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C hildren are typically removed from their homes and placed into the fos- ter care system as a result of being

severely abused and/or neglected by their primary caregivers (Pew Commission on Children in Foster Care, 2003). In the United States, out of all cases investigated by child protective services, more than 75% of children were neglected, more than 15% of children were physically abused, and just under 10% were sexually abused. In 2011, there were approximately 400,540 children in the foster care system, a substantial num- ber of children in the United States (Child Welfare Information Gateway, 2011).

In addition to experiencing traumatic events at the hands of their caregivers, these children are particularly vulnerable for fur- ther trauma as a result of removal from the home and frequent changes in their envi- ronments ( Jones Harden, 2004; Leslie et al., 2005; Vig, Chinitz, & Schulman, 2005). This combination of abuse and/or neglect and removal from caregivers can negatively affect the mental health of children in the foster care system (Dozier, Albus, Fisher,

& Sepulveda, 2002; Schneider & Phares, 2005). For example, up to 80% of children in the foster care system have at least one psychological disorder (Stahmer et al., 2005). As a result of being traumatized in so many ways, children in foster care are left feeling afraid and confused and are particularly vulnerable to the development of posttraumatic stress disorder (PTSD) (Racusin, Maerlender, Sengupta, Isquith, & Straus, 2005). These children experi- ence staggering rates of PTSD, with 60% of sexually abused children diagnosed with PTSD, 42% of physically abused children diagnosed with PTSD, and an additional 18% of children in foster care who had ex- perienced neither physical nor sexual abuse diagnosed with PTSD (Dubner & Motta, 1999).

Children in foster care have been re- moved from their homes often under cir- cumstances that were, at the least, stress- ful, if not traumatic (Webb, 2007). Some children are removed quite suddenly by child protective services (CPS) because of violence or neglect in the home and/or

ChaPter 18

Trauma Narratives with Children in Foster Care individual and GrouP Play theraPy

David A. Crenshaw Kathleen S. Tillman

Crenshaw, D. A., & Stewart, A. L. (Eds.). (2014). Play therapy : A comprehensive guide to theory and practice. 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 01:42:39.

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18. Trauma narratives with Children in Foster Care 263

substance abuse by one or both parents. A recent survey of placements by CPS to the Group Emergency Foster Care (GEFC) program at the Children’s Home of Pough- keepsie (CHP) revealed that the 20 most re- cent admissions were related to substance abuse by one or more parent. The GEFC is one of several foster care programs at CHP, a nonprofit child care agency founded in 1847. Other reasons for CPS emergency re- moval include incarceration of one or more parents; psychiatric hospitalization of a par- ent, and chronic illness or death of a par- ent. Children’s exposure to violence may take various forms, including witnessing or being victimized by verbal, physical, or sexual violence and sometimes a combina- tion of these.

These children often encounter a range of providers, including county social workers, community- based mental health therapists, psychiatrists, and school- based support teams. Unfortunately, the organi- zations working on behalf of children in foster care are overburdened and strive to address their primary charge for services. This workload often leaves staff so busy that they do not find the time to coordinate care or do not see coordination of care as their role for youngsters in the foster care system. With these kids, in particular, it is vitally important for mental health profes- sionals and school personnel to communi- cate with one another about the strengths, and also the triggers, for these youngsters. The more information that we can gather about these youth, the more comprehensive and coordinated the interventions for them can be. It is important for these teams to meet regularly and frequently so that they can develop therapeutic goals that can be achieved in multiple areas of the child’s life. For example, a community mental health provider may be working on helping the child identify triggers and utilize healthy coping skills. If this therapist communi- cated with the social worker, the child’s foster family, and the child’s school, all of these newly learned skills could be utilized

and positively reinforced in various milieus, thereby fostering even greater success for the child.

Additionally, it is vitally important for mental health providers and individuals who interact with children in the foster care system to seek out supervision and consul- tation from one another. It not only bene- fits the child for a team of providers to work together, but it also benefits the providers. When a clinician is feeling overwhelmed or stressed by a particular child or situation, talking about the situation with a colleague can help the clinician challenge negative thinking, develop new perspectives, and try new ideas. Also, when team members work together, they are able to present a united front and to remain calm and consistent for the children, while also supporting one an- other. All of these efforts promote self-care for clinicians and stability and the best care possible for children in foster care.

