Tag Archives: play therapy

Behind the Book: Partners in Play: An Adlerian Approach to Play Therapy

By Bethany Bray October 10, 2016

It’s often said that play therapy reaches young clients through their own natural “language” of play. When combined with tenets of the Adlerian method, play therapy becomes a tool for the therapist to build an egalitarian relationship with the client while focusing on the individual and photo-1473662711507-13345f9d447chis or her dynamics with others, according to Terry Kottman and Kristin Meany-Walen, co-authors of Partners in Play: An Adlerian Approach to Play Therapy.

“The Adlerian belief in the ability to make new choices and to reinterpret situations provides a vehicle for play therapists to work with children to get out of their boxes, change their lifestyle patterns, increase their social interest, make shifts in the goals of their behavior and a host of other forums for determining their paths,” write Meany-Walen and Kottman in the book’s second chapter. “One of your primary responsibilities as an Adlerian play therapist is to discover how each child expresses his or her special and wonderful self and to convey a sense of celebration in his or her uniqueness to the child, parents and other people who interact with him or her. Sometimes the child expresses uniqueness in a way that others do not appreciate.”

Meany-Walen, an assistant professor of counseling at the University of Northern Iowa, and Kottman, who runs a play therapy counseling, training and workshop center in Cedar Falls, Iowa, are both licensed mental health counselors and registered play therapists.

The third edition of Partners in Play was published earlier this year by the American Counseling Association.

 

Q+A: CT Online contacted Kottman and Meany-Walen recently to learn more about this unique approach. Their responses are co-written, except where noted.

 

Your book focuses on Adlerian play therapy, which combines play therapy techniques with the Adlerian method. Why do you think they are a good fit? Why does that combination work to help young clients?

Adlerian psychology has a clear and easy-to-follow way to conceptualize clients and figure out what is “underneath” the presenting problem. Before the development of Adlerian play therapy, there was no precedent for working with individual child clients, nor was there a precedent for using play as a treatment modality using Adlerian psychology. We believe that combining Adlerian psychology with play therapy was a logical way to capitalize on the Adlerian methodology for conceptualizing and developing a treatment plan [while] at the same time using play, the “natural” language of children, to communicate with them.

 

What are some key takeaways that you want counselors to know about this topic?

We want counselors to learn about the myriads of ways of using play, art techniques, sand tray, active games, movement and dance, bibliotherapy and therapeutic storytelling as a vehicle for helping children, adolescents, parents and family members to grow in positive directions. We believe that the four-phase model of Adlerian or Individual Psychology — building a relationship with the client, exploring the client’s lifestyle, helping the client gain insight into his or her lifestyle, and learning and practicing new skills — is an amazing vehicle for working with clients. We value the systematic way Adlerian counselors conceptualize clients — looking at assets and strengths, interpersonal dynamics, intrapersonal dynamics (like personality priorities, Crucial C’s*, goals of misbehavior, mastery of the life tasks), problem-solving skills, self-defeating thought patterns and so forth — as a way to determine the best way to decide on the direction and structure of the therapeutic process.

 

* The Crucial C’s are one method that Adlerians use to conceptualize clients. They were developed by Amy Lew and Betty Lou Bettner, who suggest that all people need to have courage (the willingness to try new things without a guarantee of success), connect (the desire and ability to build relationships with other people), be capable (the belief that they are able to master ideas and skills) and count (the belief that they are valuable and special without having to earn love or worthiness).

How does Adlerian play therapy fit with your personality and style as a counselor? What made you want to specialize in this area?

I (Terry) am a very encouraging and exuberant person. Adlerian play therapy reflects my personality by being positive and playful. I was drawn to Adlerian psychology because it is so focused on the strengths of the client, which is exactly what I wanted to do when I became a counselor. I love playing, have always loved playing and had spent my whole life working with children in some capacity. When I was in high school, I worked part time in a pediatrician’s office. When I was in college, I taught swimming lessons to young children and volunteered in an after-school program for children who came from low-income families. I got my first master’s degree in elementary teaching and my second master’s degree in special education. I loved working with children in schools. It was a natural transition for me to work as a school counselor and to become a play therapist.

Adlerian play therapy was also a natural fit for me (Kristin). I had often considered the experiences of my youth, and my perceptions of those experiences, as instrumental in shaping who I was as an adult. I explored many different counseling theories, and Adlerian psychology was most consistent with how I understand people and how I want to work with them. The systematic way of understanding people’s ways of belonging and operating in the world, from an Adlerian perspective, helps me to feel organized and productive, both of which are important parts of my lifestyle.

By happenstance, I took a class from (co-author) Terry Kottman where I began learning about the value and art of play therapy. I started to use some of the play therapy concepts with my own child, who was 8 years old at the time. I noticed drastic improvements in his mood, his behaviors and our relationship. I wanted to help other children and families in the same way.

 

One of the things that prompted you to write the first edition of this title (in 1995) was a rising interest in play therapy. Two decades later, is the field still growing?

Yes, it is. The field of play therapy continues to grow, with the Association for Play Therapy growing from 3,346 members in 1998 to 6,166 members in 2015, increasing at the rate of about 1.5 percent each year. There is a wider understanding of the importance of credentialing of play therapists (registered play therapists, or RPTs) among mental health professionals and with the public.

 

What is one thing you wish you knew about play therapy as a new counselor? What advice would you give to recent counseling graduates who are starting out and are interested in play therapy?

I (Terry) wish I had known that play therapy was not just for children — that teens, adults and members of families can also benefit from using play therapy skills and techniques (including art techniques, sand tray, active games, movement and dance, bibliotherapy and therapeutic storytelling) as a way to express themselves, explore their issues, gain insight, and learn and practice new ways of communicating, solving problems and interacting with others.

