Mindfulness-Based Play-Family Therapy: Theory and Practice, by Dottie Higgins-Klein

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1 CHAPTER SUMMARY Mindfulness-Based Play-Family Therapy: Theory and Practice, by Dottie Higgins-Klein (Norton Series on Interpersonal Neurobiology, W. W. Norton & Co., 2013) Introduction: A Word about Mindfulness and the Zen of Play Therapy Chapter 1: Early Child Development and Play-Family Therapy: Mahler and Separation & Individuation. This part presents a fundamental premise of this book, that it is essential for child therapists to have both a firm grasp of the structure and details of normal early development, especially the first three years of life, and also an understanding of how the events of a particular child's early development relate to the issues presenting in that child's life at a later age. The information gathered in the individual's developmental history is the basis for developing a good treatment plan. This information can also be used for prevention Chapter 1 outlines Margaret Mahler s theory of Separation and Individuation, which emerged from her twenty years of research into the roots of attachment and personality development. Included in the chapter are many examples of normal development that are of practical use for those who work with families. This theory is amplified and furthered by discussion of: The contribution of Daniel Stern on child development, particularly during the first months of life; A framework based on research of Allan Schore (Interpersonal Neurobiology) on the roots of attachment and affect regulation, including the development of shame; An understanding of the development of aggression that is rooted in the research of Henri Parens, particularly it's significance during the Rapprochement phase; Reference to the Secure Base theory of Bowlby & Ainsworth and the importance of attachment experiences in the early years. This chapter breaks down development into age-grouped sensitive periods, and helps the therapist to understand the significance of each period. In MBPFT, the therapist is trained to understand how the connections with the early emotional history inform the present treatment plan, and the necessity of being able to explain this to the parents. 1

2 Chapter 2: Background and Overview of Mindfulness-Based Play- Family Therapy The following nine essential components define MBPFT. They show how it is rooted in the valuable practices of Play Therapy and Family Therapy, as well as how it is unique. MBPFT includes integrating the therapy into the emotional context of the child's threegenerational family life, understanding the importance of early development, Mindful Parenting Meetings and, when indicated, cooperating with the larger school and environment. It can include a wide range of Play Therapy modalities and settings. Nine Characteristics of MBPFT 1. The Four Segment Evaluation Precedes the Treatment Phase 2. A Parent Is Present with the child for Discussion of Life Circumstances 3. The Child s Individual Play Therapy Is Kept in the Imaginary Realm 4. Play Therapy Is Versatile and Inclusive of Most Theories 5. A Multicultural, Multiethnic Perspective is Valued 6. Family Therapy Is Based on Systems and Relational Therapy 7. Regular Mindful Parenting Meetings Are Held 8. Multiple Family Members Are Included 9. Treatment Often Involves Cooperation with Other Professionals The MBPFT Mandala and a Word about Working within the Broader Social System Corners I and II: Extended Family and Friendships, the Community, and Family Values Corners III and IV: Collaborating With Other Professionals Chapter 3: Intake, Four Segment Evaluation, and Special Considerations The Intake Procedure. A summary of the first contact. The Four Segment Evaluation. The evaluation, generally four sessions, gives the playfamily therapist time to become grounded in the presenting problems, the developmental history of the concerned child, and brief family histories of both parents. This chapter makes a thorough practical presentation of how to go about this crucial evaluation process. It includes reference to detailed case study of a bi-racial family for each of the four sessions (see Chapter 2

3 9). The four transcripts include summaries and transcripts of the therapist's first meeting with parents and the gathering of the child's developmental history, a meeting with the entire nuclear family, an evaluative play session with the child for whom they have the most concern, and a session in which both parents explore their own family histories via the use of a genogram. This allows the therapist to understand any trauma and attachment history which helps when working with the child. This four-part process grounds the therapist in both the presenting issues and the larger context, and it allows the therapist to make a wellinformed treatment plan. Also including are suggestions for adapting the evaluation phase to a variety of settings. Segment I: The Therapist Meets the Parents The First Goal: Joining Empathically The Second Goal: Taking a Developmental and Social History The Third Goal: Showing the Mandala Segment II: The Full Family Meeting The First Part: Group Talk Time The Strengths and the Problems The Second Part: Family Sandtray Story Segment III: Introducing to the Child to Play Therapy Segment IV: The Family History Meeting Genogram Developmental History and Family History Feedback Duration of Treatment: Qualifying Factors Adapting the Four-Segment Evaluation and MBPFT to a Variety of Settings Children Experiencing Separation or Divorce Children in Stepfamilies Children Who Have Entered the Family through Adoption Children Who Have Entered the Family through Foster Care Children Who Have Witnessed Domestic Violence or Have Experienced Physical or Sexual Abuse Children in Bereaved Families Children with Attention-Deficit Disorder (ADD) and Attention-Deficit Hyperactivity Disorder (ADHD) 3

