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Mikella Millen, MA, LCAT Clinical Lunch and Learn Webinar Series July 2014 1
Mikella Millen, MA, LCAT
Clinical Lunch and Learn Webinar Series
July 2014
1
Understand the basic principles of non-directive play therapy as they relate to trauma treatment
Learn about verbal reflective techniques to help children move through posttraumatic play, and develop a sense of control and safety
Explore ways that “avoidance” can arise within the therapist during traumatic reenactment
Introduction to Play Therapy
Role of Non-Directive Play Therapy
Play Therapy Techniques for Trauma Treatment
Posttraumatic Play and Interventions
Avoidance and Secondary Trauma
Outcomes and Symptom Relief
Q&A
Do you currently use play therapy in your work with child clients?
A. Yes
B. No
C. No, but I would like to start using
A modality of therapy, used mostly with children or young adolescents, that uses the act of play to explore thoughts, feelings, behaviors, and memories/experiences
Therapist is invited to participate in the play, gently helping the child to explore conflicts while being and feeling supported by therapist
Builds upon the natural innate process most children already use to explore conflicts, and share thoughts and feelings
Usually involves free-play activities that are unstructured, such as dolls, puppets, doctor
kits, toy cars, animal figurines, free drawing/painting, or even building blocks, or rolling balls.
Directive play- Therapist participates directly in the play, to guide child towards identified issues or conflicts, or towards resolutions
Non-directive play- Child initiates and directs play, while therapist creates environment to support child’s process and allow child to understand own problems
Enactment- Person externalizes a past relational conflict, by creating a similar conflict in present moment
Reenactment- A literal and exact externalization of a past experience
Avoidance- Coping mechanism in trauma and secondary trauma response
(Traumatic Play) Resolution- Meaning making, or sense of reparation in the world of pretend.
6 year-old boy who experienced
severe abuse and neglect
Isolated in the home for years, very intelligent but extremely delayed speech
Unknown trauma, but engaging in enuresis around foster home, violent outbursts, specific phobias, and dissociative symptoms
A client-centered approach based on the assumption that play is a natural medium to explore problems, and that clients have an innate capacity to find solutions to their own problems - Virginia Axline, 1974 (student of Carl Rogers)
Emphasizes the importance of reflecting feelings so that the child can “gain insight into his/her behavior.”
Axline, V. M. (1974). Play Therapy. New York, NY: Ballantine Books.
Allows children to project unresolved feelings and thoughts about their inner life or trauma experiences onto dolls, puppets, play interactions, and sometimes the therapist. Numerous studies have shown that PTSD symptoms decrease beyond the average rate with Play Therapy treatment. (TF-CBT)
Part of the avoidance component of trauma response includes feelings of isolation, estrangement, and cognitive defenses such as self-blaming, denial, and distorted world view. By allowing another person to witness the “reliving” of the trauma in a safe therapeutic environment, the therapist can assist the child in addressing these issues.
Creating and holding a safe space
Reflecting feelings and behaviors
Unconditional positive regard
Creating a permissive environment where anything can be expressed
Setting boundaries when necessary to ensure an appropriate holding environment
Reenactment during which the child attempts to gain mastery by exploring the traumatic memory within the realm of play (Eliana Gil,
1991.)
Characterized by a “ritualistic” play scenario that is “very literal and devoid of apparent enjoyment or freedom of expression.”
Serves a purpose but after becoming “fixed,” it is necessary to therapeutically intervene
Gil, E. (1991). The healing power of play. New York: The Guilford Press.
Please chat your answers into the chat box to the right!
Have you ever had a client that has expressed traumatic play?
What were some signs that this was happening?
What was this like for you as the therapist?
Did you use any techniques or interventions before, after or during traumatic play?
Please chat through chat box on the right.
Therapist should be mindful to gently redirect from traumatic play, if possible, until some degree of therapeutic trust is developed
Create a safe space, by identifying the objects, toys, activities which the child finds soothing. Make sure there are objects to soothe dolls/puppets as well (play food, blankets, doctor kits, etc.)
