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Play Therapy -- Anytime, Anywhere

By Larry Shapiro for ChildsWork/ChildsPlay

There are tens of thousands of professionals who help children with emotional and behavioral problems, and yet only a small percentage would describe themselves as play therapists.

Play therapy was the first psychological technique that acknowledged the special way that children think and relate to adults. Before the introduction of play therapy in the 1930's and 1940's, children were most often treated as "little adults" when they went for treatment of an emotional disorder. It was assumed that they could develop insight into their problems through techniques such as word association and dream analysis, and that this insight would alleviate their emotional conflicts.

But pioneers in the field of child psychotherapy, such as Anna Freud and Melanie Klein, realized that children do not have the cognitive ability to think and talk about their problems the way that adults do. They saw that children "play out their problems," through dolls and puppets and other toys, and they reasoned that this would be a better channel of communication than conventional talk therapy.

But in spite of the interest in these new techniques, play therapy was not widely practiced. Rooted in psychoanalytic theory, you needed years of training in this highly theoretical method of helping children, and it was presumed that it might take many months, if not years, for children to show any progress.

In the 1960's and 1970's, play therapy took a much more practical direction. Paralleling the development of humanistic and client-centered therapy, a new non-directive approach to play therapy was developed by therapists like Virginia Axline and Clark Moustakas. Believing that the relationship between the therapist and child was the paramount therapeutic vehicle, non-directive therapy de-emphasized the need for theoretical interpretation of a child's play. The goal of play therapy was seen as providing experiences where children could resolve past conflicts and learn new, more appropriate behaviors.

In the last 30 years, we have seen an expansion in the techniques that are considered play therapy, making it accessible to an ever-growing number of children. The emphasis has been on more directive techniques, like game therapy, as well as on training other people in the child's life to use play therapy techniques. For example, Filial Therapy was developed by Bernard and Louise Guerney to teach parents basic play therapy techniques. The Primary Mental Health Project, developed at Rochester University in New York, has demonstrated that play therapy techniques can be taught -- in a relatively short period of time -- to paraprofessionals, who in turn can make a significant difference in preventing emotional problems in at-risk children.

Yet in spite of all of the exciting ways that play therapy techniques are being used to treat children, many counselors still associate play therapy with its early roots. They may think that play therapy needs to be done in a well-stocked play room, and that it requires years of specialized training. They may see it exclusively as a long-term process, impractical for the vast majority of today's children. Nothing could be further from the truth.

Play therapy techniques can be utilized anytime and anywhere, because children like to play anytime and anywhere. Play is a way that children relate to others, and it is not confined by time or place.

Once could easily argue that play, in and of itself, is therapeutic. Many studies have shown that humor in any form is beneficial to the body and the mind. When we laugh, our immune systems become stronger, stress bio-chemicals such as cortisol are reduced, our attitude improves and we become more optimistic and even more friendly. It would certainly seem likely that play would have these same results -- and not just for children. Play has the same health and mental health benefits for adolescents and adults, as well as for children.

As counselors and therapists, our challenge is to bring play techniques into all of our work. Don't think of play therapy as a single modality, the way that it was practiced thirty or more years ago. It is simply a tool to communicate with children. When you play with children, you are establishing a relationship with them on their terms. When you play with children, you are helping them find the joy in living, no matter how serious the problems they must face. When you play with children, you are finding your own pleasure in your work.

I once heard a story about a child psychiatrist, who dressed for work every day in a clown suit. I don't know whether the story is true, but I like to think about what it would be like to be a depressed child and have a clown for a therapist. Or what it would be like to be an ADHD child and go to someone for help who did not judge me because I was having problems in school, or because I frequently lost my temper? What would it be like to step into a world of play, even for one hour a week, where the true joy of childhood was never forgotten?

I am not advocating that you go out and by a clown suit. There are subtler ways to tell children that you will share your sense of fun. There are simpler ways that you can tell children that you will enter their world of imagination, and share a view of the world where life is not just one problem after another. There are hundreds of techniques that can be used to help children through play and playfulness. Just remember that you never need a reason or an excuse to play.