Theory and research

One way that therapists can best support these children is by helping them process their traumatic experiences through the sensitive and attuned creation of a trauma narrative that captures the experience of what happened to them (Amir, Strafford, Freshman, & Foa, 1998; Cohen, Manna- rino, & Deblinger, 2012; Cohen, Manna- rino, Kleithermes, & Murray, 2012; Cohen, Mannarino, & Murray, 2011; Gidron et al., 2002; Pennebaker & Susman, 1988; also see Badenoch & Kestly, Chapter 36, this volume). A trauma narrative is essentially a story that children tell about their experi- ences with traumatic event(s) (e.g., abuse, neglect, and/or removal from the home). This record of what has occurred empow- ers the child to express thoughts and feel- ings without judgment while allowing the therapist to gently challenge harmful think- ing that the child may have developed in response to the trauma. The purpose of creating this narrative is to help the child

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create a less harmful, more integrated, and healthy account of experiences (Cohen, Mannarino, & Deblinger, 2006). Trauma narratives have been found to help children reduce anxiety and decrease abuse- related fear, while also reducing the abuse- specific distress that parents experience (Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011).

Trauma narratives help the child con- vey his or her story in verbal, written, or artistic forms (National Child Traumatic Stress Network, 2007): “[It] is often a diffi- cult process for children to reach the point where they are able to tell the story of a traumatic event, but when they are ready, the telling enables them to master painful feelings about the event and to resolve the impact the event has on their life” (p. 1). In order to help young children feel more at ease when expressing their perceptions of traumatic experiences, clinicians can use children’s primary language of play when creating the trauma narrative. Clinicians can use several different play-based modali- ties to assist children with what can be a very difficult process: creating the trauma narrative. Sandplay, puppet shows, art ac- tivities, song writing, and book creation are examples of play-based approaches that can be used, depending on their developmen- tal levels, in both individual and group play therapy to assist children in the creation of their narratives. It is imperative to never lose sight of the therapist’s role in facilitat- ing the child’s telling of his or her story, but it is also imperative to bear in mind that it is the child’s story, not the therapist’s. The trauma narrative is not co- created with the therapist; it is strictly the child’s. The thera- pist’s role is to help children find develop- mentally and trauma- informed language to enable them to create a cohesive story that gives expression, meaning, and perspective to their lived experiences.

In addition to the stressful family context leading up to the removal, they frequently experience the removal itself as traumatic. We have witnessed the vivid recall of narra- tives related to the removal years later and

were astonished at how emotionally rivet- ing and binding these narratives are even in these significantly delayed disclosures. This discovery has made us more sensitive as clinicians to the psychological cost and burden that results from children carrying internally, sometimes for years, these heart- wrenching narratives until someone finally asks them to tell the story of their removal from home. Most children in foster care, unless quite young, will never forget the day, if not the exact moment, the removal from their home happened. Since we now know there is a precortical memory system that records memories during the preverbal period, we also know that younger children carry the terror of that moment in the form of one or more of the following: visual, au- ditory, olfactory, sensory, motor, tactile, kinesthetic, and/or visceral memories. Memories from the preverbal period can’t usually be recalled consciously or verbally, but certain cues or reminders can trigger them, and they can be acted out behavior- ally (Gaensbauer, 2011; Green, Crenshaw, & Kolos, 2010).

Facilitation of Trauma narratives in Foster Care and residential Treatment

The Sanctuary Model

Due to our understanding of how the origi- nal memories can be buried, often by fear, shame, and neglect of their central impor- tance by their subsequent caregivers, CHP has addressed this clinically cogent issue in multiple ways. All staff members at CHP are trained extensively in a trauma- informed treatment model—the sanctuary model— developed by Sandra Bloom (2000). The education of our staff, including all sup- port and maintenance staff, ensures that everyone on campus working with the chil- dren shares a basic knowledge, framework, and language with which to understand and communicate in helpful ways with and about children with histories of trauma.

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18. Trauma narratives with Children in Foster Care 265

The training begins with an intensive 3-day focus on trauma and how it impacts chil- dren and is followed up regularly with ad- ditional trauma- informed training.

Individual Play Therapy: A Developmentally Sensitive Approach

Since 2008, play therapy, a developmentally sensitive intervention for children 7 years and younger (in the case of traumatized children, even adolescents will sometimes need the safety and distance permitted in symbolic play), has been offered to children at CHP whose needs call for an individual approach. Many young children are unable to share their trauma story verbally but are adept at playing it out or depicting it artisti- cally through drawings and artwork. Other children as young as 2 years of age are able to make pictures depicting the trauma events in sandplay therapy.

Empirical research reveals that individu- als whose trauma memories are more orga- nized and coherent are less likely to develop PTSD (Dorsey & Deblinger, 2012). Play ther- apy offers many opportunities to work safely with trauma memories that are triggered in the playroom or brought into the play ther- apy room by a child haunted by such memo- ries or intrusive images. The play scenarios of preschool children recently and suddenly removed from their homes integrate key components of the empirically supported trauma- focused cognitive- behavioral ther- apy (TF-CBT) model (Cohen, Mannarino, & Deblinger, 2012). Playing out the violent or terrifying scenes these children witnessed in their homes allows for their safe, grad- ual exposure to the distressing images and vivid memories that are typically central in PTSD symptoms. Since the children are ini- tiating the play scenes, they are in charge and in control— which is so important for children whose lives have been chaotic and out of control. When children get too anx- ious in the course of playing out the events, they typically break off the play or rapidly shift to something else that is safer. In the

process the children learn to pace and self- regulate— extremely important skills, since the common denominator for nearly all of the children with complex PTSD is the poor ability to regulate their emotions.

