Appendix 3.4. TF-CBT CogniTive Coping
Pa rt II
tF-CBt p
DeveloPmental
aPPlICatIons
105
4
Play applications p
and skills Components
Athena A. Drewes Angela M. Cavett
Overview Of Tf-CBT Play
aPPliCaTiOns and skills COmPOnenTs
Play is as natural to children as breathing. It is intrinsically motivating, an end in itself, transcending differences in ethnicity, language and culture, and it is associated with positive emotions (Drewes, 2005, 2006, 2009; Lidz, 2006; Tharinger, Christopher, & Matson, 2011). Play is perhaps the most developmentally appropriate and powerful medium for young children to build adult–child relationships, develop cause–effect thinking critical to impulse control, process stressful experiences, and learn social skills (Asso- ciation for Play Therapy, 2011; Chaloner, 2001).
Play not only is essential for promoting normal child development but has many therapeutic powers as well (Russ & Niec, 2011; Schaefer &
Drewes, 2009). Empirical literature (Reddy et al., 2005; Russ, 2004; Russ
& Niec, 2011) has found that play relates to or facilitates problem solving, which requires insight ability, flexibility, and divergent thinking ability; the ability to think of alternative coping strategies in coping with daily prob- lems, to experience positive emotion, to think about affect themes (positive and negative), and to understand the emotions of others and take the per- spective of another; and aspects of general adjustment.
description of Population
Utilizing play-based techniques within structured cognitive-behavioral ther- apy (CBT) can be a very useful modality for children 3 years of age and older depending on their emotional and developmental maturity. Children and teens who are challenging to engage in treatment may respond well when the therapeutic environment is playful and when play-based techniques are utilized by a playful therapist, all of which can offer relief from intensely emotionally charged work in dealing with feelings and trauma experiences.
Blending play and play techniques into CBT (Drewes, 2009) allows effec- tive delivery of CBT while not affecting its theoretical underpinnings. Knell (1993; Knell & Dasari, 2009) demonstrated that CBT could be modified for use with young children utilizing puppets, stuffed animals, bibliotherapy, and other toys with which cognitive strategies could be modeled. Over the past 10 years, there has been increased attention toward adaptation of CBT for use with preschoolers (Knell & Dasari, 2011). Consequently, the use of a CBT play approach with children between 2½ and 6 years has developed incorporating cognitive, behavioral, and traditional play therapies (Knell &
Beck, 2000; Knell & Dasari, 2011). Thus, play-based activities developed by creative play therapists may be integrated into CBT components to sup- port engagement and enhance participation when working with children and teens (Knell, 1993; Knell & Dasari, 2011; Meichenbaum, 2009).
Play applications with young Children
Although the change mechanisms of play and play therapy are not fully researched, Singer and Singer (1990) see play as reinforcing when it allows expression of positive affect and appropriate control of negative affect.
Golomb and Galasso (1995) found this to be the case in their research with preschoolers. Research has shown that developing a coherent narrative is central to the structured techniques that Gaensbauer and Siegal (1995) used with toddlers who had experienced traumatic events. These researchers believed that the change mechanisms of play among younger children were similar to those among older children with PTSD.
In the 20-plus years since trauma-focused cognitive-behavioral therapy (TF-CBT) was developed (Cohen & Mannarino, 1996; Deblinger, McLeer,
& Henry, 1990), it has become “clear that children respond very differently to therapy than adults, and the element of play became a crucial ingredient in engaging children in the therapy process as did the important involve- ment of parents” (Briggs, Runyon, & Deblinger, 2011, p. 169). Difficult and emotion-laden trauma material can be more easily digested, with play and play-based techniques becoming a sort of “enzyme” (Goodyear-Brown, 2010) that dissolves the painful connection to traumatic memories, thereby
easing the discomfort and increasing control and confidence within the child. A new pairing can then occur whose basis becomes associated “with laughter, playful competition, pride and feelings of courage and confidence”
(Briggs et al., 2011, p. 174; Deblinger & Heflin, 1996).
Traditionally, TF-CBT has utilized structured and educational play over nondirective, child-led, or pretend play. Play is used to help engage children and parents in treatment; create a playful, safe, and therapeutic environ- ment; help facilitate communication between the therapist and child; and teach specific skills (Briggs et al., 2011). It is important to note that nondi- rective or child-led free play is only included in TF-CBT for a few minutes at the end of sessions, as a reward or for relaxation and self-soothing transi- tion from intense feelings that may have been aroused during the session.
