Flexibly Sequential Play Therapy (FSPT): A New Model of Trauma Treatment

Transcription

1 Flexibly Sequential Play Therapy (FSPT): A New Model of Trauma Treatment Paris Goodyear-Brown, LCSW, RPT-S [email protected]

2 Type II trauma conceptualizations Complex trauma Complicated PTSD Disorders of Extreme Stress NOS Developmental trauma disorder

3 Key concepts for treating traumatized children Psychosomatic symptoms Amygdala alarm Decreased reactivity to physical injury The portals for therapeutic learning Follow the child s need Kinesthetic involvement The dyadic dance: towards and away from the trauma content Identifying and handling post-traumatic play

4 Commonalities in current trauma treatments Safety Stabilization Affect regulation Addressing cognitive distortions Some form of exposure

5 COMPONENTS OF FSPT Flexibly Sequential Play Therapy for Trauma Treatment Flexibly Sequential Play Therapy (FSPT) A components model for play-based trauma treatment Enhancing Safety and Security Assessment and Augmentation of Coping Soothing the Physiology Increasing Emotional Literacy Play- Based Gradual Exposure Addressing the Thought Life Making Positive Meaning of the Post-Trauma Self Relaxation and Stress Management Parents as Soothing Partners Continuum of Disclosure Experiential Mastery Play Trauma Narrative

6 Treatment Goal/ Interventions Assist the client in re-establishing a sense of safety and security Learning to Bear It (transitional object) Containment of Perpetrators (Helping clients empowerment experiences through manipulation of perpetrator symbols ) Therapist as Megaphone (Amplify safety messages) (Align self with client) Safe Place Productions (Creating an external image that can become an internalized resource)

7 Treatment Goal/ Interventions Assessment of coping and augmentation of positive coping strategies Coping Tree Copecakes (Detailing components of healthy coping) Crowning Community Family Play Genogram Coping Umbrella Coping Bubble Wrap

8 Physiological systems The hypothalamic-pituitary-adrenocortical (HPA) axis is an integral part of how the body responds to stress. The autonomic nervous system (regulating heart rate, respiration, the galvanic skin response) The neuroimmune system which regulates the body s response to sickness and disease Psychosomatic symptoms

9 the extreme nature of the external threat is often matched by an extreme and persisting internal activation of the neurophysiological systems mediating the stress response and their associated functions -Bruce Perry, 1999

10 Treatment Goal/ Interventions Assist client in managing anger, anxiety and stress reactions through relaxation and guided imagery The Balancing Act (Encourages relaxation through focused attention) The Bubble Fall (Gives clients concrete visual images that induce relaxation) Chum Chants (CBT skill rehearsal) Five Count Breathing (Encourages relaxation through targeted deep breathing process) The Big One (Encourages Deep Breathing) Pinwheels (Providing an external focal point for deep breathing exercise)

11 Treatment Goal/ Interventions Assist protective parents to enhance their protective, supportive function SOOTHE Strategies PCIT "You're a Star" Board Filial Therapy Theraplay Good Behavior Book Sweet Dreams Lotion Potion Child Parent Relationship Therapy

12 Treatment Goal/ Interventions Assist client in completing full spectrum feelings identification and verbalization Color My Heart Take Your Temp

13 Treatment Goal/ Interventions Assist client in completing full spectrum feelings identification and verbalization Butterflies in My Stomach (Targets fear and anxiety) Fruit Loops Feelings Necklace (Allows for assessment of events/situations that trigger various feelings) The Sands of Time (Allows for uncovering layers of feelings) (Is process based) Clearing It Up (Demonstrates that a multiplicity of feelings can exist simultaneously) (Empowers clients to face their feelings)

14 Anyone can be angry, that is easy. But to be angry with the right person, to the right degree, at the right time, for the right purpose and in the right way-this is not easy. -Aristotle

15 Treatment Goal/ Interventions Assist the client in identifying the nuances of anger escalation Volcanos Anger Buttons Anger Thermometers Blow It Up, Blow It Out

16 Continuum of Disclosure The glimpses that children show us: making sense of the snapshots

17 Treatment Goal/ Interventions Inviting Disclosure Zip It (Implants message that secrets can be shared in the playroom) Finding Your Voice (Sends a message that the child will eventually find the strength to tell the story of the trauma) The Creep and the Creepy Crawly (Invites clients to pinpoint body parts that have been made to feel uncomfortable) Gabby the Gecko (Uses a therapeutic metaphor to give the child powerful permission to tell the secret)

18 Experiential Mastery Play A form of gradual exposure

19 Create a trauma narrative Help client re-create the facts of the trauma, followed by thoughts, feelings and body sensations

