THE IMPACT OF Play Therapy for TRAUMA ON CHILDREN …hstrial-lrochford.homestead.com/3_Handouts.6_slides_per_page.pdf · Play Therapy for Traumatized Children ... Nondirective Techniques

4/30/2012

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Play Therapy for Traumatized

Children

An Integrated Model for

Working with Childhood

Trauma Utilizing

Directive and

Nondirective Techniques

THE IMPACT OF TRAUMA ON CHILDREN Traumatic events can be

stressful, debilitating, painful,

and confusing. Recovery

includes helping individuals

restore physical and emotional

control and safety. Treatment

best done in context of a safe

relationship and hope.

Traumas are laid down differently in memory;

explicit versus implicit memories

Traumas are often fragmented or

compartmentalized experiences

Dissociation is highly linked to trauma

Dissociation occurs along a continuum: normative,

episodic, and a range of disorders

Dissociating during traumatic events good

predictor of development of later PTSD

Brain chemistry and the impact of stress

Trauma affects the whole person: Responses must

be wholistic

“ not eve r y ch i ld w i l l be a success stor y , but we should assume eve r y th ing i s r eve r s i b le unt i l p r oven othe rw ise ” B e sse l van d e r Kolk

AFFECT

COGNITION

SENSORY VISUAL

AUDITORY

BEHAVIOR

Clinical Goal: ASSIMILATION OF

FRAGMENTS Removing Dissociative

Barriers: Mastery

The process of assimilation

What did you say to yourself about that?

As you said that, what did your body do?

What were you looking at/hearing?

How did you feel?

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Impact on specific domains in complex trauma

Attachment is often a central issue

Biology: Recent research on the effects of stress on the development of the brain (0-4, most vulnerable: (Siegel, 1999; Perry & Szalavitz, 2006; Stien & Kendall, 2004)

Affective and Behavioral Dysregulation

Dissociation (more common in females)

Cognitive functioning (deficits in overall IQ, need special ed, lower grades, poor scores on tests, 3 x the dropout rate)

Issues of Identity: Self-image and self-esteem

Consensus Areas for Treatment Recommended by

NCTSN Six Core Components of complex trauma

intervention (NCTSN):

Safety (the child feels cared for)

Self-regulation (helping child modulate arousal)

Self-reflective information processing (reflect)

Traumatic experiences integration (resolution)

Relational engagement (appropriate attachments)

Positive Affect Enhancement (self-worth)

As a result, my approach to treatment includes:

1. Lead with non-directive approach with child which a) allows for child to be in charge and 2) allows natural healing mechanisms to emerge

2. “tickle the defenses” create opportunities to stimulate natural healing mechanisms

3. Directive strategies: gently challenge child’s defenses in service of the child and obtain systemic support (the shift to psychoeducation)

Engage/educate parents to do work at home

Utilizes three Phases of Treatment (Judith

Herman) Phase One Goal: Focus on Safety

Primarily active approach through advocacy and case management: Safety in school and home (child’s environment) (Medical): Parent services/coaching

Predictability of child’s therapy environment

Assess child’s utilization of Post-Traumatic Play and other natural healing strategies (Gil,2006)

Observation of defensive mechanisms: Pacing

Address acute symptoms w/caretakers/child

Introducing the Play Therapy Room: The Tour Play Therapy Offices

Sand Therapy

Art Therapy

Doll-house, babies, bottles

Trucks, fire engines, cars

Masks, capes

Puppets and Theater

Constructive toys

Medical

Food, plates

Miscellaneous: Music

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Phase One: Safety and Assessment

Orient the child to environment and clinician

Establish therapy relationship (foundation of work) & set context

Meet child where child is

Provide nondirective therapy primarily

Include play-based assessment techniques

Allow for accessing of natural reparative resources (Post-trauma play)

The Benefits of Child-Centered Play Therapy

Offers child opportunities for self-direction

Avoids power struggles

Allows child to externalize whatever is on his/her mind

Encourages self-regulation

Based on belief that play offers child varied communication opportunities

Relationship-promoting

Brain science suggests play useful: Encouraging

Plasticity Relationship (touch)