A core value of TF-CBT is flexibility, which allows the clinician to uti- lize a playful approach in order to reach children and develop a therapeutic relationship. Indeed, “the success of the evidence-based model (TF-CBT) is founded on the creativity, adaptability, and playfulness of the clinician.
The use of diverse structured play approaches highlights the flexible and adaptable nature of TF-CBT” (Briggs et al., 2011, p. 174). Therefore, the application of play and play-based techniques are consistent with and have increasingly been incorporated into TF-CBT for use with young children to assist in engagement along with the educational and skill-building compo- nents that make up TF-CBT.
special Considerations
Challenges may exist in implementing TF-CBT with young children who are verbally and/or cognitively limited and perhaps have more difficulty using TF-CBT components. Using developmentally appropriate play to imple- ment TF-CBT components allows children and parents to feel more relaxed and engaged. Because play is the language of children (Landreth, 2002), it can be utilized to help gain their interest and maintain attention as well as process and comprehend each of the components through a multimodal approach that developmentally and culturally taps into the natural learning style and life experiences of children. Without a playful aspect to the com- ponents, young children may view treatment activities as though they were formal, academic tasks and may become disinterested or refuse to partici- pate. Play also allows children to learn concepts that may be difficult when described verbally but better understood when visually and experientially processed. Furthermore, because trauma is not always processed on a verbal level, play allows children to use a multisensory approach to access their trauma memories and create their trauma narrative (e.g., by playing out the trauma through the use of a dollhouse rather than trying to articulate horrific images and memories verbally). Thus, playful interventions struc-
tured to achieve the goals of the TF-CBT components are engaging and invite children to more readily and easily communicate their experiences with their therapist and overcome common difficulties encountered during treatment. However, it is important for the TF-CBT therapist to be comfort- able directly addressing trauma while simultaneously being playful in order to be authentic and believable.
aPPlying Play-Based TeChniques TO assessmenT and engagemenT
All of the techniques that follow may include the parent as needed or indi- cated during the treatment process. Having the child practice the various techniques in many different settings, incorporating repetitions within the therapy sessions and over time, and having the child teach the techniques to the parent helps to ensure generalization and the likelihood of mastering and using them.
assessment strategies
TF-CBT identifies biopsychosocial problems common among children who access treatment and who have been traumatized by the CRAFTS spectrum:
Cognitive problems, Relationship problems, Affective problems, Family problems, Traumatic behavior problems, and Somatic problems.
Several play interventions that may be used to assist in assessment include Stepping Up to Success and the Caterpillar to Butterfly Treatment Plan (Cavett, 2010). In Stepping Up to Success, the child and parent think of the three to eight main presenting problems and treatment goals on which they want to focus. They are then encouraged to make stairsteps from con- struction paper or foam representing the problems to be addressed, and on each step the child writes the problem identified. Treatment goals for each of the presenting problems are then written on footprints, which are attached to the step.
Caterpillar to Butterfly Treatment Plan utilizes a simple story played out with a butterfly puppet. The story tells of a big, fuzzy caterpillar that creates a cocoon in the trees after eating a full meal of leaves. It dreams of having beautiful wings and being with other butterflies, but wonders how it could change. The caterpillar realizes that it has, within itself, the ability to become all that it wanted to be, but getting out of the cocoon would require working very hard in order to become free. The child is told that therapy is like the caterpillar making a cocoon and changing into a butterfly. The child is helped to identify what behaviors need to be changed (represented by the caterpillar), what needs to be learned (the cocoon), and what the positive
behaviors would be (the butterfly). The child then creates a butterfly from construction paper and decorates it, along with making a caterpillar out of pipe cleaners and a cocoon from construction paper.
Activities during the assessment phase can also include directed play using, for example, painting, dollhouses, storytelling, clay, and puppets.
These allow exploration of the child’s strengths, talents, worries, and prob- lem areas as well as an informal assessment of his or her emotional, cogni- tive, and developmental levels and the ability to use imagination and pre- tend play.
unique engagement strategies
The “Talking Ball” Game (Leben, 2008) involves the therapist having mem- bers taking turns rolling a ball from one (the sender) to another (the receiver) across a table. The sender asks the receiver a question—for example, “What is your favorite food?” or “What is your biggest worry?”—to explore likes, dislikes, interests, hobbies, ways of coping with worries, and so on. The game continues for 5 to 10 minutes or until every player has a chance to ask three questions.
