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 Play therapy for traumatized children 

Play therapy for traumatized children. Playing as a psychological therapy has been used by experts in the field to work with children for decades and is usually utilized with children from ages 3 to 12. The idea of play therapy is that playing is a behavior that comes naturally to children and, for the longest time in their development, is also the way children communicate, explore, learn, and express their feelings. Play is a child’s language, and it’s also an enjoyable activity that develops self-expression and self-efficacy and allows for an opportunity to relieve intense emotions such as stress. Play therapy as a treatment modality was initially developed in the early 20th century and nowadays refers to a myriad of treatment modalities that include playing as the main technique. The difference between regular playing and play therapy is the psychologist's presence, who will guide the child on how to express their feelings and solve their problems. Play therapy is used with children presenting issues such as behavioral problems, learning difficulties, social issues, and trauma from sexual abuse, neglect, and natural disasters.

= Overview of play therapy = Expressive therapies refer to a therapeutic approach while using play or arts. Expressive therapies are a method that allows the participant to express themselves in other ways other than verbal. Being able to communicate in non-verbal ways could facilitate the expression of difficult feelings or memories. Some expressive therapies are art therapy, sand therapy or sand play, and play therapy.

The beginning of play therapy could be traced to Anna Freud and Melanie Klein, who is known to pioneer the work with children in the early 1900's. Anna Freud used playing to create an environment where the child felt safe and where the kids would trust the therapist to verbalize their struggles. Play therapy was seen as a vehicle to interpret the child’s internal world from which the clinician could guide the child’s development and insight. However, the approach of these pioneers was psychoanalytic, and research has since then pointed out some limitations to this theoretical orientation. Psychoanalytic play therapy is more suitable for children who can verbally express their situations and are developmentally ready to gain insight in their behaviors. Play therapy has continued to develop over the years, and a model that was more suitable for children that experienced trauma and that settle the framework for more contemporary play therapies, was Levy’s "release therapy" model in which children could comprehend and work on their trauma by re-enacting the traumatic experience through the safety of playing.

Play therapy can be seen in other therapeutics modalities such as behavioral, cognitive-behavioral, and humanistic. Different theoretical perspectives will utilize play therapies in different ways. For instance, a humanistic approach will be non-directive, meaning the treatment will be less structured. The therapist will most likely follow the children’s needs and desires when deciding what and how to play.

= Nondirective vs directive play therapy = Play therapy could take two modalities, non-directive, or directive. These modalities will depend on the clinician's theoretical orientation (i.e., Behavioral, humanistic, psychodynamic) and on the specific case representation of the client. In regard to non-directive play therapy, the clinician will not lead the therapy/game giving the child the freedom to choose what they want and how they want to play during the session. The purpose of this modalities is to allow the child to express their feelings at their own rhythm. The clinician will not give guidelines and will follow the child's games and narrative. In directive play therapy, the clinician will become a guide, choosing the toys before the session starts and giving the children guidelines through the session. Clinicians who use this modality will have a specific issue they will want to evaluate during the play session. By choosing specific toys or games, they facilitate the expression of an emotion or the emerging of a particular theme during the game.

= Working with trauma = Children exposed to severe trauma will find it difficult to speak about their experience. If the abuse occurred by a loved one, the child may find it even more difficult to speak about their feelings and struggles out of fear of the consequences and, in some instances, even to protect their loved ones. Symptoms produced by traumatic events may appear like the symptoms stated in the DSM-V criteria for Post-Traumatic Stress Disorder (PTSD), but other times a child will still present symptoms and not meet criteria for this diagnosis. Furthermore, children’s symptoms may differ from those of adults in their presentation as children do not communicate their stress in the same way. For instance, children may experience more psychosomatics symptoms (e.g. headaches, stomach issues).

Child abuse is usually thought of as sexual, physical abuse, or neglect. But there are a multiple of other situations that may cause trauma to children like emotional abuse or natural disaster.

Some principles when working with children exposed to trauma are to provide them with a safe therapeutic environment, perform a detailed assessment of the situation, work on fomenting a trusting relationship with the child and their caregivers, work in a multidisciplinary context in order to ensure all the child’s needs are covered, maintain cultural considerations in mind, and provide psychoeducation to caretakers to give them guidelines as to how to manage the situation and work with their child.

A main goal when working with children exposed to trauma is for them to be able to face what happen to them in a trusting environment where they know they would not be hurt again, understand what occur, and learn coping strategies to deal with their stress and symptoms. Some other goals of therapy could be for the child to learn how to express difficult thoughts and feelings, for the child to be able to regulate their emotions and behaviors, and to increase their self-esteem and self-efficacy.

