Fawns in Gorilla Suits: Creative and Hopeful Play Therapy Strategies with Aggression and Violence

1. Fawns in Gorilla Suits: Creative and Hopeful Play Therapy Strategies with Aggression and Violence David A. Crenshaw, Ph.D., ABPP, RPT-S Founder, Rhinebeck Child & Family Center, LLC Clinical Director, Children’s Home of Poughkeepsie Faculty Associate, Johns Hopkins University www.childtherapytechniques.com dacrenshaw@childrenshome.us

2. Our Own Internal Work • We can’t begin to access the internal life of children unless we do in an ongoing way our own internal work. The tools of the trade can be useful, I don’t wish to devalue them in anyway, but I am convinced that far more pertinent to healing the injured spirit of a child is our way of being with a child.

3. Creating a Safe Place • An important part of making a safe place where the child can explore and eventually tell their own story is the safety offered by the therapist’s way of being with the child.

4. Exploring the Internal Space • If a child is out-of-control behaviorally, my assumption is there is something out of control internally. I want to create a therapeutic context primarily mediated by a trusting, collaborative relationship where that internal space can be explored, and not only contained but given voice.

5. Relational World of the Child • I also want to explore just as fully the child’s relational world—the key attachments in the child’s life, those who love him or her and those loved by him or her; any disruptions, ruptures, cut-offs or disconnection because these are likely mirrored in the internal world of the child.

6. Safety via Symbolic Play • Fantasy play, and artistic creations, and clinical use of symbols with children in the context of a solid, trusting therapeutic relationship often allows a deeper exploration both of their internal world and relational world than they could ordinarily tolerate.

7. Questions to Important to Dismiss • Freud spent 30 minutes a day after seeing his patients to examine the reactions stirred in him as a result of his interactions with his patients. Children, certainly aggressive and sexualized children, stir a wide range or emotional reactions in us—what do we do with that? • Do we push it away, do we bury it, or do we examine it? Do we travel at a velocity that doesn’t allow for pause, let alone stop, to reflect, to learn, and to face our own vulnerabilities?

8. Questions that can Make or Unmake the Therapist • Instead of growing from such encounters with our child clients, a cumulative residue of unexamined feelings and reactions develops and compounds. What is the result—the impact on our psychic, our spirit, our health? Do we value ourselves enough to even care? • Are we so use to putting ourselves in a secondary role that we don’t even notice? What other questions do you regard as too important to dismiss?

9. Honoring our Own, Unique form of Genius (David Whyte) • Residing within, is a deep well of previous intuitions, inherited wisdom, and strengths because by definition we all are here today because we came from a long line of survivors. This well can only be accessed by listening carefully, ever so carefully, to the deep silences that speak volumes when we are attuned to our internal well of unique genius. When fully attuned we will be guided to the path of our star, the star we were born to follow, the star to which we belong.

10. Diagnostics of an Unhealthy Way of Being • Impatience with the rest of the world that is not charging around like we are! • The feeling that the only legitimate players are the ones traveling at the same velocity we are! • When we play back the message on our answering machine and we sound like we are half-dead!

11. Diagnostics: Continued • When we get a new referral, and we say: “Oh dear God why me?” • When we think the session is about over and we look at our watch and it is only 10 minutes into the session! • What are some other diagnostics of an unhealthy way of living and being for those of us doing this work?

12. Robert Brooks • “It is amazing how fast anger diminishes when we find ways to boost dignity.”

13. Kenneth V. Hardy • “When we find ways that children can contribute, focus on ways they can give, it elevates their spirit. If they feel they have nothing to contribute, nothing to give, it punctures their spirit.”

14. Walter Bonime, M.D. “No matter, how frustrated, impotent, enraged, depressed, hopeless you may be feeling in your work with a child, it can begin to match the intensity of those same feelings within the child.”

15. Bruce Perry • “Deprivation of key developmental experiences (which leads to underdevelopment of cortical, sub-cortical, and limbic areas) will necessarily result in persistence of primitive, immature behavioral reactivity, and, thereby, predispose an individual to violent behavior.”

16. Predatory, Aggressive Behaviors • In a group of boys living in a RTC whose past experiences included exposure to severe and prolonged domestic violence, a subset of the hyperaroused, reactive boys developed predatory, aggressive behaviors. A chilling finding from Bruce Perry following this subset of boys was their decrease in heart rate when asked to discuss specific violent acts in which they had been involved. Some of these youth reported a soothing, calming feeling when they began “stalking” a potential victim.

17. James Garbarino • “When you peel away the layers with youth who commit violent crimes what you invariably come to is a “traumatized child within.”