Novelty

Physical Exercise (Aerobic)

Mindfulness or focused attention

Nutrition

Sleep

Repetition & sensorimotor stimulation

Cautions

Externalization does not necessarily

mean child is ready to see, confront,

or deal with externalized material in

any other way than that provided

through play

Play therapy variables:

Externalization, safe-enough

distance, projection, management,

processing

The dangers of “rushing in”

Phase One: Safety Efforts

Advocate & Case

Manager: Foundation

Case coordination

Finding those invested

in child

Clarifying what’s going

on to best of our ability

Maintaining focus on

risks

The initial phase of treatment is designed to establish a therapy relationship (comfort and security); to orient the child to the environment; to gain some assessment information; and to create a treatment team that works in the best interest of the child. Looking for an invested other, who is primarily interested in the child, is critical. In addition, asking parents for assessment information assists us in helping the child.

Parents’ assessment instruments include:

Child Behavior CheckList (Achenbach – ASEBA)

Child Sexual Behavior Inventory (Friedrich – PAR)

Trauma Symptom CheckList for Young-Children (TSCC-YC – PAR) Children fill out:

Trauma Symptom Checklist for Children (Briere –

T S C C – P A R )

First Phase of Treatment – Parental Engagement

(Cont’d) Guiding parents to support, set limits,

manage problem behaviors, answer questions

ATTACHMENT-BASED THERAPIES

Crisis intervention with parents: Referrals to groups, readings (Common issues: family loyalty and splits; who knows; system procedures)

Identify family strengths and available resources (w/attention to the presence of cultural practices and integration of those)

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Play-Based Assessment Techniques: Integrating

directives gradually Art

Free picture: Anything you want, anything that comes to mind

Self-portrait

Kinetic Family Portrait: A picture of you and your family doing something together, some type of action

Benefits, Challenges, and Use of Art Therapy

Staying with the

metaphor

Amplification

Finding thematic

material

Prioritizing and

locating entry

points

Exploration vs

interrogation

Art Therapy a valuable

assessment tool

Malchiodi, C. (1998).

Understanding

children’s drawings.

NY: Guilford

Publications

Processing Art

Right versus left-hemisphere activity

Subjective experience of “life of the

picture

Developmental issues: On or off-

target

Words or messages

Spending time with the art

Amplification questions/comments

Build a World: Sand Therapy

As you can see, this box is filled with soft, white sand

Pick as few or as many miniatures and build a world in the sand

…or anything that comes to mind

No right or wrong way to do this

Tell me about what you’ve built

Color Your Feelings

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ENVIRONMENT AND SAFE ENVIRONMENT PROJECT

Developed by Barbara Sobol and Karen Schneider

Projective Technique

Basket of miniatures the child can take

Pick an animal, then build an environment:

Now make the environment safe

New directive

Individual Play Genogram

Draw a picture of a family play genogram

Pick a miniature(s) that best show thoughts and feelings about everyone in your family

Pick a miniature that shows relationship between you and others

Other Expressive Techniques

Phase One: post-trauma play can emerge naturally

Children bring

their traumas into

the room

The unconditional

witness

Valuing what is

created/showing

interest

Therapeutic

curiosity

Post-Traumatic Play: Natural Reparative

Mechanism

Post-Traumatic Play: Gradual Exposure

Inviting, documenting, facilitating, intervening

Observing changes

Affective variables/discharge

Differences in relational interactions

Changes in out-of-session behaviors

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Definition of PTP

Definition:

Post-Traumatic Play is a unique type

of play employed by traumatized

children. This play has several

characteristics:

Characteristics of Post-Trauma Play

Literal

Robotic, rigid, extremely structured

Repetitive

Usually non-interactional

Children can seem self-absorbed

Can utilize sounds

Flat affect seen/joyless

Advantages of trauma play

Intent:

Mastery through gradual exposure, tolerance and expression of affect, controlled recall

Organization versus fragmentation/chaos

Creation of Narrative (explicit vs implicit)

