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CHAPTER

Play Therapy With Survivors of Interpersonal Trauma:

Overcoming Abuse and Crime CHARLES EDWIN MYERS

Our world is full of wondrous events, such as the laughter of children and sunsets, andconversely, our world is full of horrific events, including child abuse and other crimes against children. We expect childhood to be a time of fun, happiness, and play. However, for some children, childhood can be a time of fear, horror, and pain. A myriad of traumatic experi- ences can adversely affect children, including natural disasters, acts of mass violence, child abuse and neglect, and domestic violence. While natural disasters such Hurricane Katrina and the 2010 Haiti earthquake can be traumatizing to children, the harshest of traumas on children are those involving interpersonal trauma, primarily child abuse and neglect, domestic violence, and acts of mass violence, such as the terrorist attacks of September 11, 2011, and the 2013 school shooting in Newtown, Connecticut. For the purposes of this chapter, interpersonal trauma is defined as any traumatic event a child experiences that is clearly caused by another person.

In this chapter, characteristics of interpersonal trauma, including child abuse and crimes against children, are defined, and it is illustrated why play therapy is an appropriate approach for working with child survivors of interpersonal trauma. Second, play therapy approaches with demonstrated effectiveness in alleviating the symptoms of child survivors of interpersonal trauma are reviewed. Third, procedural modifications needed to meet these children’s needs are described. Fourth, specific techniques and strategies known to facilitate growth and healing for child survivors of interpersonal trauma are explored. Finally, the research and evidence base for the use of play therapy in the treatment of interpersonal trauma are discussed.

417 O'Connor, K. J., Schaefer, C. E., & Braverman, L. D. (2015). Handbook of play therapy. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-06-08 01:46:38.

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418 HANDBOOK OF PLAY THERAPY

DEFINING THE POPULATION

Interpersonal trauma is a silent epidemic affecting many children (Kaffman, 2009). In the Diag- nostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), the American Psychiatric Association (APA) described posttraumatic stress as being caused by exposure to actual or threatened death, serious injury, or sexual violence. Children can develop posttraumatic stress by directly experiencing or witnessing a trauma, learning of a trauma experienced by family or friends, or repeated or extreme exposure to aversive details of a trauma (APA, 2013). In the case of interpersonal trauma, direct experience can include child physical or sexual abuse, kidnapping, being held hostage, torture, human-made disasters, and severe motor vehicle accidents. Witnessing can include threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, accident, and trauma happening to others, particularly a primary caregiver. Learning of a traumatic event or accident happening to a close friend or family member may include hearing about a violent personal assault, suicide, or a serious accident or injury. Repeated or extreme exposure to adverse details may include hearing the story reiterated or seeing the traumatic event repeatedly on television or the Internet. The effects of interpersonal and intentional traumatic events can be especially severe or long lasting (APA, 2013, pp. 273–274).

Characteristics and Special Needs Children are relational beings. They learn about themselves and the world around them through their interpersonal relationships with significant others in their lives. Younger children desire close relationships with adults, in particular with their parents and teachers. In mid-childhood, children begin to develop social hunger, the desire to build significant relationships with peers, which continues to grow through adolescence. One of the most serious aspects of interpersonal trauma is the damage it can do to children’s and adolescents’ desire to form and maintain such relationships. Furthermore, interpersonal trauma can have a pervasive and long-lasting impact on children’s neurological development because their brains are still developing (van der Kolk, 2005). The effect of interpersonal trauma on brain development may result in lasting brain dys- function, affecting children’s health and quality of life throughout their lives (Anda et al., 2006). Recent advances in neuroscience provide insight to the effects of trauma, supporting much of what play therapists have noted anecdotally.

Interpersonal trauma is a form of psychological trauma that involves the breaking of trust due to death, abandonment, abuse and neglect, or domestic violence (Findling, Bratton, & Hen- son, 2006). Interpersonal trauma response is an individual child’s reaction to an unexpected relationship-based traumatic event that is experienced intimately and forcefully (Everstine & Everstine, 1993). Interpersonal trauma overwhelms a child’s internal resources (Briere & Scott, 2006), resulting in internalized feelings of helplessness and vulnerability and a loss of safety and control (James, 1989). Relational trauma, a specific form of interpersonal trauma, involves the rupturing or severing of interpersonal relationships with significant others, and in the case of children, interpersonal trauma frequently involves a primary caregiver (Dayton, 2000).

Children who experience relational trauma may feel isolated and experience a range feelings, thoughts, and physical sensations that are both confusing and frightening (Gil, 2010). In response to interpersonal trauma, children often experience a sense of betrayal as result of a person they love either being the source of their pain or failing to protect them from pain (Shaw, 2010). Interpersonal trauma can have profound effects on children’s current and future development, resulting in lifelong challenges.

O'Connor, K. J., Schaefer, C. E., & Braverman, L. D. (2015). Handbook of play therapy. ProQuest Ebook Central <a onclick=window.open('http://ebookcentral.proquest.com','_blank') href='http://ebookcentral.proquest.com' target='_blank' style='cursor: pointer;'>http://ebookcentral.proquest.com</a> Created from capella on 2021-06-08 01:46:38.

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Play Therapy With Survivors of Interpersonal Trauma: Overcoming Abuse and Crime 419

Effects of Interpersonal Trauma Exposure to childhood trauma is extremely common (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Kisiel et al., 2014). The effects of interpersonal trauma can be pervasive and profound. Young children are particularly vulnerable to traumatic events (Shaw, 2010) because they lack the cognitive ability to process intrusive and distressing experiences (Dass-Brailsford, 2007). In addition, childhood is a time of great development across all domains of growth (i.e., behavioral, cognitive, emotional, psychological, physical, social). Trauma affects children holistically, and traumatic events can severely interrupt their development (van der Kolk, 2005). This interruption can have a devastating effect when the trauma occurs during sensitive periods—periods when the body and mind are hardwired for expansive growth (Berk, 2009). When children experience trauma during a developmental sensitive period, their opportunities to achieve full development in that area are greatly inhibited; in more severe cases, children may never reach their full potential.

