Integrative Play Therapy

Athena A. Drewes, Sue C. Bratton, Charles E. Schaefer

• Publisher: Wiley
• Year: 2011
• ISBN:
  9781118064269
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

An integrative approach to play therapy blending various therapeutic treatment models and techniques

Reflecting the transition in the field of play therapy from a "one size fits all" approach to a more eclectic framework that integrates more than one perspective, Integrative Play Therapy explores methods for blending the best theories and treatment techniques to resolve the most common psychological disorders of childhood.

Edited by internationally renowned leaders in the field, this book is the first of its kind to look at the use of a multi-theoretical framework as a foundation for practice.

With discussion of integrative play treatment of children presenting a wide variety of problems and disorders—including aggression issues, the effects of trauma, ADHD, anxiety, obsessive-compulsive disorders, social skills deficits, medical issues such as HIV/AIDS, and more—the book provides guidance on:

• Play and group therapy approaches
• Child-directed play therapy with behavior management training for parents
• Therapist-led and child-led play therapies
• Cognitive-behavioral therapy with therapeutic storytelling and play therapy
• Family therapy and play therapy
• Bibliotherapy within play therapy

An essential resource for all mental health professionals looking to incorporate play therapy into treatment, Integrative Play Therapy reveals unique flexibility in integrating theory and techniques, allowing practitioners to offer their clients the best treatment for specific presenting problems.

Section III

Integrative Play Therapies for Internalizing Disorders of Childhood

Chapter 7

Cognitive-Behavioral Play Therapy for Traumatized Children

Narrowing the Divide Between Ideology and Evidence

Janine Shelby and Karina G. Campos

Introduction

The benefits of directive (i.e., therapist-led) versus nondirective (i.e., child-led) play therapy have been debated by play therapists for decades. Recent discussions, however, include greater emphasis on integrating the two approaches. Several authors have proposed specific methods of integrating directive and nondirective play therapy approaches for child trauma treatment (Gil & Jalazo, 2009; Goodyear-Brown, 2009; Shelby, 2010; Shelby & Felix, 2005). Also, several authors have advocated blending play therapy with cognitive-behavioral therapy (CBT; Drewes, 2009; Knell, 1993, 2009; Schaefer, 1999; Shelby & Berk, 2009). Even outside the field of play therapy, several authors have described the importance of developmental sensitivity in CBT (Holmbeck, Greenley, & Franks, 2003; Ollendick & Vasey, 1999; Peterson & Tremblay, 1999; Shirk, 2001; Weisz & Hawley, 2002), with some proposing that play methods be increasingly integrated into cognitive-behavioral therapies (Grave & Blissett, 2004).

Despite this increased interest in integrated approaches, the directive versus nondirective play therapy debate has not yet been settled by research and continues to surface in play therapy literature. Attempts to integrate play therapy treatments—either internally among various play therapy approaches or externally with CBT—have been hindered by conceptual difficulties defining play therapy (e.g., play as a vehicle to teach CBT skills, or play as a change mechanism) and identifying what, precisely, constitutes a developmentally sensitive treatment (e.g., use of simplified language, inclusion of age-salient content, implementation of treatment via play therapy or pedagogical methods specifically designed for the age level, or selection of treatment components based on the cognitive capacity or developmental level of the child). Finally, the dearth of randomized controlled trials comparing play therapy or play therapy integrated treatments to well-supported child trauma treatments (e.g., Trauma-Focused CBT [Cohen, Mannarino, & Deblinger, 2006]; Alternative Families CBT [Kolko & Swenson, 2002]) makes it difficult to draw empirical conclusions regarding the efficacy of integrated directive/nondirective or CBT/play therapy blended treatments.

Despite the challenges, we postulate that evidence from cognitive-behavioral treatments for young children and play therapy ideology are complementary in nature. In fact, considerable overlap may exist between some processes that occur in effective child-led play therapy and the hypothesized change mechanisms of CBT (Shelby, 2010). To demonstrate our point, we will describe separate treatment vignettes involving, first, CBT, and then, child-led play therapy for the same young trauma survivor. Then, we will describe a third vignette, referred to here as cognitive-behavioral play therapy for trauma (CBPTT), which involves elements of directive, and nondirective play therapy as well as CBT. Following a brief discussion contrasting the three treatments, we will highlight our view that an integrationist perspective is often advantageous for young survivors, who benefit from effective, skills-based, engaging, and developmentally sensitive treatments.

