DANIEL S. SWEENEY AND MADELINE LOWEN
A scared child stands in the middle of your play therapy room. Her head is lowered, and she hesitates to touch the toys even with her eyes. She seems to be trying to take up as little space as possible; the world has taught her she is small. Her parents have told you about her trauma and her fears, but the words of an adult cannot portray the world of a child who has been traumatized. Despite the best intentions of the adults who care about her, this child is radically alone in a reality of fear, shame, and isolation.
An angry adolescent is compelled to come in for counseling because of his delinquent behavior. Underneath that anger, you see a desperate loneliness in him. He feels unheard and misunderstood. He has been labeled by the adults in his life and can’t begin to describe the pain underlying his “diagnosis.” At the outset of coming in for counseling, he sees himself as a mandated client and refuses to talk. Why should he? The counselor is just another adult who will probably label him.
The training, orientation, and experience of many of us in the helping professions are similar. Many therapists would suggest, perhaps insist, that this scared child and angry teen must talk about what they are feeling, what they have experienced, and what they are currently experiencing. We all know the classic counseling question: “How does that make you feel?” Naturally, these clients must verbalize their pain and frustration in order to begin the therapeutic process and experience healing. Or do they? Could it be that these two (and many other) young clients might not be able to express their stories and the accompanying pain through verbalization alone?
We suggest that therapists working with young clients who have experienced chaos, turmoil, and trauma must consider certain developmental components and trauma dynamics. Perhaps nonverbally based psychotherapeutic interventions—interventions that are play-based, expressive, and projective in nature—are not just helpful but necessary. That is the focus of this chapter: exploring the developmental fit for child and adolescent psychotherapeutic interventions.
As therapists, we strive to come alongside our clients in painful realities, offering them empathy and companionship on their road toward healing. Carl Rogers (Rogers & Truax, 1967) described this goal of “accurate empathy” as being “completely at home in the universe of the patient . . . sensing the client’s inner world of private personal meanings ‘as if’ it were the therapist’s own” (p. 104). Although Rogers began to advocate for the healing power of empathy many decades ago, the ultimate act of empathy occurred long before that. More than 2,000 years ago, the God of the universe made himself “completely at home in the universe” of humans, becoming a man and walking among us as Jesus Christ. Like the examples set by both the father of client-centered therapy and God the Father, it is our job as therapists to enter the reality of our clients. The young girl and adolescent boy standing in your office trying to find a safe place need this very type of empathy; they need someone to enter their worlds and meet them there.
While many therapists are well practiced in the act of empathy, as therapists we live in the reality of adulthood; the inner world of children has become far removed from our own daily experience. The challenge when working with children, especially those who have been traumatized, is to step out of our own universe and find our way into theirs. Far too often, we as therapists treat children like adults who have been zapped with a shrink ray. We expect them to enter our adult world, acting and thinking like we do, just in smaller bodies. Once again, the ultimate example of a radically different type of empathy can be seen in Jesus, who calls children to himself just as they are: “Let the little children come to me, and do not hinder them, for the kingdom of God belongs to such as these” (Mk 10:14). In fact, he takes this a step further, telling the adults that they must become more like children: “Truly I tell you, unless you change and become like little children, you will never enter the kingdom of heaven. Therefore, whoever takes the lowly position of this child is the greatest in the kingdom of heaven” (Mt 18:3-4). For a Christian therapist, entering the world of the child is not only best-practice therapy; it also reflects Christ’s vision for the kingdom of heaven.
Entering into the world of a traumatized child or teenager can be particularly difficult for therapists. Not only is it emotionally difficult to witness the pain of a child and the darkness of a world that caused it, but also there are unique psychological and biological ramifications for traumatized youth. This chapter is meant as an initial guide, and we hope it will motivate therapists seeking to journey into this reality of young clients. The chapter provides signposts for this new territory, offering direction regarding the neurobiology of trauma, the unique developmental characteristics of children and teenagers, and an exploration of expressive interventions that will help the therapist enter the world of this population regardless of his or her theoretical orientation.
Adult-focused therapy often relies heavily on verbal communication skills, emotion identification, abstract conversations, and behavior management techniques. These foundational elements, however, are the very things that children and teenagers are still in the process of developing. Although Jean Piaget (1962) is often criticized for his small sample size and the conclusions he drew, his framework for cognitive development is still widely used to describe the transition that occurs from concrete to abstract thinking (Berger, 2014). According to Piaget, children younger than age 11 or 12 do not have the ability to think abstractly or reason in hypotheticals.