Interpersonal trauma may result in dysregulation of affect and behavior, disturbance of attention and consciousness, distortion in attributions, and interpersonal difficulties (D’Andrea et al., 2012). Similarly, Kisiel and colleagues (2014) found children who experienced interper- sonal trauma had significantly higher levels of affective/psychological, attentional/behavioral, and self-regulation challenges. Furthermore, Edelson (1999) found child witnesses of domestic violence had increased difficulties with behavior and emotional functioning, cognitive function and attitudes, and long-term developmental problems.

Children with interpersonal trauma may experience feelings of anger, anxiety, betrayal, depression, fear, guilt, helplessness, and of being overwhelmed and ashamed (Damon, Todd, & McFarlane, 1987; Edelson, 1999; Finkelhor, 1986; Kaufman & Wohl, 1992; Lisak, 1994; McMahon, 1992; Namka, 1995; Ruma, 1993). Furthermore, these children may struggle with hostility, insecurity, interpersonal relationships, self-esteem, self-image, sexuality issues, social isolation, trust, and withdrawal (Brier & Scott, 2006; Edelson, 1999; Finkelhor, 1986; Hall-Marley & Damon, 1993; Lisak, 1994; Martin & Beezley, 1977; Middle & Kennerly, 2001). Due to the sense of betrayal and break in trust, children who experience interpersonal trauma frequently have difficulties with separation and abandonment (Cattanach, 1992; Damon et al., 1987), experience confusion and loss, and are often hypervigilant (Cattanach, 1992; Martin & Beezley, 1977; White & Allers, 1994). In addition, interpersonal trauma can negatively affect school performance by causing cognitive and behavioral challenges. Students may experience cognitive difficulties including problems with attention, concentration, and functioning. They may also experience behavioral difficulties such as problems with problem solving and conflict resolution, negative and uncooperative attitudes, opposition and defiance, and running away (Edelson, 1999; Finkelhor, 1986; Hall, 1997; Ko et al., 2008; Martin & Beezley, 1977).

Child Abuse and Domestic Violence Children play out their personal experiences of child abuse and domestic violence when they experience safety in a therapeutic relationship with a play therapist. Maria, a 6-year-old Latina girl, played with the dollhouse in her school counselor’s office and moved the little girl doll into the bedroom,making an audibleclick as she pretendedto lock the door(Myers, 2007).She picked up two adult dolls, one female and one male, and held them before the bedroom door. She then had the mom doll slap the dad doll and screamed at him, “Don’t ever touch my daughter again!” André, a 4-year-old African-American boy spoke with a squeaky voice due to scarring of his vocal chords. The scarring developed as result of him having cried all night when his parents abandon him night after night to feed their drug addiction. André would nurture the baby doll with the

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420 HANDBOOK OF PLAY THERAPY

love and tenderness that he himself had not experienced and had desired. He would end each session by pulling the dollhouse over in a crash, symbolic of his experience of his family. These stories are examples of the kind of abuse- and neglect-related trauma many children endure and play out.

The Child Abuse Prevention and Treatment Act (CAPTA, 2010) defined child abuse and neglect as:

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm. (p. 6)

Child abuse is a pervasive societal problem (Kaffman, 2009). Child abuse affects millions of children each year (Children’s Bureau, 2013). In 2012, more than 3.8 million U.S. children were the subject of at least one child abuse report (Children’s Bureau, 2013), and in 2013, there were 681,000 confirmed reports of individual children suffering child abuse or neglect and 3.3 million children received protective services (Children’s Bureau, 2014). These children experienced neglect (78.5%), physical abuse (17.6%), sexual abuse (9.1%), psychological mal- treatment (9.0%), medical neglect (2.2%), and other/unknown types of issues (10.6%). Child abuse occurs across gender and race. Reported demographics reflect the national population with a gender breakdown of 51% girls to 49% boys and a racial breakdown of 44% White, 21.8% Latino, and 21% African American.

Finkelhor, Turner, Shattuck, and Hamby (2013) conducted a national study of 4,503 children under age of 18 years. They found 54.5% of these children had suffered physical assault, 9.5% endured sexual victimization, 25.6% experienced child maltreatment, 40.2% underwent prop- erty victimization, and 39.2% experienced indirect victimization. At least 48.4% of participants reported experiencing more than one type of victimization (polyvictimization) in the previous year. Finkelhor and colleagues (Finkelhor, Ormrod, & Turner, 2007; Finkelhor, Ormrod, Turner, & Hamby, 2005; 2009; Turner, Finkelhor, & Ormond, 2010) found similar results across a series of studies on child abuse. While these numbers are alarming, many cases of child abuse never reach the authorities; for example, researchers estimate that only 10% of child sexual abuse is ever reported (Besharov, 1994; Ledesma, 2011; London, Bruck, Ceci, & Shuman, 2005; Paine & Hansen, 2002; Shaw, 2010).

The National Institute of Justice (NIJ, 2003) discovered comparable results in their study on youth victimization (i.e., sexual assault, physical assault, physically abusive punishment, and witnessing an act of violence) when interviewing 4,023 U.S. adolescents. Participants reported experiencing sexual assault (8.1%), physical assault (17.4%), and physically abusive punishment (9.4%) and witnessing violence (39.4%) (NIJ, 2003, p. 4). Unfortunately, the occurrence of child abuse is probably higher. Participants revealed that 86% of sexual assaults and 65% of physical assaults were never reported to authorities (NIJ, 2003, p. ii).

Other important statistics are those related to child abuse perpetrators. Perpetrators of child abuse and neglect do not belong to a specific demographic; they can be found in all ethnicities, races, and socioeconomic levels (Douglas & Finkelhor, 2005; Finkelhor et al., 2005; NIJ, 2003), making all children vulnerable. The Children’s Bureau (2013) analysis of perpetrators across all 50 states disproved the stereotypical image of child abuser being a stranger. Out of 512,040 perpetrators, 80.3% of child abuse and neglect cases were perpetrated by the children’s caregivers, 88.5% of those being biological parents. In addition, 53.5% of perpetrators were female, 45.3% male, and 1.1% unidentified. These facts create a disconnection for many children; the person who is a source of love is also a source of pain, resulting in one of the worst forms of interpersonal trauma.