Group Play Therapy approaches

Preschool Play Therapy Group

A preschool play therapy group for chil- dren admitted to our GEFC program was begun in the summer of 2012 and has be- come a fixture in the services offered to the children. Toddlers and preschoolers (3–5 years) rely extensively on play to share their feelings and perceptions, even if lan- guage is available to them, because play is the more natural and available means of ex- pression for this age group. Play, because of its natural, anxiety- allaying properties, also becomes a safer means of communicating about threatening parts of their world.

It is Wednesday morning at CHP. The in- terns and I (Crenshaw) gather at 10:30 A.M., as we do each week to plan our group play therapy session with children in our GEFC program. We discuss the common themes in the play of each of the children and how we can help them create their trauma narratives in play and artwork, the only vi- able languages of these preschool children. 11:00 A.M. arrives and so do the children. We gather them in a circle for the opening rituals. When the free play begins, Ben, age 4, goes to the sandtray and places the army men and tanks in the sand. The two sides begin to battle, and then an earthquake hits and buries the tanks and army men. Allen, age 3, takes over in the sandtray, where he has two muscle men fighting it out. He then puts some wine bottles in the middle of the sandtray. After that he breaks off his sand- play and goes to the drama center.

Another child, Mike, age 5, wants to make a picture in the sand. He uses two wrestling figures and a miniature that looks like Elvis with a guitar. He sends the Elvis figure to fight—and defeat— the two wrestlers. Not

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only do the wrestlers lose but they are dead, and Mike buries them under the sand. Mike then moves to the family playhouse. He takes everything out of the house—all the people and the furniture— and says that the family is moving. He continues with his nar- rative by saying that “the next house has no toys.” A 4-year-old, Rita, in the group for the first time, takes everything off the shelves and dumps the huge supply of miniatures in a disorganized pile in the sandtray, ap- parently reflecting the chaos that her life has been so far. Each child, in his or her own way, is telling his or her story in the only way possible: by creating the trauma narrative in the language of play, the only language the child can reliably use to share the pain of his or her inner world.

We have conducted the weekly preschool play therapy group in GEFC regularly since the summer of 2012, except for brief breaks for fine- tuning and recalibrating. Usually these breaks take place during transitions related to colleges and universities because the groups are facilitated by me and psy- chology and social work students from area colleges and universities.

Although the group has met regularly, there are frequent changes in the toddlers and preschoolers who attend. It is impor- tant that we use a brief and highly focused model of intervention because the pro- gram has an intended stay of 30 days or less. Many, though not all, of the children are placed within the 30-day period in fos- ter homes. Since CPS typically brings the children to GEFC, rarely are they returned to the family they were living with prior to removal. If the family of removal was their biological parent(s), there is a long road back before CPS would return the child to the home. The parent(s) would first be re- quired to successfully complete a number of programs, including several of the follow- ing: therapy, parenting classes, child abuse prevention programs, drug treatment and/ or rehabilitation, and in some cases, fam- ily therapy. If removed from a foster home because the child was not safe or too dis-

ruptive, it would be highly unlikely that the child would return to that home in the near future. All the young children in the group, some less than 2 years of age, share the common background of recent, sudden removal from their home.

Removal from home can be a traumatic experience for young children especially when unexpected and not understood. Three years ago our clinical staff at CHP began collecting narratives of removal from our older children and were aston- ished at how vivid and emotionally riveting they were, even when the story of removal was told years later. In our weekly clinical seminars we engaged in extensive discus- sions of how the children in out-of-home placements carry these powerful narratives within and are rarely asked to share them. As clinicians we became more sensitive to the idea that the trauma narrative, as Cohen, Mannarino, and Deblinger (2012) pointed out, for children who experience ongoing trauma or complex trauma is really a case of a life narrative rather than a story of discrete trauma events. Many a child in foster care, and especially in residential treatment, ex- perience life as a continuous horror story, a nightmare that never ends. One essential part of that life narrative is the emotional story of removal from home(s). An example from a 5-year-old: “My mom was lying on the floor. I don’t know if she was dead or not. A neighbor called the police. An am- bulance took my mom. I don’t know if she is still there. I don’t know if she is dead. I came here [CHP] with a lady in a white car.” Some children in foster care have been re- moved from as many as 22 placements, as documented in a case of an older adoles- cent who was placed in our GEFC program. In such extreme cases, the concept of a life narrative, as outlined by Cohen and col- leagues, takes on new meaning.