The Lingering Effects of Trauma: Helping Youth Cope With Violence

By Debra Whiting Alexander for The Bureau For At-Risk Youth

Karla had just taken a seat in the high school auditorium when the lights went out. The curtains slowly opened and the cast of 12 were standing on the stage with their backs to the audience. It was an eerily quiet opening for a musical production but Karla remembers thinking it was a cool dramatic effect. There was a hush across the audience waiting in anticipation. When the cast suddenly turned and faced the audience, Karla saw what she thought were play guns in their hands. But when they opened fire and bullets sprayed from one end of the auditorium to the other, she realized the screams of the victims were real. It was no act and there would be no play.

Karla was shot in the leg. She crouched to the floor with other screaming students and their families, dragging her leg in a desperate attempt to find her dad. She tried frantically to remember which section of the auditorium he had chosen to sit in. It was becoming difficult to breathe when deep heavy sobs began to overtake her. And then she lunged awake screaming for her father in the pitch-black night of her bedroom.

"The nightmares are back", Karla announced. "I can't believe this is happening again. They aren't dreams of what really happened, but I feel the same terror. This time I was afraid for my dad." Karla sat in my counseling office trembling as she described her nightmare to me. She would be the first of four students that day to share post trauma reactions with me. It was nearing the second "anniversary" date of the school shooting that changed their lives forever. On that morning, a total of four people were murdered and more than 20 students were wounded. Physical wounds will be life long for some, and for many others the psychological wounds will be too. For most, the lingering effects of that traumatic morning will continue to come and go.

What To Expect

It is normal for children as well as adults to experience a wide range of reactions following a traumatic event. Although not everyone will experience post trauma reactions, given enough stress, everyone will have reactions to it. Some will experience symptoms immediately while others find symptoms emerging later. There is no right or wrong way to move through the process you must go through to resolve such an event.

Exposure to murder or the threat of murder is among the most difficult traumas people can face. Students tell me they can't concentrate in class, are easily startled and complain of nausea, loss of appetite and sleep problems. All ages regress developmentally and some survivor's go to great lengths to avoid reminders of the event. Reliving memories through flashbacks, intrusive thoughts and images and nightmares is common. Physical complaints of headaches, diarrhea and severe anxiety also happen frequently. Research indicates that exposure to trauma can even cause profound physiological changes to the brain and central nervous system.

Most survivors experience intense feelings of fear and worry that the incident will happen again. The sense of safety and security they once had in the world has been stolen from them. Questioning spiritual beliefs and the meaning to life is an important part of trying to make sense of something that may have completely shifted the foundation of values and beliefs one was raised on.

Daily routines and activities are difficult for trauma survivor's to follow and life often feels as though it will be permanently disrupted. Teens often say they feel like they're going "crazy." The roller coaster of emotions they experience makes them feel as though they are "losing their mind." You can assure them they are not crazy. What happened was.

Trauma reactions can and do happen to emotionally healthy people. They cannot be prevented by maturity, strength, courage or good mental health. The temptation to self-medicate disturbing thoughts, feelings and physical sensations is especially high for adolescents. Many believe if they can numb and block out frightening reactions they will go away on their own. Clearly, using the distractions of drugs, alcohol, sex or food only complicates the survivor's ability to move on. They often get "stuck" on the emotional roller coaster that can cause one to feel so "crazy." .

Traumatic memories can replay themselves and interfere with daily living. They are memories like no others. They are difficult to shake and impossible to erase. Like adults, children and adolescents need to talk about them, understand what they went through and learn ways to cope with distressing symptoms. It's been said what you can't put to words, you can't put to rest. Professional debriefing is an opportunity for those involved or impacted by a trauma to talk about what they went through, gain an understanding about the range of normal responses they can expect and learn techniques for coping with distressing symptoms. The sooner survivor's of trauma receive emotional first aid the better.

Adolescents may refuse help from others for many of the same reasons adults do. They may be afraid of becoming too overwhelmed by talking about it. If they start to cry, many fear they won't be able to stop. Reviving troublesome memories that evoke difficult feelings and symptoms is extremely painful. Others simply feel it is just impossible to explain what they went through. Some may be struggling with feelings of guilt and anger about their role in the event. Others believe in order to forget what happened, it's better not to talk about it. By disclosing their true thoughts and feelings survivor's often say they fear they will be seen as having a "mental condition." Many also fear they may upset others by sharing the graphic parts of the experience they continue to be most troubled by.

A pre-teen once asked me; "Don't you have a pill or something you can give me to just make me forget?" Part of successful counseling involves helping survivor's understand the value of remembering. Techniques can be taught to help survivor's learn to live with the images and find a reason to go on.

