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Trauma Focused Integrated Play Therapy

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Tara Brittney

on 7 August 2015

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Transcript of Trauma Focused Integrated Play Therapy

Means of expression for child clients who have experienced interpersonal trauma
Allows child to externalize whatever is on his/her mind
externalization can be symbolic and contained
Children are more reluctant to discuss thoughts and feelings
Child may have already been interviewed several times
Children are unable, or find it difficult, to express themselves or their experiences through verbal exchange and/or metacognition
Mastery through gradual exposure, tolerance, and expression of affect
Avoids power struggles

Trauma Focused Integrated Play Therapy

What is TF IPT?
An integrated model which utilizes child centered play therapy to assess and process trauma
Incorporates several theories including CBT, post-trauma play, attachment therapies, and systemic views
Informed by both trauma theory (traumatic events overwhelm the person’s perceived capacity to cope) and phenomenological aspects of trauma impact and physiological responses
Incorporates both directive and nondirective strategies, and prioritizes expressive therapies
non-directive play therapy - child in control of session activites, decision-making and change left with child, unconditional acceptance: not symptom focused, permissive and reflective, responsive to child's cues, respectful and empathic
Attends to developmental needs of children, by incorporating evidence-based practices and promoting resolution of traumatic events by direct or indirect processing of traumatic incidents

Adapted from Eliana Gil's TF IPT Two-Day Workshop
Why Use Play and Expressive Therapies?
Play creates positive feelings between those who play; helps form attachment; enhances the relationship; facilitates positive interactions
Provide a vehicle for child to process experiences or express themselves
natural medium for self-expression
Play = primary language of childhood (toys are the words, play is the language)
Art = expression through literal and symbolic creativity
Power of metaphor allows child emotional distance from thoughts while working through various scenarios that elicit fear, conflict resolution, safety, etc.
Exploration vs. interrogation
Right vs left hemisphere activity
Advantages of Trauma Play
Trauma Impact
AFFECT
COGNITION
AUDITORY
VISUAL
BEHAVIOR
ASSIMILATION OF
FRAGMENTS
dissociative barriers
SENSORY
Process of assimilation:
What did you say to yourself about that?
As you said that, what did your body do?
What were you looking at/hearing?
How did you feel?

Primary Goals of TF IPT
Create an environment of safety, trust, and comfort
Break cycles of denial and secrecy
Correct cognitive distortions through psychoeducation
Encourage the expression of affect
To process traumatic material
Comprehensive assessment of child’s phenomenological experience of trauma and trauma impact
Explore and express thoughts and feelings associated with abuse
Bring traumatic memories into conscious awareness in order to decrease post-trauma symptoms
To encourage social reconnection
Ensure child’s access to internal and external resources
To return to pre-trauma developmental functioning
Increase coping strategies and self-regulation to restore pre-abuse functioning
Enhance self-esteem and sense of competence

Nondirective strategies allows child to be in charge and allows natural healing mechanisms to emerge

Directive strategies gently challenge child’s defenses (allow opportunity for psychoeducation)

“Tickle the defenses” create opportunities to stimulate natural healing mechanisms


TF IPT Treatment Includes:
Structure of TF IPT
Phase One
Phase Two
Phase Three
Establishment of Safety
Sessions 1 -5
Processing of Traumatic Material
Sessions 6-10
Social Reconnection
Sessions 10-12
Parent Engagement
Parent/Caretaker psychoeducation
Psychoeducational materials given at intake and reviewed for up to three sessions before beginning of treatment
Clinician-caregiver contact throughout treatment
Clinicians have contact with parents after each phase of therapy to learn about child’s progress and reinforce therapy lessons
Children will be given out-of-session tasks and parents will be notified of these
Parents have ample opportunities to ask questions, receive specific psychoeducational materials, and request additional services
Parents check in with children’s therapists on an as-needed basis and clinicians keep them informed of children’s progress
*research suggests that parental support may be a more important factor in a child’s recovery than any factor associated with circumstances of abuse

Additional Components of TF IPT

During nondirective play clinician assesses for potential use of post-trauma play, documents play themes, and generally allows and encouraged the child to use play as a form of gradual exposure to traumatic event

Typical characteristics of posttraumatic play (Maltby, 2011):
1.
It’s repetitive
. Children are typically creative and play evolves and changes naturally. Posttraumatic play is repetitive—both within and across play sessions.
2. It’s avoidant
. Children who have not experienced trauma usually involve trusted adults in their play. Posttraumatic play is often secret or hidden from others. These children may avoid physical closeness with the adult in an attempt to keep the posttraumatic play hidden.
3. It’s intense.
Posttraumatic play often feels intense and driven. You might get the feeling that the child is compelled to play a certain story or game rather than freely choosing it. The child may appear hyper-focused. This play usually lacks the “playful” quality that marks typical play.
4. It’s disrupted
. Play disruptions are when a child is suddenly unable to play. This disruption can be either sudden or gradual. When children are engaged in posttraumatic play, the play will often stop abruptly.
5. It’s not fun
. Typically developing children have fun when they play. Even if they are playing out a “negative” story or theme, they enjoy expressing these feelings and inhabiting those roles. Posttraumatic play, on the other hand, isn’t fun. Children do not enjoy it; they feel compelled to do it.

In short, it is not the content of the play that is most important, although the content can, at times, offer some insight into a child’s world. It is the process of the play that differs when a child is experiencing posttraumatic play.