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Play Therapy With Survivors of Interpersonal Trauma: Overcoming Abuse and Crime 421

Domestic violence was the unspoken secret in many families for decades; people did not want to acknowledge domestic violence occurred, especially not in their family (Myers, 2008). If domestic violence did occur in a family, the attitude often was “what happens at home stays at home” (Carlson, 1984). Since the 1970s, Americans are more willing to acknowledge the exis- tence of domestic violence and are more open to talking about how domestic violence affects our society and impacts our children (Kot, Landreth, & Giordano, 1998). Increased awareness and acknowledgment of domestic violence has resulted in higher levels of reporting; for example, more than 25% of couples reported at least one physical aggression occurring in their homes (Straus & Gelles, 1990). Domestic violence, like child abuse and neglect, crosses all social class, education, and socioeconomic demographics (Lloyd, 1990). The effects of domestic violence on children are invasive and pervasive, resulting in chaotic home settings (Tyndall-Lind, Landreth, & Giordano, 2001) and jeopardizing the physical and emotional well-being of the children in home, as well as their safety and development.

Why Play Therapy Is Appropriate Play is an important and vital element of childhood. The pervasiveness of play in childhood is evident in its appearance in all cultures across the globe, regardless of location, race, or socioe- conomic status. Play occurs in unlikely circumstances, such as in the concentration camps of the Holocaust (Glazer, 1999) or following a devastating earthquake in Haiti (Myers, 2011). Play serves many purposes, including the healthy development and healing of children.

Role of Play in Childhood and Development In the 1700s, Rousseau postulated that play is essential to the healthy development of children (Bratton, Ray, Rhine, & Jones, 2005). Much later, in the 1900s, the United Nations Committee on the Rights of Children (United Nations, 1990) proclaimed play as a universal and inalienable right of childhood and emphasized the importance of play to the development and wholeness of children. Furthermore, according to the American Association of Pediatrics, children learn how to interact with the world around them through play (Ginsburg, Committee on Commu- nication, & Committee on Psychosocial Aspects of Child and Family Health, 2007). Landreth (2012) described play as being the central activity of childhood, in which children learn about themselves, others, and the world around them. Children learn to respect themselves, to con- trol their feelings responsibly, and to be creative in confronting problems. Children are able to imagine new ways of being through play, explore their identity in relation to others (Cattanach, 1992), and learn and practice new skills in safe and supportive environments (Boucher, 1999).

Child development theorists, educators, and mental health specialists widely recognize the importance of play in childhood (Baggerly & Landreth, 2001). Play has a direct association with a child’s cognitive, affective, and social development (d’Heurle, 1979) and is a developmen- tally appropriate learning strategy in working with children (Bredekamp, 1987; Erikson, 1963; Montessori, 1964; Piaget, 1952).

Play and activity are the natural mediums of communication for children (Axline, 1947/1969; Ginott, 1959; Landreth, 2012) and are a young child’s primary modes of emotional expression (Hall, 1997). Through play, children can communicate what they are unable to say in words. Children use toys to express emotionsabout their self-perceptions,aboutothers, and about signifi- cant events they have experienced (Ater, 2001). Young children, ages 2 to 6 years, are in Piaget’s (1952) preoperational stage, and older children (7 to 12 years) are in the concrete operations stage. During these stages, children use concrete expressions of internal experiences and symbol- ism to express those internal feelings and thoughts. According to Piaget (1962), play provides a bridge between children’s concrete expressions and their abstract experiences.

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422 HANDBOOK OF PLAY THERAPY

Healing Properties of Play Play is the most natural and healing process in childhood. Play provides a means for children to play out their feelings, thoughts, and experiences, similar to how an adult might “talk out” difficulties (Mader, 2000). Erikson (1963) believed children have the capacity to find recreation and to self-cure when engaging in play. Play can be a particularly valuable mode of communica- tion and processing for children who have experienced interpersonal trauma because it presents a safe mode of expressing their innermost feelings and fantasies (Mann & McDermott, 1983). The power of play in the healing and growth of children and its therapeutic value is well established (Caplan & Caplan, 1974). Play therapy provides a natural conduit for the healing nature of play for children with a history of interpersonal trauma within a safe and supportive environment.

The Effect of Interpersonal Trauma Children with a history of interpersonal trauma often experience a sense of great loss of trust and betrayal. This loss of trust and betrayal may occur when a bond with a caregiver is sev- ered, especially due to child abuse or domestic violence where a child loses trust in the ability of caregivers to keep them safe. Acts of mass violence can also cause a since of loss of trust in care- givers ability to keep them safe. For example, many children were killed or injured in the 1995 bombing of the federal building in Oklahoma City that housed a day-care center and the 2012 school shooting in Newtown, Connecticut, and many children loss caregivers in the 9/11 terror- ist attacks.

Posttraumatic Play Behaviors Play therapists working with children who have experienced interpersonal trauma need to be knowledgeable of the characteristics of posttraumatic play behaviors, effective play therapy approaches, and play therapy research related to working with children who have experienced interpersonal trauma. In 1976, three men hijacked a school bus in Chowchilla, California. They kidnapped the 26 children, ages 5 to 14, and their bus driver and drove them around in two vans with blacked out windows until late into the night. The kidnappers then forced the children and bus driver to climb into a hole in the ground that lead to a buried moving van, leaving their hostages buried alive for 16 hours, until they were able to escape. The children recalled how scared they were, thinking the men were going to kill them, hearing the sound of men shoveling of dirt on top of the van, and being held in a dark, small space for hours with no ventilation and with temperatures reaching up to 110 degrees inside (Terr, 1981, 1983).

In her work with the children of the Chowchilla kidnapping, Terr (1983) observed the chil- dren exhibited specific posttraumatic behaviors in their play. Children exposed to this trauma respond in one of four ways: (1) intense and repetitive thought of the trauma, (2) reenactment of the trauma, (3) fear of things highly correlated to the traumatic event, and (4) a sense of future- lessness (Terr, 2003, p. 234). Other childhood trauma experts and researchers (Gil, 1991, 2006, 2010; James, 1989, 1994) have noted similar posttraumatic play in their clients and subjects. Fin- dling and associates (2006), in their review of the professional literature on children and trauma, identified and defined five specific posttraumatic play behaviors: (1) intense play, (2) repetitive play, (3) play disruption, (4) avoidant play, and (5) negative affect.

