Integrating Brief, Strength - based Therapy and Play ( A. K. A Play ! Play ! We Don ’ t Have All Day !”) Heather Thompson Assistant Professor of Counseling.

Integrating Brief, Strength-based Therapy and Play

(A.K.A Play! Play! We Don’t Have All Day!”)

Heather Thompson

Assistant Professor of Counseling

Western Carolina University

Integrating Brief and Play Therapy

Research

TheoryPractice

Context

• Practice

• Theory

• Research

• Trauma

• Skills

• Self-concept

• Self-efficacy

• Mastery and competence

• SFBT and Play Therapy

Practice & TheorySelf-

concept

Feelings about self

Behaviors and

Choices

Thoughts about self

Research

• Time

• Resources

• Space

• CBT & SFBT

• Social skills

• 5-10 hours group

Today’s Journey

• How is play compatible?

• Why integrate play?

• How to integrate play and brief therapy

• How to assess growth and development

Solution-focused brief therapy (SFBT)

Non-directive play therapy (NPT)

Focus on the present

Build on strengths

Help children experience

positive behaviors

Build self-efficacy

Focus on the present

Build on strengths

Help children experience positive

behaviors

Build self-efficacy

Compatibility

Solution-focused brief therapy (SFBT)

Non-directive play therapy (NPT)

• Establish and work toward

goals

• Promote behavioral change

• Promote decision-making and self-

responsibility

• Enhance frustration tolerance

• Facilitate emotional regulation &

impulse control

• Facilitate understanding and

expression of emotions, intentions,

wants, desires

• Promote understanding of the

connection between emotions,

intentions, reactions, and behaviors

Why Integrate Play?

Why Integrate Play?Evidence-based (school counseling withelementary-aged children)

• 16 sessions decreased ADHD and anxiety symptoms (Ray, Schottelkorb, & Tsai, 2007)

• 14 sessions decreased behavioral problems(Ray, Dee, Blanco, Sullivan, & Holliman, 2009)

• 10 sessions improved internalizing and externalizing reported by teachers and parents (Flahive & Ray, 2007)

• 8 sessions for academically at-risk increased academic achievement (Blanco & Ray, 2011)

• 6 sessions increased self-efficacy (Fall, Balvanz, Johnson, & Nelson, 1999)

• 4 sessions increased self-esteem and internal locus of control (Post, 1999)

http://www.youtube.com/watch?v=_4ovwAdxCs0

Why Integrate Play?

• Developmentally appropriate

– Trust, autonomy (self-control), initiative (power), and

industry (confidence)

– Unable to verbally express complicated emotions [guilt,

shame, resentment] and how they are affected by them

– Young children can feel, but they cannot analyze their

feelings and thoughts

– Metacognition (knowledge about our cognitive

processes and how to regulate them – choosing “the

right tool for the job”) is limited

• Assimilate experience through symbolic

play

Play + imagination = re-enactment and

reorganization of the original experience

Memories are altered each time they are

revisited and that alteration is influenced by

the impact of the present moment

Why Integrate Play?

Multimodal Integration Left Hemisphere

Explicit Language-based Knowledge

Language, speech, analytical thinking and sequential processing,

and the process of creating narrative

Right HemisphereImplicit Sensory-based

KnowledgeIntuition, emotions,

sensory, automatic skills, and creativity

Various modalities by which the brain constructs and stores

experiences. Play engages two main forms of cognition: explicit

and implicit thought.

Play accesses non-verbal sensory-based knowledge and stimulate

the left and right hemispheres and integration of knowledge

(Levy, 2008)

Implicit Cognitions• Are not easily described with words

• Occur outside of our awareness because they are not embedded

in a narrative

• Do not require cognitive mediation through the cortex

• Are not consciously recallable until integrated with explicit

cognition

• Early attachment experiences become implicit memories

• Become relational patterns that influence future relationships

• Play allows for the restructuring of implicit attachment issues

• Play facilitates integration

(Fosshage, 2004; Kay, 2009; Lyons-Ruth, 1999; Pally, 2005)

Observe Neurons fire (as if)

Affective resonance Empathy

• Early life trauma decreases capacity for

perspective-taking

• Hypothesize that this may be due to failure or

under-development of Mirror Neurons

Mirror Neurons & Perspective-Taking

(Fogerty, 2009 ; Iacoboni 2005; Rizzolati & Craighero 2004; Wolf et al. 2001)

Brain Derived Neurotrophic Factor (BDNF)

• Chemical compound that prevents

cell death and facilitates growth of

new neurons

• Reduced by chronic stress and

depression

• Increased by play therapy (Gordon et al., 2003; Kolb & Wishaw 2003)

Why Integrate Play?

