Don`t Be a One Trick Pony - Colorado Association for Play Therapy

Don’t Be a One Trick Pony:
Integrating Play Therapy
Techniques for Complex Trauma
Elizabeth Konrath, LPC, RPT
Heather Bryan, LPC, RPT
Who are we?
✹ Lizzie Konrath, LPC, RPT
✹ Heather Bryan, LPC. RPT
✹ [email protected]
✹ [email protected]
✹ MA in Counseling from Creighton
University
✹ MA in Counseling at Lesley University
Goals for Today:
✹gain knowledge of research about using an integrative
approach to treating complex trauma.
✹Increase understanding of the benefits and obstacles to
using an integrative approach to treating complex trauma.
✹Gain knowledge of several different approach/practices to
play therapy.
✹Determine how to form treatment plans and decide what
modalities to use when with clients
✹To walk away with some new tools to utilize when working
with children
✹AKA- learn some stuff….and have fun!
Define the Terms:
✹ Integration:
✵ a fusion of one or more theories
of psychotherapy
✵ has a consistent theoretical
basis and standards for practice.
✵ be practiced in the same way by
different practitioners and
applied in a similar manner to
different clients.
✹ Eclecticism
✹ use techniques from a variety of
therapies, put together to best serve
an individual client
✹ approaches used for two different
clients may be completely different
✹ each practitioner may have very
different ways of providing
treatment.
Eclectic Vs. Integrative
The eclectic approach is like having a tool kit,
which contains a number of possibilities,
whereas the integrative approach takes a
number of pieces and fuses them together into
a brand new tool.
Current Research on Integration
✹Most therapists claim to be integrative
(Norcross and Goldfried, 2005)
✹General shift away from one-size-fits-all
treatment (Norcross and Goldfried, 2005)
✹Research shows no one single approach is
clinically effective for all clients (Drewes,
2011, Phillips and Landreth, 1995)
✹Many evidence based therapies
encouraged to have integrative approach
when working with children and
adolescents or clients with complex trauma
(Shaefer, 2003)
Current Research Regarding
PLAY THERAPY
✹IT DEPENDS!
(Kenney-Noziska 2012, Cavett, 2009; Drewes, 2011; Gil, 2006;
Gil & Shaw, 2013; Weir, 2008; Wynne, 2008, (Kenney-Noziska,
Schaefer, & Homeyer, 2012).
Benefits of Integration
✵Organic for PTs
✵Focuses on most relevant and specific interventions
✵Helps address treatment goals more clearly
✵Specifically based on clients needs, not randomly chosen
or forced on client
✵Uses techniques from evidence based/evidence informed
models
✵Culturally sensitive, more diverse population of clients
✵Addresses a myriad of symptoms/clinical issues
(attachment, acute or chronic trauma, anxiety, depression,
family issues, etc)
Challenges to Integration
✹“Purist” models—value specialization
✹Push by insurance companies, agencies, and
funding sources to use short term, specific
approaches
✹Expensive (trainings, Certifications)
✹Overwhelming
✹Time consuming
✹Confusing to know what to use when
✹No specific organization (which treatment, by
whom, for which clients, under what
circumstances?)
✹Lack of evidence based play therapy models
Special Consideration: Trauma
✹What is complex trauma?
✹The importance of Play Therapy when addressing
trauma
✹“Bottom Up” approach focusing on lower
parts of brain before moving to upper
cognition
✹Integration between right and left
hemispheres of brain
✹Empowerment and inner healing of client in
client’s natural language
✹Opportunities for mastery and repair
Key Elements of a Positive Developmental
Experience: Bruce Perry
✹
Essential to normal
development as well as to
any therapy for children
who have missed out on
these experiences of have
experienced trauma:
✹
Relational (safe)
✹
Relevant
(developmentally
matched)
✹
Repetitive (patterned)
✹
Rewarding (pleasure)
✹
Rhythmic (resonant with
neural patterns)
✹
Respectful
Areas for Treatment Recommended
by NCTSN
✹Six Core Components of intervention:
Safety (the child feels cared for)
self-regulation (helping child modulate arousal)
Self-reflective: information processing (reflect)
Traumatic experiences (resolution)
Relational engagement (appropriate
attachments)
Positive Affect Enhancement (self-worth)
Issues of Attachment/Relational Trauma
✹Impact on entire family
system
✹Clients’ needs for
control and safety
(nondirective vs.
directive)
✹physical and emotional
safety before can
address trauma
✹Must have secure
relationship with
therapist and a
caregiver outside of
therapy
Different Modalities to Integrate
✹What are the modalities you use?