Additional Components of TF IPT (Continued)
Assist children in creating trauma narratives that can be completed in verbal and nonverbal ways
Teach children about how their brains work in order to support them making good choices and feeling more in control
Termination sessions encourage the development of optimism by providing children with opportunities to say meaningful goodbyes and to view their lives in a more balanced way (a life that includes both positive and negative events)


Nondirective Play Therapy Time
Sessions 1-12
Goals
Provide children with opportunities to express their thoughts and feelings in nonverbal ways
Allow children to utilize the curative aspects of play therapy, especially, post-trauma play
Allow clinicians assessment opportunities through play observation
Directives
Nondirective play therapy time is built into each session (following a structured activity and before mindfulness breathing and affective scaling)
Therapist introduces nondirective play at the outset of treatment: “some of the time we will be talking about or doing an activity that I choose for us to do and some of the time you can choose whatever you would like to do.”
Use Play Assessment Observation form
At Home Review
Parents will receive informational materials regarding the benefits of nondirective play therapy and are encouraged to practice simple activities with their children


Nondirective Play Therapy Time
Sessions 1-12
Special considerations and processing suggestions:
Maintain a posture of unconditional acceptance allow child to direct the play, manage frustration, engage with play materials, and lead the therapist’s participation
Use reflective listening, set necessary limits, observe children’s play (both process and content), and create a safe and predictable environment
Observe thematic material, children’s interpersonal skills, their ability to solve or resolve conflicts or problems, their ability to participate in developmental play, and their capacity for enjoyment of their play
Evaluative comments are kept to a minimum and are considered counterproductive in that they create a child’s expectation for external validation

Beginning and Ending the Session
Affective Scaling
Done at beginning and at end of session
Encourages children to identify feelings and to show clinicians intensity of their feelings
Show Feelings Worksheet and “point to the feeling that you’re feeling right now.” If feeling is not on worksheet, children are asked to make a drawing and name the feeling
Once child points to the feeling state, clinicians find the Affective Scaling Worksheet and the feeling the child has selected. Clinicians then say, “as you can see, the feelings on this page are different sizes. Point to the size of the feeling that you’re feeling right now.”
At Home Review
Encourage children to use the two worksheets at least twice during the week
Encourage children to have their parents or siblings use the worksheets at least once during the following week


Beginning and Ending the Session
Mindfulness Breathing Exercise
Breathing exercise encouraged at both beginning and end of session to orient children to the room, to focus them, and to help them transition to the therapy hour
Tell children that each time they come to therapy they will be taking a few minutes when they first come in and before they leave to sit and relax and take a few deep breaths (clinician demonstrates first)
Ask to sit in comfortable position
They can close their eyes or keep them open as they listen to the sound of a chime as long as they can
Ask child to bring attention to their breath and tell them that if their minds wander, that’s okay, just bring their focus back to their breath and feel their tummy rising and falling
Then, when they hear the sound again, ask them to listen until they can’t hear the sound anymore, and slowly, gently open their eyes
At Home Review
Children are encouraged to teach their parents/siblings this breathing exercise
Children are encouraged to use this breathing exercise prior to sleeping

In Preparation for our next training:
Read all of Introduction and Phase One (pg 1-42)
Prepare any questions/concerns you may have in order to discuss at scheduled conference call

Structure and Repetition
Must ensure clinical approaches are:
culturally and developmentally-appropriate
engaging
time-sensitive
repetitive

Tasks must engage WHOLE child
intellectual
emotional
physical
expressive
greater potential to elicit more client participation
Curative Aspects of Play
Developmental growth and learning
Mastery and control
Decrease of anxiety through affective discharge
Release endorphins and promotion of well-being
Communication and externalization of inner world
Helping children assimilate stressful experiences "shrinks" the problem
Brainstem
Plays an important role in the regulation of the primitive functions of the body such as breathing, body temperature, blood pressure and heart rate. Trauma to the brainstem can impact the brain’s wiring to cause excessive reactions to threats.

ex) a traumatized child may be quickly aroused to a self-protective flight or fight response that will appear to be excessive.
Midbrain
Helps with movement, sleep, appetite, arousal (physiological
readiness for activity), etc. For example, children who have
experienced complex trauma often have a hard time falling and staying asleep, their appetites may seem different from their peers, and they may have a hard time with movement and coordination (motor regulation).
Limbic System
Helps manage our emotions. For example, children who have experienced complex trauma have a hard time identifying, understanding, expressing and managing their feelings. This can contribute to difficulty with turn-taking, sharing and peer relationships.
Cortex
As the thinking part of the brain, it is the strategy center involved with higher functions such as sensory perception, spatial reasoning, conscious thought and language - it helps manage thinking and learning. For example, children who have experienced complex trauma may have poor concentration, attention, and short/long term memory as well as difficulty with organizational skills including processing information, planning and problem solving.
A Child's Brain on Trauma
Benefits of Play
Left vs Right brain
left hemisphere is analytical and evaluative (more conscious and deliberate)
right hemisphere uses symbol, metaphor, fantasy (more access to unconscious)
processing occurs on different levels
useful to stay in right-hemisphere activity as long as possible: don't rush to verbal discussion/explanations
Relational
Physical, experiential
Structure of TF IPT Sessions
Affective Scaling

Structured Mindfulness Breathing Exercise

Directive Play: Each session includes 4-5 play-based techniques used both as therapeutic experiences, as well as to inform an assessment of overall functioning

Nondirective Play

Structured Mindfulness Breathing Exercise:
[Repeat]

Affective Scaling:
[Repeat]

Integrated Component: Parents receive coaching as needed during the intake session and throughout the therapy process

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