Yes Virginia, Play In Therapy is Evidence Based

Evidence  Based  NeuroCogni2ve  Play  

Lynne  Kenney,  PsyD  www.lynnekenney.com  

EBT’s  CBT  &  Play  

! One  challenge  clinicians  who  use  play  as  a  modality  encounter  is  how  to  write  treatment  goals  and  progress  notes  that  incorporate  evidence-­‐based  methods  into  their  work.  

! What  follows  are  evidence-­‐based  methods  and  modali2es  one  may  reference  in  treatment  plans          and  progress  notes.    The  key  is  to  focus  on  the  rela2onships  between  the  skill  deficits  and  what  cogni2ve-­‐behavioral  or  evidence-­‐based  tools  you  use  to  meet  treatment  goals.  

CBT  Assump2ons  

! Thoughts  determine  feelings  and  behaviors    ! Psychological  disorders  involve  maladap2ve  thinking  

! CBT  helps  a  pa2ent  overcome  difficul2es  by    ! iden2fying  and  changing  dysfunc2onal  thinking    ! Changes  in  thinking  are  presumed  to  lead  to    ! Changes  in  Feelings  ! Power  to  choose  new  behaviors  

Communica2on  Skills  (Mahaffy  &  Kenney,  2012)  

!  Language  –  Recep2ve  –  Expressive/Labeling  –  Intraverbal  (asking  and  answering  “Wh”  ques2ons,  commen2ng,  etc.)  –  Interverbal  (knowing  what  you  are  saying  outloud)  –  Vocabulary  (generaliza2on  and  discrimina2on  of  new  words)  –  Social  Language  (pragma2cs)  

•  Gree2ng  •  Informing  •  Reques2ng  •  Talking  turns  in  conversa2on  •  Staying  on  topic  •  Informing  the  uninformed  listener  •  Asking  for  help  when  not  understanding  •  Rephrasing  when  misunderstood  •  Introducing  topics  •  Telling  a  story  or  experience  in  a  clear  sequence  

Communica2on  Skills  II  

–  Vocal  Imita2on  –  Tone  (high,  medium,  low,  angry,  sad,  defiant)  –  Volume  of  voice/voice  inflec2on  –  Syntax  and  Grammar  –  Requests  (making  and  responding  to)  –  Interpersonal  (sta2ng  needs  and  requests)  – Managing  verbal  impulsivity  –  Responding  calmly  and  appropriately  – Managing  talking  space  between  speaker  and  listener  –  Using  appropriate  facial  expressions  –  Refraining  from  sarcasm  or  belialing  

Social  Competency  Skills  

–  Eye  contact  – Gree2ngs/Goodbyes  (addressing  friends  by  name)  

– Ask  “on  topic”  ques2ons/comments  (age  appropriate)  – Manners  (please/thank  you/  “May  I___?”)  

–  Reading  social  cues  –  Reading  non-­‐verbals  – Understanding  social  norms  –  Repea2ng  social  rules  of  engagement  

Group  Engagement  Skills  

Sidng  s2ll  in  circle  2me  Staying  on  task  in  circle  2me  Responding  with  raised  hand  

Transi2ons  between  tasks  Following  rules/direc2ons  Ini2a2ng  tasks  Remaining  on  task  un2l  comple2on  

Group  responses/songs  

Par2cipa2on  in  group  ac2vi2es  

Following  mul2-­‐step  direc2ons  

Copying  from  model  Cleaning  up  

Family  Interac2on  Skills  

Listening  with  eye  contact,  nodding,  repea2ng  back  

Responding  with  ac2on  

Responding  with  words  

Monitoring  verbal  tone,  rate  of  speech  and  volume  

Responding  to  single  task  demands  

Responding  to  series  of  task  demands  

Responding  immediately  when  asked  to  do  so  

Using  task  lists  

Self-­‐ini2a2on  in  tasks  

Nego2a2ng  politely  Using  manners  

Responding  to  2me  limits  

Caring  for  another’s  needs  with  words  or  ac2ons  

Respec2ng  space/privacy  

Accep2ng  “no”  

Choosing  an  alterna2ve  when  the  answer  is  no  

Managing  verbal  intrusions  

Wai2ng  one’s  turn  

Managing  2me  

Types  of  Play  

! Child-­‐centered  ! Communica2on  related  ! Cogni2ve-­‐behavioral  ! Direc2ve  ! Expressive  arts  ! Imaginary  play  ! Non-­‐direc2ve  ! Medita2on  ! Mindfulness  ! Movement  

