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COVID: Using the DAN Model with Couples to Increase Family Resilience

The COVID‐19 pandemic has massively impacted our society, affecting both wider systems and smaller ones alike. Families across the world have had to adapt to a new style of living, dominated by uncertainty, which is testing their resilience. Within this context, we have asked ourselves, as systemic therapists, what can be done to provide support and a sense of understanding to families. In this article, it is argued that therapeutic tools taken from a manualised intervention to promote resilience in couples can provide valuable help to families who are struggling in this difficult time. This intervention, developed at the Iscra Institute in Modena, Italy, is called Digital, Analogic, and Narrative (DAN). The tools used in the DAN model are described in this paper and their application in practice is illustrated through a case study.

included in our manualised preventative intervention for couples, called DAN (whereby DAN stands for Digital, Analogic, and Narrative), may constitute an excellent form of help for families in need of ways to increase their children's resilience, to avoid the development of more severe mental health difficulties. The DAN model we have been using since 1990 has helped many families find their way among the multitude of obstacles they might face, and COVID-19 represents yet another challenge families can overcome with the help of our systemic therapists.

Manualisation and systemic therapy
Providing an evidence base for therapeutic interventions has become an increasing political necessity for their survival. One way to ensure a significant outcome in comparative trials is to outline the specific different steps of a psychological intervention, through manualisation. As systemic therapists, this can appear to be an infeasible task, as to do so would potentially undermine the fluidity and creativity of our epistemological approach. However, the need to provide evidence of therapies' efficacy has pushed systemic clinicians to think creatively about how this can be accomplished, providing a valuable research base for the approach (see Pote et al., 2003;Stratton, 2005).
This framework is what prompted the research team at the Iscra Institute for Systemic Psychotherapy in Modena, Italy, to focus on the topic of manualisation (Bassoli, Mariotti, & Frison, 2004) and develop the DAN manualised intervention (see Mariotti et al. forthcoming). For this manualisation we decided to focus on processes, rather than procedures, describing different digital, analogic, and narrative therapeutic tools that combined would promote reflexive thinking and resilience in couples and, consequently, in their wider family system. A pilot research study was conducted, in which trainees at Iscra carried out the manualised intervention with non-clinical couples who had a newborn baby. A client consent form was completed by each participant and no family here described can be identified. Each trial was conducted jointly by two trainee therapists.
The different sections of the DAN are outlined in this article. The tools used are described and explained, with reference to their application in the context of a case study from the Iscra research pilot. In the final section of the paper, an overview of the overall DAN structure will be provided.

Case study
The case study describes the intervention carried out by two trainee systemic therapists with a young couple, who we will call Terence and Aurora, 2 who have a fouryear-old son and a newborn daughter. Terence works as a metalworker and is an only child. His father owns the business for which he works. He fears being left with significant debts, and he has therefore now taken on a second job. He expresses his economic concern by bringing out the disappointment towards his parents; he hopes to be completely different from them, even though they often attempt to be close to him. He was raised by his paternal grandmother, whom he describes as the 'pillar of the family' and his point of reference. Aurora is of Southern Italian origin but has always lived in the north of Italy. She graduated from an Art Institute and did a master's degree. She has done several jobs but is now unemployed. She is the second-born of three siblings: her elder sister is married and has four children; the younger brother is single. Her relationship with the family of origin is particularly good: she talks to them often and wishes to share a lot with themto an excessive extent, according to Terence.
Terence and Aurora met at a dinner and they got together almost immediately. Initially they argued about the possibility of Terence not being faithful, since he remained a close friend of his ex-girlfriends. Their first son, Gabriel, was born from an unexpected pregnancy. Terence wanted Aurora to get an abortion. After significant disagreements over opposing ideas about parenting, the couple married and shortly after faced a second unexpected pregnancy. Terence did not hide his disappointment on this occasion either, claiming not to be cut out for family life or to raise children. The couple spends little time together and Aurora claims to suffer more because of this.
The application of the manualised intervention with this couple is considered in the following section, which briefly describes the different sections and tools of the DAN.