The advice I would give recent counseling grads who are starting a career in play therapy is to obtain really good training in play therapy. I believe it is essential to explore the different approaches to play therapy and find one that fits with your personality and what you believe about how personalities form and how people change. After that, find training that includes being observed with children and getting feedback about your skills and abilities.

 

What prompted you to create a third edition of this title? What new information will readers find?

The counseling field continues to evolve as we make discoveries and learn from our experiences. We wanted to provide updated information about play therapy, counseling and how the two merge. Since the last edition, we have seen an increase in the importance of evidence-based treatments and research. In the current edition, we include information about some of our ideas of researching Adlerian play therapy as well as published accounts of Adlerian play therapy. We also included various resources for readers such a list of activities to use with children and informal assessments to use with children, parents or teachers.

 

In addition to your book, what resources would you recommend for counselors who want to learn more about play therapy?

For beginning play therapists who want to know about play therapy skills, another book I (Terry) wrote that is published by ACA would be a good resource: Play Therapy: Basics and Beyond (second edition). Another excellent resource is the website of the Association for Play Therapy (www.a4pt.org).

 

 

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Branding-Box-Partners-in-PlayPartners in Play: An Adlerian Approach to Play Therapy is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

 

 

 

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Do preteens still play in counseling?

By Mark Loewen December 10, 2015

As a play therapist, I’m used to explaining the ins and outs of play therapy. Because play is a universal concept, most people understand that it is also a child’s “language” and can be used to address many issues in therapy. However, when it comes to preteens, play therapy takes a slight shift.

Whereas children don’t always have the ability to articulate their thoughts and feelings, preteens are becoming more able to hold conversations about important issues. They can still become very uncomfortable, however, if they have to sit across from an adult for a “serious” talk. Plus, by the time most preteens come to counseling, they’ve heard a lot of talking already.

Play is still very important to preteens, although it starts to look a little different. As children mature, activities move away from fantasy play to more structured games. Still, children of this age often feel trapped between childhood and the teen years. In play therapy, preteens often vacillate between play that is more common to younger children and activities that appeal more to teenagers.

At our counseling practice, we often use games and interactive activities to take the pressure off. Preteens enjoy both regular board and card games and also specialized therapeutic games. Games can be used to deal with anxiety, power and control issues, self-esteem, relationships and difficult behaviors. Specialized therapeutic games address topic areas such as depression, anger, anxiety, aggression, life changes, coping skills and much more. Skilled play therapists can use almost any game to address difficult issues with children and teenagers.

Preteens are also developing creative skills. They are moving into using abstract thought as life opens up to endless possibilities. Expressive arts are a great tool to address new thoughts and feelings. Using specific art materials, clients build, sculpt or draw to represent their struggles and find alternative solutions.

Preteens also enjoy using the sand tray and an array of miniatures to represent their “worlds.” Using miniatures provides a feel that is similar to setting up toys. At the same time, the child is using these

Image via Wikimedia Commons

Image via Wikimedia Commons

miniatures with a few guidelines that make the activity feel challenging. Sand tray therapy is a great way to allow kids in early adolescence to work through their issues without feeling pressured or judged.

Additionally, interactive activities can be used to teach mindfulness meditation skills. By learning to direct their breathing and use creative imagery, kids become more aware of their feelings and what’s behind them. By recognizing intense emotions, they are better able to control them and listen to what these feelings are trying to say to them.

In conclusion, preteens are balancing child’s play and teen activities. Given enough freedom, children of this age group may allow themselves to delve into pretend play, dressing up or other activities that are more typical for younger children. On the other hand, they also like the challenge of activities that are considered to be more grown-up. Maintaining this balance requires their counselors to maintain a great level of flexibility and a nonjudgmental attitude. As a result, preteens will know that counseling is a place where they can use any of their internal resources at any time to address any issue at hand.

 

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Mark Loewen is a licensed professional counselor, registered play therapist and parent coach in Richmond, Virginia. He is the owner of LaunchPad Counseling (launchpadcounseling.com), a practice that helps children, teens and parents cultivate their inner resources to overcome stressful circumstances. Contact him at mark@launchpadcounseling.com.

 

Involving parents in child-centered play therapy

By Phyllis B. Post August 25, 2014

When young children, ages 2 to 9, are experiencing emotional and behavioral problems, the usefulness of talk therapy is limited because they often cannot communicate effectively using words. Play therapy continues to gain momentum as a viable approach to work therapeutically with young children because it is based on the premise that children communicate best through Dad&daughter_smalltheir usual way of relating — play. Using play in therapy is the most natural and effective way to help children.

Children are most often referred for play therapy when they demonstrate problems with friends, at home or at school. There are many different approaches to play therapy, but all are structured, theoretically based and developmentally appropriate, allowing young children to communicate and learn in the way that is most natural to them. Play therapy is different from “just” playing. It helps children express their feelings, assume responsibility for their behaviors and develop problem-solving skills. Play therapists are trained mental health practitioners who specialize in helping young children. An increasing number of master’s degree programs in counseling are including course work and training in play therapy. In addition, mental health practitioners can attend training provided by the Association for Play Therapy and the newest division of the American Counseling Association, the Association for Child and Adolescent Counseling.

As mentioned, a variety of approaches to play therapy exist, but I have found child-centered play therapy, as developed by Garry Landreth, to be particularly effective. Based on the work of Carl Rogers, a basic premise in child-centered play therapy is that children possess an innate force within themselves to grow and heal. Therefore, child-centered play therapists do not direct children on how to resolve their problems or use interpretation with children to promote their growth. Instead, child-centered play therapists relate to children in the playroom in ways that demonstrate a firm belief that children learn the most and heal most effectively when they themselves decide what to do in therapy sessions. Through a supportive and caring relationship with child clients, therapists help these children understand themselves, accept their feelings, assume responsibility for their behaviors in the playroom and learn to control their own behaviors.