Active versus passive stance

Remembering while not having acute pain

Processing or “working through”

Eventual assimilation/suppression of processed material

Facilitation and/or spontaneous play TF-PT

Provide literal symbols

Ask child to bring symbols from home

Set context: express interest in

learning more about/understanding

event(s)

Show versus tell

When spontaneous, observe,

document with care & precision

Assessing Trauma Play for Usefulness: Search for

Change Changes

In characters

In story themes

In beginnings or endings

In sequence

In affective expression

In verbalizations or interpersonal

exchanges

External Interventions with Trauma play that gets

“stuck” Behavioral narratives

Efforts to change sequence

Wondering outloud

Eliciting personal

interactions/movement of some kind

Role-playing

Open-ended questions

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“Stuck” trauma play

Videotaping

Mirroring

Story Boards

Shifting from Non-Directive to

Directive

The need for more distance

The need to access resources and create

changes in play

Desired Outcome

Explicit narrative with acquired meaning

Expression of affect

Processing accomplished at developmental level (Eventual cognitive re-evaluations)

Coping strategies/Mastery

Future orientation: View of event(s) in the past and realistically (“Something that happened to me, not who I am”)

Traumatic Material Integrated, Loss Processed

Phase Two Goals and Approaches: Trauma-Focused Work: Overriding Goal: Empowerment/Integration

Trauma-focused work, by definition, attends to traumatic experiences, although approaches vary. Attempts are made to:

help children clarify and understand their thoughts, feelings, sensations, responses;

identify cognitive confusions and discuss;

assist to identify, express, and regulate emotions and self-soothe, develop healthy alternative coping strategies;

experience mastery through controlled recall; organize a narrative; utilize supportive system/attach; future orientation

Phase two: process trauma which emerges naturally or invite part ic ipat ion

PHASE TWO INCLUDES

SESSIONS REGARDING

MINDFULNESS STRESS

REDUCTION AND THE

USE OF BIO-DOTS;

PSYCHOEDUCATION

ABOUT “OTHER KIDS

WHO ARE ABUSED”;

TEACHING THE CBT

TRIANGLE, AND THEN A

FEW SPECIFIC TASKS

ABOUT THE ABUSE AND

“NARRATIVE .”

THE EMPHASIS ON CONSCIOUS PROCESSING

When children select their

symbols, their metaphors, their

stories, their outcomes, their

helpers, their struggles, their

victories…must they be linked

to real-life experiences? And

what risks do you run in doing

so?

(Example of “This mommy has

no Milk”)

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The need to face carefully

“Though the single most common therapeutic error is avoidance of the traumatic material, probably the second most common error is premature or precipitate engagement in exploratory work, without sufficient attention to the tasks of establishing safety and securing a therapeutic alliance.” Judith Herman, 1992, 1997, p.172

A metaphor: bubble wrap and clarity

Respecting defenses

“And the day came when the risk

to remain tight in the bud was

more painful than the risk to

blossom” Anais Nin

Phase Two More Directive Tasks: Challenging Denial

RECONSTRUCTIVE

TASKS

The child is given task to pick a miniature, doll, puppet that represents him/her and something that represents alleged offender. “Show me what happened first, next, next”

Situational: Where were you, what happened then?

Repeat and sequence

CARTOON NARRATIVE

This is what you’ve told me so far, then this, then this. (Draw it out for child or child draws on page with boxes)

Fill in bubbles for “head, heart, and feet…what you said to yourself, what you felt, what you did”

PHASE TWO

The Color Your Life Technique (O’Connor)

Sand: Before and After I Told About the Abuse

PHASE THREE: SOCIAL RECONNECTION

FLOWERS IN VASE:

RESOURCES IN YOUR

LIFE HOPE FOR THE

FUTURE: GLASS HALF-FULL, HALF EMPTY

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SAYING GOODBYE PROPERLY

CELEBRATION DESIGNED TO

REVIEW MATERIALS; OFFER

RESOURCES; OBTAIN

COMPLETED ASSESSMENT

INSTRUMENTS; MAKE

REFERRALS AS APPROPRIATE;

CELEBRATE THE COMPLETION

OF TREATMENT.