This means that child clients (and many teenage clients who are developmentally younger than their chronological age) are concrete thinkers, lacking the cognitive ability to explore their trauma in ways that many traditional adult therapies require. On top of this, children and teenagers do not have fully developed frontal cortices, meaning that they are still learning self-management, self-regulation, and other basic executive functioning skills (Berger, 2014). Additionally, neuroimaging studies show that the adolescent brain continues the development process (Blakemore, 2012), underscoring the need for therapeutic flexibility throughout child and teen therapy. Trauma treatments that ignore these realities unfortunately treat children like miniature adults, rather than as a unique demographic with different needs.
Because traditional therapy is often a verbal process, it is important to also understand the language development of children. Most children speak their first words around the age of one and then steadily build their vocabularies until they are able to speak in short sentences by the age of two. From this point on, their vocabularies explode, and they continue to perfect their grammar and syntax. It isn’t until middle childhood that most children begin to understand puns and metaphors in language (Berger, 2014). Even for children who have large vocabularies and impressive language skills, their brains are still learning how to communicate using verbal speech. Especially when it comes to expressing strong emotions, children are frequently unable to put these feelings into words. Landreth (2012) advocates that verbal speech is not the first language of children. Instead, he believes that play is a child’s language and toys are the words. Honoring this “first language” of children is one of the major distinctions between play therapy and talk therapy. Not only does this meet the language needs of children, but it also embraces the concrete thinking described above.
Another element of child development that is critical to trauma treatment is emotional development. At birth, babies exhibit primarily distress and contentment, which expands to include laughter and smiles around four months of age, followed by anger in the months immediately after. During these early stages, emotion is a relational process, with children experiencing and reciprocating emotion from their primary caregivers. The strength and security of these early attachment relationships are strongly correlated to emotional health and regulation as well as resilience throughout life. During early childhood, from age two to six, the primary emotional goal is for children to learn and master emotional regulation (Berger, 2014). By the time they reach adolescence, this emotional regulation faces significant obstacles. Adolescents experience an increase in emotional intensity leading to impulsivity, moodiness, and increased reactivity (Siegel, 2013). Therefore, we believe that psychotherapy with child and adolescent clients should take into account these fundamental developmental realities.
In addition to the developmental characteristics described above, distinct characteristics of the effects of trauma (for children, adolescents, and adults) point to the benefits of using play and expressive therapies. This and the following section of the chapter will briefly explore these considerations.
To begin with, it is important and foundational to summarize our basic rationale for play and expressive therapies. Sweeney (1997), Homeyer and Sweeney (2017), and Sweeney, Baggerly, and Ray (2014) suggest several:
Play is arguably the child’s natural medium of communication, as opposed to the verbal communication that is the primary medium of adult therapy. This is often the case for adolescents as well. Adult therapy presupposes the client’s ability to engage verbally, cognitively, and process abstract concepts. We consider it unfair and dishonoring to expect children (and possibly some older clients) to leave their world of expressive play and enter the adult world of verbal communication.
This also applies to verbally precocious youth. We contend that it is an error to assume that children and youth who appear to have verbal skills are thus able to express their emotional lives in words. Their verbal abilities do not necessarily mean that words are the appropriate means of relational connection.
Expressive therapies inherently have a unique kinesthetic quality. Play and expressive media provide an unparalleled sensory experience, which meets a basic need that people have for kinesthetic experiences. We assert that this is an extension of basic attachment needs, which convenes in both experience and relationship.
Play and expressive therapies create the necessary therapeutic distance often needed for traumatized clients. These clients may be unable to express their pain in words but can find expression through projective media. It may well be easier for a traumatized child or adolescent to express self through a toy, a sandtray therapy miniature, or creative arts than to directly verbalize the pain.
This therapeutic distance creates a safe environment for abreaction and catharsis to occur. All clients who have experienced trauma and crisis need a therapeutic setting in which to abreact—a place of safety where painful issues can emerge and be relived, and thus a safe place to experience the intense negative emotions that are often attached.
Play and expressive therapies create a place for traumatized clients to experience control. We assert that a fundamental result of traumatizing experiences is a loss of control for those in their grip. A crucial goal for these clients must be empowerment, recognizing that the loss of control inherent in trauma and chaos is intrinsically disempowering. Words alone may be therapeutically limiting in this process.
Expressive and play therapies provide a unique and natural setting for the emergence of therapeutic metaphors. The most powerful metaphors in therapy are those that are generated by clients themselves (as opposed to those by therapists), and expressive therapy creates an ideal environment for this to occur. Toys and expressive media serve to facilitate clients expressing their own therapeutic metaphors.