4 Children with Autism and Developmental Delays Counseling: MBPFT in a School Setting Chapter 4: The Six Stages of Mindfulness-Based Play-Family Therapy Play-Family Therapy adds Talk Time. This is a twenty-minute meeting of therapist, parent, and child, that precedes each play therapy session. When possible, the parents take turns accompanying the child for sessions. The parent/child interactions of Talk Time nurture the intimacy of the relationships that the child and parents have with the therapist, help to develop the habit of acknowledging, and transform the capacity to discuss difficult issues. While Talk Time appreciates family relational and systems theories, it can also include a cognitive/ behavioral approach, role playing, mindfulness games, explaining the brain at the child's level, and helping children express and modulate feelings. The key ingredient is that a parent participates. For application of the theory the reader is directed to summaries and some detailed transcripts of six year old Oumar's play therapy (in Chapter 9). It includes a poignant session where he enacts the heart of his trauma through a hunting scene. Micro View and Macro View Stage I: Talk Time: Family therapy/parent Child Interaction o Stage I, Part A: Checking In the Strengths o Stage I, Part B: Discussion of Real-Life Problems Therapy Modalities Useful for Stage I, Part B Behavior Therapy Cognitive Therapy Awareness of Contextual Elements Role-Playing Sibling Sessions Parenting Support in Context Advocating for the Child Reframing Negative Behaviors Mindsight o Stage I, Part C: Transitioning from Talk Time to Play Therapy 4

5 In the Play Therapy Room Stages II and III: Exploring the Playroom Expectations and Limit Setting Stage IV: Deeper Awareness o Moving toward Mindful Play Therapy Stage V: Integration Stage VI: Closure of the Session & Closure of the Treatment Course Variations in MBPFT Sessions Negotiating Changes in the Session Motivation Challenges Connecting A Word about Mindfulness-Based Sandtray Therapy Sandtray Therapy with Children Ages 3 to 12 Sandtray Therapy with Adolescents and Adults Recommended Reading Chapter 5: The Language and Metaphors of Play Therapy This chapter elaborates on two of the most important skills for the play therapist to learn: l) language: how to respond with words and silence to the child in the pretend realm, in the present moment in the play room, and 2) metaphors: how to appreciate, understand, and interpret what the child is saying through the metaphors of his or her play. This important chapter trains the therapist on how to hold the space in a way that avoids interrupting or interpreting and offers the child the safety to stay in the implicit, intuitive, right brain experience which is an essential component of rewiring the brain. Through imaginative play the child creates metaphors that heal the pain and traumas of life by uniting the right and left brain on the child's terms. Language. One of the most important skills for the play therapist to learn is how to communicate reflectively with the child in the playtime, including an understanding of when to speak and when to be a quiet witness. This chapter gives examples of dialogue between therapist and child during the various stages, illustrating mindful responses that encourage the spontaneous, mindfully based play. Also included are examples of responses that are less effective because they may introduce intrusive thinking at a time when healing is occurring through right brain process. Metaphors. The metaphors that emerge in a child s play are sometimes quite obvious, 5

6 and at other times, more complex, and the therapist's ability to translate their meaning develops with time and experience. This chapter uses Bruno Bettelheim's work with fairy tales to discuss the nature and meaning of children s metaphors. The text discusses themes that arise in the various stages of play therapy and how to accomplish the challenging task of extracting the dynamic from the content of the child s play themes, in order to share only the dynamic at parent dialogue and feedback meetings. An important element of Mindfulness Based Play-Family Therapy that is similar to client-centered play is that the therapist is trained to minimize her own imaginary themes while giving primacy to the child s play projections. This is particularly recommended with the child who is able to be spontaneous in his play. Staying as much as possible in the present moment gives the child an invitation to explore his own deepest thoughts and feelings, through his own imaginative means, rather than being diverted by verbal intrusion or leftbrain interpretations of the therapist. Imagination and Reality Similarity of Play Therapy and the Fairy tale Speech and Silence in Play Therapy The Use of Language during the Exploratory Stage of MBPFT The Use of Language during the Limit Setting Stage of MBPFT The Use of Language during the Deeper Awareness Stage of MBPFT The Use of Language during the Integration Stage of MBPFT The Use of Language during Directed Play Therapy Talking to Parents about the Child s Play Chapter 6: Family Therapy in Mindfulness-Based Play-Family Therapy Based on Systems and Relational Family Therapy This treatment of family therapy is basic and introductory, and is full of concrete interventions that attempt to gently ease child therapists into expanding skills that will invite them to be more competent to address systemic problems. This introduction to family therapy addresses the topic of higher and lower functioning in families across the socioeconomic spectrum. When families are willing to participate in deeper healing experiences, the functioning level of the whole family improves and that benefits not only the present, but also future generations. Contextual Family Therapy theory provides the framework for the task of mixing play therapy and family therapy into a new paradigm of MBPFT that offers a solid theoretical 6