Why work with parents?

Although there is consensus among play therapists that effective consultation with parents can maximize beneficial outcomes for children, parental involvement in the process often does not extend beyond the intake session and brief periodic check-ins when parents bring their children to therapy. But effective parent consultation can help parents better understand why play therapy is beneficial for their children, how play therapy interventions are purposeful and that the effectiveness of the interventions can be assessed. In addition, these consultations can provide parents support and hope, both of which help prevent early termination by the parents.

Although play therapists may be aware of the importance of parent consultation in helping children, many therapists are not confident about how to approach consultation with parents. In a national survey in 2008, Tim VanderGast found that play therapists identified consulting with parents as one of their greatest needs in clinical supervision. Because child-centered play therapists focus on the relationship with the child rather than on the presenting problem, they face unique challenges when helping parents understand how this popular theoretical approach helps children with specific goals that are established to assess progress.

The goal of this article is to provide some practical guidelines for therapists as they consult with parents when conducting child-centered play therapy. In addition to describing child-centered play therapy to the parents, these guidelines include:

  • Learning about the child and developing a trusting relationship with parents
  • Addressing objectives and goals
  • Relating established goals to the child-centered approach in the playroom
  • Providing ongoing parent consultations

Learn about the child and develop a trusting relationship with the parents

Parenting is often difficult and stressful. When issues create the need to involve a young child in therapy, the counselor’s ability to convey to parents the core conditions (as described by Rogers) of empathy, acceptance and genuineness cannot be overemphasized. It is through these conditions that a strong therapist-parent alliance starts to form. Additionally, consultation meetings provide an opportunity to model the person-centered approach with parents, showing them the power of the basic principles that will be used with their child in child-centered play therapy. To begin building this trusting relationship, I recommend that therapists meet parents for the initial session without any children present.

The first step is listening to the parents’ description of the child. This process results in a better understanding of the parents’ perception of the problem, as well as their worldview and the child’s cultural context. For example, when a mother who had not completed high school described her reasons for bringing her child to play therapy, the therapist sensed the mother felt uncomfortable in the elementary school environment and felt intimidated by her child’s teacher. In this situation, the therapist could demonstrate sensitivity to the mother’s perspective by responding to her feelings of uncertainty and discomfort in that environment. However, I would caution that even as therapists attend to the parents’ concerns, the focus should remain on the child’s issues rather than on the parents’ issues.

Address objectives and goals

Communicating the objectives and establishing specific goals for therapy are important for several reasons. First, the process demonstrates to parents that play therapy interventions are purposeful, which might not be as obvious in child-centered play therapy as it is in talk therapy with older children or adults. In addition, the objectives and goals are useful in evaluating the effectiveness of the play therapy. They become the benchmarks to assess progress during ongoing consultations with parents. Finally, we cannot ignore the fact that outcome goals are required in the managed care environments in which many counselors work.

As described by Landreth in the third edition of his book Play Therapy: The Art of the Relationship, child-centered play therapy adheres to the objectives of helping children become:

  • More self-reliant
  • More accepting of themselves
  • Better problem solvers
  • Better able to assume responsibility for their own behaviors

The idea of setting specific goals in addition to those four broad objectives can feel uncomfortable to child-centered play therapists. They may fear that they unconsciously possess some expectations and biases that could inadvertently cause them to direct the child in play therapy or to view the child’s behaviors in the playroom through the lens of the established goals. Awareness of this possibility is important and should be monitored through clinical supervision. However, a combination of broad objectives and specific behavioral goals is optimal for monitoring the effectiveness of therapy.

Focusing on the overarching objectives that can be observed in the playroom and in the child’s life outside of the playroom helps us to recognize broad-based changes. Focusing on more specific goals related to the issues presented by parents ensures that attention is also directed to changes in those behaviors that might not be observed in the playroom. Therefore, using both broad objectives and specific behavioral goals is useful in monitoring the effectiveness of play therapy interventions.

In the initial meeting with the parents, the play therapist strives to establish goals that reflect the family’s cultural context, given that each family has its own expectations and experiences with the meaning of help seeking, mental health and play. During this process, play therapists must be sensitive to the parents’ cultural backgrounds because the parents’ values will influence the types of goals established for their child. For example, in some cultures, compliance with authority, both at school and at home, is highly valued. Thus, the goals that evolve for the child through the therapist-parent interaction could focus on compliance and responsiveness to limits. In other cultures in which children experience more permissive relationships with their parents, the goals for play therapy might include enhancing the child’s self-confidence and ability to make decisions. This collaborative process between parents and therapists will result in a consensus on the goals for play therapy.

Setting goals with parents is hard work, and it takes practice. Goals must be concrete, measurable and observable to ensure that progress can be tracked. In addition, goals that are strength-based and that focus on solutions provide hope for parents.

As parents talk about the reasons they sought play therapy for their child, the work of the play therapist is to help them “translate” their concerns into specific behaviors that can be assessed and to set benchmarks to determine how they will know when their child has changed. For example, a mother brought her 5-year-old son to play therapy because he was “out of control” at home and at school. The therapist asked, “What does ‘out of control’ look like?” With that helpful nudge, the mother was able to elaborate, saying, “When it is time for him to get dressed in the morning, he screams for about 15 minutes and hits himself. He says ‘no’ to every request I make of him. And the teacher sends home a note almost every day about him yelling and hitting other children at school.” Based on this specific description of the boy’s behaviors, it became possible to establish realistic goals.