Why?
✹Fit for the client’s needs
✹Fit for therapist’s personality
✹Consider training involved
✹Supervision
Theoretical Framework
Adjustment
Disorders
Trauma
Processing
Attachment
Physical and Biological needs
Remember: The MODEL is not a fix, its an AVENUE
(VERY Brief) Overview of Theraplay
✹
A method of enhancing attachment, engagement, self-esteem &
trust in others.
✹
Relationship-focused treatment
✹
Interactive, physical, engaging, & fun
✹
Based on attachment theory; modeled on patterns of healthy
parent-infant interaction that lead to secure attachment
✹
Direct, here and now experience
✹
Guided by the adult
✹
Responsive, attuned, empathic, and reflective
✹
Pre-verbal, social, right brain level
✹
Multi-sensory
✹
Developed by Ann Jernberg in 1969
THERAPLAY: Basic Goals
✵
Create secure, attuned, joyful relationship
✵
Increase regulation
✵
Create a positive change in child’s and parent’s
inner working models
✵
Optimism, competence and long term mental
health
✵
Empower parents to carry on at home
Observable Elements
✹
Parents and child in session
together;
✹
Guide parents to interact positively
with their child;
Parent has direct experience of
Theraplay.
✹ Attuned, empathic & reflective
response to child’s needs;
✹
✹
Nurturing touch;
✹
Focused eye contact;
✹
Playful Give and Take;
✹
Co-regulation of affect by
alternating active and quiet
Theraplay Domains
Structure
Engagement
Challenge
Nurture
Theraplay Dimensions for
Treatment Planning
✹
✹
Structure:
✹
Nurture:
✵
Safety
✵
Regulation
✵
Organization
✵
Secure Base
✵
Regulation
✵
Worthiness
Engagement:
✵
Connection
✵
Attunement
✵
✹
Challenge:
✵
Support
exploration
✵
Growth and
Mastery
✵
Competence and
Confidence
Expansion of
Positive Affect
Theraplay Dimensions to
Plan Treatment
Nurture: Parents are soothing,
calming, and reassuring
(rocking, feeding, cuddling);
Make the world feel safe,
predictable, warm, secure:
Safe Haven
Challenge: With secure base,
encourage child to strive a
bit, to take risks, to explore
and enjoy.
Nurture most helpful for:
✹
Children who are
overactive, aggressive and
pseudomature;
✹
Parents who are dismissive,
harsh, punitive or have
difficulty with touch and/or
displaying affection
Challenge most helpful for:
✹
Children who are
withdrawn, timid or rigid;
✹
Parents who have
inappropriate
developmental
expectations, are
competitive
Theraplay Dimensions to
Plan Treatment
Structure: Parents co-regulate baby
physically and emotionally;
Assure basic safety; are
trustworthy; Set up predictable
sequences of organized
interaction in caregiving and play
routines.
Engagement: Provide attuned,
playful interactions that help
baby regulate; Focus exclusively
on baby providing sensitively
timed, delightful interactions;
Create strong connection and
optimal arousal, joy.
Structure most helpful for:
✹
Children who are overactive,
undirected, overstimulated, or
who need to be in control;
✹
Parents who are poorly
regulated or disorganized, have
difficulty setting limits/being a
confident leader, rely on
verbal/cognitive structuring, or
are over or under stimulating
Engagement most helpful for:
✹
Children who are withdrawn,
avoidant of contact or too rigidly
structured;
✹
Parents who are disengaged,
preoccupied or inattentive, out of
synch with the child, rely on
verbal/cognitive engagement,
who do not enjoy the child
“Typical” Theraplay Treatment
Approach
✵
25 weekly sessions (approximately)
✹
Intake Interviews – Developmental History
✹
Marschak Interaction Method (One session for each parent)
✹
Parent Feedback and Treatment Planning (1x every 3-4 sessions)
✹
First Three Treatment Session (Parents Observe)
✹
Parents More Actively Participate (After 2nd feedback meeting)
✹
Later Sessions Parents Actively Plan/Facilitate
✹
Final Goodbye Theraplay Session w/ Child and Parents
✹
Final Parent Session
✹
Periodic (Quarterly) Check in Sessions (4 over next 12 months
Extended Development Play-Based
Assessment: Eliana Gil, PhD
✹Assess child’s overall
functioning
✵(Greenspan’s
dimensions)
✹Identify
vulnerabilities/strengths
✹Contextual/Systemic work
✹Utilizes play and art
therapy techniques to
assess a child’s functioning.