The DAN Tools
The DAN model is a manualised intervention developed over the past two decades at the Iscra Institute in Modena, Italy. The intervention is aimed at promoting family wellbeing by applying systemic therapeutic methods through working with couples. Over the years, the DAN model has been perfected by including widely used digital, analogical, and narrative tools, and a pilot study has been undertaken by having trainee family therapists carry out the intervention on young families. The DAN model was presented in a European trial (European Commission, 2014) and tested in Modena comparing its outcome results with families who received no treatment and families who received home visits during the first year of life of their latest newborn.
The tools developed by the Iscra research team, such as the three-dimensional genogram, the Relational Style Profile couple interview (RSPc), and the better formed tale, are briefly described in this section. It is argued that the manualised DAN intervention is a simple way of applying important and established systemic techniques that will promote family wellbeing by helping young couples develop reflexivity and resilience.

The digital section
The Relational Style Profile couple clinical interview. Digital thinking refers to the most structured stage of thought and communication, focusing mainly on its contents. In other words, focusing on what is being said, rather than how it is said. The RSPc interview (Mariotti & Langella, 2011) is a structured questionnaire born from the need to replicate essential elements of the systemic therapeutic conversation in a procedural way. Individuals' answers are inputted into an Excel spreadsheet that processes the questionnaire's results.
The interview has three different sections. Firstly, a brief introduction is provided, explaining the questionnaire, and basic demographic information regarding the couple is collected. The second is 'Generative Forces': that is, how everyone differentiated themselves from their own parental figures. In the third sectionwhich concerns the couple's relationshipreflexive questions are overlapped in a 'dichotomy-environment matrix structure' (Mariotti & Langella, 2011) using triadic questions.
From the second part, relating to generative forces, four categories are obtained: Fusional/Dependent, Similar/Differentiated, Mediatory/Aversive, and Mixed. These describe the type of relationship the individual has/had with their parents.
The third part, called 'Performative Styles', provides an overview of how the above dichotomies apply to an individual's significant life contexts: Self, Couple, Family, Friendship, Work, and Values. This allows for an in-depth descriptive analysis of significant semantic value, identifying how a dichotomy may become harmful or favour resilience. For example: 'Is the order/chaos dichotomy good or bad in the context of family or friendship?' The cross-comparison of the answers that each couple member provides supplies information about similarities between the two, their ability to accurately describe each other, and their reflexivitythat is to say, whether each one is aware of how their partner would like them to be, and to what degree such awareness is present.
A first subtest describes the procedural aspects of the life phase in which the couple finds itself at present. The process relating to the individual styleacquired within the family systememerges from the second subtest. Finally, the variability introduced by the structural coupling (Maturana, 1978) with the partner emerge from the third subtest.
The RSPc in the case study. Some of the results fed back to the couple in the case study are outlined as follows.
The profile that emerged for Terence from the RSPc suggests similarities with his parents, as well as an ability to tolerate differences and to mediate in the presence of conflict (he describes himself as a mediator between a chaotic mother and an orderly father). In the couple, this presents itself as a predisposition to tolerate the differences of his partner. A very marked difference emerged between how Terence felt he is and how he felt his parents would like him to be, suggesting a certain degree of conflict and a tendency towards rupture and opposition to his parental figures. Talking about himself, he states he can come across as quite blunt and everyone rubs this in his face; when faced with unexpected events, such as his wife's pregnancy, he is entirely rational and not emotional. When asked how he thinks Aurora would want him to be, he answers by saying: 'with different values,' 'more feminine.' Aurora generally appears to be similar to her parents, although she portrays herself as a mediator between an emotional mother and a rational father. In general, Aurora feels that she has fulfilled her parent's expectations. This profile suggests a strong attachment between family members, based on similarities, and a rather low ability to tolerate differences. This results in a tendency to adopt the style acquired in her family also within the couple. When asked how she thinks Terence would want her to be, she reports this would not be significantly different from how she already is, although she does feel she has to work on being closer to Terence. Aurora describes herself as an optimist, but Terence disagrees with this. In turn, Aurora responds to his comment stating: 'Since being with you, I no longer am [an optimist]!' During its administration, the couple felt the RSPc to be a complex instrument and difficult to understand. However, the discussion of its results with the therapists prompted discussions on everyone's relational styles, which remained key areas of interest throughout the whole intervention. Focusing on the questionnaire feedback becomes an excellent way for the couple to compare themselves to each other and to discuss their relational styles. As a matter of fact, both are interested in hearing and commenting on the answers provided by their partner, and their participation in the process is encouraged by the therapists. The discussion leads to some disagreements between the two, which allows the therapists to explore how the couple deals with conflict: Terence tries to distance himself from his wife in moments of disagreement, while Aurora feels the need to deal with the topic when it first emerges. Aurora expresses the discomfort she feels when Terence seeks someone else to talk to about his problems, rather than talking to her. In different situations, they both appear to strive to meet each other's needs but, despite their efforts, they often struggle to find common ground.
Role reversal. Rooted in the concept of paradoxical interventions (Selvini Palazzoli, Boscolo, Cecchin, & Prata, 1975), the role reversal involves the couple behaving in a way that is opposite to usual for a set amount of time, in their family environment. This is set as a home task following the discussion on the RSPc outcomes, which outline the two individuals' main relational styles.
Role reversal in the case study. A simple example of role reversal is taken from the case study. As mentioned above, Aurora feels that the two do not spend enough time together as a couple and that Terence does not take enough initiative in this. Terence, on the other hand, feels that Aurora is often too keen on spending time with her family of origin. These elements were very much reflected in the results from the RSPc, and therefore Terence and Aurora were set the following tasks: Terence was asked to organise three 'moments' for the couple; Aurora must accept what he organises and be open to his proposal. At least twice, Aurora must refrain from organising meetups with the rest of their families. She will have to involve Terence in this process, who will have full responsibility in organising these meetings, or deciding not to, depending on what he prefers.