20 Key Structures in Memory Brainstem Amygdala Hippocampus Corpus collosum Prefrontal cortex (includes the Orbitofrontal cortex)

21 Memory Implicit Explicit Integrated Nonverbal memory present at birth, generates emotions and perception Behavioral responses, bodily sensations, and mental models Semantic or factual memorybegins at one and a half years of age Autobiographical (episodic) memory, develops after 2nd birthday Requires the transfer of info across the corpus collosum More difficult to impact change in emotional responses

22 The Right Hemisphere Dominant during the first three years holistic, parallel, visual spatial Self-soothing Non-verbal aspects of language (tone, gestures) Encodes facial expressions

23 Linear Logical Linguistic The Left Hemisphere Sequencing of events using words

24 Coherent Narratives 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. -Siegel, p.15, (2003). An Interpersonal Neurobiology of Pschotherapy. In Healing Trauma: attachment, mind, body, and brain

25 Anchoring Activities Name five objects in the room Draw two objects in the room Name two sound you hear Count the number of holes in your tennis shoes Sing a simple song together Play I Spy Provide a grounding touch, if appropriate and pre-arranged Work in the sand or with clay

26 Treatment Goal/ Intervention Build coherent narratives for the child Timelines "I Remember When" Sandtray Stories Puppet Plays Memory Books The Toddler Book

27 Treatment Goal/ Interventions Assist clients in processing somatosensory memories related to the trauma See No Evil, Hear No Evil Putting the Pieces Together Monster Ears Google Eyes

28 Treatment Goal/ Interventions Identifying and challenging trauma related cognitive distortions The Why Wheel Repairing Self-Esteem Erase the Place Put a Positive Spin on It Punching Holes in that Theory Thinking Caps

29 Extinguish trauma induced avoidance symptoms Help client successfully overcome anxiety induced avoidance patterns

30 Graduated Exposures-Building Stepladders by Scenario Help the client make a hierarchy of fear inducing stimuli Help the client rank these in order of difficulty Begin with the easiest task first Make the tasks small enough that the client experiences many initial successes -as adapted from Wolpe as described by Shapiro, 1989

31 Making Positive Meaning of the Post Trauma Self While encouraging a meaningful goodbye

32 Before, During and After Helping the client make meaning of the trauma that includes a positive sense of self

33 Flexibly Sequential Play Therapy (FSPT): A New Model of Trauma Treatment Paris Goodyear-Brown, LCSW, RPT-S [email protected]

34 References Cassidy, J. (1994). Emotion regulation: Influences of attachment relationships. In N. Fox (Ed.), The development of emotion regulation. Monographs of the Society of Research in Child Development, vol. 59: Cassidy, J. & Shaver, P. R. (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford. Cohen and Mannarino, A. P. (1998). Interventions for sexually abused children: Initial treatment outcome findings. Child Maltreatment, 3, Greenbough, W. T. & Black, J. E. (1992). Induction of brain structure by experience: substrates for cognitive development. In MR Gunnar & CA Nelson, (Eds.), Minnesota Symposia on Child Psychology 24: pp Hillsdale, NJ.: Erlbaum. Hembree-Kigin, Toni L. & McNeil, Cheryl B. (1995). Parent-Child Interaction Therapy. New York: Plenum Press. Herschell, A.D., Calzada, E.J., Eyberg,S.M., & McNeil, C.B. (2002). Parent-Child Interaction Therapy: New directions in research. Cognitive and Behavioral Practice, 9, Jernberg, A.M. & Booth, P.B. (2001). Theraplay. San Francisco: Jossey-Bass Publishing.

35 References Kagan, R., (2004). Rebuilding attachments with traumatized children. Binghamton, NY: The Haworth Maltreatment and Trauma Press. Lovett, J. (1999). Small Wonders: Healing Childhood Trauma with EMDR. New York: The Free Press. Main, M. (1995). Attachment: Overview, with Implications for Clinical Social Work. In S. Goldberg, R. Muir & J. Kerr (Eds.), Attachment Theory: Social, Developmental and Clinical Perspectives, pp Hillsdale, N.J.:Analytic Press. Milner, B., Squire, L. R. & Kandel, E. R. (1998). Cognitive neuroscience and the study of memory. Neuron, vol. 20: pp Perry, B. D. et al. (1995). Episodic memory and autonetic consciousness: developmental evidence and a theory of childhood amnesia. Journal of Experimental Child Psychology, vol. 59: pp Perry, B. D., & Azad, I. (1999). Posttraumatic stress disorders in children and adolescents. Current Opinions in Pediatrics, 11, Rauch, S. L. et al. (1996). A symptom provocation study of posttrauamtic stress disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53, Schaffer, H.R. & Emerson, P. E. (1964). The development of social attachments in infancy. Monographs of the Society for Research in Child Development, 29 (3, Serial No. 94).