Children in the preschool play group make pictures in the sand of a small turtle looking futilely for its mother; play out pup- pet stories where the mother has left—the word is that she is in New York City, but no

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one knows for sure. In the family playhouse violent scenes are enacted where the furni- ture goes flying and the people get knocked over. Some of these play scenes allow for a directed intervention that presents an alter- native scenario intended to challenge some of the cognitive distortions common to these children (Dorsey & Deblinger, 2012). In one example, the play therapist, in the form of a fireman, arrives on the scene and states emphatically, “These children are not safe. We must take them to a place where they will be safe from harm.” The children are then removed and taken to a “safe home for children.” When the children arrive at the safe home, the fireman addresses the children again with strong affect: “You chil- dren have done nothing wrong. You were brought here because this is a safe home for children.”

Sensitive statements of attunement are used to help empathize with the frightened and bewildered children, some less than 2 years of age. The play therapist might say: “It is so hard to be away from your family, from your mommy [sometimes Daddy, too], but your mommy needs help with her prob- lems before she can take care of you and keep you safe.” We emphasize to the chil- dren that “we are not your family, we are not your home, and we know you miss your mommy and your home, but we will do our best to take good care of you and to keep you safe until your mommy gets the help she needs to stop drinking [or to stop using drugs, or stop getting into violent fights] so that she can take care of you and keep you safe.” This kind of cognitive work is an essential part of evidence- based TF-CBT (Cohen, Mannarino, & Deblinger, 2012). The cognitive work is woven into the play scenarios produced by the children in a developmentally appropriate and sensitive way to therapeutically communicate with them. The goal is to enhance their capacity to develop a cohesive trauma narrative and to gain the meaning and perspective that are so elusive for young children, unless created in their natural language of play.

“Mommy and Me” Group

In 2010, CHP opened a Young Mothers’ Program (YMP). Many of the high-risk ex- pectant mothers, and those who already have delivered their babies, have expressed the conviction that they don’t want their babies to ever be taken away from them or placed in foster care. As a result, what the young mothers refer to as the “Mommy and Me” group began in the fall of 2012. The purpose was to create a relaxed, comfort- able, and safe context in which the moth- ers could engage in playful interactions with their babies to increase bonding and strengthen attachment.

The Mommy and Me group, co-led by my colleague Stephanie Carnes (social worker for the YMP) and me, has gone through three phases since it began. Since many of the young women had come into foster care as a result of intervention by CPS, it is not surprising that there was a significant lack of trust and a fear that the group leaders were there to judge or evaluate them. Dur- ing this first phase of mistrust and apprehen- sion, the young mothers sat in chairs or on the sofa, but some of them did put their ba- bies down on the blanket in the playroom to play with the group leaders. Not only did the young mothers not sit on the play mat with their babies, but they were also quite hesitant to engage with their babies and the other young mothers. In the second phase of tentative exploration, some of the mothers joined their babies on the floor and began to engage in playful interactions with their own babies and the other babies in the room. During the third phase of active en- gagement, the mothers not only engaged with their babies and the other babies in a playful manner but also began to bond with each other and share some of their concerns as young mothers in foster care.

Issues that spontaneously arose in the group discussions were concerns about monitoring and scrutiny by CPS, including fears of their babies being removed from their care and wanting to protect their ba-

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bies from violent partners both now and in the future. The latter was an especially per- tinent issue for the majority of the young mothers who were involved currently, or in the past, in relationships involving in- timate partner violence. In the beginning of this third phase, a group trauma narra- tive began to evolve, although denial and minimization on the part of the adolescent mothers was still evident, especially among those still involved in abusive, violent re- lationships. This limited the therapeutic value of the collective narrative for some of the mothers. Noteworthy is that they could discuss such sensitive issues at all, since they began the group with significant mistrust toward the group leaders and each other.

The late Walter Bonime (1989), a highly acclaimed psychoanalyst, explained that an active declaration of trust from those whose sense of trust has been badly damaged is a monumental breakthrough and a sig- nificant step in the healing process. In the third phase of the group with the greater trust that was established, the group leaders were able to incorporate psychoeducation, including the attachment and bonding pro- cesses. We attribute the modeling of play- ful interactions with the babies in the first phase, and the facilitation and encourage- ment of the mothers’ play with their babies and the other babies in the group in the second phase, with the dramatic increase in trust that allowed the work of increased disclosure and sharing in the third phase to take place.

Sibling Play Groups

In recognition of how important sibling bonds are to children removed from their families, a number of sibling groups have been treated in play therapy with the goals of strengthening and reinforcing the sib- ling ties as well as facilitating the creation of the shared trauma narrative in the sup- portive context of the sibling group. In one family, a total of seven siblings were treated together in a home leased and staffed just for this purpose by CHP.

