by Eileen Prendiville
Trauma and other adverse life circumstances impact on children in ways that restrict their ability to engage fully with the world. Development is interrupted – any experiences that cannot be assimilated must be accommodated to. The development of a physical and emotional sense of self is interrupted and the young person may not develop the ability to empathise with others and form healthy relationships. If the child has been mistreated or abused they may continue to respond to the world as if it were a dangerous place even after their safety has been secured. This all contributes to significant difficulties, e.g. with boundaries, that need to be addressed in creative ways, so that the child or young person can begin to live in keeping with their current reality.
Traditional ‘talking therapies’ do not meet the needs of children – the language of childhood is play. Non-directive play sessions provide the ideal starting point for therapy with young clients. The recurring themes in their play will highlight the child’s confusions and stuck points and their projective play provides a window into their inner world that enables us to better understand their worries and needs. Child centred therapy facilitates the client in connecting with their core, creative self. It involves the use of creative techniques and media and takes account of the young person’s developmental level, dependency, and emerging needs. The use of play therapy, sand play therapy, projective techniques, therapeutic stories, creative therapies, and sensory stimulation are central and an understanding of the developmental play model assists the therapist in ‘reading’ the child’s non verbal communications. As with all therapy, the therapeutic relationship and the safety provided by the structure of the therapy itself makes it safe for the child to engage in the process, explore their life experiences and feelings, and risk new ways of being in the world.
Young clients are different to adult clients in many ways, the most significant of which is their naturally dependent status; they need others to take care of their needs for safety, protection, and basic care. Children need adult help, support and care to assist them in negotiating the world. They lack the maturity, the access to resources, and the capacity to utilise services without the assistance of an adult.
The younger the child the smaller their world is. They are introduced gradually to an expanding world as they grow and engage with the extended family, community, schools, and wider world. Emotional development is shaped by parents’ capacity to successfully contain the child’s emotions, sensations and distress. Ideally, the child should experience the satisfaction of having their needs met by their caretaker. The parent’s ability to attune to the child and successfully provide this containment will impact on the child’s potential to tolerate and master difficult sensations and make sense of their world.
Young clients, from pre-school years to the cusp of adulthood, must be seen and met in the context of their family and the wider community. They are still in the process of becoming. The young client needs others to support their healing. In therapy clients become more aware of their vulnerability, defences loosen; they start to see their world as it truly is. The ego develops, the client becomes more adept at evaluating experiences, contradictions are highlighted, and core beliefs are explored. This presents challenges, and invites the client to abandon old ways of being and take risks in trying new roles and behaviours. This is too much for a child/teenager to tackle without adult support.
Therapy work with child clients is more complex than similar work with adults. While both possess the potential to direct their own healing, adults have more power both in the therapy relationship and in shaping their world outside therapy. They can take responsibility for instigating change; can make independent choices in regard to their living arrangements, personal relationships, and personal safety. They have life experiences that enable them to reach fuller understandings of the dynamics of their own experiences. They have awareness of the systems in place (legal, medical) to support them if needed. Of course even adult clients are often not ready yet, to make the changes they may subsequently choose, they benefit from the support of the therapeutic relationship to take the risks they deem desirable in their lives. Children and young people also benefit in similar ways. However the resources available to the adult (life experience, knowledge, power, choices) are not available in the same way to the young client. They cannot, for example, secure their own protection, choose their caregivers, their home, or their school, or access legal assistance to instigate changes in their lives. They need the help of an adult to support them in their healing and take responsibility for ensuring that their basic needs for food, heat, safety and protection are met before the child can engage fully in therapy.
Before engaging in therapy with a child/young person it is essential to learn about them and their situation. The family will not be able to support the child’s development or healing if they have serious unmet needs of their own. Having relevant information to hand about their home life and living arrangements helps ensure that interventions do not serve to make the child more vulnerable or susceptible to harm or unnecessary distress. It will help in planning intervention and evaluating if adequate supports exist to make therapy a viable option. The time may not be right, a different intervention may be more suitable e.g. an abuse investigation, a medical examination to rule out possible physical problems, family therapy etc. It may be necessary to delay starting therapy until the pre-conditions can be met. The parents may be the initial focus for intervention.
No one individual or agency can meet the range of needs that emerge when working in a child-centred way. Multi-disciplinary teamwork and working in partnership provides greater opportunities for effective intervention with vulnerable families. This broad-based approach to work with children helps ensure safety, and effectiveness. Therapists who work with children in isolation are often frustrated in their work and find that the child gets ‘stuck’ or cannot move forward because the bigger picture is not being seen or addressed. Children and young people cannot be given responsibility for changing their world – only adults have that power. Likewise, the child or young person should not be expected to take risks in a vacuum – the safety and containment that exists in the therapy room and relationship needs to be extended to their world at large. It is essential that the child is not being undermined or abused if they are to be able to benefit from the process of therapy.