What You Can Do

Parents and concerned adults can do a lot to help children and teens survive traumatic experiences. Victims must find their own way to go on but with support and guidance you can help them find relief from distressing symptoms. You can also help them figure out how to endure profound suffering and loss. Remember the following:

• Be willing to listen when the child is ready to talk.
• Openly acknowledge the trauma and what happened honestly.
• Help reestablish a sense of safety and security.
• Increase comfort and adjust for your child's own unique fears.
• Tolerate temporary behavioral and mood changes.
• Educate yourself and your family about the normal responses to trauma.
• Give hope and be prepared to address spiritual questions and concerns.
• Seek professional help if stress is prolonged or cannot be alleviated.
• Seek support and consultation from a trained trauma specialist who can provide you with a variety of helpful strategies.

Moving through the myriad of experiences following a traumatic event is never an easy process and there are no quick fixes. A traumatic memory for most can only be integrated through a painfully slow process. Understanding this is the first step. Love, empathy, support and professional assistance, if necessary, can help take you the rest of the way.

Reaffirm The Future With Hope

I tell people the trauma they suffered will always be a part of their life but it is not all of life. It may be a sentence, page or chapter in their life story, but it's not the whole book. No doubt there will be more tragedies to endure in the chapters yet to be written, but there will be many good memories too. How they transform their suffering from this tragedy can help them respond to stress in the future. I ask my clients, "How has this changed you? In what ways are you different?" Children and adolescents often say the same thing; "I appreciate everything about my life more", "I don't take things or people for granted" and "My beliefs and goals have grown stronger."

The evening following Karla's visit to my office, a school performance was taking place in the auditorium of her high school. Her dreams had turned the same event into a horror story just one night earlier. After she shared the nightmare with her father he asked if it might be better if she didn't attend. Karla told her dad, "No, it wouldn't be better. I can't stop living my life. It was a dream about the past. Not my future." That evening, Karla and the rest of her school enjoyed a terrific performance. It was a good memory all could add to their life stories.

We must acknowledge to our children that a part of life is not good or secure. But that trauma is not all of life. It is just a part. Eventually what's good about life returns to help balance what's not.

About Debra Whiting Alexander, Ph.D.

Debra Whiting Alexander, Ph.D. is the author of Children Changed by Trauma: A Healing Guide (New Harbinger Publications, 1999) and two series of creative healing books for children and teens recovering from post trauma stress; Something Bad Happened series and The Way I Feel series (The Bureau For At-Risk Youth, 1991).

She consulted on the video Saving Our Schools: From Hate And Violence (Heartland Media, 1999) and is currently working on a video project regarding the emotional aspects of emergency care (EMP International, Inc., 2000).

She is currently a Trauma Consultant and Counselor for the Springfield School District and Professor at Northwest Christian College in Eugene, Oregon.

Changed By Trauma: Helping Youth Cope In The Aftermath Of Tragedy

By Debra Whiting Alexander for The Bureau For At-Risk Youth

City bombings, random acts of crime, wars, violence at home and school…today, a growing number of children are victims and witnesses to acts of human cruelty -- and even second-hand exposure to trauma can be problematic. Children have experienced more and more events that are beyond normal human experience, and what they have learned is that life is not safe.

Most adults are not prepared for the experience of helping youth through such intense emotional, psychological, physical and spiritual injuries. The effects can be far-reaching. Not only does trauma impact learning (students can't learn when they aren't relaxed), it can change the whole course of a child's or adolescent's continued healthy development. Schools have the unique opportunity to respond to traumatized children in a number of helpful ways, but it can be difficult to know where to begin and what to do.

Common Reactions

It's natural for all children impacted by trauma to feel, think and behave differently in response to an abnormal event in their lives. Intense emotions, frightening thoughts, physical symptoms, and spiritual confusion are all normal reactions following a life-changing event.

Children and teens cope in a variety of ways to overwhelming stress. A few of the more common symptoms include: anxiety, worry, anger, sadness, nightmares, and fear. Some kids become overactive, while others appear lethargic and withdrawn. They may complain of physical aches and pains, have difficulty concentrating in class, and have trouble sleeping or eating. They may want to avoid friends, social activities and school. Some children will talk repeatedly about what happened, while others will refuse to discuss it at all. They may display aggressive behaviors, and express distressing and repeated themes in play, art or writing. All ages may act younger than they are. Separation anxiety and clinginess are especially common.