Family Therapy and Family Play Therapy

Cognizant of how crucial it is to work closely with parents who sincerely want their chil- dren to return home, family therapy has also been an important part of the services offered. In the case of the seven children, the family therapy extended for 3½ years due to the severity of the trauma experi- enced by the children and their mother. When the family consists of preschool chil- dren, the work may take the form of family play therapy (Gil, 1994).

Clinical Considerations in using Play Therapy with Complex Trauma

Although not included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychi- atric Association, 2013) as an official diag- nosis, many clinicians recognize the value of the concept of complex trauma that has been proposed to describe the effects of repeated childhood abuse and other chronic stressors, as compared to single- event trauma (Courtois & Ford, 2009). A high percentage of children in foster care, especially those in residential treatment centers, would meet the criteria for com- plex trauma. The Adverse Childhood Ex- periences (ACE) studies (Filitti et al., 1998) have shown that not only the mental health but also the physical health of children exposed to multiple adverse events can be adversely impacted. The study focused on adverse childhood experiences such as physical and/or sexual abuse, neglect, sub- stance abuse or incarceration of a parent, major psychiatric disorder in a parent, and separation or divorce. The critical thresh- old in the research appears to be four or more adverse childhood events: Those children exposed to four or more adverse events were at significantly higher risk for poor mental and physical health outcomes in adult life, including longevity— on aver- age 10 years shorter (Filitti et al., 1998). An internal, unpublished survey (Crenshaw &

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Alstadt, 2011) of the CHP’s last 100 admis- sions in 2010 indicated that 87% of children and adolescents had experienced four or more of the seven risk factors, with some youth exposed to all seven. Children with such childhood histories often suffer from complex trauma because the high degree of exposure to risk factors would ordinar- ily overwhelm even the best of coping and resilience within the child. There will, of course, be exceptions. There are some chil- dren with such harsh beginnings in life who do not show signs of PTSD, let alone com- plex trauma. Resilience is remarkable to be- hold in such clinical populations.

strategies and Techniques

Modifications of TF‑CBT for Complex and Ongoing Trauma

Recently there has been a growing recog- nition in the field that children in foster care (Dorsey & Deblinger, 2012) —especially those children in residential treatment (Cohen, Mannarino, & Navarro, 2012), children with complex trauma (Cohen, Mannarino, Kliethermes, et al., 2012), and children with ongoing trauma (Cohen et al., 2011) —require modifications in the em- pirically supported TF-CBT protocols. The modifications take the form of changing the proportion of time devoted to different components of the protocol and extending the length of the treatment, a refreshing change that I (Crenshaw) have advocated for (Crenshaw, 2006, pp. 35–36; Crenshaw & Garbarino, 2008, pp. 85–86). Treating youth with complex trauma, for example, requires devoting proportionally more time to coping skills and establishing safety than the original model entailed (Cohen, Man- narino, Kliethermes, et al., 2012). Titrating the gradual exposure to the trauma themes and material was also recommended for youth with complex trauma, as was extend- ing the consolidation and closure phases to address traumatic grief and to allow more time to generalize trust adequately.

I (Crenshaw) remember well a phone con- versation I had with Judith Cohen when the 16-session protocol for treating childhood traumatic grief was first published (Cohen & Mannarino, 2004). I was so thrilled that they were doing research on treatment so relevant to those of us who work with child trauma, but I was dismayed that only two sessions in that original protocol were al- located for creating the trauma narrative. My deep respect for the work of Cohen and Mannarino was solidified on that day that I told Judith Cohen that the repeatedly trau- matized children I work with could never do a trauma narrative in two sessions. Cohen agreed wholeheartedly and empha- sized that there is no substitute for clinical judgment. The difference between treat- ing single- event trauma, what Lenore Terr (1991) called Type 1 trauma, and repeated or complex trauma, what Terr called Type 2 trauma, is akin to the difference between fighting a forest fire with a garden hose as opposed to helicopters dumping slurry (a mix of water and fire retardant) on the fire from above. Complex, or Type 2 trauma, requires a more comprehensive, complex, and in-depth approach that extends beyond the original protocols developed primarily for single- event trauma.

When working with children who face ongoing traumas, it is of the utmost im- portance that clinicians emphasize safety (Cohen et al., 2011). It might even be ques- tioned how effective any therapy can be if the child in the present circumstances is unsafe. Safety becomes the priority in such cases and requires communication with a wider social and community network, in- cluding family, school, and in many cases child protection agencies and courts (see Shelby & Maltby, Chapter 23, this volume). Clinical experience in foster care has re- vealed the “parental blinders syndrome,” a characterization I (Crenshaw) used to describe what too often happens when pa- rental figures have not faced or resolved their own trauma experiences. Numerous clinical experiences point to the inability of some parents with unresolved trauma

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to keep their children safe from ongoing trauma because they don’t see the danger themselves. They don’t see the risk, the perils, the threats to their children because fully confronting those dangers would trig- ger trauma memories of their own unre- solved loss and/or abuse.