The analogic section
The 3D genogram. Analogic communication focuses not on content, but on processes: that is, importance is given to how things are being said rather than what is said. This indicates a non-verbal means of communicating, whether that be through body language or physical movements, as well as speech tone and volume (Figure 1).
The three-dimensional (3D) genogram (Mariotti, 2014) represents a creative application of the traditional genogram (Bowen, 1980). This genogram is co-constructed through the use of small coloured blocks of wood, of different shapes and sizes. The tool provides particularly useful information on the 'relational' distance between significant people and generational boundaries. The couple is asked to represent, each in their own set area, their own past, including their family of origin and any significant people known outside of the family context. Subsequently, working together, the couple uses the wooden blocks to represent their present and a hypothesised realistic future.
The 3D genogram has proven to be a powerful tool for several reasons: The use of wooden blocks makes administration simple as well as informative.
The choice of shapes, colours, and distances provides information on the different relationships described, allowing for a meta-communication of meanings. Operating styles emerge from the intertwining of three factors: a. the observed interactive behaviours of the family members while completing the task; b. the types of rules that inform family action; c. the ways in which each family constructs their reality. Therefore, the tool provides a good overview of the view of the world shared in the family and how this determines family functioning.
The 3D genogram in the case study. In the representation of their present on the genogram, Terence and Aurora place the wooden blocks representing themselves equally distant from that of their son Gabriel. On Aurora's side, in a row, she places her father, who is the closest to her, then her mother, and finally her paternal grandmother, who despite being no longer alive still maintains an important place in her heart. In front of her father, she places her brother and sister. On Terence's side, we can see his uncle, who at the moment is particularly close to him especially due to work. The couple discusses the possibility to also add the uncle's wife to the genogram, but they decide not to, as she is not seen to be particularly important. Then there is his paternal grandmother, who still maintains a superiority in terms of the size of the block used to represent her. The couple adds their dog and removes Aurora's friends, as well as Terence's ex-girlfriends. The therapists ask Aurora to modify the present representation. After having placed her parents equally distant from her, she adds Terence's parents on her side. Terence promptly moves them away as much as possible, placing them on a chair opposite the desk on which the genogram is being constructed. In the representation of their hypothesised future, the couple add their newborn daughter. They then start discussing Terence's parents. Aurora would like to include them, stating: 'There is no harm in hearing from them from time to time.' Aurora places her own parents in a central position, in front of herself and Terence. In response, Terence moves his and Aurora's parents to her side, away from him; he states that he does not need other parents and that even if he did, it would not be them. The representation of the future for Terence is very similar to that of Aurora; the only difference is that Aurora's grandmother is only present in the latter.
Once all genograms have been completed, the therapists highlight the strengths the couple have shown, such as the fact that in their representation both parents were equally distant from Gabriel. The couple recognise this as a point of strength, stating that they have several friends who definitely do not maintain the same distance from their own child. This allows the therapists to discuss the unhelpful effects of triangulation (Haley, 1967;Minuchin, 1974). The genogram therefore becomes a powerful tool for reflection, as well as highlighting important topics that are often put across through meta-communication.
The house drawing. While the 3D genogram explores the couple's wider relational network, the systemic house drawing (Bassoli, 2008) focuses on the family's most private space: their home. The family house is, in most cases, the place where the family eats, sleeps, and lives. Consequently, exploring the couple's perception of this environment can highlight existing affinities and differences within the system. Therefore, this tool provides a chance to visualise the dynamics of balance and relational boundaries in a quick and simple way, expressed by the couple through the means of drawing.
The couple is asked to draw their family home. The therapist should guide this work by asking prompting questions, such as asking where the house is, who occupies which places and when, and whether different family members experience the house differently. This analogic mode of exploring family balances allows the couple to efficiently communicate information in a way that is not explicit. At the same time, it allows the therapists to gather important information about the relational dynamics within the family.
As with the 3D genogram, chronological work is also done with this tool. Each person in the couple is individually asked to draw their house of origin where they grew up, the 'house of the past'; subsequently, they draw their current home, the 'house of the present'; and finally, they are asked to illustrate their 'house of the future,' which focuses not on realistic expectations, as the 3D genogram of the future did, but rather on wishes and hopes about the future composition of the nuclear relational network.
Family meal video. Like the house drawing, this task focuses on exploring the family's interactions in their home environment. The couple is asked to record a usual family meal (lunch or dinner), for approximately 15 minutes. The video is then brought to the following session for discussion. Although the task is fairly simple and straightforward, it allows the therapist to explore, together with the couple, triadic interactions and instances of reflexivity as they occur in the footage. This also provides the couple with a chance to observe and reflect on their interactions, from an outside perspective, in the context of a daily situation.