One question therapists can ask parents is, “How will you know when your child has changed and no longer has this problem?” This information provides the basis for benchmarks for change. In the example above, goals were created that specified how many days each week the child would comply with his mother’s requests, not have a tantrum at home, not hit himself and not receive a report from the teacher about problem behaviors in the classroom. Such clearly stated goals are helpful not only in assessing change but also in managed care environments that require the monitoring of behavioral outcomes for insurance reimbursements.

It cannot be overstated, however, that establishing such goals with parents prior to the start of child-centered therapy does not change the way that play therapists relate to the child in the playroom. There are no predetermined interventions during the counseling sessions that seek to change the child’s behavior. Instead, therapists consistently offer a safe relationship and an environment in which the child is free to be self-directive. In fact, in a chapter for the 1997 book Play Therapy Theory and Practice: A Comparative Presentation, Landreth and Daniel Sweeney recommended that child-centered play therapists continually reflect upon their way of being in clinical supervision to address the issue of inadvertently directing the child’s behavior.

Relate established goals to the child-centered approach the playroom

Perhaps the most challenging part of the initial consultation with parents is explaining how the behaviors of the counselor in the playroom help children achieve both the broad objectives and the established goals of play therapy. Play therapists can help parents by describing how each of the established goals could be addressed in the playroom. Using the earlier example, if a young child is “out of control” at home and school, the play therapist might explain to the parents that through the safe relationship with the therapist, the child will learn to assume responsibility for his decisions in the playroom and will have opportunities to demonstrate self-control if setting limits is necessary in the play therapy session. In this way, parents can recognize that what occurs in the nondirective playroom can be helpful in addressing issues occurring at home and at school.

Provide ongoing consultations

Every four or five sessions, therapists should meet with the parents without the child being present. The purpose of the ongoing consultations is to maintain and foster a strong therapist-parent alliance, allow the parents and play therapist to collaboratively assess the progress toward goals, and further educate parents about child development, parenting skills and community resources.

It is important for child-centered play therapists to maintain case notes to document significant events, attitudes and play themes in the play sessions. In addition, reviewing case notes can be useful when assessing progress toward goals. For example, if a child is experiencing anxiety outside of the playroom, case notes can help identify changes in behavior that indicate anxiety in the playroom as well, such as when making decisions about what to do in the playroom, facing the therapist or interacting with the therapist. For a child presenting with goals related to aggressive behavior outside of the playroom, documentation of play sessions could note changes in the child’s response to limits setting. Case notes can be reviewed to identify play session themes (for example, themes of power, mastery or nurturance) to share with the parents. When meeting with parents, play therapists should remain sensitive to maintaining the child’s confidentiality by not disclosing specific play behaviors or the child’s verbalizations during play sessions.

Maintaining and fostering a strong therapist-parent alliance: A primary goal for these meetings is to foster a warm relationship with the parents. The counselor can do this by acknowledging the parents’ experiences, struggles and feelings and responding with empathy and care. Through listening to the parents, the play therapist is better able to support and educate when it is appropriate.

Assessing progress: If parents share more general concerns about themselves at the beginning of the session, the counselor can focus the session on the child by asking an open-ended question such as “How have things been going with ___?” Using active listening skills at this time ensures shared understanding of what the parents are saying. Play therapists should listen for information related to the stated goals for therapy. If the parents do not address each of the goals identified in the first intake session, the therapist can systematically address the goals not mentioned. It is not uncommon for a review of the original goals to surprise parents. Some parents will have no memory of certain goals because the issues will have resolved themselves.  

During these ongoing consultation sessions, the therapist can share themes observed in the play therapy sessions, especially if they relate to the established goals of therapy, such as the child’s ability to control behaviors when limits are set or an increasing ability to assume responsibility for decisions. After reviewing the goals, the therapist and parents collaboratively determine whether the original goals were met, whether they need to be modified or if it is time to terminate the relationship.

Providing education on parenting skills and community resources: If the decision is made to continue play therapy, the therapist and parents set a time for their next meeting. Once it is established that the parents will be returning, the play therapist can also share appropriate parenting skills based on the needs of the parents and child. Most parents are eager to learn new approaches to discipline and highly value the skills of limits setting and choice giving. In addition, teaching the skills of responding to the child’s feelings and returning responsibility to the child has been found to reduce parental stress and create a more positive environment in the home. That outcome can influence the entire family system.

Ongoing meetings with parents also provide opportunities to address other needs the child may have that are not currently being met. The therapist can then provide or recommend appropriate resources. For example, if a child appears to have a learning disability, the play therapist should make an appropriate referral for the child to be assessed for needed services.

Conclusion

Child-centered play therapists focus on the relationship with the child rather than the presenting problem. Thus, therapists face unique challenges in helping parents understand how this theoretical approach supports children in progressing toward specific goals. To demonstrate the effectiveness of their work with children and to respond to the demands of managed care in agency settings, play therapists must skillfully share the objectives of child-centered play therapy, establish behavioral outcome goals and then assess progress toward achieving those goals. The guidelines proposed in this article are specifically designed so that child-centered play therapists can collaborate with parents to more effectively help young children.

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Phyllis B. Post is a professor in the Department of Counseling at the University of North Carolina at Charlotte and the founder of the Multicultural Play Therapy Center at the university. She is a licensed professional counselor supervisor and registered play therapist. Contact her at ppost@uncc.edu.

Letters to the editor: ct@counseling.org

The toll of childhood trauma

By Laurie Meyers June 23, 2014

Little-girl_brandingMention the word trauma to Americans in the 21st century, and their thoughts are likely to turn to images of terrorism, war, natural disasters and a seemingly continual stream of school shootings. The horrific scenes at Newtown and Columbine still dominate public consciousness, particularly when our society discusses child trauma. While those events make headlines, however, counseling professionals say the most pervasive traumatic threat to children is found not in big events or stranger danger, but in chronic and systemic violence that happens in or close to the home.