Be aware of the qualities of materials: some materials easily end themselves to projection, such as dolls, puppets, direct play, and drawing/painting.
Verbal Reflections
Redirecting, orienting
Guided soothing
Narrative approach
A literal narration of what is explicitly occurring during the play
Avoids interpretations unless significant evidence of underlying feeling is present (and even then with great caution)
Exists within the metaphor of the play scenario
Or reflects observed state of the child
Direct observation (organizes, helps ground, assists very young children in expression) ◦ “I see the girl was sitting in the bedroom, but now
she has moved to what looks like the bathroom”
Inviting the child to project, externalize, and gain insight (creating space for the child and therapist to interact with or interpret the action occurring in the play scenario) ◦ “So the little boy was fighting the bad guys, and
everything was going great until suddenly he lost the fight and died. I wonder what happened?”
Reflecting the child’s shifting behavior (only what is actually observed, serves to interrupt rigid play and ground the child to the present moment) ◦ “I notice that whenever the boy begins to take a
bath, you start humming a song.”
◦ “The last time the family went to the park it seemed like suddenly you needed to put the dolls away.”
Why Interrupt Post-Traumatic Play? ◦ Child is not yet flexible enough for alternate narratives,
but is observably disturbed by continued reenactment
How do you Interrupt Post-Traumatic Play? ◦ “What would happen if…” Wondering aloud
◦ Taking a break
◦ Inviting the child to detach slightly and give comment on the play scenario
◦ Taking on the role of a character in the play scenario (should be initiated by the child or discussed at the beginning of the play)
Continued engagement in a traumatic reenactment without resolution can cause increased anxiety, fear, and powerlessness
An unaltered, rigid narrative has developed and repeated at least five times with the exact same outcome
The child appears visibly distressed or dissociates
Therapists inaccurately assess whether the play is truly traumatic, and stops play with disturbing content immediately although it may not be a reenactment.
The therapist is placed in the role of the “abuser” in the play scenario and it feels uncomfortable
The therapist is eager to “rescue” the character under stress and the play scenario halts prematurely
An interruption helps create space in the narrative, but frequently is not enough to resolve. Begin by reflecting observed relationship between content of the play and apparent affect expression and behavior
Invite the child to consider alternate outcomes
Invite the child to participate as the “creator” of this scenario
Ask the child to describe what characters are feeling. Can we help them?
What are secondary avoidance responses?- Therapist changes the course, content, duration, or interprets the play for reasons other than a direct response to the child’s stress level
Secondary avoidance responses typically arise when: ◦ Therapist empathizes strongly with the client and cannot
tolerate the child’s stress level during post-traumatic play
◦ Therapist is afraid that reenactment will re-traumatize the child
◦ Child becomes aggressive during post-traumatic play and creates safety concerns
Verbal reflections are key to working through secondary avoidance responses
Reflections help ground both the child and the therapist in the present moment, helps therapist stay alert
Allows for gentle exploration of alternate outcomes, alleviating risk of child being re-traumatized
Verbal reflections help connect feelings and behaviors during aggressive outbursts (gentle intervention without completely halting the play)
Cognitive and verbal framework created for memories which may have been rooted in sensory experience
Therapist bears witness and provides ego strength and healing support
Child develops increased tolerance of feelings, memories, and thoughts associated with the trauma, can lead to explicit processing (breaking the metaphor)
Materials owned by ICL, Licensed by CTAC
Association for Play therapy
http://www.a4pt.org/?page=EducationTraining
http://www.a4pt.org/?page=AudioTests
Eliana Gil (videos and books), Bruce Perry, Virginia Axline
Expressive Arts Therapies Summit
Jewish Board of Family and Children’s Services MKSE
https://www.jbfcs.org/professional-training/martha-k-selig-educational-institute/#.U7659oUzJqc
Helping the Helpers:
Occupational Stress and Self Care Lydia Franco, LMSW and
Kara Dean-Assael, LMSW
Wednesday, August 6, 2014 12-1pm
Presentation questions:
CTAC-related questions:
www.ctacny.com
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