Play-Based Treatment of Trauma Mastery Test

1. John Briere identifies two categories of abuse: Acts of Omission and Acts of Commission. Acts of Commission involve only indirect forms of abusive behaviour, such as sexual abuse.

2. Elian Gil cautions against exploring parent support and guidance in the initial assessment process because children are vulnerable to the influence of their parents and this might contaminate the assessment process and undermine the therapeutic relationship.

3. There is a considerable amount of research that relates insecure attachment to experiences of child physical abuse and neglect.

4. Gil’s extended developmental assessment is a non-structured approach that uses a combination of both directive and non-directive strategies; the initial phase is primarily non-directive.

5. Exposure of children to mildly stressful experiences can help them become more “stress resilient.”

6. Kendall-Tackett, Williams and Finkelhor (1993) found that over 40% of children who have been physically abused are symptomatic upon assessment.

7. Friedrich (2002) argues that all 4-treatment goal areas (attachment, emotional dysregulation, self-perception, and family relationships) should be equally emphasized in trauma treatment.

8. An example of Freud’s notion of “repetition compulsion” is when a sexually abused child engages in reactive sexual behaviors.

9. As noted by the Canadian Incidence Study of Reported Child Abuse & Neglect (2003), there is likely an underreporting of familial abuse.

10. Gil notes that trauma negotiation involves 2 learned adaptive responses, mastery and avoidance.

11. There are a substantial number of children who show little or no apparent reaction after a traumatic event, and this is mostly due to denial.

12. An individual may present signs of cognitive constriction as well as signs of emotional dilation.

13.The left hemisphere is linked to implicit information processing versus more conscious processing, which is linked to the right hemisphere.

14. Alan Schore’s model emphasizes the importance of the right hemisphere in affect regulation. He argues that the right hemisphere holds explicit memories that stem back to early relational experiences, and in the case of early relational trauma, it is the lack of nonverbal affective/synchronous experiences that leads to dysregulation.

15. A child in therapy may use the therapeutic relationship to test out and discard their old internal working models of self and self-relationships, however, the therapeutic relationship can’t be used to bridge new models of self as this only occurs in the presence of the caregiver.

16. “Denial and numbing” may be seen as defences against intrusion of intolerable emotions or memories.

17. Van der Kolk suggests that many problems of traumatized children can be understood as efforts to minimize objective threat and to regulate their emotional distress.

18. Gil argues that there are a number of possible “therapy formats” within an integrated treatment approach, ranging from individual, to group and parent-child therapies, and parent support groups.

19. Intrusive re-experiencing phenomena may represent an attempt to organize or integrate part of the traumatic experience. The Experiential Mastery Technique (Shelby) may help with this integration process as the child gains a sense of mastery over some part of the traumatic experience, in the context of a safe setting or relationship.

20. Gil asserts that in using expressive techniques, the clinician is able to gather information about the child from two dimensions – process and content. “Process” informs the clinician about the symbol, metaphor or story presented through the use of materials and relates to the child’s links to real-life issues.

21. Susan Harter’s work on self-perception suggests that in treatment of traumatized children it is best to emphasize optimism and bolster their self-identity or self-esteem, versus simply providing accurate reflections of who they are.

22. There are 3 types of insecure attachment; the insecurely attached child operates from the basis that there is unpredictability, a lack of reciprocity, and/or punitiveness in the caregiver-child relationship.

23. Studies of the play transcripts of insecurely attached children show the child can play the victim and victimizer roles. This finding is consistent with Bowlby’s notion that children re-enact not only their role in the damaging relationship but also model the role of the parent.

24. Trauma narratives can really only be created in specific ways, based solely on CBT principles.

25. There is some evidence (e.g., research by Pynoos et al) that suggests that traumatic stress interferes with narrative coherence, emotion regulation, and self-concept.

26. Charles Schaeffer would argue that in Quadrant III, Non-Intrusive Responding, there is an element of classical conditioning as the child gradually approaches troublesome stimuli in their play.