Intense play has a compulsive and driven quality. Posttrauma children can be so absorbed in their play they shut out the world around them. To the play therapist, it may feel sometimes as though the child forgets the therapist is in the room. During her play therapy, Jana, a 7-year-old, African-American girl who survived Hurricane Katrina and relocated to Texas, displayed two examples of intense play. One example occurred when she was at the easel and painted a picture

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Play Therapy With Survivors of Interpersonal Trauma: Overcoming Abuse and Crime 423

that was almost entirely blue water with the exception of a little sky at the top and a little figure in the middle of the water calling for help. The other example occurred in the sandbox as she buried dolls, animals, and other objects (representing the things lost to the flood waters). She did both of these in focused silence.

Repetitive play is a specific play or play theme the child feels compelled to play out the exact same way each time. Repetitive play may occur both during a single session and across sessions. During her play, Karina, a 6-year-old Latina girl, would go to the sandtray, take a toy cauldron, and place a little sand in it. She would repeat this play behavior a few times each session and continued to do so for several sessions. This was her attempt to understand and accept what had happened during a tragic accident when her 3-year-old cousin reached into a bucket of water into which she had placed glitter and drowned. While repetitive play may be reparative in allowing the child to make sense of an experience and to develop a sense of mastery over the outcome (Terr, 2003), it may also be retraumatizing when a child becomes stuck in the repetitive play. Play therapists need to be sensitive to how repetitive play is affecting a child and may need to intercede with a more directive, problem-solving approach (Gil, 2006, 2011a).

Play disruptions are a form of dissociation during which traumatized children suddenly switch their play to protect themselves when the emotions and thoughts represented in their play became too intense for them. John was an 8-year-old European-American boy whose mother had left him to be raised by her mother. Whenever the ideas of family and his mother arose in the course of play therapy, he would suddenly switch his play to something less threatening.

Avoidant play is a child’s disconnectedness or avoidance of the play therapist. Children and play therapy are both relational; however, when children have experienced a trauma, especially an interpersonal trauma, they are often distrustful of others and will avoid or disconnect. Lupita, a 6-year-old Latina girl, had witnessed the rape and murder of her mother. During the few ses- sions, Lupita would enter the playroom and stand by the door, looking at the floor with her fists clenched. Through gentle reflection and tracking, she eventually began to feel safe enough to engage in play and talk to the play therapist.

Negative affect is the physical representation of children’s emotions that are either flat or incongruent to their play. For example, after the 9/11 terrorist attacks, children built towers out of blocks and then knocked them over with toy planes. Their affect was completely flat, showing no emotion while playing out what had to be a terrifying event.

Research strongly supports the fact that children with interpersonal trauma do play differ- ently from other children. Findling and colleagues (2006) compared two treatment groups of children receiving play therapy, one group presenting with a history of interpersonal trauma and the other group presenting with other concerns. The researchers defined interpersonal trauma as trauma involving the interpersonal loss of trust in a significant caregiver through abandonment or abuse. Myers, Bratton, Findling, and Hagen (2011) continued this study with the addition of a normally developing group with no known history of interpersonal trauma who were receiv- ing play sessions. Researchers in both studies used the Trauma Play Scale (TPS; Findling et al., 2006). The TPS is an observationalassessment of the five posttraumaticplay behaviorspreviously described. The TPS assesses these behaviors in 5-minute increments across eight consecutive ses- sions, excluding the initial session. Using repeated measures, Findling et al. (2006) found clinical significance for the average TPS scoreand for all posttraumaticplay behaviors,with the exception of repetitive play, as well as statistical significance between the two clinical groups for the average TPS score after having omitted repetitive play. The researchers omitted repetitive play because the raters were blind to the children’s histories and this inhibited their ability to determine the literalness of the play and whether the play was posttraumatic, mastery, or self-grounding. Myers et al. (2011) found large effect sizes and statistical significance between children with

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424 HANDBOOK OF PLAY THERAPY

Table 21.1 Summarization of ANOVAs on Pilot and Present Studies’ Findings

Findling et al., 2006 Myers et al., 2011

Trauma versus Nontraumaa Trauma versus Normally Developingb

𝜂p 2 at 𝛼 =.05 𝜂p

2 at 𝛼 =.025 Average TPS Score .28 p = .080 .74 p < .001 Average TPS Score, Omitting

Repetitive Play .41 p = .025 .77 p < .001

Intense Play .31 p = .062 .86 p < .001 Repetitive Play .00 p = .836 .40 p = .020 Play Disruptions .20 p = .148 .56 p = .003 Avoidant Play .26 p = .094 .57 p = .003 Negative Affect .26 p = .094 .65 p = .001 aClinically referred children with a history of trauma (n = 6) vs. clinically referred children with no known history of interpersonal trauma (n = 6). bClinically referred children with a history of trauma (n = 6) vs. children normally developing with no known history of interpersonal trauma (n = 7). Source: Myers et al., (2011).

interpersonal trauma and normally developing children on the average TPS score and on all five posttraumatic play behaviors. See Table 21.1 for the specific significance for each study.

THEORIES BEST SUITED TO WORK WITH THIS POPULATION

In working with child survivors of interpersonal trauma, it is important to use developmentally responsive approaches that meet their individual needs. Perry and Szalavitz (2006) proposed that recovery from childhood interpersonal trauma requires the rebuilding of trust, regaining of confi- dence, returning of security, and reconnecting to love. Bratton (2004) added that children need to release and regulate emotions and gain or regain a sense of mastery, coping, and competence. Play therapists can best meet these needs by including reparative experiences in the therapeutic relationship (Benedict, 2006; Bratton, 2004). Four approaches that meet the needs of children with interpersonal trauma in developmentally responsive and relationship-based approaches are child-centered play therapy (Landreth, 2012), child–parent relationship training (Landreth & Bratton, 2006), Cognitive-Behavioral Play Therapy (Cavett & Drewes, 2012), Ecosystemic Play Therapy (O’Connor, 2007), and trauma-focused integrated play therapy (Gil, 2011a).