! Parallel  Play  ! Perpendicular  Play  ! Reciprocal  Play  ! Re-­‐construc2ve  Play  ! Sand  Tray  ! Social  skill  related  ! Story-­‐telling  ! Trauma-­‐based  ! Visualizing  and      verbalizing  

Tools  of  Play  

! Dolls  &  Dollhouses  ! Drawing  and  Art  ! Kimochis  ! Medita2on  and  Mindfulness  ! Music  and  Dance  !  Playgrounds  !  Puppets  !  Sand  Tray  !  Sport  Courts  !  Therapy  animals  ! Water/bean  tables  

Modali2es  

! Child-­‐centered  Play  ! Solu2on-­‐focused  Play  ! Behavior  Modifica2on  ! Cogni2ve  Behavioral  Therapy/EBT  

! Developmental  Play  ! Psycho-­‐educa2on  ! Skill  Development  

! Auditory,  learning,  social,  communica2on,  academic  

Techniques  

!  Alliance  Building  !  Animals  !  Art    !  Child  as  teacher  !  Games  !  Make-­‐believe  !  Modeling  !  Music  (inTime,  drums,  body  as  orchestra)  !  Pretend  !  Sand  Tray  !  Scaffolding  !  Social  Stories  !  Worksheets  

Cogni2ve  Restructuring  

!  Iden2fy  nega2ve  thoughts  that  predict  bad  things  will  happen-­‐  thinking  traps  

!  Evaluate  nega2ve  thoughts  to  determine          if  they  add-­‐up  

!  Use  realis2c  posi2ve  self-­‐talk  to  argue          with  nega2ve  thoughts  and  reshape  thoughts  

!  Replace  thinking  traps  with  coping  thoughts  !  Challenge  Nega2ve  Thoughts  !  Challenge  Nega2ve  Expecta2ons    !  Posi2ve  Self-­‐Talk    

Ac2ve  Listening  Skills  

! Aaending  (alert,  orient,  interact)  ! Acknowledging  ! Non-­‐verbal  communica2on  ! Resta2ng  ! Reflec2ng  !  Summarizing  ! Ques2oning  !  Providing  feedback  !  Suppor2ng  speaker  ! Checking  percep2ons  !  Silence  

Anxiety  Interven2ons  

!  Cognitive awareness and restructuring identify and challenge negative thoughts and expectations; positive self-talk

!  Exposure methods (imagination, in vivo) !  Psycho-education !  Somatic management skills training

self-monitoring, skill identification and execution

Distress  Management  

! Learn  to  iden2fy  precursor  thoughts  ! Learn  to  iden2fy,  name  and  label  feelings  ! Establish  level  of  distress  (ra2ng  scale  1-­‐5)  ! Develop  Ladder  of  s2muli  or  triggers  situa2ons,  objects,  cues,  sensa2ons  

! Develop  list  of  pre-­‐planned  calming  skills  

Social  Asser2veness  

! Child  learns  to  iden2fy  needs,  thoughts,  feelings,  impulses  and  behavior  

! Child  role-­‐plays  language  in  session,  prac2ce  generaliza2on  at  home  and  in  school  

! Use  toys,  puppets  sand  tray  to  prac2ce  ! Use  relaxa2on,  coping  strategies  and  fear/worry/feeling  ra2ngs  during  interven2ons  

Execu2ve  Func2on  Skills  

Aaen2on,  focus,  distrac2bility  Alert,  orient,  engage,  respond  Cogni2ve  control,  shih  and  flexibility  Tracking  (visual,  auditory)  Memory,  input,  manipula2on,  output  Emo2onal  regula2on  and  modula2on  Problem  solving,  decision  making  Impulse  control  and  management  Organiza2on,  planning,  and  2me  management  Motor  management  planning,  pacing,  ini2a2on,  maintaining,  stopping  

Thinking  Skills  

Organiza2on  Planning  Decision-­‐making  Ini2a2on,  execu2on,  review  Aaen2on  to  detail  Finding  the  data  Problem  solving  Explaining  one’s  answer  Crea2vity/Imagina2on  

Self-­‐Regula2on  Skills  

Percep2on  ~  sensory  Recognizing  internal  energy  state  Recognizing  escala2on  or  de-­‐escala2on  Ini2a2ng,  maintaining  and  changing  energy  Labeling,  naming  or  expressing  a  feeling  U2lizing  calming  skills  

EBT  Skill  Analysis  

Problem   Skill   Domain   Modality   Tools   Ac7on  Child  bites  classmates  

Impulse  ID   Thinking   Role  Play   Hula  hoops   Child  was  encouraged  to  describe  the  antecedents  to  bi2ng  behavior.  