Goal Three Work and Approaches

Phase Three Goal: Social

Reconnection and Future Orientation

Pair Therapy, Group therapy, and family

therapy

Discussion of trust and safety (what’s been

learned) Anchoring in resources

Promoting competence and well-being

Prevention and skills training (education

and family dialogue)

Rationale for Use of Expressive Techniques

Opportunity for varied expression & externalization of self :

Assists communication

Allows for safe distance through projection, management,

processing

Intrinsically pleasurable & user friendly

Brings forth metaphors and helps narrative formation

Offers opportunities to contain, master, regain personal control

Challenges defenses gently

Rationale for TF-CBT

Focuses on direct management of trauma

Active use of parental support

Creates self-monitoring possibilities

Teaches control through mastery of thoughts, feelings, and behavior

Treats the system to address trauma variables (fear, safety) through direct skill-building & specific techniques (relaxation, in vivo work)

The Sequence of Interventions

There is a consensus of areas to

target in therapy;

There are varied, evidence-based and

evidence-informed, trauma-informed

practices;

Dr. Bruce Perry suggests the most

critical factor is not WHAT we do (all

have merits) but WHEN we do it!

Basic Principles of NMT: Dr Bruce Perry, Child Trauma

Academy Hierarchy of increasingly complex

functions relate to optimal functioning;

“Lower” parts, brainstem and midbrain mediate simple regulatory function; more complex functions mediated by neocortical structures.

Experiences leave a “record” within matrix of brain, dependent on nature of experience and time in development

Developmental challenges & relationships contribute to risk or resiliency: mediating factors

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THE BRAIN MATTERS & ATTUNED CAREGIVERS

MATTER Resources Abound

Helpful manual for CBT

Stallard, Paul

(2002). Think Good – Feel Good: A cognitive behaviour therapy workbook for children and young people. NY: John

Wiley.

THINK

FEEL

DO

Important Assessment/Treatment

Models Bruce Perry’s Neurosequential Model of Therapy

Pathways Assessment-Based Trauma Model (Chadwick

Center, San Diego, CA)

An Integrated Model for Treatment of Early Child Abuse

(Cincinnatti Children’s Medical Center, 513-558-9007)

Blaustein, M. E., & Kinniburgh, K. M. (2010).

Treating traumatic stress in children and

adolescents: How to foster resilience through

attachment, self-regulation, and competency (The ARC Model). NY: The Guilford Press

Important Assessment/Treatment

Models Complex Trauma Working Group of the

National Child Traumatic Stress Network (www.nctsnet.org/nccts/nav.do?pid=typ_ct)

TF-CBT (www.musc.edu/tf-cbt)

CBT for physical abuse

Dr. David Kolko (www.pitt.edu/~kolko/

Eye-Movement Desensitization and Reprocessing

Originator Francine Shapiro

EMDR for children (www.childtrauma.com/endrch.html)

Integrative Treatment of Complex Trauma and Self-Trauma [email protected]

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Evidence-Based/Practice-Informed

Keeping up with data

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT: Deblinger, Cohen & Mannarino)

Parent-Child Psychotherapy

(PCP: Lieberman & vanHorn)

Child-Parent Interaction Therapy (Eyberg; UCDavis)

Measuring your effectiveness

Circle of Security (Cooper, Hoffman, Marvin, & Powell) (www.circleofsecurity.com)

Filial Therapy (Guerney)

Child-Parent Relationship Therapy (CPRT: Landreth and Bratton)

Neurosequential Model of Therapy (NMT: Perry)(www.childtraumaacademy.com)

Others in process.

SELF-CARE IS CRITICAL TO OUR

CLIENTS

I have worked with trauma

since 1973. I have had bouts of

burnout. I use expressive

therapies for self -care as well

as humor, time in nature, time

with animals and nonabused

children, I turn to my family, I

use mindfulness and yoga.

Citations in Handout

van der Kolk, B. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35:5, 401-408.