7 framework for the therapist to also see the parents for therapy without violating the child's confidentiality. The chapter introduces Contextual (Nagy) and Structural (Minuchin) Family Therapies with an emphasis on many concrete interventions and their practical applications to MBPFT that therapists will appreciate. Many Family and Play Therapists today report feeling limited by a cognitive/behavioral approach. Although this approach has great value and may be included among the strategies of MBPFT, CBT trained therapists are yearning for a framework and interventions that are better able to get to root-level issues with very stuck families. Family therapists who have been resistant to seeing children in individual play therapy value this mindfulness-based approach. Although some Play Therapists have been exposed to family systems, family therapy training often has not been part of graduate work for many child therapists. Many Play Therapists will appreciate training and a theoretical framework to make the interventions that help the parents to see their side of problems. If parents want their own therapy, this method offers an ethical option for the parent to be seen by the same therapist who sees the child, when deemed clinically advisable. Resilience in Higher-Functioning and Lower-Functioning Families The Brain Loss in the Family Diversity in Families The essence of Contextual Family Therapy has always been that it is rooted in the empathic relationship between client and therapist, and in the invitation to heal relationships at a deep intrapsychic level. This chapter contains twelve core concepts of Contextual Therapy interwoven with practical application to MBPFT. Using ordinary language, it elaborates on the following ideas: multi-partiality; asking questions and dialogue; trust, love and care; fairness in relationships; acknowledgment; parentification; loyalty including split loyalty; destructive and constructive entitlement; scapegoated family members; exoneration & forgiveness; concern about future generations; and the self of the therapist. These concepts offer play-family therapists concrete direction for work with even the most profoundly stuck family problems. These concepts offer therapists concrete direction for work with even the most profoundly stuck family problems in Relational Ethics. The Five Dimensions of CFT The First Dimension: Objective Facts The Second Dimension: Individual Psychology The Third Dimension: Systems of Transactional Patterns (Systems Therapy) The Fourth Dimension: The Ethic of Acknowledging, Earned Trust, and Fairness 7

8 The Fifth Dimension: The Ontic Level of Relating o How Does the Contextual Therapist Intervene to Promote Healing? o Weaving CFT with Mindfulness-Based Play-Family Therapy o Mutuality, Dialogue, and Intersubjective Relating Structural Family Therapy: A Systems Approach Realigning Power Assigning Tasks Enacting Transactional Patterns Boundaries and Relating: Using Good Communication Skills Twelve Core Concepts of Contextual Therapy and Their Application to MBPFT 1. Multidirected Partiality 2. Questions and Dialogue: Secrecy vs. Privacy 3. Trust, Love, and Care 4. Fairness in Relationships: Giving, Taking, and Receiving 5. Acknowledgment a. Acknowledgment during the Initial Evaluation b. Acknowledgment during Weekly Sessions c. Acknowledgment during Mindful Parenting Meetings 6. Parentification 7. Loyalty a. Who Owes Loyalty to Whom? b. Split Loyalty c. Loyalty to the Therapist 8. Destructive and Constructive Entitlement a. Destructive Entitlement b. Destructive Entitlement and the Brain 8