This kind of ongoing trauma, much of which takes place out of public view, leaves deep scars that can cause a lifetime of emotional, mental, physical and social dysfunction if left untreated. Research shows that chronic, complex trauma can even rewire a child’s brain, leading to cognitive and developmental issues.

The good news is that counselors in all areas of practice — in schools, agencies, shelters, clinics, private practice and elsewhere — can and are working with children and, when possible, their parents to stop the cycle of violence, or at least to mitigate its effects.

Behind closed doors

The number of children exposed to violence in the United States is staggering. According to the National Survey of Children’s Exposure to Violence (NatSCEV), funded by the U.S. Department of Justice and the Centers for Disease Control and Prevention (CDC) and carried out by the University of New Hampshire’s Crimes against Children Research Center, more than 60 percent of children surveyed had been exposed to direct or indirect violence during the 12 months prior to the survey. Nearly half — 46.3 percent — had been assaulted at least once in the past year, meaning they had experienced one or more of the following: any physical assault, assault with a weapon, assault with injury, attempted assault, attempted or completed kidnapping, assault by a brother or sister, assault by another child or adolescent, nonsexual genital assault, dating violence, bias attacks or threats. One in 10 had experienced some form of maltreatment, which includes nonsexual physical abuse, psychological or emotional abuse, child neglect and custodial interference. Other CDC research indicates that 1 in 4 girls and 1 in 6 boys are victims of sexual abuse. However, many experts emphasize that due to the stigma involved, sexual abuse is underreported.

Significant exposure to violence and trauma can also lead to illness later in life. From 1995-1997, the CDC, in collaboration with Kaiser Permanente, collected detailed medical information from 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. These patients also answered detailed questions about childhood experiences of abuse, neglect and family dysfunction. The initial study, Adverse Childhood Experiences, as well as more than 50 studies since using the same population, found that adult survivors of childhood abuse are more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease and liver disease. They are also more likely to engage in risky health behaviors such as smoking and drug and alcohol abuse. In addition, adult survivors of child abuse may have autobiographical memory problems; exhibit increased problems with depression, anxiety and other mental illnesses; and struggle with suicidal tendencies.

NatSCEV data, collected between January and May 2008, indicate that one in 10 children surveyed experienced five or more incidents of direct violence. It is this kind of ongoing abuse that can cause polyvictimization, or what many researchers call complex trauma — repeated exposure to traumatic events over time and often at the hands of caregivers or other loved ones.

“This cumulative trauma has much more serious effects than a single event,” says David Lawson, a licensed professional counselor (LPC) and licensed marriage and family therapist in Nacogdoches, Texas, who has worked with victims and perpetrators of sexual and domestic abuse since the 1980s. Because the abuse is ongoing, it disrupts a child’s sense of security, safety and self and alters the way he or she sees others, explains Lawson, an American Counseling Association member who is also a researcher and professor in the school psychology and counseling program at Stephen F. Austin State University in Nacogdoches.

“In childhood, attachments are still forming, and abuse can shatter this developing ability,” says Jennifer Baggerly, an ACA member, LPC and play therapist who studies child trauma intervention. “It can also distort their forming personality and the way they interact with people as a whole.” This distortion can cause the child to believe that the world is an unsafe place and that people aren’t trustworthy, adds Baggerly, an associate professor and chair of the Department of Counseling and Human Services at the University of North Texas at Dallas.

That pattern of uncertainty and instability can cause cognitive distortion, dissociation and problems with emotional self-regulation and relationship formation, and even alter a child’s brain structure, notes Lawson, the author of Family Violence: Explanations and Evidence-Based Clinical Practice, published by ACA in 2013.

“Children get stuck in flight or fight,” adds Baggerly. “Everything is a threat, so instead of strengthening the prefrontal cortex, the brain operates more from the limbic system, which causes them to be more hypervigilant.”

Because they are almost constantly on alert, these children and adolescents most of the time use what Lawson calls their “survival brain” instead of their “learning brain.” Childhood and adolescence are periods in which the brain is developing rapidly and crucial cognitive skills are being learned. If children and adolescents spend too much time in survival mode, they are not accessing areas in the brain that are responsible for learning developmentally appropriate cognitive skills and laying down the neural pathways that are critical to future learning.

“As the child gets older, this chronic hypervigilance — and the overload of cortisol that comes with it — completely remaps the brain and just stifles development,” says Gail Roaten, president-elect of the Association for Child and Adolescent Counseling, a division of ACA. “You see them lose ground cognitively, especially in their ability to learn.”

Support and stability

Traumatized children’s problems with cognition, learning, self-regulation and development can last a lifetime, making it more likely that they will continue the cycle of abuse in their relationships, abuse drugs and alcohol, have trouble finding and keeping jobs or end up in the criminal justice system. Adults who were traumatized as children also are much more likely to face a host of physical and mental health problems.

The situation is far from hopeless, however. Counseling interventions for trauma can make a dramatic difference, and the earlier a child starts receiving therapy, the better. A variety of techniques have proved to be effective, but interventions are most successful when a supportive environment is created, Lawson emphasizes. Whenever possible, a parent or parents should be participants in a child’s therapy (as long as they are not the perpetrators of the abuse), and if not the biological parents, then foster parents or grandparents.

“I try to bring in whoever can help build a support system for the child,” Lawson says, “because an hour a week [of counseling] is woefully inadequate, and I need to have them able to take what they learn in therapy into the home.”