Siegel, D. J. (1999). The developing brain: How relationships and the brain interact to share who we are. NY: Guilford Press

Stien, P.T. & Kendall, J. (2004). Psychological trauma & the developing brain:Neurologically based interventions for troubled children. NY: Haworth Press

Citations in Handout

Perry, B. & Szalavitz, M. (2006). The boy who was raised as a dog. Basic Books

Kendall-Tacket, K. Williams, L.M. & Finkelhor, D. (1993). Impact of sexual abuse on childen: A review and synthesis of recent empirical studies. Psychological Bulletin, 113, 164-180.

Malchiodi, C. (1998). Understanding children’s drawings. NY: Guilford Press.

Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective approaches. NY: Guilford Press

Selected References

Gil, E. (2003). Play Genograms, In C.F. Sori & L.L.Hecker, The therapist’s notebook for children and adolescents, pp.49-56, NY: Haworth Press.

Lowenfeld, M. (1979). The World Technique. London: Allen & Unwin.

Peterson, L.W. & Hardin, M.E. (1997). Children in distress: A guide for screening children’s art. NY: W.W.Norton.

References (Cont’d)

Reddy, L. A., Files-Hall, T. M., & Schaefer, C. E. (2005). Empirically based play interventions for children. Washington, DC: APA

Friedrich, W. N. (2002). Psychological assessment of sexually abused children and their families . Thousand Oaks, CA: Sage

Cohen, J. A. & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child & Ad Psychiatry, 35, 42-50.

Kolko, D. J. & Swenson, C. C. (2002). Assessing and treating physically abused children and their families: A cognitive behavioral approach. Thousand Oaks, CA: Sage Pub

Carey, L. (Ed.), (2006). Expressive and creative arts methods for trauma survivors. Jessica Kingsley, London

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References (Cont’d)

Webb, N.B., (Ed)., (2006). Working with traumatized youth in child welfare. NY: Guilford Press

Siegel, D. J. & Hartzell, M. (2003). Parenting from the inside out. NY: Jeremy Tarcher/Penguin

Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective approaches. NY: Guilford Press

Weber, A. & C. Haen (2004). Clinical applications of drama therapy in child and adolescent treatment. Philadelphia, PA: Routledge

Bratton, S. C., Ray, D. & Rhine, T. The Efficacy of Play Therapy with Children: A meta-Analytic Review of Treatment Outcomes, Professional Psychology: Research and Practice, 36:4, 376-390.

References (Cont’d)

Weber, A.M. & Haen, C. (2005). (Eds.), Clinical applications of drama therapy in child and adolescent treatment. New York: Guilford.

Greenspan, S. I. (1997).Developmentally based psychotherapy. Madison, CT: International Universities Press.

Homeyer, L. & Sweeney, D. Handbook of Sandplay Therapy. (available from Self Esteem Shop)

Guerney, L. (2003). Filial therapy. In C. E. Schaefer (Ed.), Foundations of Play therapy (pp. 99-142). New York: Wiley.

References (Cont’d)

Deblinger, E. & Heflin, A.

(1996).Treating sexually abused children and their families: A cognitive behavioral approach. Thousand Oaks, CA: Sage

Schaefer, C. E. (1993). The therapeutic powers of play. Northvale, NJ: Aronson

Professional Association/Organizations

National Center on Child Abuse and Neglect (NCCAN)

The National Child Traumatic Stress Network (NCTSN)

National Center on the Prevention of Child Abuse (NCPCA)

American Professional Society on the Abuse of Children (APSAC)

Childhelp USA

The Child Trauma Academy (E-LEARNING ON TRAUMA AND ATTACHMENT)

American Association on the Treatment of Sex Offenders (ATSA)

Professional Association/Organizations

American Art Therapy Association

(AATA)

Association for Play Therapy (APT)

FOR INFORMATION

ELIANA GIL, PH.D., GIL CENTER

FOR HEALING AND PLAY

PHONE: 202-257-2783

EMAIL: [email protected]

WEBSITE: WWW.ELIANAGIL.COM

AND WWW.GILCENTER.COM