Transcript Play Therapy with Abused Children

Hardwired for Connection,
Healing, Resiliency & Hope:
A Trauma Treatment
Framework
Presented by: Mary U. Vicario, LPCC-S
St. Aloysius Orphanage
Finding Hope Consulting, LLC
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The Impact of Trauma on Brain
Development, Attachment &
Developmental Milestones
All behavior is purposeful
Sigmund Freud
Strategies for disconnection are an intense
yearning for connection in an atmosphere
of fear
Maureen Walker
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The Importance of Relationships
Human development is dependent on relational
connection for:
 Access to resources

Life –beliefs are developed through early
relationships

Developmental milestones

Brain development are embedded in relational
experiences
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The Significance of Relationships to Human Development

Emotional Development
begins chemically in the
brain at six months
gestation (Schupp, 2004)

The ability to trust, and
the brain chemistry
connected with it, begin
at one month of age.
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Human Brain Development and Relationships
Humans are the only mammals for whom:
 The whites of the eyes are clearly visible

50% of brain development occurs after birth.
(Experience-Dependent Maturation of Neuronal
Systems) (Putnam, 2004)

Synaptogenesis: The birth of the connectors
(synapses) that are needed for brain development
increases dramatically after birth and are dependent
upon environment-stimulated activity
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Relational Revolution Amy Banks,
MD & Mary Vicario, LPCC-S
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Brain Growth & Interaction
Why the loss of connections?

Repeated use of specific connections strengthens those
connections

Connections that are not used atrophy; they are pruned
away

The brain “grows itself” from and for whatever
environment it experiences (Rintoul, 1999)

“What fires together wires together and what is wired
together fires together” (Putnam, 2004)
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Experiences which strengthen connections are:
(Rintoul, 1999)
1.
Frequent, regular, and predictable
2.
Occur in the context of a safe, warm, supportive
relationship
3.
Are associated with positive emotions
(fun, humor, excitement, comfort)
4. Involve several senses
5. Are responsive to a child’s needs, interests, or initiative.
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Growth of the Human Brain
from birth to 20 years
7 years
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Human Brain Development & Relationships (Schupp, 2004)

The Cortexes are in charge of planning, organizing and
executing action while regulating emotions. It performs the
functions of Freud's concept of the Superego

The Limbic System houses our emotions and is loosely
similar to Freud's concept of the Ego.

The Brain Stem is our “primitive brain.” It controls the
autonomic responses of our parasympathetic nervous
system and resembles Freud's concept of the Id.
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Meet The Cortexes
AKA: The King of it All
As the Executive Control Center, the Cortexes:

Read non-verbal cues like facial expression, tone of voice, body
language & posture. It’s our social navigator

Control Self Regulation = the ability to regulate emotional
arousal to accomplish a task or tolerate unpleasant emotional
stimuli (mood stability, frustration tolerance, impulse control)

Control Working Memory, Organization, Planning, Problem
Solving, Sequencing
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Cortex Development
(Forbes & Post, 2006)


It is developed by connecting the facial expression of the caregiver
with what the infant is feeling at the time which because of Mirror
Neurons will mirror the caregivers feelings.
Pleasurable sensations develop on one type of nerve fibers and
painful emotions develop another type.
(Social Pain Overlap Theory or SPOT Theory)

It is not fully developed until 25 years of age. It is the reason
adolescences does not end until age 25

It also can be “influenced” throughout the lifespan
(Neuroplasticity)
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Welcome To The Limbic System
(Schupp, 2004)
The Amygdala:
 Houses emotional memory
 Identifies threat
 Sets into motion fight or flight
response
 Decides between the need for
aggression (fight) from fear
(flight)
 Starts developing at 6 months
gestation & continues until 18
months of age.
The Hippocampus:

Tracks memory & time

Controls consciousness

Maintains identity

Maintains Circadian
Rhythms to regulate sleep,
appetite, digestion, blood
pressure

Self Sooths & regulates
emotions

Calms the Amygdala by
accessing short term
memory (in the cortex)
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Welcome to the Brainstem
The brainstem controls bodily functions:
Arousal
Bladder
Bowl
Digestion
Perspiration
Breathing
Startle responses
(Things you should not need to think about)
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Brain Development (Rintoul, 1999)

The Cortexes should be the largest part of the brain

The Limbic system the next in size

The Brain stem should be the smallest

Their influence on functioning should be in a ratio that
resembles an upside down pyramid. (Perry, 1993)
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Brain Chemistry & Trauma
When the amygdala discerns there is a life
threatening event, it signals the hypothalamus
which releases
epinephrine,
norepinephrine &
cortisol to prepare the body to fight or flee

These chemicals are so strong that repeated
exposure to them damages the brain.
(Schupp, 2004)
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Brain Chemistry & Trauma
Over time with repeated release of fight or flight chemicals
(Schupp, 2004)

The cortexes ability to plan, organ and execute action while
regulating emotions is damaged.