Child-Centered Play Therapy Child-centered play therapy (CCPT) is a nondirective, play-based approach that provides chil- dren with a voice (Guerney, 1983, Landreth, 2012; Myers, 2008). CCPT has a strong research background (see Research/Evidence Base section later in chapter). Axline (1947/1969) pioneered CCPT in her work with children in the 1940s. As a student of Rogers, Axline applied Rogers’s (1957) nondirective principles of empathy, genuineness, and unconditional positive regard in her work with children. Many other play therapists (Guerney, 1983; Landreth, 2012; VanFleet, Sywulak, & Sniscak, 2010) have subsequently contributed to the development of CCPT.

CCPT includes a philosophy toward the attitudes and behaviors in living one’s life with chil- dren (Landreth, 2012). The philosophy involves a deep and abiding belief in the constructive, self-directing ability of children (Landreth & Sweeney, 1997). Play therapists using CCPT strive to relate to children in ways that release their inner directional, constructive, forward-moving,

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Play Therapy With Survivors of Interpersonal Trauma: Overcoming Abuse and Crime 425

creative, and self-healing powers (Landreth 2012). Within this relationship, CCPT therapists create an environment that empowers children to engage in self-exploration and self-discovery, resulting in their ability to express their inner experiences and engage in constructive growth (Landreth & Sweeney, 1997).

Several elements of CCPT facilitate a child’s growth and healing. The developmentally responsive nature of CCPT meets the needs of children and provides them opportunities for growth, mastery, and healing (Landreth, 2001; Landreth & Bratton, 1998). The symbolic nature of play within CCPT provides children a safe and nonthreatening way of expressing their emotions, experiences, and thoughts (Axline, 1947/1969; Bratton, Ray, & Landreth, 2008; Landreth, 2001). The CCPT therapeutic relationship provides children with a caring environ- ment characterized by empathy, genuineness, and unconditional positive regard, enabling them to move toward greater self-acceptance, self-esteem, and self-understanding (Axline, 1947/1969; Landreth, 2012).

Child–Parent Relationship Training Child–parent relationship training (CPRT; Landreth & Bratton, 2006) is 10-week filial therapy model developed by Landreth. Guerney (1964), a CCPT therapist, originally developed filial therapy. Guerney believed many children’s problems resulted when parents lacked parenting knowledge and skills (Landreth & Bratton, 2006). However, Guerney also viewed parents as allies in the therapeutic process and as potential therapeutic agents of change in the children’s lives and sought to train parents in the basic principles of CCPT. Originally, Guerney would meet parents weekly for about a year, but later reduced the treatment time down to 5 or 6 months. Landreth (Landreth & Bratton, 2006) saw a need for a more streamlined and structured approach that still provided parents with skills they needed but within a time frame to which parents would be comfortable committing themselves.

Central to CPRT is the training of parents in basic CCPT skills so they can conduct weekly, 30-minute play sessions with their children (Landreth & Bratton, 2006). Parents learn the skills of reflective listening, recognizing their children’s feelings, self-esteem building, tracking, and therapeutic limit-setting. CPRT therapists use a variety of methods to train parents in these skills, including dyadic instruction, play session demonstrations, role-playing, and group supervision of parents’ play sessions.

Of particular importance in working with children who have experienced abuse or neglect is the common experience of betrayal, harm, loss, or rejection by a caregiver. CPRT’s strength in working with this population is the power to restore healthy relationships between children and caregivers, whether with a caregiver who may have caused harm to the child or a caregiver who either (in the eyes of the child) did not protect the child from harm or is a remaining care- giver after the loss of a caregiver. Following an external familial event, such as a school shooting, CPRT provides caregivers an avenue for helping to restore a sense of safety and security within their children. By enhancing the caregiver–child relationship, caregivers are able to establish or reinforce a healthy attachment and safe place for their children. Play therapists have conducted CPRT with many children with interpersonal trauma, including with children in domestic vio- lence shelters, with nonoffending parents of children who have experienced child sexual abuse, and with parents who are incarcerated (Costas & Landreth, 1999; Harris & Landreth, 1997; Smith & Landreth, 2003).

Cognitive-Behavioral and Ecosystemic Play Therapy In contrast to CCPT, some play therapists see the value of sometimes using a more therapist-directed approach in order to address specific concerns related to the abuse or

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trauma a child has experienced (Bethel, 2007). O’Connor (2007) reported the possibility that child survivors of abuse who are treated in nondirective play therapy approaches may be in therapy for extended periods of a half year or more without ever approaching content in their play or engaging in any verbalizations related to their traumatic experiences. He contended these children might become overly comfortable with therapy and adapt to avoiding their feelings and thoughts related to the trauma rather than more actively coping and recovering. Ruma (1993) identified two advantages in using cognitive-behavioral play therapy (CBPT) over nondirective play therapy approaches. In contrast to the CCPT belief that children, through their innate self-actualizing nature, will address their traumatic experiences, CBPT play therapists direct, or structure, play sessions in ways that address the trauma. Within the structure set by the CBPT therapist, children have control as to how, what, and when they address the trauma (Ruma, 1993). In addition, CBPT provides children who have learned not to express their feelings, particularly in families of abuse and domestic violence, with a framework (e.g., systematic desensitization, contingency management, modeling, behavioral rehearsal, positive self-statements) in which to relearn how to express their full range of emotions.

Ecosystemic Play Therapy (EPT) is an integrative approach to play therapy utilizing exist- ing theories and techniques and incorporating cognitive developmental theory as an organizing framework (O’Connor, 1991, 2007). The use of the word “ecosystemic” indicates the importance of considering the interaction of the child and all of the systems in which he or she is embedded when conceptualizing the child’s difficulties and developing a treatment plan (O’Connor, 2007). O’Connor identified two elements of EPT that differ from most play therapy theories: the way in which a child’s underlying motivation is understood and a developmental focus. EPT therapists view children’s behavior as their best attempt at meeting their basic needs while avoiding conse- quences. By understanding a child’s motivation, EPT therapists help children learn to effectively meet their needs. EPT therapists also focus on any delays in the child’s developmental progress and how those delays might relate to the child’s ability to meet his or her needs. The overarching goal of EPT is to help children resume developmentally appropriate functioning in all aspects of their lives.