Explanations and Disclosures

Our goal is to give readers a general impression of each treatment, rather than to delineate full treatment protocols (see Trauma-Focused CBT [Cohen, Mannarino, & Deblinger, 2006] and Alternative Families CBT [Kolko & Swenson, 2002], as well as Child-Centered Play Therapy [Landreth, 1991] and Psychodynamic Play Therapy [Axline, 1947, 1964] for more detailed descriptions of the treatments loosely described in our vignettes). Therefore, we will provide a greatly abbreviated and condensed version of selected aspects of each treatment approach. Also, we present hypothesized positive outcomes in each of the treatments we portray in an effort to present a balanced view of three potentially successful therapies. The first two treatment descriptions are fictionalized (i.e., hypothesized based on treatment experiences with other, similar children), but the third therapy description closely resembles the course of treatment the youngster actually received. As a final caveat, we recognize the existence of several research-based dyadic treatments—offering a different sort of integrated, developmentally sensitive treatment—but discussion of these therapies is beyond the scope of this chapter, which is written to compare individual psychotherapies for traumatized children.

Case Example

Last year, 5-year-old Stephen was brought to our child trauma clinic by his devastated and guilt-ridden mother, Lauren. A month earlier, the single mother had been shuffling her three children into the family car, ensuring that lunches were packed, homework assignments were in hand, jackets were worn, and faces were, at least mostly, free of the milk moustaches acquired from breakfast. As Stephen pretended to punch his older brother in the arm, he accidentally ripped his older sister's art project, which then required Lauren to settle and calm the children. It was a particularly trying morning.

“Let's just get going,” Lauren thought. She put the car in reverse gear and began backing the car out of the driveway. Suddenly, she heard her youngest child scream, and she realized that the car door on his side was open. To her horror, Lauren turned to see her son fall out of his car seat, which had somehow failed to latch. With a thud, he fell onto the pavement. Lauren immediately stepped on the brake, got out of the car, and ran to her son. However, in her panic to reach him, she failed to put the reversing car into the park gear, and she subsequently watched with disbelief as her car ran over her child. Stephen sustained extensive pelvic injuries, but remarkably, he fared quite well from a medical perspective.

A month after the accident, he appeared in the child trauma clinic in his wheelchair, endorsing numerous symptoms of posttraumatic stress disorder (PTSD). Stephen had intrusive and recurrent thoughts of the traumatic event, physiological arousal upon exposure to reminders of the event, pronounced avoidance of sitting in his car seat, and avoidance of riding in—or even discussing—cars. In fact, the family used public transportation to arrive at the session because Stephen refused car travel. In addition, he exhibited hypervigilance and excessive startle response. He experienced nightmares but endorsed this symptom only if the therapist referred to them as “morningmares,” because his bad dreams always seemed to happen to him in the morning, immediately before his mother woke him up to get ready for school. He also reported other symptoms known to occur among young traumatized children (Pynoos et al., 2009), such as stomachaches and headaches, and the loss of previously acquired skills, including the ability to separate from his mother and fall asleep on his own.

Three Possible Treatments

Treatment Option 1: CBT

Basic Tenets

A basic premise of CBT is that thoughts influence behaviors and feelings, but that altering any of the three components of this cognitive triangle results in changes among the other two. Although originally attributed to the work of Beck (Beck, Rush, Shaw, & Emery, 1979) and Ellis and Gieger (1986), several specific CBTs now exist for childhood anxiety disorders. Elements common among most child trauma CBTs include the following: (a) thorough assessment and diagnostic formulation; (b) the development or enhancement of adaptive coping strategies; (c) psychoeducation; (d) hierarchical exposure to excessively or inappropriately feared stimuli; (e) the alteration of thoughts, behaviors, and feelings to alter anxiety level; (f) cognitive restructuring regarding misattributions or excessive guilt; and (g) caregiver involvement in the treatment to promote caregiver understanding, skill-building, and reinforcement of therapy techniques used with the child (Kendall et al., 2005; Shelby & Berk, 2009). Exposure is an important constituent of the treatment. That is, as children experience—either real or imagined—anxiety-provoking situations under safe conditions, they learn to manage their distress related to the exposure.

Research

There is little doubt as to the effectiveness of CBT for childhood and adolescent anxiety, with response rates ranging from 65% (Kendall et al., 2005) to 93% (Cohen, Mannarino, & Deblinger, 2006). Given that CBTs offer such benefit to older children, it is unfortunate that so few studies have examined the experience of children younger than 8 years of age (Grave & Blissett, 2004).

Stephen Receives CBT

Session 1: In the first session, the therapist conducts an assessment (i.e., including use of standardized instruments, caregiver report, behavioral observations, and child interview) and assigns a diagnosis, which is then matched to a treatment known to be helpful for that particular disorder or condition. Stephen's symptoms are targeted and monitored throughout the course of therapy. After learning more about the therapy, Stephen and his mother agree to participate in future sessions.