– Self-control (emotional regulation, attention

control, impulse control)

– Self-efficacy (self-esteem, confidence)

– Social skills (consideration for others, reading

social/emotional cues, perspective-taking)

(Arnold, Kupersmidt, Voegler-Lee, & Marshall, 2012; Brody, Flor, & Gibson, 1999; Jimerson, Egeland, Sroufe, & Carlson, 2000; McLelland, Morrison, & Holmes, 2000; Raver & Zigler, 1997; Vidal, Rodeiro, Emery, & Bell, 2012;

Vitaro, Laroque, Janosz, & Tremblay, 2001; Von Suchodoletz A, Gestsdottir S, Ragnarsdottir H, et al., 2013)

Why Integrate Play

• Assess real-world application

• Freeze-frame

How to integrate

• 35 minute session• 15 structured exercise – Developing goals– Monitoring success– Teaching skills– Practicing skills

• 20 non-directive play therapy– Multimodal integration– Real-world application– Freeze-frame

SFBT Goals Corresponding SFBT TechniquesEstablish and work toward goals

Establish and work toward goalsPromote behavioral change

Build on strengths Build self-efficacy

Build on strengthsBuild self-efficacyPromote behavioral change

Build self-efficacy Promote behavioral change

Miracle question: “A miracle happens while your asleep…”

Specific, concrete, behavioral goals: “What would you be doing differently if you weren’t feeling so sad?”“What would others notice if you weren’t feeling so sad?”“How would others respond to you if you weren’t feeling so sad?”

Exceptions: “Tell me about a time when you experienced a small miracle?”

Scaling questions: “Rate your success on a scale of 1-10.” “How come it was a 5 and not a 4?” “What can you do to make it a 6?”

Positive reinforcement:Acknowledging efforts, reminding the child of past or unacknowledged successes, and encouraging child to think of ways to move up the scale – “Wow and How”

NPT Goals Corresponding NPT Techniques

Conscious awareness of emotions, intentions, needs, etc.

Draw on strengths & builds self-efficacy

Build self-efficacy & enhance frustration tolerance

Promote decision-making and build self-efficacy

Facilitate emotional regulation and impulse control & promote decision-making and self-responsibility

Reflecting feelings, prosocial behaviors, intentions, and meaning

Reflecting success, exceptions, and positive changes

Facilitating esteem and encouragement FEE

Facilitating decision-making and self-responsibility FDR

Limit setting LS

Play Therapy Techniques

AA – acknowledging nonverbal behaviors

RF – reflecting feeling, intentions, experiences,

needs, wants, hopes, and desires

FEE – facilitating esteem-building and

encouragement

FDR – facilitating decision-making and responsibility

LS – limit setting

http://www.youtube.com/watch?v=JIMWOOlR_9g

Tracking - Labeling Toys

• Avoid labeling toys

– Reasonable to label clearly defined toys

• Children will often correct you

– “It’s not a dog. It’s a baby.”

• Be non-gender-specific

– “You’re showing it who’s the boss.”

Tracking

• Octavious pushes a truck across the

sandbox.

• Celia scoops up sand and puts it in a

bowl.

• Ashley gets up and begins looking

around the room.

Reflecting Feelings

• Avoiding leading, influencing, or judging

– “I wonder what would happen if the mean witch

was nicer to the children?”

– “You seem angry with the puppy. I wonder how

that little dog feels?”

– “You want other people to be nice to you when

you’re sad, but you’re mean to the doll when it

cries.”

Reflecting Feeling, Meaning, Intentions

• Ashley: Begins to write on the chalk board. “I like to draw

on the board, but my teacher said the board is just for her.”

– You wish you could draw on the board too.

• Ashley: Looks at you with her hands on her hips and says,

“We don’t get to play when we want to either. We have to

do what the teacher says.”

– It’s frustrating when you can’t play when you want to.

• Ashley: Picks up the bubbles and smiles. She blows a

bubble and laughs.

– You feel happy when you blow bubbles.

• Avoid giving advice, hints, suggestions

– “Maybe if you put the other end in first it would

fit.”

– “I’m sure you’ll figure it out if you keep trying.”

– “I wonder what would happen if you flipped it

over.”

Facilitating Decision-making

Facilitating Decision-Making• Celia: Enters the playroom, looks around the room, and says:

“What should I do?”

– In here, you get to decide. You can play with the toys in many of the

ways that you might like to.

• Celia: Picks up a crayon and piece of paper and says: “I know

what I can do.”

– You figured it out. You know exactly what you want to do.

• Celia: Begins to draw and says: “I’ll make a birthday card for

Jess.”

– You’ve decided to make a card for your friend.

• Celia: “What colors should I use for my rainbow?”

– You can choose what colors you’d like for your rainbow.

• Rita washes her hands and then looks at you and says “How do I dry my

hands off?”

– “You don’t like it that your hands are wet and you’re not sure how to

dry them off.”

• Rita responds, “Can I use the blanket?”