Encourage Open Discussion

The more children and teens are able to talk about and/or express what happened with people who understand, the sooner the difficulties will diminish. Most children, however, regardless of their age, need help identifying their thoughts and feelings following a tragedy. They also benefit from a structured environment in which they are permitted to talk directly about what happened and learn effective coping skills.

What you can do:

• Help kids feel safe. Address common fears and adjust for them in daily routines.
• Provide physical comfort. It's especially important for younger children, but everyone benefits from a nurturing environment.
• Take time to listen. Allow for structured opportunities to listen to all thoughts and feelings that students want to voluntarily share. Teens especially may have a need to analyze and fully discuss with one another what happened and why.
• Address concerns and answer questions. Keep your answers and explanations simple and direct. Children want real facts. Be honest without sharing graphic or disturbing details. If you don't know the answer to a question, be honest about that too. Correct any distortions and misinformation you hear.
• Remain composed. Provide a calm, serious and undramatic response to what children say and ask.
• Use open questions. To help facilitate discussions ask questions like, "What is your understanding about what happened?" "What would you like to know?"
• Create a climate of acceptance. Don't criticize, judge or shame a child for anything they say or do and make sure everyone in your group or class understands this rule. Accept and validate everything that is expressed.
• Understand cultural differences. Some behaviors and styles of expression within your student population may be common to their culture. Be careful not to assume that behaviors different from your own mean they are trauma-induced problems.
• Educate. Reassure students that the more they tell the story, the less intense and frightening the emotions become. Help them understand the wide range of normal reactions they can expect to see and prepare them for what may be different in the days, weeks and months ahead. Remind younger children that thoughts and feelings can't make bad things happen.
• Talk about changes. Ask children about the ways they feel different and what they notice in those around them. Normalize their examples and acknowledge the common and unique ways all have felt changed by the experience.

Decrease Stress

Like adults, children and youth will react to stress differently and have varying thresholds for it. Minimize stress whenever you can.

What you can do:

• Take time to relax. Be flexible and lower your expectations of children for a while. Take breaks through the day and help children relax through simple breathing exercises, silent meditation/prayer, classical music or taking walks where the sounds of nature can be heard.
• Model coping tools. Explain what you do to help yourself. Brainstorm with kids other ways they can take care of themselves.
• Hold parent meetings. Educate families about trauma reactions and ways families and caregivers can help. Your job as a teacher, administrator or counselor will be made easier when parents have the tools and understanding of how best to support their kids.
• Maintain routines. There is comfort in the predictable routines in life. Make sure children know what to expect throughout the day.
• Monitor media. Review for age-appropriate content and themes. Even some family movies can restimulate post-trauma stress.
• Increase supervision. Prevent unsupervised gatherings and emotional drama at school by monitoring halls closely and having supportive adults available to all kids throughout the day.
• Be proactive. Provide a way to channel energies into constructive activities like helping others.

Reassure And Remind

All children need the loving support of the adults around them in order to regain a sense of security and trust. They need to know that no matter what happens, the adults around them will do everything in their power to keep them safe.

What you can do:

• Remind children of what went right. You might ask, "Who helped?" "What good things happened when we needed them to?" "What unexpected things have people done to help others?"
• Address issues of death concretely. Let kids know the greater the loss, the longer the time it will take to feel better again. Acknowledge that death is permanent and sad and that grieving is a process. Reassure them that it won't always feel as sad as it does right now.
• Empower. Give children choices and outlets for expressing thoughts and feelings. Help them regain a sense of power and control. Review general safety rules and precautions and practice problem-solving skills.
• Identify resources. Help students think about all the outside resources they have to support their continued healing. Family members, counselors, nurses, doctors, friends, clergy and spiritual beliefs and values can be helpful resources to seek out for extra help.
• Renew hope. Help kids understand that trauma is a part of life, but not all of it. Explain that they won't forget what happened, but can survive the memory. Reassure them that healing happens even in the hurt.

Most kids recover from a trauma without professional assistance, but others may develop post-traumatic stress disorder (PTSD) or other persistent problems that will require help from someone trained in treating post-trauma stress.

Children are changed by trauma and although the emotional recovery process isn't easy or quick, it is possible to find hope and healing in the aftermath. The support children receive from caring adults after a tragedy can help them avoid long-term emotional harm. The school environment is an important, if not critical piece to children's adjustment and full recovery.