The amygdala is damaged & no longer accurately recognizes
danger

The hippocampus no longer effectively tracks memory,
controls consciousness, identity or circadian rhythms

The brainstem misfires causing enuresis, encopresis,
digestive issues, impulsive aggression from an over active
startle response
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What Do You See?
When the cortexes no longer effectively:
1.
2.
3.
4.
plan
organize
execute action
regulate emotions
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What Do You See?
When the amygdala
is no longer
accurately
1.
recognizes danger
2.
responds to danger
3. Self soothes
When the
hippocampus no
longer effectively
1.
tracks memory
1. controls
consciousness
2. maintains identity
3. Regulates sleep &
appetite
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What Do You See?
When the Brainstem misfires autonomic
responses (things you do not think about) like:
Arousal
Bladder
Bowl
Digestion
Perspiration
Breathing
Startle responses
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Clients with PTSD will need help with:



Transitions AKA Shifting
cognitive set = The ability
to shift from one mind-set
to another.

Problem Solving = the
ability to organize a
coherent plan

The amygdala can interfere
with this when it sets off
the flight or fight response

The flight or fight chemicals
released by the amygdala
(corticosteroids) damage
the cortex which is needed
to plan for transitions &
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problem solve.
Requires the coordination
of the Amygdala and the
Cortex
Since trauma causes a
transition from safety to
danger all transitions
become associated with
danger
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Interventions
Transitions:
5 – 10 minute warning
using a timer that
shows the time
passing with color
not sound
Problem Solving:
“Bored” box
Visual Schedules
Red, (Orange) Yellow,
Green cards to
indicate need for
assistance
Replace “No & Stop”
with “Yes you can
(when) & “Pause”
“Hold that thought”
Homework/Chore/ Play
Cards the child can
organize in any order
they want.
Red & Green snack cards
Violence in Children’s Lives
By The Percent of Children Exposed in the United States per Year
(US Dept. of Health and Human Services, 1997 & 2010)
1997
 Exposure to domestic
violence – 5 to 16%
 Violent crime
victimization – 5.6%
 Physical Abuse – 1.2%
 Sexual Abuse – 0.12%
 Victim of bullying at
school – 7.9%
 Teen suicide attempt –
8.8%
 Fighting with peers –
33.2%
2010


Physical Abuse - 0.16%
Sexual Abuse - .08 %
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Violence in Children’s Lives

According to Schupp (2004) 40 million
women in the United States reported sexual
abuse prior to the age of 18 which is equal
to one out of three girls which = 33%

The statistic for boys has reached one out
of five which = 20%
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Additional Traumatic Factors
(Adapted from: Pynoos, Steinberg, Goenjian, 1996)









Exposure to direct life threat
Injury to self – extent of physical pain
Witnessing of mutilating injury/grotesque death (especially to
family or friends)
Hearing unanswered screams or cries of distress
Being trapped or helpless
Unexpectedness or duration of the experience
Number and nature of threats during episode
Degree of violation of physical integrity of child
Degree of brutality and malevolence
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Resulting Belief Systems from Trauma
Attachment
 Abuse destroys trust
 Instills a feeling of
hopelessness
 Jeckle and Hyde
themes
 Connection is
dangerous.
 We are all in this
alone.
Why children hold themselves
responsible



Overwhelming
feelings, especially
shame, influence
development
Cannot face reality of
vulnerability to
malevolent
caregivers
Limitations of Preoperational thought
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Trauma Induced & Co-occurring
Disorders
Everything an abused child does after the abuse is
designed to give them a sense of safety
Eliana Gil
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PTSD vs. Complex PTSD
(Herman, 1992)
PTSD =