Goals of EPBDA
✹Identify “symptomatic” behavior
✹Assess trauma impact
✹If appropriate, provide diagnosis
✹List risk factors
✹Provide treatment recommendations
EDPBA Techniques
✹Sand Tray
✹Color your feelings
✹Free drawing
✹Self-portrait
✹Kinetic family drawing
✹Family genogram
Trauma-Focused Integrative Play Therapy
Eliana Gil PhD
✹Structured integrated treatment model
which encompasses the basic
principles of evidence-based practices
such as TF-CBT and three-phase
trauma treatment model originally
proposed by Dr. Judith Herman.
✹Utilizes expressive therapies to help
engage children in the treatment
process.
✹Combination of directive and nondirective
TF IPT Goals of Treatment
✹To create an environment of safety,
trust, and comfort
✹To process traumatic material
✹To encourage social reconnections
✹To return to pre-trauma developmental
functioning
TF IPT: 3 Phase Model
✹Phase 1: Establish Safety (sessions 1-5)
✵ Setting the context (orientation and demonstration
of session routine)
✵ Build a world in the sand
✵ Free drawing/collage
✵ Color Your Feelings
✵ Play Genogram
✵ Environment Project
✵ Affective Scaling
✵ Mindfulness/Breathing
✵ At Home Review
TF IPT: 3 Phase Model
✹Phase Two: Processing Traumatic Material (sessions
6-10)
✵ Mindfulness Stress Reduction
✵ Psychoeducation
✵ Cognitive Triangle
✵ Timeline/Color Your Life
✵ Before and After I Told (Drawing, Collage or Sand
tray)
✵ At Home Review
TF IPT: 3 Phase Model
✹Phase 3: Social Reconnection (sessions 11-12)
✵Focus on Resources (Flowers in the Vase,
Shields)
✵Learning Optimism
✵At home review
✵Saying Goodbye/Graduation Celebration
Other Modalities Commonly Used in Play
Therapy:
✹Family play therapy
✹Equine therapy
✹Sand Tray
✹Art/Expressive therapy
✹Filial Therapy
✹Trauma-Focused CBT
From Theory to Application: Bridging
and Integrating
Case Study: Jayden
✹ Five year old Caucasian male
✹ referred for an EPBDA due to sexually acting out
behavior and alleged sexual abuse of himself and his
half sister.
✹ presents with the following behaviors that are of
concern; extreme mood disturbances, nightmares,
separation anxiety, bed wetting, increased anxiety,
excessive self stimulating behaviors (frequent
masturbating), startle reflex to loud noises, symptoms
of childhood depression and an inappropriate
knowledge of sexual behaviors for his age.
✹
WWPTD?
✹How do you begin?
✹Break into groups to:
✹Create treatment plan
✵Determine what are the client’s/family’s
needs
✵In what order you would address these
needs?
✵What modalities can you use to address
those needs?
Jayden’s Treatment goals:
✹ Identify “symptomatic” behavior,
assess impact of alleged trauma,
identify risk factors and provide
treatment recommendations.
✹Increase feelings of safety and ability to
self-regulate.
✹resolution of traumatic experience
✹Self-reflective
✹Increase safe and appropriate
attachments and positive self worth
Timeline of Treatment
✹Extended Play Based Development
Assessment
✹Child-center play therapy and Integrative
trauma based play therapy
✹Individual counseling for Jayden’s mother
✹Group counseling for Jayden’s maternal
grandparents
✹Theraplay
Case Study: Oliver
7 year old Hispanic male
In foster care in Guatemala until age 2; adopted by
devoutly religious Mormon family
No information about prenatal care or first two years of
life
Physically and sexually abused by family relative from
ages 5-7
Presenting problems include: difficulty with affect
regulation, running away, aggression, impulse control,
sexualized behaviors, poor social skills, depression
Mother sought services to keep Oliver in her home; was
also seeking RTC for him.