Transference, a natural part of the therapeutic process, may be a challenge that can be effectively addressed through play and expressive therapies. This is because of the availability and use of expressive media, which create alternative object(s) of transference. Regardless of various theoretical perspectives on transference, expressive therapies provide a means for transference issues to be safely addressed if and when needed. The toys and expressive media can become objects of transference or the means by which transference issues are therapeutically addressed.
Play and expressive therapies are effective interventions for traumatized clients. The neurobiological effects of trauma (such as prefrontal cortex dysfunction, increased activation of the limbic system, and deactivation of the Broca’s area, the part of the brain responsible for speech) seem to underscore the need for nonverbal interventions. Potential neurobiological inhibitions on cognitive processing and verbalization certainly contend for the benefits of expressive intervention. We will expand on this in the next section.
Finally, we assert that deeper intra- and interpersonal issues might be accessed more thoroughly and rapidly through play and expressive therapies. These therapeutic interventions create opportunities for nonverbal expression, which facilitate for clients a safe means of processing, and often an accelerated one.1
Having provided the rationale for this specific therapeutic approach in working with children and adolescents, we can now explore the nature of expressive therapies in relation to trauma. Schaefer (1994) suggested several interrelated hallmarks of expressive therapies that provide a sense of therapeutic distance and the related safety that traumatized children and adolescents need in therapy:
Symbolization. Clients can use a sandtray miniature or create art to represent an abuser or victimizing situation. For example, it can be much safer for a client to select a predatory animal puppet to represent an abuser (as opposed to verbally discussing victimization). A client might create or select a building with barred windows to represent being held captive. This could represent a presenting issue that involves actual abduction or the overwhelming feeling of inescapability.
“As if” quality. Clients can use the pretend quality of play/drama to act out events as if they are not real life. For example, for a young victim or witness of domestic violence, it is often challenging to process such a trauma verbally. With expressive therapies, clients can “manage the unmanageable,” controlling in the as if element of the expressive therapy that which could not be controlled in the depths of the traumatizing situation.
Projection. Clients can project intense emotions onto the expressive media, which can then be used to safely act out these strong feelings. It can feel much safer for children and adolescents to project complex and possibly frightening emotions onto animals, puppets or dolls than it would be to directly verbalize them. This therapeutic distance creates a greater sense of safety.
Displacement. Clients can shift negative feelings onto the expressive media rather than expressing them directly toward an abuser or perpetrator. Play and expressive therapies not only provide the opportunity for abreaction to occur but also facilitate relational connection through the setting, the media, and the process.
These basic elements of expressive therapies interweave in the therapeutic process, providing the opportunity for metaphor and symbolism to facilitate access to the traumatized client’s inner world. Gil (2012) summarizes these dynamics, suggesting that expressive therapy
allows for externalized creations of internal “worlds” of affect, cognitions, perceptions, picture memories, and compartmentalized aspects of difficult life experiences. This therapy allows for mental and physical assimilation, access to symbol language and metaphor, and the possibility of both chronicling events (creating narrative scenarios), and utilizing a type of guided imagery that can promote insight and change. (p. 256)
Traumatized clients truly need the safety of expressive therapies to explore and express these “internal worlds.”
As described above, expressive therapies provide for an experiential, sensory, and nonverbally based therapeutic experience. In contrast, more traditional talk therapies focus on the executive functioning of the cortical area of the brain, which has limited ability to process trauma (van der Kolk, 2014). When expressive therapies are used in conjunction with or as an alternative to verbally based interventions, we posit they allow clients to process deeper neurobiological issues. In this section we review the neurobiology of trauma as well as the implications for treating traumatized children and adolescents (for a more thorough exploration of the neurobiology of trauma, see chap. 3 of this book).
Physiological changes in the brain. It is well known that trauma can eventuate in significant neurobiological activity. There is an increased production of catecholamines (e.g., epinephrine and norepinephrine), which results in increased sympathetic nervous system activity—where the fight/flight/freeze response is located (De Bellis & Zisk, 2014). Initially there are often decreased levels of corticosteroids and serotonin, the most pronounced effect likely being the diminished ability to moderate the catecholamine-triggered fight/flight/freeze response. Additionally, there are increased levels of endogenous opioids, which may result in emotional blunting, memory impairment, and pain reduction (De Bellis & Zisk, 2014). It is imperative that clinicians (and clients) realize that protracted exposure to traumatic stress affects the adaptation of these chemicals. Essentially, this may permanently alter how people deal with their environment on a daily basis.