The therapist is responsible for all safety and boundary issues in relation to the therapy and for providing the optimum environment in which healing can take place. At the most basic level this includes ensuring that the therapist is adequately trained and competent for the work involved. Specific training in child psychotherapy, play therapy or creative therapies is an advantage. Personal therapy, ongoing professional development, ethical work practices and supervision need to be given priority.
The building of a therapeutic relationship is dependent on both the client and therapist mutually agreeing to engage in therapy. We can not ‘slip’ therapy into children without their knowledge or consent, or ‘do it’ to children without them being an equal partner in the relationship and making a clear contract or agreement in regard to the work. Limits to confidentiality - for example where issues of child safety are raised – must be made clear.
Child-centred mediums and approaches
A child is not a small adult. This simple fact impacts on all elements of our work with children, yet it is often ignored and leaves children feeling unseen and unheard and results in frustration for the workers involved. Play is the language of childhood and is the primary medium for communication.
Speech can only be a second, less expressive medium. The child cannot utilise their full potential for self-expression if we restrict their use of play and thus prevent true creativity and spontaneity. To work in a non-directive child-centred way means abandoning our traditional ways of communicating – speech is only second best, asking questions is outlawed, judgmental comments, even praise, are banned, our own agendas must be thrown out, and we must share power while holding responsibility for the safety of the child, the therapeutic relationship and ourselves.
One of our aims is to ensure that the person the child meets most in therapy is themselves, the more space the therapist takes up in the process the less space that is available to the child. The therapy room itself is important. Its size, furnishings and equipment (toys, art materials, creative materials, sand play therapy supplies and other resources) must be considered from the perspective of the clients. Materials should be chosen to assist the young client in self-expression and facilitate embodiment, projective and role-play. This will facilitate the client in directing their own healing and strengthening their physical and emotional senses of self and exploring their own and others roles in their life.
In summary, play therapy seeks to provide a therapeutic space for children to use in a way that meets their needs – to express emotions, explore life experiences, experiment with new ways of being, and, perhaps, gain insight into their realities. The space is made safe by the presence of a non- judgmental, attentive, accepting adult who accepts and respects them just as they are. The child chooses whether to engage in therapy or not, and sets the pace and direction of the sessions. The therapist ensures that safety issues are never compromised. Increased awareness and healing can take place within the context of the relationship that develops between the child and the therapist. The worker can reflect back the child’s words, the content of their activities, or the feelings expressed in their play. Empathic listening is central. A focus is maintained on both verbal and non-verbal communications. This helps to intensify the child’s experiences, facilitates increased awareness, and gives the child the experience of being witnessed - both seen, and heard in a holding relationship. Symbolic play is not interpreted to the child. Symbolism and metaphor enable the child to explore issues in a safe way, and to direct the course and pace of the therapy according to their needs.
Younger children are more inclined to resolve issues on a sub-conscious level, to engage in less direct conversation, and to address their difficulties through symbolic mediums – therapy need not be insight based. The healing can occur within the metaphors of the child’s play. Change occurs at the core of the personality. A lot of therapeutic play evolves around physical activity, story-making and exploration of roles. For the pre-school children in particular, play will develop around themes connected with home life and fairy tales. Slightly older children will incorporate their experiences of school into their play. Pre-teens and adolescents will be attracted by opportunities for dramatic play, creative therapies and therapeutic board games. The ‘self’ develops: self-esteem, self-image, self-efficacy and self- confidence will all be enhanced.
The child cannot be seen in isolation. Their family – both caregivers and siblings may benefit from support, information, advice, counselling or therapy. Groupwork or individual work may be appropriate to meet their needs. The child’s therapist needs to have a link to the caregivers either directly or via another professional. The care-giving parent is generally the most important person in the child’s life and must feel respected and included in the work with their son or daughter. They have enormous power to assist (or sabotage) the child’s healing. Effective therapy empowers the caregiver in providing a broad therapeutic environment for the child outside of the therapy settings. Traumatised children need more than a one-hour therapy session every week. The other 23 hours are vitally important also! Caregivers can provide opportunities for developmentally appropriate play, creative expression, sensory experiences, positive relationships and containment for the child or young person. The world needs to become predictable to the child and they need to experience safety and security. The home is a good place to start.
Therapeutic work with children and young people is very different to work with adults. The child does not have the independence, maturity, life experience and ability to take care of their own needs for safety, nurturance, education, and support. However, given a supportive environment, child- centred approach, and a strong therapeutic relationship, all children, like adults, possess a striving for wholeness and the potential to heal themselves and recover from any traumatic experience.
Eileen Prendiville is Clinical Director of The CARI Foundation and is core trainer on CARI’s Child Psychotherapy Training Course and therapeutic play workshops.