O’Connor (2007) identified two primary curative elements of EPT: the therapeutic relation- ship and the therapist’s ability to engage the child in developing problem-solving strategies. Through the relationship, EPT therapists create a safe environment in which they can provide children with the experiences and explanations needed to alter their understanding of traumatic events. EPT can engage children in active problem solving geared toward enabling them to get their needs met in developmentally appropriate ways that take into consideration the degree to which the systems the child is embedded in support or impede the child’s efforts.

Trauma-Focused Integrated Play Therapy Gil (2011a) introduced a structured, integrated treatment model called trauma-focused inte- grated play therapy (TF-IPT). It is based on her years of working with child survivors of traumatic experiences. Starting with a nondirective model, Gil integrated evidence-based practices such as trauma-focused cognitive-behavioral therapy (TF-CBT) and Herman’s (1997) three-phase trauma treatment model. Gil (2011b) wove creative therapies (i.e., play therapy, art therapy, sand therapy) and attachment-based principles (i.e., understanding the need to conduct treat- ment within social and familial contest) into the TF-IPT curriculum. TF-IPT provides children (ages 5 to 17 years) with opportunities to engage fully into their own treatment and reparative work while sensitively recognizing the natural need for children to protect family members and other trusted individuals when discussing interpersonal trauma (Gil, 2011a).

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The primary goal of TF-IPT (Gil, 2011a) is to facilitate management of the child’s trau- matic experience. Gil emphasized the importance of breaking the cycles of denial and secrecy, correcting traumatic memories to decrease posttrauma symptoms, encouraging improved social interactions, and preventing the need for unhealthy coping strategies. Gil (2011a, p. 1) identified the specific treatment goals of TF-IPT to be (a) creating an environment of safety, trust, and com- fort; (b) processing traumatic material; (c) encouraging social reconnections; and (d) returning to pretraumalevels developmentalfunctioning. Gil (2011a, 2011b) laid out the TF-IPT three-phase model as follows: Phase one focuses on the establishment of safety and relationship building, phase two facilitates the child’s processing of traumatic material, and phase three prepares a child for termination of counseling and assists him or her in reconnecting socially.

PROCEDURAL MODIFICATIONS

Child survivorsof interpersonal trauma frequently present with substantial emotional and behav- ioral concerns. For example,the behaviors of these children are often survivalresponsesthey have learned either to avoid abuse or to control it. Ziegler (2002) stated some abused children push their abusers into abusive action as a way of relieving the tension of always being on guard. Con- ducting play therapy with this population requires a number of considerations and modifications.

First, play therapists working with children in interpersonal training need to have a solid foundation in play therapy and a strong understanding of interpersonal trauma and the effects on children. Second, they need to be compassionate and understanding. Third, play therapists need to be self-aware, particularly of their own issues related to interpersonal trauma. Children who have experienced interpersonal trauma bring emotionally laden experiences and stories into the therapeutic session, and these may trigger something within the clinician. Play therapists who have worked through their own similar issues in counseling or supervision reduce the likelihood of overidentification with their child clients and countertransference. And, last, because child abuse, neglect, and other crimes against children can raise strong emotions in the play therapists who work with them, it is necessary to seek supervision and consultation, or even counseling, periodically.

The characteristics of a child survivor are an important consideration in determining the course of treatment. Considerations include the severity and type of presenting behaviors. A cen- tral goal in working with this population is repairing shattered relationships with significant others, if possible. Depending on the severity of damage to those relationships, a child may be better suited for an approach that directly focuses on repairing relationships, such as child–parent relationship training or Theraplay®1 (Jernberg & Booth, 1999; Landreth & Bratton, 2006). How- ever, sometimes a child’s presenting behaviors may be so severe the play therapist may determine that working with the child and the parent together from the beginning may be overwhelm- ing for the parent and/or the child. In such cases, the therapist may choose to work with the child one-on-one in an approach like child-centered play therapy, Ecosystemic Play Therapy, or trauma-focused integrated play therapy. Another important consideration is determining the appropriateness of including children with a history of sexual abuse in group play therapy. While group play therapy can be beneficial for these children, it is important to ensure none of the children are acting out sexually in order to protect all of the children in the group. Again, an initial period of one-on-one play therapy may be useful in preparing children to benefit from group work.

1Theraplay is a registered service mark of The Theraplay Institute, Evanston, IL.

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Logistical concerns include playroom setup, toys, and materials, as well as treatment frequency and duration. While the specifics of these concerns may vary between approaches, there are some common threads. Children with interpersonal trauma may come from chaotic environments, and need predictability and stability in order to reestablish a sense of safety. Play therapists provide predictability and stability through the way they are in the playroom and the way they structure the play session and the playroom. Play therapists provide a nurturing and supportive environ- ment for children through caring acceptance of the child and through being consistent and predictable in their being with the child (Landreth, 2012). Play therapists provide predictability in the playroom by grouping toys according to the emotions they typically engender (e.g., aggres- sive, control, nurturing), thus facilitating children’s ability to express themselves. Toys serve as a child’s words in play therapy; when children are unable to find the toys they need to express themselves, it is analogous to when adults have trouble finding a right word. In addition, pro- viding toys with a connection to a child’s trauma (e.g., planes and blocks to create buildings after 9/11) may facilitate the child’s ability to express and work through internal emotions and experiences. Play therapists also need to consider the duration and frequency of the play sessions. Usually, play therapy sessions last 45 to 50 minutes. Developmentally, younger children (ages 3 to 6 years) may be able to attend to the therapeutic process for only 30 minutes, whereas older children may be comfortable with 45 to 50 minute sessions. Traditionally, play therapy sessions occur once a week; however, some children may need more or less frequent play sessions. For example, children living in a domestic violence or homeless shelter may require frequent ses- sions because the period of time during which they will be able to access treatment may be short as their living arrangements change. On the other hand, children who are approaching the end of treatment may start to meet every two weeks or once a month in preparing for termination while still receiving support.