Perceived life
threatening situation
with intense fear
response
Intrusive, avoidant,
and hyper-arousal
symptoms present
Complex PTSD =


A history of prolonged or
repeated totalitarian
control with resulting
Alterations in






Affect regulation
Consciousness
Self perception
Perceptions of the
perpetrator
Relations with others
Systems of meaning
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The Cycle of Abuse

Bonding with the Aggressor AKA The Stockholm
Syndrome (Rawlings & Carter, 1977)

The Impact of Defenses
(Denial, Dissociation, Minimizing, Manipulation)

Partnering with or becoming an abuser
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Child Abuse & School Problems
(Dawud-Noursi, Lamb & Sternberg, 1998)

Greater than 50% of abused children have significant school
problems (including conduct problems)

Greater than 25% of abused children require special
education programs

Several studies suggest CAN decreases IQ

CAN victims 2 X's more likely to be unemployed as adults
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Trauma-Related Psychopathology (Rossman et al, 2000)
Affect dysregulation
(depression, mood swings, panic attacks, affect liability)

Use and abuse of substances to regulate mood, sense of
self, and behavior

A History of Child Abuse or Neglect is the single best
predictor of alcohol or other substance abuse in women

Attentional problems
(ADHD Symptoms, impulsivity, hypervigilence)
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The Effects of Fear on Behavior

What the search for safety can look like?

How to use it to promote healing?
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Biologically Based Fear Responses (Forbes & Post, 2007)
1.
2.
3.
4.
5.
6.
7.
Manipulating
Lying
Stealing
Hording
Aggression
Defiance/”Button
Pushing”
Poor Eye Contact
8.
Food issues
1.
2.
3.
9.
10.
11.
12.
Gorging
Starving
Purging
Sleep issues
Enuresis
Encopresis
Self harm
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The Top 5 Things to Remember When
Addressing Biologically Based Fear Responses
5.
Irritation Equals Fear (Forbes & Post, 2007)
4.
All behavior is purposeful (Sigmund Freud)
3.
Everything an abused child does after the abuse is
designed to give them a sense of safety (Gil, 1991)
2.
Connect Limits with safety (Use the Phrase that
Pays)
1. The one whose amygdala is calm wins! (Forbes &
Post, 2007)
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Manipulation
(The Consolation Prize of the Disenfranchised)

Is nothing more than a survival skill learned by those who do
not have direct access to the resources they need to
survive.

To address manipulation, teach clients to:
 directly seek what they need
 when it is safe to do so and
 teach the significant others in their lives to respond
directly.
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The Safety Script:
“ This is a safe place, and I won’t
let anyone _________ you,
so I can’t let you ____________
because this is a safe place.”
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Lying is Learned When
Reality is not
allowed to be
real
The truth is what
you need it to
be to get the job
done
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Interventions for Lying
Identify their goal – their perceived need for
the lie.
1.
2.
3.
To Avoid Punishment?
To access a perceived need?
To solve a problem
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Kitchen Set & Toy Food
Food = Love (AKA Nurturance)
 Neglect will be acted out through
stealing and /or hording of food
 Sexual Abuse will be acted out on food
 They will use food to have a sense of
power
 Cooking, in play or at home, with a
parent is very healing
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Interventions for Food Issues
1.
2.
3.
4.
5.
6.
7.
8.
Discuss favorite foods
Plan menus
Have caregiver or positive person do steps 1 & 2 and go
shopping for the food with client
Make placemats
Identify what they would like to talk about over dinner
Prepare & enjoy a meal together
Plan ways to have weekly if not daily meals with positive
people (Resilience factors 1 & 2)
Plan birthday parties or other celebrations
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Interventions for Sleep Issues & Nocturnal Enuresis
Before Bed:
1.
Identify daily successes
2.
Rewrite unpleasant parts of the day
3.
Identify one challenge from the day
4.
Make plans for the challenge
5.
Write dreams
6.
Remind child they can rewrite dreams while
having them
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Interventions for Oppositional-Defiance
1.
Give a 5 minute warning for transitions
2.
Connect the request/limit with safety
3.
Use descriptive vs. evaluative directions
4.
Give space (physical & emotional) for compliance
5.
Pay it forward - Tell them what you know they are going to do
(that is positive)
6.
Use a Success Calendar to record daily something they
did to accomplish something in a positive way, made the
world a better place, helped someone, etc.
7.
Use Descriptive instead of Evaluative praise
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To tone down your buttons ask yourself:
1.
Identify your implicit memories
2.
Who did this to me when I was the client’s
age or lately?
3.
What do I expect and how did that come
to be my expectation?
(It’s most helpful to do this in advance of the stressor
by making it a regular part of your day)
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The Three R’s of Trauma
Treatment
The one whose amygdala is calm wins!
Heather Forbes
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The Three R’S of Trauma Recovery
Re-experience: When the client is able to
1.
processes the trauma in a realistic way
experiencing whatever levels of pain, anger, loss,
or other emotions are elicited by a CLEAR
MEMORY (perceives the event accurately and in
detail) of the event
2. Does not feel irrationally responsible for having
caused the event.
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Emphasize for clients the healing power of
their words