9 c. Constructive Entitlement 9. Scapegoated Family Members and Family Monsters 10. Exoneration and Forgiveness 11. The Revolving Slates and Concerns about Future Generations 12. The Self of the Therapist Chapter 7: Parent Education and Mindful Parenting There is a required meeting with parents after every fourth session. The child does not attend. The therapist shares the significance of the dynamic of the child's play, while maintaining the child's privacy on the literal content of the play. Parents are invited to discuss issues and problems of any of the family members, including, of course, the child for whom they have the most concern, (the MC). As discussed in Part 1, the therapist has the ability to explain the connections of both early child development and family history with the child's present behaviors. A basic understanding of Interpersonal Neurobiology helps the therapist to understand and explain the current impact of the child's implicit body memories from earlier traumatic experiences. A conscious aim of the meetings is that parents develop deeper insight into how their own behaviors may be impacting the problems of their children. Are parents' reactions triggered by implicit memories from their own childhood? This kind of attention by parents to understand their own inner experience in the moment increases their compassion for their children and helps them avoid putting the label of identified patient on the child of most concern. Parents are often more open to discuss their own parenting styles, attachment issues, and traumas because they have already shared their autobiographical narratives in the fourth-segment evaluation. The therapist's coaching of parents through role-play can be a helpful right brain experience through which they learn new ways of being with their children. (Includes references to the work of Siegel, Kabat Zinn, Schore, Badenoch, etc.) This chapter also includes a summary and some text of the early Parent Feedback and Dialogue meetings of the same family in the Case Study. The Frequency and Structure of Meetings The Agenda Including Forms Normal Child Development Issues Awareness of Cultural Diversity Recommending Books to Parents: Bibliotherapy o Books about Communication and Discipline 9

10 o Books about Mindful Parenting The Dialogue: Relational Dynamics Mindful Parenting and How the Brain Works Therapy for Parents Family Secrets A Case Study Chapter 8: Weaving It All Together: Early Childhood Development, Mindfulness-Based Play-Family Therapy, and Parenting MBPFT functions on many levels, both simultaneously and sequentially. This Chapter describes the sequence of developmental stages, considers how problems in the older children (3-12) who come to therapy, may be related to disruptions that originate during certain earlier stages. This chapter provides guidance for healing interventions. Each age grouping is represented in a chart that combines important intersecting pieces of theory. The charts illustrate the interface of the following six categories. There are concrete examples of how to include parents into the treatment. Mindfulness-Based Play-Family Therapy According to Mahler s Stages of Separation and Individuation MBPFT for Children with Issues Originating During Awakening and Symbiosis (Birth to Six 6 Months) MBPFT for Children with Issues Originating During Development of Early Trust (Birth to Six Months) MBPFT for Children with Issues Originating During the Early Practicing Stage (7 to 10 Months) MBPFT for Children with Issues Originating During Development of Object Constancy (7 to 10 Months) MBPFT for Children with Issues Originating During the Later Practicing Stage (10 to 18 Months) Integration of Attachment Theory with Mindfulness Based Play-Family Therapy 10

11 Chapter 9: A Mindfulness-Based Play-Family Therapy Case Study Case Study: Introduction to the Caruso-Harris Family Four Segment Evaluation o Segment I: Therapist and Parents Meet Oumar's Developmental History o Segment II: The First Family Meeting Family Strengths and Problems The Caruso-Harris Family Sand Story Reflections on the Sand Story o Segment III: Introduction of Oumar to Play Therapy Talk Time: Scary Dream Empowerment Game and Application Oumar s Spontaneous, Nondirected Play Therapy Session Reflection of First Play Session o Segment IV: Family History: Parents Attend Arnie s History: The Smith-Harris Family Sharon s History: The O Ryan-Caruso Family Reflection of the Family Histories Oumar s First MBPFT Session Following Evaluation Talk Time o Reenacting Oumar s Scary Dream Sandstory Play Therapy Session o Reflection of Play Therapy Session The Exploratory and Limit Setting Stages Talk Time o Honest Dialogue Oumar with his father Play Therapy: A Summary of Early Sessions 11

12 o A Family Meeting Trauma Reality Sandtrays o Preparation to Create the Trauma Reality Sandtrays o The First Trauma Reality Sandtray Talk Time Session -- Following the First Reality Tray o Facing Into the Dream The Second Trauma Reality Sandtray o The Deeper Awareness Stage o The Zen of Play Therapy The Integration Stage Family Therapy: Oumar Confronts His Father o Reflection of Father/Son Dialogue Couple Sessions With Sharon and Arnie o The Parents Address Fairness Issues and the Give and Take of Family Life o Couple Therapy Using Sandtray Miniatures: An Honest Dialogue The Sibling s Play Therapy o Linda s Sandtray Sessions Conclusion Appendix A: Sample Forms and Questionnaires Appendix B: Supervision and Training in Mindfulness-Based Play- Family Therapy Onsite at the Family & Play Therapy Center and Available Worldwide, Live Online Index Bibliography 12