– “You think the blanket might work. You can choose to use the blanket.”

• Dedra writes a word on the dry erase board and asks with a perplexed look

“Did I spell it right?”

– “You look confused. You’re not quite sure it’s right.”

• Dedra responds “I know. Is it right though?”

– “It’s important to you that you spell the word just right. In here, you

can spell words anyway you want to.”

• Debra says, “But is it right?”

– “You really want to get it right. Well let’s see if we can figure it out

together…”

• Empower children to struggle with new

challenges

• Help children learn to deal with frustration

– “You’re trying to put those two pieces

together…It’s frustrating when it doesn’t do

what you want…Now you’re trying a different

way…You figured it out! You feel proud.”

Facilitating Esteem

Facilitating esteem

• Do not praise or criticize the child’s

play, behaviors, art, etc.

– Negates internal locus of evaluation

– Negates permissiveness

Facilitating Esteem & Encouragement

• Octavious: Builds a tall tower out of blocks and says: “Look at this. Isn’t it

amazing?”

– You worked hard and you’re proud of your work.

• Octavious: “Yeah. But what do you think of my tower?”

– You want to know what I think of your tower, but what matters is how

you feel about your tower.”

• Octavious: Walks over to the chalkboard and says: “I am proud of my

tower. I know how to do multiplication.”

• You’re proud of your tower and you’re proud of your math skills.

• Octavious: Multiplies the numbers 20 times 20 and writes 400 on the

board. He says, “Look at this!!”

– You know how to do multiplication with big numbers and you’re

excited about it.

Limit Setting

• Protect child, therapist, or materials

• Helps child feel secure

• Promotes therapist acceptance of

child

• Facilitates decision-making, self-

responsibility, and self-control

ACT Model of Limit Setting

• Acknowledge the feeling, want, desire. “You really want to paint the wall.”

• Communicate the limit. “The wall is not for painting”

• Target acceptable alternative. “You can choose to paint the paper, or you can choose to paint on the popsicle sticks.

• If you choose to paint on the wall, you choose not to play with the paint anymore today (Child paints on the wall).

• I see you have chosen not to paint today. You can choose to put the paint brush on the easel or you can choose to put the brush on the shelf.

Limit Setting • Jess: Picks up a dart gun and aims at you.

– Looks like you’d like to shoot me with that gun, but people are

not for shooting. You can choose to shoot the wall or you can

choose to shoot the pillow.

– You’d really like to shoot me with that gun, but…

– It you choose to shoot the gun you choose not to play with it

anymore.

– I see you’ve chosen not to play with the gun. You can choose

to put it on the table or you can choose to give it to me.

• Ashley: “What would happen if I pulled the head off this doll?”

• Octavious: “I don’t have any cars like this at my house. Can I

take this one? I’ll bring it back next week.”

Questions

• Do not ask questions

• Be careful how you respond to

questions

• Listen empathically and respond to the

intention of the question

Responding to Questions• “What is this?”– “You’re trying to figure out what that is.”

• “Is this a real knife?”– “You’re surprised to find that in here.”

• “How much time is left?”– “I’ll let you know when we have 5 minutes left.”

• “Why do you talk like that?”– “You think I talk funny.”

– “That’s just the way I pay attention to you.”

Strength-based Assessment Strategy

• How do we know if our intervention

was effective?

– First, we identify what it is that we wish

to accomplish.

– Second, we find a way to determine if

our goals are being met.

Strength-based Accountability Strategy

• School success behaviors

– Self-control (emotional regulation, attention

control, impulse control)

– Self-efficacy (self-esteem, confidence)

– Social skills (sharing, taking turns, reading

social/emotional cues, perspective-taking)

(Arnold, Kupersmidt, Voegler-Lee, & Marshall, 2012; Brody, Flor, & Gibson, 1999; Jimerson, Egeland, Sroufe, & Carlson, 2000; McLelland, Morrison, & Holmes, 2000; Raver & Zigler, 1997; Vidal, Rodeiro, Emery, & Bell, 2012;

Vitaro, Laroque, Janosz, & Tremblay, 2001; Von Suchodoletz A, Gestsdottir S, Ragnarsdottir H, et al., 2013)

Self-control • Taking turns • Sharing • Listening• Not giving

up • Solving a

problem

Self-efficacy • Helping

someone • Not giving up• Solving a

problem• Making a

good choice• Creating

something• Having fun

Social skills• Taking turns • Sharing • Apologizing• Helping

someone• Listening to

others• Complimenting

Strength-based, specific, and concrete behaviors

•Evidence-based•Developmentally appropriate•Integration of explicit and implicit knowledge•Promotes school success skills

Integrate because…

•Reflection, Facilitating Esteem, Facilitating Decision-making, Limit Setting

Techniques include…

•Self-control•Self-efficacy•Social skills

Assess behavior change

Questions? Comments?

Email [email protected]