WWPTD?
✹How do you begin?
✹Break into groups to:
✹Create treatment plan
✵Determine what are the client’s/family’s
needs
✵In what order you would address these
needs?
✵What modalities can you use to address
those needs?
MIM
✹
Observations?
Timeline for Treatment
1. Assessment: Background info,
Marschak Interaction Method
2. Theraplay /Parent coaching
3. Sandtray
4. Directive work transitioning to
Nondirective/Child Centered work
5. Circle of Security
6. Family therapy (Equine Therapy)
“not every child will be a success story, but we should assume everything
is reversible until proven otherwise”
Bessel van der Kolk
FOR MORE INFORMATION
THERAPLAY:
Phyllis Booth, MA, RPT-S, THE
THERAPLAY INSTITUTE OF
CHICAGO
✹
PHONE: 773-753-4674
✹
EMAIL:
[email protected]
✹
WEBSITE:
WWW.THERAPLAY.ORG
On TF-IPT and EPBDA
Gil Institute for Trauma
Recovery and Education
✹Phone: 703.560.2600
✹Website:
www.gilinstitute.com
References
✹ Booth, P., & Jernberg, A. (2010). Theraplay: Helping parents and children build better relationships
through attachment-based play (3rd ed.). San Francisco: Jossey-Bass.
✹ Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A
meta-analytic review of the outcome research. Professional Psychology: Research and Practice,
36(4), 376–390.
✹ Cavett, A. (2009). A playful trauma-focused cognitive behavioral therapy. Play Therapy Magazine,
4(3), 20–22.
✹ Cohen, J. A., Mannarino, A. P., & Deblinger, E. (Eds.). (2012). Trauma-focused CBT for children
and adolescents: Treatment applications. New York: Guilford Press.
✹ Drewes, A. A. (2009, October). Integrating play therapy and cognitive-behavioral therapy. Mining
report presented at Association for Play Therapy, Clovis, CA.
✹ Drewes, A. A. (2011). Integrating play therapy theories into practice. In A. A. Drewes, S. C. Bratton,
& C. E. Schaefer (Eds.), Integrative play therapy (pp. 21–35). Hoboken, NJ: Wiley.
✹ Drewes, A. A., Bratton, S. C., & Schaefer, C. E. (Eds.). (2011). Integrative play therapy. Hoboken,
NJ: Wiley.
✹ Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective
approaches. New York: Guilford Press.
✹ Gil, E. (2010). Working with children to heal interpersonal trauma: The power of play. New York:
Guilford Press.
References
✹ Gil, E. (2012). Trauma-focused integrated play therapy (TF-IPT). In P. Goodyear-Brown (Ed.),
Handbook of child sexual abuse: Identification, assessment, and treatment (pp. 251–278).
Hoboken, NJ: Wiley.
✹ Gil, E., & Shaw, J. A. (2013). Working with children with sexual behavior problems. New York:
Guilford Press.
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and analysis of components. Professional Psychology: Research and Practice, 21(2), 124–130.
✹ Kenney-Noziska, S., Schaefer, C., & Homeyer, L. (2012). Beyond directive and nondirective:
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Development.
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✹ Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration (2nd
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References
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Guilford Press.
✹ Schaefer, C.E.(1995). The Therapeutic Powers of Play. New York: Jason Aronson.
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play therapy (pp. 306–320). Hoboken, NJ: Wiley.
✹ Schaefer, C. E., & Drewes, A. A. (Eds.). (2014). The therapeutic powers of play: 20 core
agents of change. Hoboken, NJ: Wiley.
✹ Siegel, D. & Payne Bryson (2011). The Whole-Brain Child: 12 Revolutionary Strategies
to Nurture Your Child's Developing Mind, Survive Everyday Parenting Struggles, and
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References
✹ Seymour, J. W. (2011). History of psychotherapy integration and related research. In
A. A. Drewes, S. C. Bratton, & C. E. Schaefer (Eds.), Integrative psychotherapy (pp.
3–19). Hoboken, NJ: Wiley.
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✹ Weir, K. N. (2008). Using integrative play therapy with adoptive families to treat
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