We believe that many therapists, though well trained in their areas of expertise, overlook the need to consider the neurobiological effects of trauma. Perry (2006) notes, “Simply stated, traumatic and neglectful experiences . . . cause abnormal organization and function of important neural systems in the brain, compromising the functional capacities mediated by these systems” (p. 29). Perry (2009) asserts that for traumatized clients to experience change, interventions must target underdeveloped and corrupted regions of the brain. Such intervention is fundamentally important for the brain regions most affected by trauma, including (but not limited to) relational connection, memory, sensory integration, executive functioning, and self-regulation. In order to resolve and reform dysfunctional neural networks, interventions must activate these systems (Gaskill & Perry, 2012, 2014; Perry, 2009), which can be done through play and expressive therapies.
One area of the brain that is particularly sensitive to trauma is the hypothalamic-pituitary-adrenal (HPA) axis, as are various noradrenergic systems. MRI scans of abused and neglected clients reveal evidence of cortical atrophy or ventricular enlargement. For example, in research of child subjects with PTSD, there is evidence of broad neuronal atrophy and diminished development (De Bellis & Zisk, 2014). This includes smaller intracranial, cerebral, prefrontal cortex areas; prefrontal cortical white matter; right temporal lobe volumes; and areas of the corpus callosum and its subregions. Research essentially demonstrates a pattern of atrophy that can be pervasive in the brain—either a deceleration of brain development or reduction of current brain volume.
A definitive example of neurobiological changes occurs in the limbic system, the part of the central nervous system that guides emotion and memory as well as behavior necessary for self-preservation (van der Kolk, 2014). Trauma may cause limbic system abnormalities in the amygdala and hippocampus. The amygdala, which readies the body for action, may get “hijacked” (Perry, 2006) by these neurobiological changes; thus the trauma victim responds before the “thinking” part of the brain (i.e., cerebral cortex) can assess threats. This results in the hypervigilance often seen in trauma victims, which can cause them to go immediately from stimulus to an arousal response without being able to make the intervening assessment of the source of their arousal. This causes them to overreact and perhaps intimidate others. We certainly see this response from traumatized children.
Verbal processing. Many of the neurobiological implications of trauma also negatively affect a client’s verbal processing abilities. For instance, clients with PTSD may experience a deactivation of the prefrontal cortex, which is responsible for executive function. This interferes with their ability to measure and respond to threats in a variety of contexts; it not only makes navigating life in general challenging, but it also interferes with the therapeutic process (van der Kolk, 2003). While increased levels of physiological and emotional arousal are occurring, the ability to process these is obstructed. Van der Kolk (2002) notes, “Trauma by definition involves speechless terror: patients often are simply unable to put what they feel into words and are left with intense emotions simply without being able to articulate what is going on” (p. 150).
This decrease in verbal processing abilities has been demonstrated in several neuroimaging studies (Carrion, Wong, & Kletter, 2013; De Bellis & Zisk, 2014; Lanius et al., 2004). When people with PTSD relive their traumatic experience, which is what we ask them to do in therapy (usually asking that they do so in words), there is decreased activity in the Broca’s area of the brain, which is related to language. At the same time, there is increased activity in the limbic system, or emotional responses (van der Kolk, 2014). When traumatized people are reliving their trauma, they have great difficulty verbalizing these experiences. This would seem to fit the definition of speechless terror. Malchiodi (2014) suggests that expressive therapies may provide a unique way to access these traumatic memories, which are “stored as somatic sensations and images” rather than as words (p. 11). She states that “sensory means” of therapy are a way to get around the brain’s natural protective instinct, which makes the trauma “literally . . . impossible to talk about” (p. 11).
Integration of the left and right hemispheres. This juxtaposition of sensory and verbal trauma memories also supports the need for trauma interventions that work to integrate the two hemispheres of the brain. The left hemisphere is focused more on linear and verbal processing; the right hemisphere, by contrast, is focused more on the nonverbal, artistic, and metaphorical. Gil (2006) notes that evidence “suggests that trauma memories are imbedded in the right hemisphere of the brain, and thus that interventions facilitating access to and activity in the right side of the brain may be indicated” (p. 68).
Trauma appears to negatively impact the integration of the two hemispheres. Specifically, trauma causes abnormalities in the corpus callosum, the fiber tract connecting the two hemispheres (Teicher, Tomoda, & Andersen, 2006). This may explain the challenges in lateralization (accessing both hemispheres) that abused clients sometimes experience, and can certainly affect the narrative of the trauma. Siegel (2003) speaks to the inherent challenges in this:
The linear telling of a story is driven by the left hemisphere. In order to be autobiographical, the left side must connect with the subjective emotional experience that is stored in the right hemisphere. The proposal is this: to have a coherent story, the drive of the left to tell a logical story must draw on the information from the right. If there is a blockage, as occurs in PTSD, then the narrative may be incoherent. . . . When one achieves neural integration across the hemispheres, one achieves coherent narratives. (p. 15)
Nonverbally based expressive therapies reach the metaphorically focused right hemisphere. As a result, the expression of the traumatic narrative is enhanced. We advocate that clients express trauma narratives; however, the expression does not have to be (and indeed sometimes cannot be) verbal in nature.
