models and the use of film, inviting clients and students to utilize key concepts of resilience: strengths, solutions, and perseverance through difficult times. REFERENCES Ballard, M. (2012). The family life cycle and critical transitions: Utilizing cinematherapy to facilitate understanding and increase communication. Journal of Creativity in Mental Health, 7(2), 141–152. 2012.685004 Becvar, D. S. (2013). Facilitating family resilience in clinical practice. In D. S. Becvar (Ed.), Handbook of family resilience. New York, NY: Springer. Berg‐Cross, L., Jennings, P., & Baruch, R. (1990). Cinematherapy: Theory and application. Psychotherapy in Private Practice, 8, 135–156. Bergsma, A. (2010). Can movies enhance happiness? Journal of Happiness Studies, 11, 655–657. s10902-009-9151-8 Brendtro, L. K., Brokenleg, M., & Van Bockern, S. (1990). Reclaiming youth at risk: Our hope for the future. Bloomington, IN: National Education Service. Calisch, A. (2001). From reel to real: Use of video as a therapeutic tool. Afterimage, 29(3), 22–24. Cann, A., & Collette, C. (2014). Sense of humor, stable affect, and psychological well‐being. Europe's Journal of Psychology, 10(3), 464–479. Cappiccie, A., Chadha, J., Lin, M. B., & Snyder, F. (2012). Using critical race theory to analyze how Disney constructs diversity: A construct for the baccalaureate human behavior in the social environment curriculum (Paper No. 9). Faculty Publications— School of Social Work. Retrieved from Conti, A., Clari, M., Carignano, F., Saccà, P., & Garrino, L. (2019). Teaching resilience and vulnerability to nursing students using films: A qualitative study. Professioni Infermieristiche, 72(2), 135–142. Datta, V. (2009). Madness and the movies: An undergraduate module for medical students. International Review of Psychiatry, 21(3), 261–266. Dayton, J., & Faris, V. (Directors). (2006). Little miss sunshine [Film]. Twentieth Century Fox. DeHaan, L. G., Hawley, D. R., & Deal, J. E. (2013). Operationalizing family resilience as process: Proposed methodological strategies. In D. S. Becvar (Ed.), Handbook of family resilience. New York, NY: Springer.

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