Session 2: Stephen and his mother receive psychoeducation, via didactic instruction and reading materials that provide specific information about typical symptoms following traumatic events. The mother also learns more about CBT, the importance of practicing CBT skills at home, common response rates to treatment, and helpful caregiver behaviors.

Session 3: In this session, the therapist teaches Stephen to identify different emotions by showing him a poster with cartoon faces depicting different feelings. Stephen then learns how to recognize his experiences of calm and fear, so that he can later employ anxiety-reduction strategies to decrease his distress and recognize when these strategies are successful. Then, after the therapist conducts a functional assessment of Stephen's symptoms, the therapist targets each of his most pronounced symptoms and determines the antecedent, behavior, and consequence of each. The therapist helps mother and son create a plan to respond to trauma triggers in adaptive ways (e.g., parent alters the environment to reduce exposure to triggers; child engages in specific coping strategies in response to triggers; parent assists child in recognizing when he should use one of his coping strategies). Homework: Lauren and Stephen are to respond in designated ways when Stephen encounters trauma triggers.

Session 4: After homework review, Stephen is shown a worksheet in which a triangle with arrows and labels depicts how thoughts, behaviors, and feelings are interconnected (i.e., the cognitive triangle). Stephen hears the therapist say that there is something he can think or do that will help him feel better, which he is relieved to know. The therapist offers examples of how Stephen's thoughts or behaviors affect his anxiety level, but the therapist's discussion requires complex understanding of cause and effect relationships, metacognition, and prospective hypothetical problem-solving skills. Consequently, Stephen is focused on the only portion of the page that he comprehends—the triangle—and he draws more triangles in the margins of the diagram.

Stephen makes several unsuccessful attempts to divert the therapist's attention to activities that would be more interesting to him. Nevertheless, the therapist speaks kindly to Stephen and smiles at him often, so he is not dissatisfied with the therapy session overall. When the therapist specifically asks about Stephen's unhelpful cognitions, he reports that he thinks “I'm never going to feel better.” Homework: Caregiver is instructed to verbalize helpful cognitions (e.g., “This is hard, but you can get through it,” or “Things will get easier”) to Stephen. The caregiver will also remind Stephen to use the helpful behaviors identified during the prior session (i.e., tell his mother when he feels scared or engage in a pleasant activity).

Session 5: After discussing the prior week's homework assignment, the therapist teaches Stephen several relaxation techniques (e.g., deep breathing and positive guided imagery), which are rehearsed during the session. The caregiver is also taught to use these skills herself. Homework: Stephen is to continue using his coping plan and incorporate relaxation practice with his mother into their daily schedules.

Session 6: From the log Lauren keeps of Stephen's anxiety reactions, coping behaviors, and outcomes, the therapist finds that Stephen has been managing trauma triggers well. Even if Stephen does not fully understand the cognitive triangle and the assumptions therein, he is benefiting from the behavioral practice that the coping plan is providing him. In session, the therapist continues to help Stephen learn to self-monitor his anxiety levels, so that he can independently engage in coping techniques (e.g., engaging in distracting behaviors, cognitive coping, or seeking social support) when necessary. During their session, the therapist and Stephen engage in a role-play activity, in which Stephen pretends to have a scary thought and then uses his newly acquired coping skills to manage the associated anxiety. The homework assignment is for Stephen to utilize these skills in response to the targeted symptoms. Lauren is also taught to remind Stephen to use these skills, whenever necessary.

Session 7: Per the mother, Stephen is successfully managing his reactions to most trauma triggers. Intrusive reexperiences show a moderate response to the interventions. Some general anxiety (e.g., high arousal) and avoidance of transportation in vehicles persist. The therapist describes how Stephen will make a trauma narrative booklet, and Stephen begins by personalizing the cover page. The therapist meets with Lauren to help her enhance her own coping skills and to explore her attributions regarding the accident. The therapist is unaware that Stephen has intrusive dreams (i.e., he denied having “nightmares” and refers to them as “morningmares”). Homework: Stephen is to monitor any remaining symptoms and use his relaxation skills to reduce anxiety.

Session 8: Stephen continues his trauma narrative by drawing a tiny stick figure being crushed by a huge tire. He then describes his dr...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Preface
• About the Editors
• Contributors
• Section I: Introduction: Importance of an Integrative Approach to Child Therapy
• Section II: Integrative Play Therapies for Externalizing Disorders of Childhood
• Section III: Integrative Play Therapies for Internalizing Disorders of Childhood
• Section IV: Integrating Play Therapy for Attachment Disorders of Children
• Author Index
• Subject Index