The narrative section
The better-formed tale. Narrative approaches aim to gain a shared understanding of people's lives through a collaboration between clients and therapist (White & Epston, 1990). The better-formed tale (BFT) is a variation of the better-formed story described by Sluzki (1982). Using cards with different pictures and one sentence on each of them, the couple is prompted to co-construct a tale that has references to their own story as a couple or as parents. The therapist also takes part in this process, ensuring relevant elements of the couple's experience are brought into the narrative.
Fifteen picture cards are shown to the couple and the therapist asks them to choose one as a starting point. The therapist then starts the story, citing the sentence on the chosen card, and passes the card to one of the clients, allowing them to continue the story. The card is then passed to the other client, who continues the story, and back to the therapist. This process goes on until the story has been concluded, when the therapist provides a brief summary of it, to consolidate its meaning. Furthermore, the therapist must add a transformative element, a positive change aimed at emphasising the couple's strengths. The couple is also assigned a BFT as a home task, to be completed with their children.
The BFT in the case study. The BFT constructed in the case study is presented here. The couple chose the card titled 'A never-ending story' (Figure 2). Therapist: Once upon a time there were a boy and a girl who fell in love and they asked themselves: will our story last forever? Will we be together forever?
Aurora: We wanted to get out of our old stories, which were keeping us prisoners, and we tried hard to stay together.
Terence: We thought we would be taking it one day at the time and didn't imagine our life would have been like this.
Aurora points out that he was the one who thought it would never be like that. Therapist: . . . but, when faced with the unexpected, they discovered that by joining forces they managed to overcome their problems and that the past, which had differentiated them, in fact made them stronger.
Aurora: We have our past, our families who can help us move forward with their life tips.
Terence: And often we do not fall on our feet. While Aurora feels represented by the story, Terence does not relate to the part where they can join forces. We then ask him if there are moments when he feels the two can join forces and he answers: 'Yes, we are here after all! When we are forced to solve important things, we join our forces. What little space we have, each one of us wants to take it for themselves.' Aurora claims that the two also experience fun moments from time to time, but Terence seems to doubt this. The therapist concludes by observing that the couple are not simply being pulled along by their story, but they are able to write their own future together.
Object and letter. This tool can be seen as incorporating analogic and narrative elements, constituting a shift from the former to the latter. Each partner must bring an object with personal emotional value and a letter in which they explain its meaning.
In the DAN intervention, this task is set as homework following the 3D genogram and house drawing. The letter will be read and discussed in the following session, shifting in this way from the 'representation' to the 'narration' of what emerged from the genogram.
Each partner is individually asked to identify an object (an object, a song, or a photograph of an object if the object itself cannot be brought to the session for practical reasons) that reminds them of them as a couplesomething from the time they were first together or related to a moment that they believe to be essential to their relationship. They are then asked to write a letter to their partner, in which they state why they chose that particular object. The letter and the object must be kept hidden from each other, until the following session takes place. Here, they will present the object and read out their letter.
During the session exploring how the home task went, the therapist asks the couple, in turn, to show the object they chose and to read out their letter. They are then asked how they think their partner will react. Once the letters have been read, the couple is asked whether they are surprised about their partner's choice and of its significance (therefore, about the importance it has for them). The therapist then summarises what has emerged, focusing on the similarities and differences in the choice and narration of the important event for the couple, and on the ability to identify an event that may be particularly important for one's partner.
Coat of Arms. The coat of arms (also referred to as the 'heraldic shield') is used as a discharge ritual in the final session of the DAN. This task allows the couple to create their own family heraldic shield, through the representation of significant elements from their story. Firstly, the couple is instructed to decide how to structure the coat of arms, closing the upper part of it, assigning a space for their family motto, and dividing it into four sections. The four sections will all have to be filled with a picture drawn by both partners together. One of the pictures will represent their past, another their present, another their 'ideal future', and the last will represent their 'expected future.' Once this has been done, the couple will have to identify a short family motto that sums up their coat of arms and write it on it.
Once the exercise has been completed, the therapist works with the couple on linking what has been said through the coat of arms with what emerged in the previous sessions, focusing on the differences between the initial and the final narrations. The coat of arms should outline family strengths, and in this way it can be a reference point in hard times. Within the DAN intervention, couples are also given a coat of arms project to complete at home with their children.
Throughout the DAN process and in this final task, the couple has the chance to understand that it is possible to focus on content that is expressed explicitly (digital), on relations between elements (analogic), and on different points of view that emerge (narrative). It is of fundamental importance to highlight how narratives are at the same time true (as they are the reality of who narrates) but also not necessarily true (as they are someone's point of view).