Play therapy theories have various views on how play therapists approach intakes, assessments, and treatment planning. Regardless of theoretical approach, play therapists need to have an understanding of a child’s personal and trauma history, as well as the child’s relationship with caregivers. With child survivors of interpersonal trauma, play therapists need to be aware of the type of interpersonal trauma and the nature of the relationship between the child, caregivers, and trauma. Understanding how a child experienced the trauma and caregivers, particularly if a caregiver was a perpetrator of the trauma, provides play therapists with important insight in understanding a child’s play, planning treatment, and accessing change and growth.

POPULATION-SPECIFIC TECHNIQUES AND STRATEGIES

Interpersonal trauma significantly alters the ability of children to perceive their daily experi- ences accurately and inhibits their ability to cope effectively (Bratton, 2004). Child survivors of interpersonal trauma need reparative experiences to regain their innate ability and potential. There are number of specific techniques/strategies to consider in meeting the needs of children of interpersonal trauma.

Perry and Szalavitz (2006) outlined four recovery needs of child survivors of trauma that are particularly poignant when considering the needs of children who have experienced interper- sonal trauma. First, play therapists need to rebuild these children’s ability to trust. Interpersonal trauma involves the rupturing of a relationship between children and significant figures in their lives, often due to abuse or abandonment or the experiencing of the world as an unsafe place following an event such as a school shooting or terrorist attack. These children often believe others will let them down, and become distrustful of others. Play therapists rebuild trust through

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being genuine, empathic, and accepting in the play sessions. Second, play therapists need to help children regain their confidence. Interpersonal trauma turns a child’s life upside down. These children often feel powerless as others inflict pain through either action or inaction. Play ther- apists can help child survivors of interpersonal trauma regain their confidence by encouraging children’s efforts. In addition, play therapists promote children’s development of decision mak- ing and problem solving by encouraging them to lead the play session. Third, play therapists need to facilitate these children in regaining a sense of security. Children who experience abuse and crime view the world as an unsafe place, not knowing when the perpetrator may strike them again. Play therapists create a sense of security by providing a safe environment in which they communicate genuine caring for their child clients. Furthermore, play therapists create a sense of security by setting limits when necessary. These children often need to believe the adults in their lives will keep them safe; through limit-setting, play therapists let children know they will keep them safe both physically and psychologically. Fourth, play therapists help children recon- nect to love. Love is healing, and play therapists facilitate and promote supportive and reparative caregiver–child attachment. This reconnection to love is particularly important when children of interpersonal trauma experience a loss of love through trauma; for some children this loss of love is repetitive (e.g., ongoing abuse and neglect).

Bratton (2004) presented a similar list regarding the use of play therapy with severely trau- matized children, overlapping with Perry and Szalavitz (2009) regarding the need to establish or reestablish physical and emotional safety and to build or rebuild trust and relationships. Brat- ton added three additional goals. First, play therapists help children to establish a healthy sense of self. Often children survivors of child abuse and crime develop a poor sense of self, viewing themselves as broken, dirty, or worthless. David Pelzer (1995) presents this internal viewpoint in his recounting of his own childhood abuse in his book, A Child Called “It.” Play therapists facilitate the development of a healthy sense of self through caring acceptance, encouragement, and validation. Second, play therapists assist children of interpersonal trauma to release and reg- ulate emotions. These children frequently have difficulty expressing their emotions in healthy, nondisruptive ways, or they may have learned to hide their feelings in fear of further abuse. Play therapists facilitate the healthy release and regulation of emotions by communicating an accep- tance of all emotions and by using therapeutic limit setting to help them learn self-control and to redirect them to acceptable means of expressing their emotions. Third, play therapists help child survivors of interpersonal trauma to gain or regain a sense of mastery, coping, and com- petence. These children commonly develop self-doubt, particularly in cases of emotional abuse, which often accompanies other forms of abuse, neglect, and crime. Play therapists facilitate the development of mastery, coping, and competence through encouragement.

Bratton (2004) described several aspects of the role of play therapists in working with chil- dren of severe trauma. Play therapists recognize these children’s critical need for safety both in and out of the therapy session; this may include the development of a safety plan for when a child feels unsafe. Safety plans include how to: get away from dangerous situations, identify people who are safe and how to reach them, find safe locations, and perhaps create a “safety kit” that contains emergency numbers and items the child may need when escaping a danger- ous situation. Play therapists need to be patient with the process. The healing process can feel painstakingly long, particularly with children who have experienced chronic or extreme abuse or neglect. Ziegler (2002) described how chronic and extreme abuse creates deep-seated neural pathways. As a result, it may take repetitive positive experiences to recreate healthy neural path- ways. Play therapists must also serve as witnesses to the child’s story. Children of abuse often keep their stories to themselves, whether from a fear of further pain or from fear created by threats from and manipulation by their abusers. Play therapists serve as witnesses to children’s stories of abuse,

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neglect, and crime using their reflective skills to communicate an acceptance and understanding of children’s stories.

A note of particular importance is that play therapists serve a therapeutic role, not an inves- tigative, forensic role. The primary focus of play therapists is the treatment of their child clients and improved emotional and psychological healing. In therapy, “the facts” of the case matter less than the child’s experience and perceptions. On the other hand, being in an investigative role requires the professional to be as objective as is humanly possible. Simultaneously treating (therapeutic) and evaluating (forensic) creates a role conflict. The therapeutic–forensic conflict can result in compromised therapy (Greenberg & Shuman, 1997; Strasburger, Gutheil, & Brod- sky, 1997). This sort of conflict often becomes an issue in contested custody cases in which the children were subjected to interpersonal trauma by one of the caregivers.In such cases, the nonof- fending parent may place pressure on a play therapist to be an evaluator. For the sake of everyone concerned, play therapists need to both communicate and maintain clear role boundaries.