By focusing on the emotional experience of the right hemisphere, interventions can open a “highway for the right to offer itself to the left” (Badenoch, 2008, p. 224). Badenoch and Kestly (2015) see expressive experiences as an opportunity to access and alter “the neural nets holding implicit memory” by creating “an embodied experience of what was missing and needed at the time of the original [traumatic] event” (p. 529). With sandtray therapy, for example, Badenoch (2008) suggests that it may be beneficial to inquire about the feelings and emotions surrounding a sandtray as opposed to looking for cognitive meaning. This avoids “a leap from the right- to left-hemisphere processes” (p. 224), allowing for healing and integration between the hemispheres to occur.
Bottom-up integration. Along with lateral hemisphere integration, trauma treatment should address the integration of the lower and higher areas of the brain. Since trauma can lead to a neurobiological alarm state, where alarm reactions can overpower cortical processing (Perry, 2006; van der Kolk, 2006, 2014), cortical areas of the brain can be overwhelmed by lower regions of the brain. This is one of the reasons Perry (Gaskill & Perry, 2012, 2014; Perry, 2006, 2009) advocates that therapy with traumatized children, as well as traumatized adolescents, begin with a focus on the lower brain regions (the brainstem and diencephalon [midbrain]) and work upward. This would include moving through higher brain areas, identified by Perry as the limbic and cortical areas. Perry and Hambrick (as cited in Gaskill & Perry, 2012) emphasize that “until state regulation or healthy homeostasis is established at the brainstem level, higher brain mediated treatments will be less effective” (p. 40).
Play and expressive therapies inherently follow this evolvement. Expressive media—from toys to sand, water to paint, puppets to dress-up clothes—are fundamentally related to the brainstem and diencephalon. In sandtray therapy, for example, Badenoch (2008) asserts that arranging the sand is an experience that “encourages vertical integration, linking body, limbic region, and cortex in the right hemisphere” (p. 223). Most expressive therapy media entail the tactility, motor action, and attunement needed to engage the brainstem, as well as the rhythmic, simple narrative, and physical warmth needed to engage the diencephalon (see Perry, 2006).
The neurobiological realities discussed throughout this section are a crucial component to any developmentally appropriate trauma intervention for children and adolescents. Van der Kolk (as cited in Wylie, 2004) sums up our main points well: “Fundamentally, words can’t integrate the disorganized sensations and action patterns that form the core imprint of the trauma. . . . To do effective therapy, we need to do things that change the way people regulate these core functions, which probably can’t be done by words and language alone” (p. 38).
With our argument for developmentally appropriate interventions, we are clearly focused on play and expressive interventions. It is thus important to define play therapy. While several definitions exist, we have chosen Landreth’s (2012) definition. Although Landreth does come from a specific theoretical orientation (child-centered), we believe his definition is cross-theoretical:
Play therapy is defined as a dynamic interpersonal relationship between a child (or person of any age) and a therapist trained in play therapy procedures who provides selected play materials and facilitates the development of a safe relationship for the child (or person of any age) to fully express and explore self (feelings, thoughts, experiences, and behaviors) through play, the child’s natural medium of communication, for optimal growth and development. (p. 11)
Sweeney (1997) and Sweeney, Baggerly, and Ray (2014) use this definition in their discussions of play therapy. We would adapt their work as we unpack Landreth’s definition:
We advocate that all therapy should be dynamic and interpersonal. Relationship is arguably the most curative element in psychotherapy and indeed should be a cross-theoretical therapeutic imperative.
All play (and expressive) therapists must be trained in play (and/or expressive) therapy procedures. While this would appear to be an obvious factor, it is unfortunately too often overlooked. All too frequently, therapists using projective and expressive techniques such as play therapy have too little training and a lack of supervised experience.
Play and expressive therapists must provide selected play materials. It is insufficient to provide a random collection of expressive media. Landreth (2012) reminds us that toys should be selected, not collected. Expressive play therapy materials should be intentionally gathered in a way that is consistent with theoretical rationale and specific therapeutic intent. Just as with the general psychotherapy process, expressive media should be congruous with therapeutic goals and objectives.
Therapy of any kind should facilitate the development of a safe relationship with clients. Traumatized clients need a therapeutic experience of safety—because people do not grow or heal where they do not feel safe. Facilitation brings about this place of safety. This is true for both directive and nondirective therapeutic interventions.