18. Attachment Research • Edward Tronick, Attachment researcher at Harvard University • The “Still Face” Experiment

19. Attachment Issues • Results indicated that boys with disorganized attachment and children with ambivalent attachment reported a higher level of externalizing problems then did secure children. Moreover, disorganized children also reported a higher level of internalizing problems than secure children. • Canadian Journal of Behavioural Science. 38(2), Apr 2006, 142-157.

20. Right Orbital Prefrontal Cortex

21. Gender Differences • Contrary to the differential socialization hypothesis, the results showed substantial gender differences in the prevalence of physical aggression at 17 months of age, with 5% of boys but only 1% of girls manifesting physically aggressive behaviors on a frequent basis. • Developmental Psychology. 2007, 43(1) 13-26

22. Temperament and Harsh Parenting • Our results suggest that a behaviorally uninhibited temperament, CU features, and attitudes favoring harsh parenting are all important for understanding the development of aggression in preschool children. • Journal of Child and Family Studies. 2006, 15(6) 745-756

23. Ways of Viewing Aggression • Reactive • Proactive • Ross Green’s work: Neurodevelopmental deficits underlying rigidity and low frustration tolerance • “Any child will do well if they can.” Ross Greene

24. Another Prism for Viewing Aggression • Impulsive/Reactive Aggression (Ross Greene) • Hot Rage—Invisible wounds to the soul (Hardy, Garbarino, Crenshaw) • Cold Rage—Bruce Perry and Kenneth Hardy (dehumanized loss) • In the latter two, research emphasizes the need for empathy based treatments, particularly with kids who have psychopathic traits who have a remarkable lack of capacity to perceive the emotional distress of a victim.

25. Revenge • Impact on resilience • “When you start out on a journey of revenge, dig two graves—one for your enemy and one for yourself.” Native American • “An eye for an eye makes the whole world blind.” Gandhi

26. Child Responsive Therapy (CRT) • An integrative approach in which the response of the therapist is based on empathic attunement with the child. The therapist responds to the cues of the child in an dynamic interplay over the course of the therapy and even within a given session to determine whether to support or to challenge, whether to gratify or frustrate, whether to strengthen coping or explore deeper issues depending on what this particular child needs at the particular place and point in time.

27. 1. Making Therapy a Safe Place • 1) Rituals mutually decided in early sessions; • 2) Calming Symbol • 3) Photograph Album Metaphor (Joyce Mills) • 4) Wave Breathing (Kevin O’Connor)

28. 2. Modulating Affect • 1) Downsizing; • 2) Addressing the hostile attribution bias by working on social and cognitive distortions; • 3) Enlisting Humor as an Ally; • 4) CBT (Child-Friendly) Strategies (Janine Shelby)

29. 3. Teaching the “Language of Feelings” • 1) The Heartfelt Feelings Coloring Card Strategies (HFCCS Expressive Cards)* • 2) Psychoeducational Tools such as the Heartfelt Feelings Strategies (HFS) (Riviere, Goodyear-Brown, Kaduson, Crenshaw); Feelings Map (Drewes); Feelings Charades (O’Connor) * Available: www.astorservices.org/heartfelt-feelings-manual.php

30. HFCCS Expressive Card (Inside) Expressive Card HFCCS available for purchase from http://www.astorservices.org/heartfelt-feelings-manual.php

31. 4. Accessing the Inner World • 1) Three Step Drawing Strategy • 2) Overidentification with the Aggressor • 3) HFCCS Relational Cards • 4) Inside/Outside (James) • 5) Symbol Association Therapy Strategies (SATS-C) available from the Self-Esteem Shop—my profits go to “Ivy’s Fund” at the Children’s Home.

32. 5. “Tickling” the Self-Observer • 1) Projective Storytelling and Drawing Techniques; • 2) Building the Reflective Function (Fonagy); • 3) Building the Frontal Lobe, the Executive Functions (van der Kolk)

33. 6. Addressing the Invisible Wounds • 1) Crucial Importance of Empathy-Based Treatments; • 2) Wounds in the family system; • 3) Wounds due to disrupted attachment; • 4) Wounds related to cultural factors

34. 7. Trauma-Informed Therapy Strategies when Indicated • “The soul would have no rainbow if the eyes had no tears.” Native American • Creating the Trauma Narrative in Symbolic Play • Case Examples of Pre-verbal Trauma

35. 8. Crucial Importance of a Resilience/Strengths Based Mindset • A Mountain of Strengths • Helping Hand • Robert Brooks: “The birds need a home too.”

36. 9. Facilitating Hope • A “delicate operation” • Pacing and timing are of utmost importance • Goal: To honor strengths without trivializing suffering—a delicate balance requiring attunement and sensitivity on the part of the therapist. • How hope can be dangerous

37. 10. Preparing for Termination Attunement to the importance to the child; • Expressed in Metaphor; • Counting Down; • Album with Letter; • Talk Show; • One Last Conversation