Finally, play therapists need to involve children’s families in the therapeutic process. The time play therapists spend with a child represents a fraction of the time the family spends with that child. Developing a supportive relationship with caregivers and providing them with the tools they need to support the work the child is doing in the play therapy session increases its effectiveness.

RESEARCH/EVIDENCE BASE

Play therapists need to be knowledgeable and skilled in approaches found to be the most help- ful in the treatment of children who have experienced interpersonal trauma. A large body of research exists that supports the use of the approaches previously described. Following are some studies regarding CCPT, TF-IJT, and CPRT that directly relate to their use in the treatment of interpersonal trauma.

Child-Centered Play Therapy Several studies document the value of CCPT with this population. Kot, Landreth, and Gior- dano (1998) examined the use of intensive CCPT with 22 child witnesses of domestic violence residing in a shelter. The treatment and control groups each consisted of 11 children. Parents of the treatment group reported statistically significant decreases in both their children’s total behavior problems and their externalizing behavior problems. The children exhibited statisti- cally significant increases in their self-concept and their physical proximity to the therapist in the session. Tyndall-Lind and colleagues (2001) also explored the use of intensive CCPT with child witnesses of domestic violence residing in a shelter. The study included 32 children in two experimental groups (n = 10 in CCPT sibling groups and n = 11 in individual CCPT) and a no-treatment wait group (n = 11). Both treatment groups exhibited statistically significant increases in their self-concept and decreases in reported behavior problems, externalizing behav- iors problems, aggressive behaviors, and anxious and depressive behaviors as compared to the control group. In another study, Scott, Burlingame, Starling, Porter, and Lilly (2003) explored the use of CCPT with child survivors of sexual abuse. Participants included 19 girls and 7 males, ages 3 to 9. After 12 sessions, results indicated children experienced a statistically significant increase in their feelings of social competency and self-concept.

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Trauma-Focused Integrated Play Therapy Gil (2011a) developed the TF-IPT curriculum as part of a multisite outcome study designed to compare the effect of TF-CBT and TF-IPT on children’s self-reports and parents’ reports of the child’s behavior. Krueger (2013) further compared TF-CBT and TF-IPT by examining trauma-related beliefs, emotion regulation, and verbal engagement and their relations to symp- toms in 42 children with complex trauma histories. Kruger reported significant changes in both treatment groups in the decrease of negative trauma-related beliefs and symptomology and an increase in verbal engagement. Furthermore, only children in the TF-IPT group experienced significant improvement in their cognitions related to their trauma. TF-IPT received a High rat- ing on the Child Welfare System Relevance Level (California Evidence-Based Clearinghouse for Child Welfare, 2013), indicating TF-IPT meets the needs of children, youth, and families receiving child welfare services.

Child–Parent Relationship Training Landreth and Bratton (2006) reported that, as of 2006, researchers had conducted 27 outcome studies on the efficacy of CPRT, or the 10-week filial model developed by Landreth that became CPRT. Four specific CPRT studies relating directly to interpersonal trauma are Harris and Landreth (1997), Landreth and Lobaugh (1998), Costas and Landreth (1999), and Smith and Landreth (2003). These are summarized in the following paragraphs.

The incarceration of a parent is a form of interpersonal trauma because it forces a break in the child–parent relationship when the child is unwillingly separated from the parent. In a ran- domized study of 22 incarcerated mothers, Harris and Landreth (1997) trained 12 mothers with children ages 3 to 10 years in CPRT. Harris and Landreth adapted the once a week for 10 weeks format to twice a week for 5 weeks to accommodate the women’s relatively short length of stay at the county jail. The treatment group received 2-hour filial therapy training sessions twice a week for 5 weeks and they conducted biweekly 30-minute play sessions with one of their chil- dren during scheduled visitation times at the jail. Compared to the control group, mothers in the treatment group demonstrated a significant increase in their empathic interaction with their children. In addition, the mothers reported statistically significant gains in parental acceptance and decreases in their children’s behavior problems. In a randomized study of 32 incarcerated fathers, Landreth and Lobaugh (1998) trained 16 fathers with children ages 4 to 9 years in filial therapy. Sessions were held in a medium-security prison during the children’s scheduled visita- tions with their fathers. Results showed the fathers in the treatment group, as compared to the control, reported statistically significant increases in their acceptance of their children and sig- nificant decreases in their stress related to parenting and in their children’s behavior problems. Their children reported increased self-esteem.

Children who experience sexual abuse at the hands of one caregiver may blame the other caregiver for not protecting them. Costas and Landreth (1999) examined the effect of filial ther- apy with 26 nonoffending parents of children (ages 5 to 9) who had experienced sexual abuse. Researchers assigned parents to groups based on geographical convenience. The treatment group of 14 parents, as compared to the control group, demonstrated statistically significant increases in their empathic interactions with their children, their acceptance of their children, and decreases in their children’s problem behaviors, anxiety, emotional adjustment, and self-concept, as well as statistically significant decreases in parental stress.

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Experiencing or witnessing domestic violence can shatter a child’s trust and sense of safety. Smith and Landreth (2003) examined the effectiveness of CPRT with mothers and children (ages 4 to 10) in a domestic violence shelter. The researchers merged the training and play ses- sions into twelve 1.5-hour training sessions across 2 weeks to match the average 2- to 3-week stays of most families in the shelter used for the study. In comparing the results of the treatment and control groups, the 11 mothers experienced a statistically significant increase in their self-concept and in their acceptance and empathic interactions with their children. The 11 children in the treatment group demonstrated statistically significant decreases in their overall behavior prob- lems, internalizing and externalizing behaviors problems, and aggression, anxiety, and depression and statistically significant increase in self-concept.

CONCLUSION

Children are amazingly resilient, but unfortunately many children face challenges even adults would have difficulty managing and overcoming. Children are naturally relational, and when those relationships are shattered due to interpersonal trauma resulting from child abuse and neglect or other crimes against them, the result can be devastating. Caring and skilled play therapists can best help these children through developmentally responsive approaches that incorporate both play, as children’s natural form of communication and healing, and a healthy and supportive interpersonal relationship. Play therapists do make a difference in the lives of children.

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