The DAN structure
Having described the therapeutic tools used in the DAN, these can now be presented in the context of the manualised structure. The intervention consists of seven sessions and one follow-up (Figure 3), as outlined below. At different points throughout the intervention, the SCORE-15 (Systemic Clinical Outcome and Routine Evaluation, Stratton et al., 2010) is administered to the couple in order to gather quantitative data on changes in family functioning over time.
First session. The couple is informed of the ethical considerations connected to the themes that will be discussed and the intervention is explained. Subsequently, the SCORE-15 is administered. The therapist listens to the family story.
Second session (one week after). The couple completes their 3D genogram and house drawing. The object and letter task is set as homework.
Third session (one week after the second one). The RSPc interviews are administered individually.
Fourth session (one week after the third). The therapist provides feedback on the couple's relational styles that emerged from the RSPc results. The SCORE-15 is administered once again. The couple is given the role-reversal home task, based on inverting the roles that emerged from the RSPc that each partner would like to be different in the other.
Fifth session (two weeks after the fourth one). The couple reports their homework's outcomes and the therapist provides feedback on this. They then go on to focus on any problems, considering ways to approach these. The family meal video recording is set as a home task.
Sixth session (two weeks after the fifth one). The family meal video is discussed. Subsequently, the BFT is administered to the couple and carried out together with the therapist. At the end of the session, the couple is assigned a BFT to perform at home, with their children.
Seventh session (one month after the sixth one). The discharge ritual is performed through completing the coat of arms. This task is also set as homework, to be done by the couple with their children.