In many cases, parents or caregivers need help learning how to support the abused child emotionally, he says. When parents come to sessions with their children, the counselor can help the parents learn not just the best way to support the child in therapy, but also how to strengthen their parenting skills.

“We really emphasize connection,” Lawson says. “Once they [abused children] have attachment, they may be ready to tell parents about their abuse and may just blurt it out at home. I try to prepare parents to listen to the child. If the parents are not comfortable addressing this [topic], I have them at least write down what the child says and then use that as a therapeutic prompt.”

In sessions, Lawson guides parents, teaching them how to interact and better bond with children who have been traumatized. Some parents and caregivers have never really learned how to play with their children, he says.

At the same time, he notes that learning positive interaction skills is not just about the fun stuff. Parents and caregivers also need to know how to effectively discipline the child. “Many times when parents find out that their child has been abused, they are hesitant to discipline or correct behavior because they feel sorry for them,” he says. “Or they come down too hard.”

Lawson encourages parents to use time-outs, to not respond when a child is acting out with attention-getting behavior and to not use corporal punishment.

In the absence of parents or other supportive adults, the counselor may become the stabilizing adult in a traumatized child’s life. Although the counselor is not with the child as often as a parent or caregiver would be, just having someone who is concerned and will listen to whatever the child wants to say can be enough for an abused child to start to heal, Lawson says, even if he or she never chooses to talk about the abuse. He notes that even in the absence of other supportive figures, the therapeutic bond between counselor and child can help in decreasing hyperarousal.

Counselors need to know that although it may seem best to address the child’s trauma right away, establishing and cementing the therapeutic relationship must come first, Lawson says. The child needs to feel safe and supported — even if it is only in the counselor’s office — before he or she can begin to process the trauma.

“You’re trying to get them in a safe place if possible, or at least a predictable place,” Lawson says. “Then we can start teaching them how to cope [with the trauma] without lashing out or
avoiding it.”

Abused children do not know how to cope with what they are experiencing, Lawson says. It is common for children who are traumatized to lash out in anger when stressed and to feel that the best way to establish some sort of stability in their lives is to try to control everything. They may be moody, irritable or withdrawn. Abused children may also bully and hit other children or turn their anger on themselves and engage in self-abusive behaviors such as cutting.

Once a child feels supported, the counselor can also begin to teach the child how to self-soothe. Lawson guides traumatized children in using calming techniques such as diaphragmatic breathing or grounding themselves by focusing on something external such as the ticking of the clock or the texture of their clothes. “The point is to experience emotions in a safe place and cut out bad coping behaviors,” he says.

Safety first

Jennifer Foster, an assistant professor in the Department of Counselor Education and Counseling Psychology at Western Michigan University, studies child sexual abuse. Much of her research has involved listening to the narratives of abuse victims and how they perceive what has happened to them. Although these children display myriad reactions and emotions, Foster says two themes are always prominent: fear and safety.

“Child victims of sexual abuse often view the world as unsafe and are likely to enter counseling with unresolved fears,” Foster says. “They need help from their counselor to learn how to cope with their fears.”

“Although adults often see disclosure as a positive thing that will put an end to the abuse, for many children it is embarrassing and frightening, especially for those who feel at fault for their abuse and believe they will be blamed or, worse, not believed,” says Foster, who studied the experiences of sexually abused children for her dissertation.

Several counseling interventions are designed to help sexually abused children regain a sense of safety. One is called the “safe place technique,” in which a counselor guides the child in visualizing and vividly describing an imaginary safe place.

“The counselor may say, ‘Close your eyes and picture a special place where you feel completely safe,’” Foster explains. “This can be followed by specific questions to capture additional details such as: What do you see? What do you hear? What do you feel? What are you doing in your safe place? The details are recorded by the counselor and used to create a script.”

Once the safe place has been established, the child can return to it mentally anytime he or she feels stressed or scared, Foster says.

Another intervention called the “comfort kit,” developed by Liana Lowenstein, helps children who engage in nonsuicidal self-injury to learn self-soothing strategies, says Foster. “Counselors help children brainstorm and create a list of items that bring them comfort and make them feel better,” she explains. “Although the process is guided by the counselor, children are the ones who choose what will go inside their box or bag.”

Foster says children commonly include items such as a blanket, music, a favorite stuffed animal, written or recorded guided imagery, a stress ball, a list of relaxation activities, bubbles (for deep breathing exercises), a favorite book, a picture of a caring person or special place, a journal and pen, art supplies and a list of self-affirmations.

Foster is also a proponent of bibliotherapy. “Children’s books about sexual abuse can introduce child victims to others who have had similar experiences, which may lead to decreased feelings of isolation and normalize their trauma-related symptoms,” she says.

Books can also provide comfort, offer coping suggestions and teach kids important lessons such as that the abuse is not their fault, Foster adds.

Because fear is a predominant issue for child victims of sexual abuse, Foster also recommends stories that specifically address feeling afraid. Her suggestions include Once Upon a Time: Therapeutic Stories That Teach and Heal by Nancy Davis and A Terrible Thing Happened: A Story for Children Who Have Witnessed Violence or Trauma by Margaret Holmes. To help older adolescents explore their memories and feelings connected to sexual abuse, Foster recommends The Secret: Art & Healing from Sexual Abuse by Francie Lyshak-Stelzer. Foster notes that the author’s artwork is particularly effective at capturing fear and the myriad other feelings generated by abuse.

Finding relief through play

Play therapy is one of the most commonly used interventions with children, particularly those who have suffered complex trauma, meaning they have experienced long-term (and often multiple types of) abuse, says Roaten, an LPC who works with traumatized children in clinics and schools, and an associate professor at Hardin-Simmons University in Abilene, Texas.