Within this context of safety, children and adolescents can indeed fully express and explore self, which is the basis for further therapeutic advancement. We argue that if insight and behavioral change are therapeutic goals, the ability to express and explore self is foundational.
Play is indeed a child’s natural medium of communication. This is a key element of play therapy. It is also, however, a key means of communication for all clients, of any age, who have a challenging time verbalizing for a variety of reasons. This is what makes expressive and projective interventions so exciting for clients of all ages.2
There are a wide variety of approaches to play therapy that are beyond the scope of this chapter. For a foundational text on play therapy, we recommend Garry Landreth’s (2012) Play Therapy: The Art of the Relationship. To explore various theoretical approaches to play therapy, we recommend Foundations of Play Therapy (Schaefer, 2011), Play Therapy: Comparing Theories and Techniques (O’Connor & Braverman, 2009), and Handbook of Play Therapy (2nd ed.; O’Connor, Schaefer, & Braverman, 2016).
There is some disagreement in the play therapy field regarding which therapeutic perspective is more appropriate with children: a directive or nondirective approach. However, we are not as concerned about a therapist’s specific approach as long as the child’s and adolescent’s best interests are kept in mind. Provided that the client’s developmental level is acknowledged and honored, a wide variety of approaches can be used.
Having said this, we need to make some comments about therapeutic theory and techniques. We believe that therapeutic work with children and adolescents can and should be cross-theoretical, not atheoretical (i.e., without any theoretical foundations). Thus, play and expressive therapy approaches and techniques should always be theoretically based. Sweeney (2011) asserts that theory is always important but theory without technique is basically philosophy. At the same time, techniques may be quite valuable, but techniques without theory are reckless and could be damaging. Sweeney (2011) further asserts:
All therapists are encouraged to ponder some questions regarding employing techniques: (a) Is the technique developmentally appropriate? [which presupposes that developmental capabilities are a key therapeutic consideration]; (b) What theory underlies the technique? [which presupposes that techniques should be theory-based]; and (c) What is the therapeutic intent in employing a given technique? [which presupposes that having specific therapeutic intent is clinically and ethically important]. (p. 236)
We suggest taking a primarily child-centered approach with young children, more so for developmental reasons than for theoretical perspective. With a therapeutic process that is led by the child, traumatized children have the opportunity to gain mastery and control and to discover their own potential and capabilities. Additionally, as noted earlier, traumatized clients have a need for therapeutic experiences in which they can regain the control lost in the trauma event/experience; thus a case can be made for a client-led process for clients of all ages.
As children move into preadolescence and adolescence, more directive, even cognitive, expressive interventions may become possible elements of the therapeutic process. Many cognitive interventions can be adapted into expressive work, which we will comment on below.
Although we do not have the space in this chapter to explore specific interventions in detail, we offer a brief survey below. In addition to the play therapy resources noted above, readers are referred to the following: Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches (Gil, 2006), Creative Interventions with Traumatized Children (2nd ed.; Malchiodi, 2015), and Handbook of Child Sexual Abuse: Identification, Assessment, and Treatment (Goodyear-Brown, 2011).
Group play/expressive therapy. The combination of expressive therapeutic work and group therapy is an exciting dynamic. There are a number of possible approaches in terms of theory, techniques, and client populations. Two resources are recommended: Handbook of Group Play Therapy (Sweeney & Homeyer, 1999) and Group Play Therapy: A Dynamic Approach (Sweeney, Baggerly, & Ray, 2014). Many standard group-therapy techniques can also be adapted for use with children and adolescents in group expressive work.
Expressive art interventions. While not many therapists are certified in art therapy, there is significant value to using art interventions with both children and adolescents (Malchiodi, 2012). These can be unstructured activities, such as scribbling, or structured activities, such as a drawing or creating a sculpture of self, family, or school settings. It is important to have adequate materials for art interventions—such as paint supplies, crayons, paper, and basic craft supplies. As always, be cautioned against interpretation.
Puppet play. Puppets can communicate things that clients are not able to. This is an example of the therapeutic distance discussed above. A wide variety of puppets is necessary so that individual or group clients can have several self-selected puppets. It is helpful to have a puppet theater, which can be a formal stage or simply a cardboard box. The clients (puppeteers) can “hide,” while the puppets are the agents of expression. This can be a structured or unstructured activity.
Sandtray therapy. There is a significant history to the use of sandtray therapy with clients of all ages (see Homeyer & Sweeney, 2017). Sandtray therapy is similar to puppet play—with the sandtray being the “puppet theater” and sandtray miniatures being the “puppets.” The sandtray and a large selection of sandtray miniatures create a pallet for nonverbal expression without the need for any artistic skill. This again creates a powerful means of therapeutic distance and nonverbal expression.