One mother, who was repeatedly abused and battered by violent male partners, took no steps to protect her teenage daughter when she became involved with a violent boyfriend despite the fact that she had walked into the room on one occasion when the adolescent boy was holding a knife to her daughter’s throat. How can therapy proceed productively without addressing the real and imminent danger in the pres- ent resulting from “parental blinders”? For such a mother to effectively protect her daughter in such circumstances, she would need to do her own trauma work so that the “blinders” could be removed. Only then could she see accurately what was happen- ing to her daughter.

During the trauma narrative and pro- cessing stage with youth experiencing on- going trauma, Cohen and colleagues (2011) recommend first making the parents more aware of the extent of the ongoing traumas their children are experiencing. In addi- tion, they recommend working with youth to modify any maladaptive cognitions per- taining to the ongoing traumas. The ado- lescent girl who was brutally treated by her boyfriend had witnessed repeated violent acts against her mother by her male part- ners. The girl regarded this violence as nor- mative behavior in romantic relationships. In addition, she had repeatedly witnessed her mother feel guilty about whatever she had supposedly done to provoke the part- ner, apologize to him, and ultimately take her abusive partner’s side. So this young girl came to believe, like her mother, that she didn’t deserve to be treated better. It is essential to test, challenge, dispute, and ultimately modify these negative cognitive beliefs.

Finally, youth exposed to chronic or on- going traumas need to engage in thera-

peutic cognitive work to learn how to dis- criminate between real signs of danger and generalized alarm reactions to trauma re- minders. At CHP many of the children who are admitted in an acute trauma state as a result of exposure to violence are unable to sleep at night because they fear the sounds of arguments that so often preceded acts of frightening violence at night in the home. They need help to differentiate between the frightful images of their nightmares and what is real in the waking state. They need lots of help learning not to assume that physical violence is coming every time they hear a raised voice. Otherwise they remain in a chronically hyperaroused physiological state, mobilized for danger.

In working with children in foster care, and especially in residential treatment, cli- nicians will encounter many children with complex trauma. When TF-CBT is modi- fied for complex and ongoing traumas, it is recommended that instead of creating a trauma narrative for each of the multitu- dinous trauma experiences, the therapist focus the child’s attention on a few of the worst ones, and also to look for themes across the trauma experiences and address those themes when creating the trauma narrative.

The Crucial Importance of the Child’s Relational World

One of the most compelling features of TF- CBT is its emphasis on involving parents, foster parents, or both in the treatment process. When it is not feasible to include these individuals, one can include caregiv- ers, such as child care workers in residential treatment facilities (Cohen, Mannarino, & Navarro, 2012; Dorsey & Deblinger, 2012). Involving the parents or caregivers is espe- cially critical in foster care and in residen- tial treatment because the frequency and se- verity of behavior problems among youth in foster care, and even more so in residential care, leave parents, foster parents, and child care workers often baffled, frustrated, and exhausted. Making them allies in the treat-

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ment process may not help them develop im- portant parenting skills, but doing so does lend important support to the children and counters the feeling that they are doing the work alone because they are “bad” and en- tirely to blame for the problems of concern.

The presence of children’s relational sup- port system is especially important when creating the trauma narrative, an essen- tial component of TF-CBT, but is also im- portant in one form or another in nearly all trauma- informed approaches to treat- ment. Family/caregiver support is critically needed when children try to put into words, or play out, the events that previously could not be shared. One caution, however, from our clinical experience: Children will not share the trauma narrative in the presence of the therapist, the parent, the foster par- ent, child care worker, or caregiver unless convinced that the listener is ready, willing, and able to hear it.

A Creative, Out‑of‑the‑Box Intervention: CHP Facility Dog Program

When foster care placements fail repeat- edly, a child ultimately ends up in residen- tial treatment. At that point there may no longer be a biological family to provide a support system for the child or even a place to visit. In some cases (at least for a long time) the child will not consistently trust the child care staff sufficiently to agree to have a child care worker participate in the treatment. In 2010 the CHP began an in- novative solution to this problem. The rela- tional support comes in the form of a four- legged animal regarded throughout history as “man’s best friend.” The CHP Facility Dog Program utilizes service- trained dogs because we want the most highly trained dogs to provide services to our children who have to testify in court, which was the impetus of the program. Rosie, a golden re- triever, now deceased, became the first dog in New York court history to be approved by a judge to accompany a 15-year-old in our program on the witness stand when she testified about the sexual abuse she had suf-

fered. Since then we have continued to use only service- trained dogs when needed in the courtroom, and we also regularly uti- lize them in the therapy room. These dogs have played an immensely valuable role in facilitating the trauma narrative process for children with complex trauma. From an at- tachment theory perspective, it is not sur- prising that the children bond more quickly with these calm and loving dogs than with human therapists because it is humans who have typically inflicted the repeated trauma they’ve suffered The children trust them because they know the dog will not hurt them, judge them, or betray their secrets. The children also learn more quickly to at- tach to and trust the therapist if the dog is present and clearly attached to the thera- pist. A clinical example follows.