“What you share, you can bear.”
(Siegel, 2004)

“The more times you tell the story, the
more power you have over it and the less
power it has over you.” (Vicario)
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Release: The client is able to:
1.
Understand that the experience occurred in
the past and does not see or react to the
experience as a clear and recurring danger in
the present. (This is the cognitive part of selfregulation)
2. No longer feels devastated by the memory of
the event (This is the emotional part of selfregulation)
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Reorganize: The client is able to:
1.
Live their life without feeling compelled to
relive or repeat the traumatic event either
consciously or unconsciously.
2. Define their life without the trauma being the
central organizing piece of who they are and
how they live their life; consciously,
unconsciously, and chemically.
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Posttraumatic Growth
(PTG)

PTG refers to a growth process by which survivors
are profoundly affected by the traumatic
experience in a way that transforms.

PTG refers to positive changes that go beyond
effective coping and adjustment in the face of
adversity; movement beyond pre-trauma levels of
adaptation.
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The Top Five Resilience
Factors
PTSD is a disorder of hope
Bessel van der Kolk
What a better way to experience hope
than to help others
Judith Jordan
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The Top 5 Resilience Factors
5. Autonomy (Agency):
When do you feel in control?
How do you define power and control?
How do you make things happen?
How do you help others, make the world a better
place, contribute to the interdependent web of
life?
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The Top 5 Resilience Factors
4. Self Esteem
A. Sense of Self – Personal Preferences
likes &dislikes
B. Sense of Self – Worth
When do I feel loved and valued? How do I show others
they’re loved and valued? How do I give and receive The Five
Good Things?
C. Sense of Self-efficacy –
How do I affect change in a positive way? How do I make
things happen for the greater good?
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The 5 Components of Mutually Enhancing
Relationships
Jean Baker Miller (1976) calls these the “Five Good Things”
that result from “growth fostering mutually enhancing
relationships.”
1. Zest
2. Clarity
3. Increased sense of worth
4. Creativity/Productivity
5. Desire for more connection
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The Top 5 Resilience Factors
3. External Support Systems
Friends
Pets
Extended Family
Neighbors
People at Church
Even Positive Fantasy
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What was Michael Jackson’s
First solo #1 hit song?
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The Top 5 Resilience Factors
2.
Affiliation (with a cohesive supportive group that works
together toward a positive goal)









System of Meaning (Rochelle Dalla, 2006)
Meaningful Work
Church Group
SPARK (Lyn Mikel Brown’s work)
Games for Change
Volunteer Work
Scouts
Sports
4H
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The Top 5 Resilience Factors
Positive Experiences with positive adults,
especially people in positions of
authority
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Top Five Resilience Factors
The Top 5 Resilience Factors
5. Autonomy (What do I have control over and how to make things
happen?)
4. Self Esteem
Sense of Self – Personal Preferences (likes & dislikes)
Sense of Self Worth – How do I give & receive love and value?
The Five good things in mutually enhancing relationships
1. Zest
2. Clarity
3. Increased sense of worth
4. Creativity/Productivity
5. Desire for more connection
Sense of Self-efficacy – How do I affect change – what do I have
power and control over – How do I make things happen?
3. External Support Systems (Can be a person, pet, fantasy)
2. Affiliation (with a cohesive supportive group)
1. YOU! Positive Experiences with adults, especially people in
positions of authority
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The World is not dangerous because of those who do
harm but because of those who look at it without doing
anything.
Albert Einstein
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To embrace the power of relationship will change
society as well as psychology ~ Jean Baker Miller
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References
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