Impulse  labeling  

Thinking   Child  was  encouraged  to  ID  and  label  the  feeling  impulse.  

Behavioral  Inhibi2on  

Self-­‐Reg   Child  was  able  to  name  two  inhibi2on  strategies.  

Problem  Impact  

Problem   Frequency   Severity   Impact  

Child  bites  classmates  

2  x  per  day   5   Removal  from  class,  isola2on,  class  disrup2on  

EBT  Progress  Note  

!  Today’s  clinical  hour  focused  on  iden2fying  thoughts  and  impulses  that  lead  to  child’s  bi2ng  classmates  in  school.  Used  thought  and  internal  energy  iden2fica2on  strategies  to  label  thoughts  and  impulses.  Once  child  was  able  to  iden2fy  thoughts  that  lead  to  impulse  to  bite  we  walked  through  the  three  steps  to  behavioral  decision  making  with  hula-­‐hoops  and  polyspots,  keeping  motor  inhibi2on  strategy  front  of  mind.  

!  Cogni2ve  reinforcement  was  employed  with  sample  incident  review  naming  each  part  of    what  thoughts  and  impulses  lead  to  which  behaviors.  

!  Child  leh  session  with  experience  labeling  worksheet  as  well  as        two  alternate  strategies,  f/u  w  teacher  Friday  for  review  of  when  and  under  what  condi2ons  new  strategies  were  employed.  

References  and  Sources  

Bannink,  Fredreik  1001  (2010)  Solu2on-­‐Focused  Ques2ons  Boyce,  Sioban  (2014)  Not  Just  Talking:  helping  your  child  communicate  from  day  one  

Connolly,  Sucheta  M.D.  Director,  UIC  Pediatric  Stress  and  Anxiety  Disorders  Clinic  -­‐  ppt    

Curran,  Linda  (2013)  101  Trauma-­‐Informed  Interven2ons  

Drewes,  Athena  (Ed)  (2009)  Blending  Play  Therapy  with  Cogni2ve  Behavioral  Therapy  

Joiner,  Lindsey  (2010)  The  Big  Book  of  Therapeu2c  Ac2vi2es  

Jongsma,  Arthur  et  al.  (2014)  The  Child  Psychotherapy  Progress  Note  Planner  

Kypers,  Leah  (2011)  Zones  of  Regula2on  

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Van  der  Kolk,  B.  (2014)  The  Body  Keeps  Score  

Young,  Wendy  (2014)  Bouquet  of  Posi2ve  Thoughts  

Research  Studies  Arnberg,  A.  &  Ost,  L.  (2014)  CBT  for  children  with  depressive  symptoms:  a  meta-­‐analysis  Cogn  Behav  Ther.  2014;  43(4):275-­‐88.  

Braaon,  S.  &  Ray,  D  et  al.  (2005)    The  Efficacy  of  Play  Therapy  Outcome  With  Children:  A  meta-­‐Analy2c  Review  of  Treatment  Outcomes.  Professional  Psychology:  Research  and  Prac2ce,  Vol  36(4),  Aug  2005,  376-­‐390.  

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Haskins,  Edmund  (2012)  The  Cogni2ve  Rehabilita2on  Manual;  Transla2ng  Evidence-­‐Based  Recommenda2ons  into  Prac2ce.    

Hove,  J.  &  Schwartz,  M.  (2014)  Deconstruc2ng  the  Ability  to  Move  to  a  Beat.  Journal  of  Neuroscience,  12  34(7):2403-­‐2405.  

LeBlanc  &  Ritchie  (2001)  Counselling  Psychology  Quarterly,  Volume  14,  Number  2,  1  June  2001,  pp.  149-­‐163(15).  

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van  der  Fels,  IM.    (2014)  The  rela2onship  between  motor  skills  and  cogni2ve  skills  in  4-­‐16  year  old  typically  developing  children:  A  systema2c  review  J  Sci  Med  Sport.    

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20  NeuroCogni2ve  Play  Ac2vi2es