In one of the most chronic and severe abuse cases I (Crenshaw) have encountered in my career, I worked with a 12-year-old boy who could neither play out nor talk out the worst of the sadistic abuse experiences he had suffered. He was able to approach some of the dark side of his life through artwork that expressed the darkness and hopelessness but not the actual events. He was placed in residential care, and due to his violent and high-risk behavior, includ- ing repeated fire setting, he had to be hos- pitalized for periods as long as 6 months to stabilize his condition and to keep him safe. In family play therapy with the presence of Ivy, our service dog, Roger (fictitious name) was finally able to begin the process of cre- ating his trauma narrative. Lying on the floor under a table next to Ivy with his arm around the dog and his head resting on her, he began to describe events that were as cruel and sadistic as any I’ve ever heard. In Ivy’s presence, Roger continued to pro- cess the terror and horror of the abuse he’d suffered repeatedly over a period of years. Roger and his family both firmly believe that he could never have shared these hor- rific events without the comfort, trust, and safety provided by lying next to Ivy as he shared trauma narratives over a 6-month period.

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Clinical Case example

I (Tillman) worked closely with Michael, an adolescent male placed in familial foster care. When Michael was 15 years old, he was placed in the custody of his maternal aunt after his father received jail time for assaulting his mother and his mother could no longer care for him, due to her own dif- ficulties with substance abuse. Before being removed from the home, Michael witnessed frequent incidents of domestic violence and often physically attempted to stop his fa- ther from abusing his mother. When he in- tervened, Michael became the focus of the abuse and suffered severe injuries at the hands of his father, including broken bones and dislocated joints.

Prior to our first meeting, Michael had never received counseling of any kind. When I went to greet Michael and his aunt in the waiting room, his size immediately stood out to me. Now 17 years old and at least 6 feet tall, Michael was a stocky, Afri- can American boy. His aunt brought him for treatment because of his “fits of rage.” When Michael became angry, he would destroy property— punching holes in the walls of the family’s home, kicking things, breaking tables, and taking drawers out of his dresser and throwing them across the room. Michael’s aunt was concerned for her safety and was wondering if he needed to be placed elsewhere.

I spent the first few sessions attempting to get to know Michael. He was quiet and polite, and showed no signs of physical ag- gression within the confines of the therapy room. I’ve found that I don’t typically wit- ness the level of aggression that families experience in the midst of full-blown dis- agreements when the child lacks the ability to self- regulate and self- soothe. I did every- thing imaginable to build rapport, but after three sessions Michael still answered ques- tions and prompts with one-word answers, didn’t make eye contact, and appeared to be disengaged.

During our fourth session, Michael asked about the dollhouse sitting directly across

from his chair: “What’s that for?” I ex- plained that sometimes it can be difficult for children to talk, so they show me things in the dollhouse, using the people and fur- niture to act things out. Michael didn’t re- spond verbally, but he slid off of his chair and onto the floor, sitting directly in front of the dollhouse. “I’m going to show you what other kids show you,” he said. I simply responded with “okay.” Honestly, I was mes- merized. I had a 17-year-old boy sitting on the floor about to play with the dolls in the dollhouse. And with that, his play began.

Michael selected a mother figure, a fa- ther figure, and a child figure. He then en- acted a terrifying scene in which his father dragged his mother down the stairs while she screamed and cried for help. The boy stood at the top of the stairs watching, not moving. The father then proceeded to kick the mother, who was now lying on the floor, several times, until she stopped screaming and simply whimpered. At that point, the father left the house, and Michael looked at me, saying, “He’s leaving to go get some alcohol.” Then the boy walked slowly down the stairs to help his mother. He laid her on the couch and got her a drink and some Ty- lenol. Then the mom told him to leave her alone, that she was okay. So the boy went to his room. He hid in the corner and he cried. Then, very abruptly, Michael turned around, looked at me, and said, “I bet that’s what other kids show you, huh?” Until this point I hadn’t moved, hadn’t tracked behav- ior, hadn’t reflected, hadn’t restated, hadn’t paraphrased— I hadn’t used any basic play therapy skills. I was afraid to startle him, afraid to cause him to feel self- conscious in his play, so I simply observed everything that he did. Still shocked by his play in the dollhouse, I said very little. “The kid in that house must have been pretty scared.” Michael stood up and sat back in his chair. “Yup,” he replied.