36 References Schacter, D. L. (1992). Understanding implicit memory: A cognitive neuroscience approach. American Psychologist, 47, Schacter, D. L. (1994). Priming and multiple memory system: Perceptual mechanisms of implicit memory. In D. L. Schacter & E. Tulving (Eds.), Memory systems (pp ). Cambridge, MA: MIT Press. Shapiro, F. (2001). Eye Movement Desensitization and Reprocessing (EMDR), Second Edition,: Basic Principles, Protocols and Procedures. New York: Guilford Press. Shelby, J. S., & Felix, E. D. (2005). Posttraumatic Play Therapy: The need for an integrated model of directive and non-directive approaches. In L. Reddy & C. Schaefer (Eds.), Empirically based play interventions for children (pp ). Washington, DC: American Psychological Association Press. Siegel, Daniel J. (1999). The Developing Mind. New York: Guilford Press. Siegel, Daniel J. & Hartzell, M. (2003). Parenting from the Inside Out. New York: Tarcher/Putnam. Silverman, W.K., & La Greca, A. M. (2002). Children experiencing disasters: Definitions, reactions, and predictors of outcomes. In A. M. La Greca, W. K. Silverman, E. M. Vernberg, & M. C. Roberts (Eds.), Helping children cope with disasters and terrorism (pp ). Washington, DC: American Psychological Association.

37 References Sroufe, L. A. (1996). Emotional development: The organization of emotional life in the early years. New York: Cambridge University Press. Timmer, S.G., Urquiza, A.J., Zebell, N.M., & McGrath, J.M.(2005). Parent-Child Interaction therapy: Application to maltreating parent-child dyads. Child Abuse and Neglect, 29, Tinker, R., & Wilson, S. (1999) Through the Eyes of a Child: EMDR with Children. New York: W.W. Norton and Company. Urquiza, A., & McNeil, C.B., (1996). Parent-Child Interacation Therapy: An intensive dyadic intervention for physically abusive families. Child Maltreatment, 1(2), Toth, S. L. & Cicchetti, D. (1998). Remembering, forgetting, and the effects of trauma on memory: A developmental psychopathology perspective. Development and Psychopathology, vol. 10, pp White, K. S., Bruce S. E. Farrell, A. D., & Kliewer, W. (1998). Impact of exposure to community violence on anxiety: A longitudinal study of family social support as a protective factor for urban children. Journal of Child and Family Studies, 7,

38 References March, J. & Albano, A.M. (2002). Anxiety Disorders in Children and Adolescents. March, J. & Mulle, K. (1998). OCD in Children and Adolescents: A Cognitive- Behavioral Treatment Manual. New York: The Guilford Press. McHolm, A. et al. 2005(). Helping Your Child With Selective Mutism: Steps to Overcome a Fear of Speaking. Oakland: New Harbinger Publications. Shipon-Blum, Elisa. (2003). The Ideal Classroom Setting for the Selectively Mute Child. Philadelphia: SMART Center. Spencer, Elizabeth D. et al. (2003). The Anxiety Cure for Kids: A Guide for Parents. John Wiley & Sons: New Jersey.

39 Creative Child Therapy Resources Resources by Paris Goodyear-Brown ( 1) Play Therapy with Traumatized Children: A Prescriptive Approach 2) The Worry Wars: An Anxiety Workbook for Kids and Their Helpful Adults 3) Digging for Buried Treasure: 52 Prop-Based Play Therapy Interventions for Treating the Problems of Childhood 4) Digging for Buried Treasure 2: 52 More Prop-Based Play Therapy Interventions for Treating the Problems of Childhood 5) 10 PEAS in a Pod (DVD) 6) Gabby the Gecko

40 Creative Child Therapy Resources Resources By Liana Lowenstein ( 1) Creative Interventions for Troubled Children & Youth 2) More Creative Interventions for Troubled Children & Youth 3) Creative Interventions for Bereaved Children 4) Creative Interventions for Children of Divorce 5) Paper Dolls & Paper Airplanes: Therapeutic Exercises for Sexually Traumatized Children 6) Assessment & Treatment Activities for Children, Adolescents, and Families: Practitioners Share Their Most Effective Techniques Resources by Sueann Kenney-Noziska ( 1) Techniques-Techniques-Techniques: Play-Based Activities for Children, Adolescents, & Families