27. The case of Jamie, a ten-year-old boy, indicates that he suffered both sexual abuse and early relational trauma. Accordingly, treatment activities primarily focused on the former area as more significant psychological wounding occurred through sexual abuse. The therapist also thought that Jamie would likely gain a corrective emotional experience by living with his grandparents and being placed out of further harm.

28. Katz and Gottman’s (1991) definition of emotion regulation can help the practitioner in play-based observations, such as examining the child’s ability to coordinate play and manage conflict with the play partner.

29. Trepper and Barnett (1989) have described four types of parental denial in child sexual abuse: denial of facts, denial of awareness, denial of responsibility, and denial of impact. As noted by Gil, the implication is that it is impossible for a parent to adopt two contrary beliefs, such as agreement of facts that the child disclosed, but disagreement over the impact of the abuse or the intent of the abuser.

30. According to Chichetti, physically abused children are seen as falling into the “angry” categorization for dysregulation.

31. It is thought that therapeutic information breaks the cyclical alternating of denial and numbing and intrusive repetitious thoughts by providing a safe environment to experience some of the emotional responses/feelings without automatic denial and numbing of the emotions.

32. Directive techniques, such as exposure training, may be inappropriate for children showing symptoms such as extreme dissociation.

33. In a Trauma-Focused Play Therapy model the therapist would never facilitate or initiate (through toy selection) posttraumatic play. However, they do set in motion the child’s natural mechanisms for gradual exposure to a traumatic incident.

34. In the interview protocol developed by Eth and Pynoos children are asked to draw specific types of picture about their trauma and then are asked to talk about their drawing, while remembering sensory experiences.

35. An advantage of directive play therapy approaches to trauma treatment in children is the demonstrated effectiveness in eliminating trauma symptoms and ability to address other non-symptomatic issues such as mistrust.

36. The Dilation-Constriction Continuum focuses mostly on the affective level.

37. One of Gil’s goals in trauma treatment is to bring some part of the traumatic experience into conscious awareness. However Gil notes that the integration of memories and narratives can be accomplished in many ways, such as through repetition in play, and should always occur at a developmentally appropriate pace.

38. Directive and nondirective approaches to play therapy have been equally researched, and both have been validated as well established and efficacious interventions.

39. There are 3 types of insecure attachment. The insecurely attached child operates on the basis that there is unpredictability, a lack of reciprocity and/or punitiveness in the caregiver-child relationship.

40. Many practitioners working from an integrated play-therapy model stress the importance of education in the stress-recovery process.

41. The integration process, in part, involves a basic restructuring of conceptual (e.g., world beliefs) and perceptual (i.e., emotional experiences) functions to accommodate the event itself and subsequent changes caused by the event.

42. Gil notes that “dynamic” forms of posttraumatic play are of great concern because they lack compensatory properties.

43. Consistent with a view of the liberating and dangerous properties of posttraumatic play, Gil generally finds it useful to first allow the child to engage in posttraumatic play for 6-to-8 sessions, during which time she watches for slight variations in the play.

44. Expressive art making techniques, such as smearing and scribbling, can be used as a precursory therapeutic activity as well as in service of the child’s defences and need to discharge feelings.44.

45. Trauma-focused Cognitive Behavioral Therapy Models include story telling/narratives, but often exclude play-based materials.

46. There is little research to support the inclusion of non-offending parents, even from Cognitive Behavioral Treatment paradigms.

47. One of the first steps in the process of treating dissociation is to help the child develop a language for the process of dissociation.

48. In Trauma Focused Play Therapy (TF-PT), psychoeducational information is provided to the child quite early in the treatment process, generally before intense processing of their trauma has occurred.

49. Play therapy can offer a corrective emotional experience for children by offering an opportunity to develop an integrated perspective. This occurs through accessing the mastery play drive, rather than through the relationship itself.

50. Non-directive play therapists argue that child-led posttraumatic play is seldom helpful, as children never gain an increased sense of control over the content/issues.

51. According to Barbara Mills, one marker of therapeutic growth in traumatized children’s play behavior is moving from disconnected play to confluence between play themes

52. The “naming game” is a thought stopping technique that can be modified to include various levels of challenge.

53. Gil asserts that traumatized children are a subset of abused children, and that children’s responses to abuse are extremely heterogeneous.