Content
Home Task  The DAN session structure [Colour figure can be viewed at wileyonlinelibrary.com] Eighth session. Two months after the seventh session, a follow-up meeting with the family takes place to review their progress and the SCORE-15 is administered once again. The structure described above has undergone a series of changes over the past several years, adapting to feedback provided by couples who took part in the DAN and trainee systemic therapists who carried out the intervention in its initial form. In this sense, it can be said that the DAN itself is a co-constructed product.

DAN and COVID
In these difficult times, the pandemic has shown us how resilience is not only a point of strength but at times can become a necessity. Systemic therapists have had to adapt, fostering their own resilience, to continue promoting wellbeing within families across the world. As we are still within the uncertain and unpredictable territory of COVID-19, the DAN intervention is offered as a map to prompt processes of reflection with couples and family systems. This allows for a merging of digital, analogic, and narrative methods to gather significant information about the system in question (the couple and their wider family) in a brief yet effective way. This simplicity provides intervention with the potential to be easily applied in counselling and therapy sessions being delivered remotely. Importantly, it is argued that the focus on processes, rather than procedures, highlights how fitting systemic tools within a manualised structure does not impede principles of the approach itself, such as that of circularity (Selvini-Palazzoli et al., 1980), or limit the creativity of practitioners.
In light of the restrictions on face-to-face working due to social distancing, we have been preparing new versions of the tools to be used through digital videoconferencing platforms, in order to allow the DAN intervention to be delivered remotely. For instance, the traditional hard paper copies of the BFT cards have become virtual jpeg image files that can easily be shared with clients through screen-sharing options or by emailing these directly to them. In this way, the RSPc, the house drawing, and the BFT have been found to be easy to administer through various tools that videoconferencing platforms offer.
On the other hand, the use of the 3D genogram has been adapted to these means by showing the instrument to the couple and asking them which wooden pieces they will choose to represent themselves and their families. It is then the therapist who moves the pieces, following the couple indications and mirroring their choices. Once the general ideas of the tool are understood, a meaning coordination can be easily reached. While most other tools have been fully adapted to the digital means (e.g., the BFT paper cards were adapted to a jpeg image format), the 3D genogram has been kept in its physical form in order to maintain its three-dimensional propertywhich would risk being lost, for instance, trying to use software such as MS Paint. However, it is not ruled out that in the future a 3D software adaptation of the tool could be developed, if needed.
In 2021 a research project at Iscra will focus on this topic and initially students will use the DAN model with their own families. An agreement with the public health system in Modena will also allow us to begin a trial comparing the results of our method with families who have not received any form of treatment and families treated with family therapy. The SCORE-15 (Stratton et al., 2010) will be administered to all groups, three times across a period of 5 months, to compare the outcomes of each experimental condition. Meanwhile, the use of the DAN model continues among our practitioners with promising results, showing a general improvement in the SCORE-15 outcomes, as well as in all other observed areas.

Conclusion
Reviewing the video recordings of the sessions and reflecting on this experience, we inevitably needed to pause to reflect on the meaning of a manualised intervention and to appreciate its apparent simplicity and transformative power: a real 'systemic challenge.' Its objective is to help the couple take time to question, focus on critical issues, but also achieve a greater awareness of one's own qualities and resources. It is an instrument to aid families in becoming 'relationally more competent,' to be able to deal more effectively with daily life, family normative transitions, and critical unexpected events.
COVID-19 has caused us to live in a different manner, closer to our family members and more distant from our friends. Furthermore, if in good health, families and family members are required to reach a new balance. This can be reached more easily by using self-reflexivity and trigenerational thinking, remembering how the future is connected to the past, that the present exists in our life cycle, if we are able to connect to it, allowing time to be our friendboth when it appears to be frozen by mourning or accelerated by the precipitation of events.
Our hope is that the DAN model will become more widely used. Over recent years, research has been conducted to demonstrate the validity of the model, which has proven to be useful and easily applicable also in the context of the COVID-19 pandemic. Our current aim is to keep working on this, strengthening our evidence base, and presenting the DAN to other countries, hoping that its benefits can be made use of widely by systemic practitioners.