Most therapeutic playrooms feature a fairly specific set of toys that might include an art center, play dough, a Bobo doll (an inflatable plastic doll modeled after the inflatable clown used in Alfred Bandura’s seminal study on children and aggression), a dollhouse with miniature people, animal figures, toy weapons, costumes and a sandbox. These toys and activities help children to act out their experiences in a safe and less negative manner, Roaten says. For instance, she recounts treating one child who “would just attack and slash the doll where the penis was. She was a victim of sexual abuse.”

In some cases, Roaten says, children just “play through,” processing their trauma entirely through play without needing to talk to the play therapist.

In many instances, Baggerly says, traumatized children act out things they aren’t able to verbalize. She once treated a 6-year-old who didn’t speak for about 10 sessions because the girl had a severe case of internalized anxiety and depression. But as the girl played, she would express her rage by taking a gun and shooting the Bobo doll in the head, stomach and groin area. Baggerly took this cue as a chance to ask the child about the anger and hurt she was feeling.

Catherine Tucker, a licensed mental health counselor who works with traumatized children in her role as a counselor supervisor and consultant, uses a child and family therapy called Theraplay, which was developed by the Theraplay Institute in the 1960s. “Theraplay works on a four-dimensional model: structure, nurture, engagement and challenge,” says Tucker, an associate professor in the college of education at Indiana State University.

Theraplay builds and enhances attachment, self-esteem, trust in others and engagement through participation in simple games. The idea is that the four dimensions — structure, nurture, engagement and challenge — are needed by children for healthy emotional and psychological development. The “play” in Theraplay is built around activities that teach participants what the elements of those dimensions are. Ideally, children engage in Theraplay with their parents or caregivers. Participating together teaches skills to parents or caregivers who don’t know how to provide the four dimensions, while enhancing the bond with the child. In the absence of parents or caregivers — whether because they are abusive or because they cannot or do not want to participate — the counselor plays directly with the child so the child can still learn how to interact in an emotionally healthy way.

The games and activities are simple — suitable for children as young as 1, yet still engaging for older children — and include things such as blowing bubbles, playing with stuffed animals, cotton ball hockey, cotton ball wars and newspaper basketball. The activities teach parenting skills and also help traumatized children with affect regulation, impulse control, feeling safe and not feeling like they have to be in control of the world, Tucker says. She notes that, oftentimes, kids who have suffered trauma feel like they have to be in charge either because a parent is abusive or simply doesn’t know how to provide a sense of security or stability, or because the child’s sense of control is being undermined by the abuse he or she experienced at the hands of another adult or peer.

Finding help at school

Counselors who are treating traumatized children should tap all available resources to help these clients, Lawson says, working not only with caregivers or other relatives but also with the child’s school. School counselors may be a source of additional one-on-one counseling for the child, or they could get the child involved in group activities with other children who are trauma victims or with children who share common interests such as music, sports or art, Lawson says. These peer networks provide abused children additional sources of support and can also teach them how to interact with people — something that many abused and isolated children have never learned to do.

Perpetrators of abuse seek to control and isolate their victims. An abusive parent has the power to cut off or severely limit a child’s healthy interactions with people outside of the circle of abuse. “[These] kids often didn’t learn social skills because they are kept away from other people,” Lawson says.

Abuse is often part of a viciously long-lived cycle, handed down from generation to generation, Lawson adds. Parents who were abused as children often grow up to abuse their own children. Even if parents with an abusive background are not abusive themselves, they may still carry on other dysfunctional behaviors, he says.

“You may have three or four generations of people [who] have a very skewed view of how to interact with people,” he says. “So they never learn how to interact with others. You have to help [these children] connect with other sources.”

School counselors also can play important roles as advocates and educators. Many people — including teachers and administrators — do not understand that many children who act out are doing so because they have been or are being abused, Tucker asserts.

“School counselors can really make a difference by making sure that kids get evaluated instead of just automatically disciplined,” Tucker says.

“So many boys end up in the criminal justice system because they were physically acting out in response to trauma,” she adds.

School counselors can also help abused and traumatized children learn how to help themselves, says Elsa Leggett, an ACA member, associate professor of counseling at the University of Houston-Victoria and president of the Association for Child and Adolescent Counseling.

“Talk to kids about safety plans,” Leggett urges. “Ask them, ‘When abusive things are going on at home, where do you go? How do you know when things are getting dangerous?’”

The most important thing that all practicing counselors can do to address childhood trauma is to ask questions, Lawson says. Children — and sometimes adults who were traumatized as children — don’t always recognize what they’ve experienced as abuse, so rather than asking “have you been abused?” Lawson instructs his students to pose questions such as “has anyone ever hit you?” and “has anyone ever touched you in a way that made you feel uncomfortable?”

ACA member Cynthia Miller is an assistant professor of counseling at South University in Richmond, Virginia, and an LPC who has worked with incarcerated women. She has seen the kind of positive change that can occur when people get the help they need, but she has also witnessed the pattern of incarceration, addiction and institutionalization that can become entrenched in generation after generation.

“If you want to decrease the amount of money we spend on treating people with substance abuse or incarceration,” Miller says, “address child abuse.”

Caring for children during a disaster

Although ongoing trauma causes the biggest and longest-lasting kind of damage, one-time events can also create problems that linger. It is particularly important for children to receive timely counseling intervention, experts say.

“Typically, most children will have short-term responses to a disaster that include five basic realms,” Baggerly says. These realms are:

  • Physical: Symptoms include headache or stomachache
  • Thought process: Children exhibit confusion and inattention
  • Emotional: Children are scared and sad
  • Behavioral: Children might become very withdrawn or clingy, or may start sucking their thumb or wetting the bed again
  • Spiritual/worldview: Children may question their beliefs about God and the world

(For more information about typical trauma responses and recommended interventions, see “Children’s trauma responses and intervention guidelines” below.)