Drama therapy. There are numerous approaches to drama (and psychodrama), which can be powerful within the play and expressive format. Oaklander (1988) asserts that “drama is a natural means of helping children find and give expression to lost and hidden parts of themselves, and to build strength and self-hood” (p. 139). It is important to have adequate props, such as dress-up clothes and accessories.
Integrating cognitive techniques. While it is crucial to honor developmental and trauma-related issues, it is possible to incorporate cognitive techniques into expressive therapy. Another reminder: be careful not to defeat the purpose of using play and expressive therapy by jumping to the use of techniques that are beyond the developmental capabilities of a child or adolescent client. Having said this, it is possible for therapists to challenge cognitive distortions using puppets or sandtray miniatures. It is also possible to employ a solution-focused technique, such as having an adolescent client create a drawing or a sandtray in response to the “miracle question” (de Shazer, 1988).
The following case examples illustrate how some of the techniques and principles we have discussed in this chapter can be applied. We will begin with the case of Abigail, a child client, after which we will look at the case of Peter, an adolescent client.
The case of Abigail. Abigail’s case was referred to me (Daniel) by her mother. Abigail was a nine-year-old victim of sexual abuse with a PTSD diagnosis. She presented with emotional and behavioral disturbances as well as difficulties with sleeping. She had been seeing another therapist in the community, and her mother contacted me, stating that Abigail’s therapy process had “stagnated.”
Although Abigail was intelligent and verbally precocious, I chose to take a child-centered play therapy approach in the beginning, with the possibility of moving on to more structured activities. In the initial session, after my brief introduction to the playroom, Abigail promptly sat down on a chair and said to me, in a rather matter-of-fact manner, “I suppose you’ll want to talk about the molest?”
This of course caught me off guard, since very few of my sessions begin this way! As I paused to formulate my response, I thought about what a shame it was that this child, even though she already talked like an adult, had such a concept of the counseling process. Here I was, a new therapist to her—a new male therapist, no less—in the first seconds of the first session, and she was disclosing a traumatic event in her life.
After a few seconds, I responded in a very child-centered manner by saying, “In here, you can decide to talk about whatever you would like, or you can choose not to talk at all.” My response surprised her even more than her own initial question surprised me. After an awkward silence, because she didn’t know how to answer or what to do, I said, “It’s probably pretty strange being with a counselor who doesn’t ask a lot of questions.” With a big sigh, Abigail responded affirmatively. Although it took her a while in that first session, she began to play, and the process developed rapidly after that.
The only thing that Abigail had known about counseling was that it involved talking. After her initial surprise at my response, she was relieved not to have to process her trauma verbally. As Abigail began to work through her feelings and experiences in the playroom—through play as well as unsolicited verbalization—positive changes began to appear in her life. After three sessions, her mother reported a decrease in anxiety, increased positive relationships with family and peers, and improved sleep. It is our contention that the primary genesis of these improvements came about by allowing her to “talk” in her language and experience the understanding of a caring therapist.
The play therapy experience for Abigail was in stark contrast to her previous cognitively based counseling experience. While not eschewing verbal therapy, in light of her developmental age (slightly regressed due to the traumatic experience) as well as the neurobiological challenges of verbalization discussed earlier, I believe that an expressive therapy intervention was the most appropriate. The safety of the relational experience in play therapy needed to precede any exploration of cognitive distortions that may have developed as a result of the trauma.
The case of Peter. Peter was a 13-year-old boy who was referred for therapy because he had responded to his own sexual victimization by victimizing a younger foster girl in his home. His parents were foster parents, and he was referred to me (Daniel) for therapy because of the obvious trauma experiences but also because of his increasing behavioral disruption at home and in school.
Initially I had a conjoint session with Peter and his mother (the father and brother refused to participate). When they arrived for this first session, I asked that they create a tray together. An ongoing dynamic that occurred in this tray involved Peter either placing or asking permission to place spiders, snakes, and lizards in the tray. Each time, his mother would say no or remove the items he had placed in the tray. Near the end of the session, his mother placed a bride and groom in the tray, and Peter asked if it represented his mom and dad. When she said that they did, he promptly placed a tank in the tray and “shot” the bride and groom.
The metaphorical meaning behind this seems clear. The mother wanted Peter “fixed” (her actual words in the initial consult), and she did not want to discuss family dynamics. Peter’s placement of “creepy crawly things” (as his mother described them) was a metaphor for his need to deal with some of the ugly issues in his life; the mother’s removal of these things was a picture of her unwillingness to face these difficult issues. This was consistent with her verbal messages before, during, and after this session.