Feeling Balloons (Drewes, 2011; Horn, 1997; Short, 1997) can be uti- lized to help explain the therapy process. The therapist has the child blow up a balloon (or does it for the child if he or she is too young or is allergic to latex), and as the balloon is blown up all the negative feelings (e.g., anger, sad, mad, hurt) are put into the balloon. Once it is blown up, the therapist, using a marker, writes on the balloon the various feelings the child indicates that are “inside,” along with names of people whom the child may have negative feelings about. The therapist explains that the balloon is much like a person’s head, with many feelings that fill it up. The therapist explores with the child what would happen if the balloon kept getting bigger, and that indeed it would pop. In real life, though, heads don’t pop; instead, all the angry and strong feelings that build up might make the child “pop”
inside, making him or her become aggressive or physical toward others.
These strong feelings get in the way of learning and feeling happy. The ther- apist explains that in each session the child will get to let out his or her feel- ings and experiences a little at a time, not all at once, in a way that the child can handle. The child is encouraged to let out some air from the balloon and note its progress in getting smaller, until finally all the air is released.
The Scavenger Hunt List (Cavett, 2010) requires the children to search their home for various items that will ultimately be used in the therapy process. They are asked to find a special stuffed animal to bring to sessions as well as something that helps them relax—maybe a picture of someone important to them, a picture of their room, something they do when they are bored, or a favorite book. The stuffed animal can be utilized during
future sessions to help ease the children’s anxieties or discomfort encoun- tered in the session and for practicing various techniques.
Tf-CBT Components
Psychoeducation and Parenting
Using playful interventions allows the parents to communicate with their child in a developmentally appropriate manner as well as help in engage- ment and gaining of skills. Difficult and anxiety-provoking topics such as sexual and physical abuse, domestic violence, and healthy sexuality can be processed in a playful way, lessening discomfort and making the psycho- education component fun. When the parents and child learn playful inter- ventions that are consistent with the TF-CBT model, the parents are more apt to use them with the child and the child more likely to be receptive and willing to practice and utilize the skill.
To better understand the relationship between children and their nona- busive parent, the play intervention Me and My Mom (Crisci, Lay, & Low- enstein, 1998) is effective. With this technique, young children make a col- lage of magazine pictures of women or men and children who remind them of their relationship with the nonoffending parent before the trauma and at the beginning of treatment. At the end of treatment, this intervention is utilized again to help provide insight into the children’s perception of what has changed in the parent–child dyad.
Special question-and-answer games that playfully explore the child’s trauma while correcting subsequent cognitive distortions, misperceptions, and gaps in information are a fun way to help the child and parent become comfortable in talking and asking questions about uneasy topics while learn- ing important information. For example, the What If Game (Budd, 2008) has the therapist make up cards with different questions that tap into vari- ous misconceptions and probe for the child’s strengths. Examples of these explorative questions include “What if you could ask anyone a question?
What might you want to know?”; “What if you could go back in time? What would you want to change?”; or “What if your pet could share something about you? What would it say?” The questions can be adapted to fit the child’s trauma situation. The child can play the game with the therapist and, once comfortable talking about the trauma, can then play the game with the parent, sharing his or her knowledge and reinforcing skills. The parent is encouraged to praise and reward the child’s efforts in playing the game and answering the questions. The What Do You Know? card game (Deblinger, Neubauer, Runyon, & Baker, 2006) facilitates dialogue on difficult topics such as sexual and physical abuse, domestic violence, and personal safety.
Questions such as “Why don’t children tell about sexual abuse?” or “What
can a child do if he or she has been sexually abused?” allow the therapist to help clarify misinformation and dysfunctional beliefs and thoughts. The card game can then be set up as a friendly competition between child and parent (after the parent has had an opportunity to prepare for the joint ses- sion), with teams competing for stickers and using a bell to ring and earn points. Adding to the fun component, on the back of each card there are small pictures of animals, along with a picture of one-quarter of an animal, so that when four cards are put together, like a puzzle, it makes the whole animal. A talk or game show format can also be utilized (Kaduson, 2001) whereby the child is empowered and becomes the “expert” who shares the newly learned information with imaginary callers who ask, via “questions”
relayed by the therapist, about similar situations and concerns that the child has. Use of these games offers the child gradual exposure to the trauma material along with practice opportunities for learning new information.