Children exposed to severe trauma will find it difficult to speak about their experience. If the abuse occurred by a loved one, the child may find it even more difficult to speak about their feelings and struggles out of fear of the consequences and, in some instances, even to protect their loved ones. Symptoms produced by traumatic events may appear like the symptoms stated in the DSM-V criteria for Post-Traumatic Stress Disorder (PTSD). However, other times a child will still present symptoms and not meet the criteria for this diagnosis. Furthermore, children’s symptoms may differ from those of adults in their presentation as children do not communicate their stress in the same way. For instance, children may experience more psychosomatic symptoms (e.g., headaches or stomach issues).

Child abuse is usually thought of as sexual, physical abuse, or neglect. But there multiple other situations that may cause trauma to children like emotional abuse or natural disaster.

Some principles when working with children exposed to trauma are to provide them with a safe therapeutic environment, perform a detailed assessment of the situation, work on fomenting a trusting relationship with the child and their caregivers, work in a multidisciplinary context to ensure all the child’s needs are covered, maintain cultural considerations in mind, and provide psychoeducation to caretakers to give them guidelines as to how to manage the situation and work with their child.

The main goal when working with children exposed to trauma is for them to be able to face what happened to them in a trusting environment where they know they would not be hurt again, understand what occurred, and learn coping strategies to deal with their stress and symptoms. Some other therapy goals could be for the child to learn how to express difficult thoughts and feelings, for the child to be able to regulate their emotions and behaviors, and increase their self-esteem and self-efficacy.

Post-traumatic play
These types of play have distinct characteristics. When a child engages in posttraumatic play, the game is literal, joy-less, repetitive, and highly structured. A child may engage so much in this repetitive game that they seem self-absorbed and disregarding their environment. Some children may experience dissociative episodes and have difficulties expressing emotions.

Trauma-focused play therapy
Gradual exposure is a technique that clinicians will use with people who experienced traumatic events. Clinicians will use trauma-focused play therapy (TF-PT) to initiate or encourage children to engage in posttraumatic play as this type of play is a way to start gradual exposure to the traumatic event. TF-PT has a series of considerations: (1) selection of toys that represent traumatic aspects of the incident and to make them visible in the play therapy room in order to facilitate the child to see the toy and pick it, (2) the child must select the toy naturally and not by direction of the clinician, (3) if by the fourth session the child continues to ignore the toy, the clinician will encourage the child to play with them, (4) observe the child playing and document the play theme noticing the sequence and conclusion of the game, (5) document repetition of the play, (6) during the play, the clinician will offer a narrative of the game based solemnly on observations and descriptions, not interpretations, (7) if and when the child narrates the game by themselves, the clinician will ask open-ended questions to encourage further communication, (8) the clinician will not offer solutions, but rather encourage the child to get to the solutions themselves, (9) the clinician can encourage dynamic movement, such as encourage movement of toys or by making voices for the characters.

Children that have experienced abused do not tend to seek therapy, but instead they end up in therapy by referral after disclosure or when an emotional or behavioral issue has arisen. Abused children will usually have difficulties talking about their experiences and will fear negative repercussions if they speak about their feelings. A non-directive approach and playtime could be beneficial as it will offer a child space and time to develop trust in the clinician and to be able to work on their struggles.

= Considerations = Understanding a child’s cultural background and the environment is beneficial for treatment as it will inform about their specific values, costumes, and support system.

A way of ensuring cross-cultural consideration in play therapy is for the clinicians to develop sensitivity and insight into other cultures. Specifically, with play therapy, the selection of toys is an essential part as children will use these tools to express their emotions and create their narratives during the games. Having toys representing the different background, races, and genders provides the child with a multitude of possibilities to accurately represent their traumatic events.

Play therapy may take a significant amount of time to show results. Children may show signs of improvement within the playroom. For instance, their game is no longer repetitive, and the children can come up with healthy conclusions for their games. But these changes are not always as evident outside of the therapy room, especially if the child is still experiencing abuse in their environment.

Children with adverse situations will present with different symptoms depending on a myriad of factors, such as developmental stage, support system, the severity of the traumatic experience, the number of traumatic experiences (i.e., if it was one occasion or multiple), and biological factors. Because of this, play therapy may not be sufficient for all cases, and many clinicians, after an initial assessment, could decide what integrative approach is the best course of action for the child.

Studies have demonstrated the effectiveness of play therapy, especially in developing social skills, emotional regulation, increased self-esteem, behavioral adjustment, and decreasing anxiety. However, the outcomes are not always clear, and research on this topic is difficult with non-directive approaches as it was hard to measure the clinical interventions.