In Peter’s subsequent sessions, following a sandtray therapy protocol (see Homeyer & Sweeney, 2017), he would create sandtray scenes, discuss the creations, respond to open-ended inquiries, and title the scenes. Many of his initial trays involved chaos and battle scenes, conflicts in which no one won. This is consistent with Allan’s (1988) stages of sandplay therapy. It was also reflective of Peter’s emotional perception of his own situation, which was certainly a place of great conflict from which he felt there was no escape. As the therapy continued, victories emerged from the battle, and provision was made for escape. This could be seen in later sessions by the addition of military forts and helicopters.
Another clear projection emerged in Peter’s early and middle sandtray scenes and was consistently reflected in his trays. He began to use two large predatory figures—such as snakes, alligators, and bears. When clients are exploring victimization issues in the sandtray, large predatory creatures are effective metaphors for the emotionally (and physically) overwhelming experiences of being victimized. (For this reason it is helpful to have a few sandtray items that are disproportionately large [Homeyer & Sweeney, 2017]). This was Peter’s way of processing the trauma of the experience of two older neighborhood adolescents molesting him—and it was typical to see two large predatory creatures in most of his early trays. Later in the therapy process, he even named the two creatures with the same names as the offenders, not knowing that I knew the names from the intake information.
As his trays progressed to reflect more order and resolution, Peter’s disruptive behavior subsided. As with play therapy, in sandtray therapy (and other expressive interventions) Peter was able to manage in the fantasy of the sandtray that which was not manageable in the reality of his abuse. As an adolescent, with greater abilities to think abstractly, he was also displaying the development of insight and coping skills with which to frame his traumatizing experience. The safety of the expressive intervention enabled him to process the trauma in a unique and effective manner.
While we cannot in this chapter provide in-depth training on the use of play and expressive therapy with traumatized youth, we hope to have whetted the appetite of the reader while pointing to helpful resources. Maintaining a focus on the therapeutic relationship, as well as recognizing the importance of developmental and trauma-related issues, will form a foundation of solid clinical work with this population.
This focus on relationship has both psychological and neurobiological benefits. Perry and Pate (1994) appropriately state:
It is the “relationship” which enables access to parts of the brain involved in social affiliation, attachment, arousal, affect, anxiety regulation and physiological hyper-reactivity. Therefore, the elements of therapy which induce positive changes will be the relationship and the ability of the child to re-experience traumatic events in the context of a safe and supportive relationship. (p. 142)
As therapists, we need to remember the importance and the dynamics of working with traumatized clients. If we focus primarily on the emotionally charged content of the trauma itself, a client’s basic physiological state can actually shift. Perry (2006) suggests that this shift may lead to both the client and the therapeutic process becoming “brainstem-driven” (p. 34); brainstem-drive therapy thwarts therapeutic relationship and the processing of trauma. In response to trauma, the anxiety, along with the diminished functioning of the Broca’s area, can lead the client to act in a primitive manner. This is in addition to the developmental limitations of young clients. All of these factors may well render the verbal language of therapy less accessible or perhaps useless: “No matter how much you talk to someone, the words will not easily get translated into changes in the midbrain or the brain stem” (Perry & Pate, 1994, p. 141).
The therapeutic implication becomes self-evident. That is, traditional verbal therapy may well be ineffective and perhaps detrimental. Again, this is not to eschew cognitively based interventions. Keeping in mind the concerns discussed in this chapter, therapists would do well to become cross-trained in expressive (nonverbally based) therapies in order to access trauma in clients of all ages, which is frequently based in the midbrain as opposed to the executive neurological areas.
One of the greatest human pains is the loneliness of being alone. Children and adolescents who have experienced trauma know and struggle with this routinely. These clients, already struggling for identity and autonomy in this world, are cruelly burdened when trauma strikes and are left feeling unfairly isolated. In his discussion of loneliness, pioneer play therapist Clark Moustakas (1974) poignantly stated, “It is the terror of loneliness, not loneliness itself but loneliness anxiety, the fear of being left alone, of being left out, that represents a dominant crisis in the struggle to become a person” (p. 16). It is in this lonely place that so many young victims of trauma reside and that Christian therapists must be willing to enter.
We assert that wounded children and adolescents must work through their pain through the world of play. We as Christian counselors must work against leaving a generation of hurting children to live out lives of fear and anxiety. Their survival may depend on it. Despite the popular adage, time does not heal wounds. Rather, it is the power of relationship that heals wounds. Yes, therapeutic relationship—but more important, relationship with God and relationship with his children. Neale (1969) wrote, “Consider the play of the child, and the nature of the Kingdom will be revealed. Christ is that fiddler who plays so sweetly that all who hear him begin to dance” (p. 174). For the sake of the children, let’s join in the play.
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