The child is praised and reinforced for participation.
Bibliotherapy can be helpful especially with young children. General books related to the specific trauma are powerful as are books related to the concept of a “bad thing that happened,” such as Brave Bart (Sheppard, 1998); No-No and the Secret Touch (Scott, Feldman, & Patterson, 1993);
The Adventures of Lady: The Big Storm (Pearson & Merrill, 2006); and A Very Touching Book (Hindman, 1983). Books can help in opening discus- sion related to the concept of trauma, psychological symptomatology, and healing. They can be read to a child along with use of puppets for storytell- ing and enactment, which can help deepen the child’s understanding. The parent and child can also use the books at home to help gradually expose the child to the trauma material and help in desensitization.
Relaxation
Utilizing animal postures, such as that of a lion, cat, snake, bird, or fish, can be appealing to younger children and can help in both relaxing them and reinforcing positive traits (Drewes, 2011; James, 1989). The children are directed to see themselves as a lion (or other favorite animal), feel- ing the lion energy moving up from the earth, through their feet, and up throughout their bodies, letting it rise up into a powerful roar. They prac- tice roaring loudly and then slowly lowering it to a whisper. They are then encouraged to silently move into a stretching posture, creating within them- selves the quiet strength of the lion as it relaxes. The children then practice the stretching and slow breathing of the calm lion. The therapist can pro- cess with the children their inner strengths and power and, using the lion metaphor, explain how the lion does not always roar and use up its energy and that there are times to “roar” and times to save energy and stretch and relax.
Using the guided relaxation Safe Place (Drewes, 2011; James, 1989) is an effective way to teach deep breathing while offering the children a relaxation tool to use at any time. While sitting with eyes closed, they imag- ine being a movie director and visualize themselves making a movie. They are directed to breathe in and out slowly and to think of a time and place when they felt safe—maybe lying in the sun at the beach, hiding under their bedcovers, or snuggling with a favorite pet. They zoom in with their camera and film the location, taking in all that is there. They then freeze the camera shot. Continuing their slow breathing in and out, they look around in their imagination and notice what they see, smell, hear, feel, and whether or not there are any people or animals there. As they continue deep breathing, they are instructed to feel how safe they are and how relaxed they feel in their body while in their safe space. Next, they give their special safe place a name, preferably one word. It is the key that will get them back to their safe place anytime they wish to go. All they have to do is remember the name.
The children continue to breathe in and out slowly, focusing on how relaxed and safe they feel. After a few minutes, they are directed to slowly move their camera back, and in another minute they will be back in the room with the therapist with their eyes open. The goal is to link the deep breath- ing with the experience of feeling safe and with the word chosen. At times when they feel upset or anxious, they can remember the word and help their body begin to relax.
The Tighten and Relax Dance (Cavett, 2010) incorporates move- ment to facilitate relaxation. The therapist models a tight dance, dancing stiffly in a circle with tight muscles. The child is invited to participate in the dance and follow along. The dance next shifts into a tight march, with stiff muscles. The therapist switches into a floppy dance/march, with a floppy, relaxed manner, ultimately flopping into a beanbag or a chair. This series is repeated several times at a comfortable rate for the child. Relaxation can also be done while playing Simon Says, with “Simon” asking the person to tighten and relax different muscle groups. The parent, child, and therapist take turns tightening and relaxing.
Personalized Pinwheels (Goodyear-Brown, 2005) or bubbles are use- ful in practicing deep breathing. The children are instructed to take a deep breath in and slowly blow it out, making the pinwheel turn or making as big a bubble as possible. While thinking of a favorite color, the children inhale and imagine this color going to all the areas in their body where they are feeling tense, angry, or worried and replacing the feelings with calm and relaxation. Then they can blow out and see how many bubbles they can make or how long they can make their pinwheel turn. A simple mantra that can be taught young children to assist with deep breathing is “Smell the flowers and blow out the candles” (Henriquez, personal communica- tion, March 17, 2011). Bubbles are also a great way to teach boundaries