During our next session, before I could say anything, Michael slid onto the floor again and sat in front of the dollhouse. He explained that he was going to show me some other things that kids show me.

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He asked if he was right, if kids came in to see me because their parents fight. I told him that they did, that it was difficult for them to talk about such events. When he reached for the figurines this time, I had a plan: I asked if I could watch and talk while he played, and he agreed. This time he selected the same three figurines (mom, dad, and son). Immediately the mother and father were arguing because dinner wasn’t ready. The boy suggested that they order a pizza, but his comment went ignored. When this happened, the boy retreated to his room. A few moments later Michael made a loud crashing noise, and the boy came running down the stairs. I reflected that the boy was scared, that he didn’t know what had happened. The boy walked in to find his mother lying on the floor, bleed- ing. The father hit the mother with a frying pan in front of the boy. The boy jumped up and tried to grab the frying pan from his fa- ther’s hand. The two wrestled, and the boy ended up on the ground, with his father kicking him several times. The boy and the mother were left on the floor as the father stormed out. Michael explained that the mom was hurt badly but that the boy was okay, that he “didn’t even cry.” I reflected feeling terrified and scared, and Michael quickly interjected with “angry and sad.”

A few sessions later, Michael asked if we could record his play to show to other kids whose parents were fighting. I said that re- cording his play was a great idea, but that we couldn’t show other kids because he would be in the video and that would break confidentiality. He said he understood, but he still wanted to record the play for us to watch later. I turned on the camera. He looked directly at the camera and said, “This time things are gonna change.” He re- peated the exact scene that he had enacted in the previous session— the scene with both mom and son being hurt. But this time, the boy dialed 911 and told them everything that had happened. The police came and they took the mom away in an ambulance. Then they called the boy’s aunt to come pick him up. I reflected that the boy stood

up for himself and his mom, that he did his best to help them both, that maybe the boy felt less scared and more proud. Michael just smiled.

A few sessions later his play included themes of interpersonal violence and the boy fighting back against the father. His play also contained themes in which the boy becomes aggressive for no apparent reason. At the end of the session, when he was back sitting in his chair, he asked, “Am I like my dad?” I asked him what he meant, and he talked about how his dad would al- ways scare him and his mom, and that now he scares his aunt and his uncle. He said that he didn’t want to be like his dad.

In one of our final sessions, Michael asked if he could record his play to show to his aunt at the end of the session. I was a little worried about what he might act out, so I said “yes” to the recording part and “we’ll see” to showing his aunt. His play in this session had a totally different quality to it. Instead of being driven by fear, terror, and helplessness, a whole new experience emerged. Michael selected three figurines (a new figure to be the aunt, a new figure to be the uncle, and the same boy figure). In this scene, the family sat down to dinner and started to argue over the boy’s grades. Unlike in previous sessions where the boy would get up and throw or break things, the boy stayed seated at the table. He said that he was trying but was frustrated. The aunt thanked him for staying at the table, and the uncle said that he was proud of the boy. Then they talked about his grades and ways for him to improve his grades. The boy even agreed to let the uncle help him with his homework. At the end, the aunt hugged him and gave him a kiss on the forehead. “I’m done,” Michael said as he climbed back into his chair, “now can we show my aunt?” I asked why he wanted to show his aunt the video and he said “‘cus that’s how things are gonna be now.” Clearly, he needed to con- vey to his aunt that he was trying and that he wanted to make healthier (nonaggres- sive) choices. So we brought the aunt into the therapy room. She watched the brief

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video clip, and she cried, and she hugged her nephew. I reflected that Michael must have been feeling proud and loved. He agreed and smiled.

Conclusion

Play therapy, artwork, sandtray, and animal- assisted play therapy allow young children, and sometimes older children, the oppor- tunity to work safely and at their own pace in confronting trauma events or themes in their lives. Not only do young children frequently lack the cognitive and lan- guage resources to benefit from language- dependent therapies, but the traumatic events themselves may be encoded in the brain in ways that are hard to access by ver- bal means. Creating a trauma narrative, or in the case of complex or ongoing trauma, theme-based trauma narratives, is espe- cially challenging in foster care because of the cumulative losses and disrupted attach- ments experienced by these children, in ad- dition to trauma exposure. Modifications of the evidence- based TF-CBT protocols are discussed in this chapter along with an illustrative case study. The work with this population can be simultaneously discour- aging and hopeful, heartrending and heart- warming, and frustrating and invigorating. Even if only one child is able to get through the thicket and go on to live a satisfying life, it is enough for us to keep giving our all.

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