Traumatized children present a significant challenge to marriage and family therapists (MFTs) due to the gravity of harm, severity of symptomology and acute need for crisis intervention. The advent of managed health care in the U.S. with its primary emphasis on “cost-effective treatment,” has placed ethical and caring therapists in a position of maximizing the healing effects of each therapeutic session for the distressed child and his or her family. Family play therapy is a modality of treatment that actively responds to this need.
It is a model of structured play therapy for child trauma survivors and their families which operates from a systemic treatment perspective. Parents are honored participants in their child’s therapy as primary facilitators of positive change, interventions, initiated by the play therapis, are structured, goal-oriented, and solution-focused in response to the specialized needs of this population.
The Power of Play
The value of play therapy is multi-faceted for children. It provides a vehicle for learning and growth in all developmental areas. Play provides an avenue for intellectual growth progressing through separate and distinct phases, according to Swiss psychologist Jean Piaget. Play increases social learning and interactive maturity and it develops gross and fine motor skills.
Play therapists emphasize the emotional components of play which allow for ventilation of feelings, “free child” activity, and the abreaction of unresolved issues and trauma. Since play is not only an instinctive form of self-expression, but also pleasurable for the child, children enter the playroom already equipped to benefit from this method of specialized treatment.
Play truly is “the child’s work” and it allows the therapist to honor the child client on his or her own developmental level in a manner which provides comfort and familiarity-both imperative components in therapy for the traumatized child. Additionally, therapists and client parents alike can engage their own “child within” and enjoy the intra-psychic freedom play provides.
What is Play Therapy?
Charles Schaefer, PhD, a prolific writer on play therapy methodology and treatment, defines play therapy as “an interpersonal process in which persons with specialized training mobilize therapeutic change in clients through play interactions.”
Diane Frey, PhD, describes multiple therapeutic advantages of play therapy which include the establishment of a strong therapeutic alliance between therapist and child. Within the safety of this therapeutic environment, child clients have the opportunity to build trust, experience pleasure, initiate self-expression on their own level, and develop an enhanced ego structure-all primary goals for a traumatized child. In addition, through play therapy, child clients can achieve catharsis and use the ego defense mechanism of sublimation to promote healing by replacing a forbidden impulse or action with an acceptable one.
For example, a “play” abusive father can be buried in the sand, never to return, creating a new sense of safety and empowerment for the child.
A playroom is designed with many different expressive mediums and toys. It may include puppets, expressive art materials, clay or play dough, picture books, and a therapeutic sandtray with differing toy figures to tell stories. As play invites strong and safe interactive process for child and parent in the midst of surviving an episode of trauma, the structured play therapist can provide guidance, nurturance, support and therapeutic interventions to heal and decrease the acute symptoms of post traumatic stress.
Active participation by parents in the playroom is a great gift to traumatized children, many of whom enter therapy distrustful and hyper-vigilant to new adults and surroundings. The playroom becomes a safe haven where feelings of safety and comfort replace feelings of anxiety, fear and the need to be physically and emotionally self-protective. Very young children with only beginning verbal skills can be treated optimally with this technique.
Treating Trauma from a Systems Perspective
Traumatized children and families are fortunate when treatment is initiated with an MFT specialized in traumatology. No other mental health professional is so oriented to the primary importance of the inclusion of family members in treatment. A systemic approach with a traumatized child recognizes the child as a “primary victim” with other family members categorized as “secondary victims.”
A traumatized family system acutely affects family dynamics, levels of hierarchy, roles, alliances and primary psychological need attainment. Parents and siblings and grandparents and relatives are generally actively experiencing the cycling of grief and are often disoriented, shameful and unsure how to best attend to the victimized child’s immediate needs and acute symptoms.
Unresolved trauma and/or childhood abuse issues of parents also become activated and further compromise the family system’s ability to maintain homeostasis.
The immediate inclusion of parents as part of family play therapy recognizes and attends to the “survival level” functioning of the child’s caregivers. Therapists attend to parents, siblings and the victimized child with immediacy to provide specific crisis intervention therapy. Assessment of each individual’s needs for physical and emotional stabilization is an initial goal in trauma therapy. The therapist may also initiate a therapeutic plan for the active involvement and support of the secondary family system and helpful community systems.
Full therapeutic engagement of primary system members of a traumatized child is unique to MFTs-a far cry from some medical or psychiatric models of child treatment which only involve the child patient with little or no feedback from parents or relatives.
Methods of Play Therapy
There are a number of differing approaches to play therapy. The approach may be child-centered in which the therapist is non-participatory in the child’s play. Non-directive play therapists operate from a Rogerian stance with the belief that the child will take therapy where it needs to go; therefore self-actualizing and healing without therapist intervention.
On the other hand, directive play therapists believe not all play is primarily therapeutic for traumatized children and actively participate, facilitate and strategically plan play interventions that are prescriptive, directive and behavioral in nature. Directive play therapists may also teach positive parenting techniques during family play therapy and role-play such interactions with the child. Therapist and parents operate as the child’s team.
Directive therapists enlist the active assistance of parents in their child’s healing-providing education, guidelines and therapeutic homework between parents and their child to occur within the home environment.
Trauma-Specific Therapist Interventions
As discussed and outlined in the DSM-IV, Post Traumatic Stress Disorder (PTSD) may evolve after an individual experiences an event with serious perceived or actual threat to life or body integrity. Children who have survived severe accidents, violence, various forms of abuse or negligence, or natural disasters often experience specific post-trauma symptoms with varying severity. In children, increased arousal symptoms include anxious attachment to a protective parent, a pervasive fear of being alone, post-trauma nightmares, a generalized fear or anxiety reactions and a numbing or restricted range of affect.
For example, on year after Hurricane Hugo in Charleston, South Carolina, a multitude of children were treated for PTSD and parents were often unaware of the initial precipitator-the hurricane-since there was no loss of life or physical injury.
Structured interventions with traumatized children and families in the playroom involve the discovery and ventilation of uncomfortable feelings through the use of expressive art, puzzles and feeling-oriented books. After reading the picture book The Hurt by Teddy Dolsky, child and parents can be directed by the therapist to create their own “hurt” out of play dough to share with each other. The therapist is able to hear and evaluate the child’s perception of his or her harm and provide child-oriented solutions and techniques.
Young traumatized children will often have nightmares with a recurrent monster that the child can draw and characterize in the safety of a parent’s presence. The play therapist can then invite the child to make friends with his or her monster by creating a play dough monster or monster puppet with the parents’ participation. Along with the therapist, parents and child can create a story that decreases the monster’s ability to harm, while adding the element of fun and humor.
If the child would not like to be friends with the monster, the therapist can suggest that parents purchase a can of Lysol or air freshener and decorate it as “Monster Spray.” The child and parents can then begin a therapeutic ritual where the child is given permission to spray the scariest places in the home. To increase a child’s level of safety and empowerment, therapists may choose to invite parents and child to create a “magic wand” for the child to use whenever he or she is frightened. The wand can be constructed in the play room and the therapist can help the family create specific magic words and messages that will decrease specific fears.
Young children operate from a position of omnipotence wherein fantasy is reality. Solution-focused interventions are internalized, create personal empowerment and help to decrease the acuity of post-trauma symptoms.