“Typically these [responses] don’t last long,” Baggerly says, “but that depends on the kind of support kids get in the immediate aftermath.”

Ultimately, the purpose of any counseling intervention after a traumatic event is to reduce or eliminate a child’s anxiety and stress, Baggerly asserts. She attempts to do that by “resetting” the child and connecting him or her to coping strategies.

“They need caring family and community support,” Baggerly says, “but if it is a huge disaster, then parents and teachers are equally traumatized, so they are not able to give support to kids. That’s when you need to bring people from outside.”

Some children are at greater risk than others, Baggerly says. “Kids who don’t have supportive family [and] who already have anxiety or have some type of developmental disability often will have ongoing symptoms that go longer than 30 days,” she explains. “Counselors need to triage to find out who is at most risk.”

During her roughly dozen years of experience working with chronic trauma and disasters, Baggerly has developed an integrated approach that she calls disaster response play therapy. The approach uses a trauma-informed philosophy in which counselors train parents and teachers in typical and atypical reactions to disasters so they can screen children and determine which ones need more help, she explains. “We also normalize typical symptoms, provide psychoeducation that informs kids about the impact of disasters, teach them coping strategies and provide them with child-centered play therapy.”

Baggerly usually begins by gathering a group of children and talking with them about rebuilding the community. She also encourages children to use expressive arts or drama to communicate their feelings.

“The other part of what we do is facilitate connection and conversation between kids and parents,” Baggerly says. “We may start out with Theraplay and do structured activities, such as holding hands or singing ‘Row, Row, Row Your Boat.’ The point is to have them [parents and children] looking at each other so that the mirror neurons can be engaged.”

Baggerly also educates parents on activities they can do at home with their children. She refers them to an online workbook, “After the Storm,” which has scales of 1 to 10 or a thermometer that kids can fill in to indicate how much stress they are feeling.

Roaten often does volunteer trauma work and provided on-site support in the wake of the April 2013 fertilizer plant explosion in West, Texas, that killed 15 people, injured more than 150 and caused extensive damage to buildings and property.

“One girl, a seventh-grader, had been standing outside in a neighborhood with a view of the plant and observed the explosion itself,” Roaten says. “So she had that image in her head and it would not go away. I taught her some deep breathing and progressive relaxation and did some guided imagery about her favorite place to be.

“When that picture came up in her mind, she could breathe, relax and go to her good place. By the fourth day I was there, she was no longer seeing the image.”

Roaten uses expressive therapy for children who aren’t very verbal or who don’t have the vocabulary to talk about their feelings. She brings a sand tray with miniatures of fences, people and buildings. She then allows children (and even adults) to set up scenarios or vignettes that help them express and act out what they are feeling.

“I might say something like, ‘Create your world before [Hurricane] Katrina; then create your world after Katrina,” Roaten explains.

Roaten also uses trauma-focused cognitive behavior therapy to help children and adolescents learn coping skills.

“You teach them about trauma and its impact on them,” she explains. “Then you teach them relaxation and breathing skills. Once you get them to be able to self-soothe, relax and be calm, you can help them deal with pictures or scenarios that come up. You help them change the story — what they are telling themselves and what that means — which helps them work through the trauma a little bit at a time.”

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Children’s trauma responses and intervention guidelines

 

Preschool through 2nd grade

Typical trauma responses:

  • Believes death is reversible
  • Magical thinking
  • Intense but brief grief responses
  • Worries others will die
  • Separation anxiety
  • Avoidance
  • Regressive symptoms
  • Fear of the dark
  • Reenactment through traumatic play

Intervention guidelines:

  • Give simple, concrete explanations as needed
  • Provide physical closeness
  • Allow expression through play
  • Read storybooks such as A Terrible Thing Happened, Brave Bart, Don’t Pop Your Cork on Monday

 

3rd through 6th grade

Typical trauma responses:

  • Asks a lot of questions
  • Begins to understand that death is permanent
  • Worries about own death
  • Increased fighting and aggression
  • Hyperactivity and inattentiveness
  • Withdrawal from friends
  • Reenactment though traumatic play

Intervention guidelines:

  • Give clear, accurate explanations
  • Allow expression through art, play or journaling
  • Read storybooks

 

Middle school

Typical trauma responses:

  • Physical symptoms such as headaches and stomachaches
  • Wide range of emotions
  • More verbal but still needs physical outlet
  • Arguments and fighting
  • Moodiness

Intervention guidelines:

  • Be accepting of moodiness
  • Be supportive and discuss when they are ready
  • Groups with structured activities or games

 

High school

Typical trauma responses:

  • Understands death is irreversible but believe it won’t happen to them
  • Depression
  • Risk-taking behaviors
  • Lack of concentration
  • Decline in responsible behavior
  • Apathy
  • Rebellion at home or school

Intervention guidelines:

  • Listen
  • Encourage expression of feelings
  • Groups with guiding questions and projects

 

Source: “Systematic Trauma Interventions for Children: A 10-Step Protocol,” by Jennifer Baggerly in Terrorism, Trauma and Tragedies: A Counselor’s Guide to Preparing and Responding, third edition, American Counseling Association Foundation, 201

 

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ACA Traumatology Interest Network

Counselors and counselors-in-training who have an interest in providing counseling services to trauma- or disaster-affected individuals and communities should consider joining the ACA Traumatology Interest Network. Network participants share insights, experiences, new plans and advances in trauma counseling services. For more information on joining the interest network, go to counseling.org/aca-community/aca-groups/interest-networks.

 

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To contact individuals interviewed for this article, email:

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org