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PHYSICAL DISCOMFORT. Some children are so sensitive to touch that they respond to physical contact with genuine distress. Chapter Six demonstrates how Theraplay can be adapted to the needs of children with special sensitivities or sensory integration problems, as well as the regulation problems we consider next. Although a reaction of distress to physical contact does not rule out the eventual use of touch, you should focus initially on engaging the child through activities that allow some distance while maintaining the interaction. Peek-a-boo, singing to the child, tossing a beanbag, or blowing cotton balls back and forth to each other are examples of such activities.
Since touch is so very important in children's development, we introduce it gradually in whatever form the child can tolerate. A child who is very uncomfortable having lotion on her skin may be able to tolerate powder instead. Firm touch may be more acceptable than light touch for some children, and it has the additional benefit of providing deep pressure to the muscles, pressure that is very soothing and organizing for many children. Such children could tolerate, for example, being rolled tightly in a soft blanket whereas they could not tolerate having their cheeks blown on or being touched with a feather.
If there is any question of whether a child has a sensory integration problem, she should be referred for an evaluation and possible treatment with an occupational therapist trained in techniques specifically designed to help the child overcome her discomfort.
OVEREXCITEMENT. Some children become overexcited by Theraplay activities. These are often the children whose regulatory difficulties (irritability, sensory sensitivities, and hyperresponsiveness to stimuli) contributed to their att5chment and relationship problems from the very beginning. In general, you must reduce the stimuli presented to the child as well as carefully monitor his level of excitement so that he can be helped to calm down before he gets out of control. Activities that excite the child within the limits of his tolerance and then help him return to a more calm state are particularly helpful. You can play "Row-row-row your boat" slowly, then faster, then faster still, and finally with exaggerated slowness, ending with a firm hug or firm pressure on the child's shoulders to make sure that he is fully settled after the excitement. After many experiences of being helped to manage excitement successfully, the child will eventually be able to monitor his own excitement level.
UNHAPPINESS. If the child cries or seems genuinely upset, you must evaluate whether the crying is a function of illness, sadness, fear, or anger. (Insincere crying is discussed later in this chapter.)
Illness. If illness is causing the crying, you must determine its severity. Minor discomfort calls for slower activity and an increase in vigilance. Major discomfort calls for discontinuation of the session altogether and for placing the child in the hands of a responsible caretaker. Yet it should be noted that therapists conducting home-based Theraplay can visit an ill child at the bedside. Many Theraplay activities can be conducted with both therapist and child closely confined and relatively quiet. Cool cloths, peek-a-boo, and 'messages" or pictures drawn on the back or on the hand in powder, for example, can all serve to make a child feel ongoing, joyful intimacy with his therapist, an intimacy all the more necessary during limes of illness and concomitant isolation and worry.
Sadness. If sadness is causing the crying, you must communicate to the child, both verbally and nonverbally, that you understand that he is feeling very sad. You should hold him and rock him and talk comfortingly to him. You should not attempt to cheer him, distract him, or tell him he "will be feeling better soon?' You should add playful games only after he is feeling better.
Fear. Sometimes the child appears genuinely frightened. While in theory it might seem difficult to distinguish genuine fear from fearful behavior designed to discourage intimacy, with experience you can distinguish the two quite easily. The cries and physical stance of a truly frightened child dearly convey a message of fear.
If you decide that it is genuine fear, you must determine whether the child's fear is a function of the situation's novelty, the separation from parent or teacher, or the intrusion of the therapist. If the novelty of the situation (for example, the new adult or the strange room) is causing the child to cry, you can acknowledge this briefly ("You never met me before, so you're frightened") but then move on quickly ("But we've got such fun things to do together, like this trick. . ?'). If the child shows only mild apprehension, the therapist may ignore the crying altogether.
If separation from mother or teacher is the problem, you can briefly reassure the crying child (for example, "Mommy's wailing for you right outside," or "You'll go back to see your teacher when we're finished playing. First I want to see what you brought to school today inside your nice striped socks. . . ooh, you brought some yummy toes. Here, let me see").
If the child's crying stems from fear of your intrusions and is not simply a way to maintain distance, then you must go more slowly and gently than is generally indicated. Her fear must be acknowledged: "I see that frightened you. Let's make sure you feel safe?' If there is someone with whom the child does feel safe, that person should be invited into the session to provide the calming security that the child needs before she can accept the positive experiences that you want to give her. On the other hand, for example, Adam's tears and cries, "I want my Mommy!" were so strongly tinged with angry resistance that it was clear that fear was not an issue.
The possibility that a fearful child has been traumatized in the past or has never felt secure must be considered. Chapter Nine explains how Theraplay can be combined with other approaches to treatment in working with children who have been abused and traumatized. Chapter Eight discusses the special needs of very young children who, because of frequent surgeries and medical traumas, have become unable to separate from their parents.
Anger. When the child cries out of anger, or shows angry behavior that is not just to keep you at bay, you must stop your playful games and acknowledge the child's feelings, matching the intensity of your words with the intensity of the child's anger: "You're really mad at me!" You can encourage a safe physical expression of the anger. For example, in the film, Here lAm (Jernberg, Hurst, and Lyman, 1969), therapist Ernestine Thomas tells Pat, "I can see you're angry:' and then, extending the palms of her hands for hitting, directs her, "harder than that, harder than that. Bigger than that!" By acknowledging Pat's anger and providing a harmless outlet for its expression, Mrs. Thomas conveys the message that Pat's feelings are legitimate. The palms of the hands allow the therapist to receive the blows without discomfort or ambivalence. Taking the initiative in directing the expression of the anger, rather than being a passive recipient only, she conveys adult control and responsibility and thus ensures that the angry activity will not go out of bounds.
If the child launches into a full-fledged temper tantrum, you must take steps to keep the child safe and stay with him throughout the episode. We describe how to handle temper tantrums later in this chapter.
EROTICIZED PERCEPTION. Rarely, the child responds to the Theraplay activities by becoming sexually stimulated. Often it is because the child has had experiences (sexual abuse or exposure to adult sexual behavior on television or from actual observation) that have made him sexually responsive to physical contact. Occasionally, children who have been raised in a depriving environment, such as in an extremely neglectful home or in an institution, have learned to use masturbation as a self-comforting behavior. When offered an appropriate comforting touch, such children may shift into their earlier pattern of associating comfort with sexual stimulation.
If a child becomes sexually aroused during a treatment session, you must, in a matter of fact manner, help the child distinguish between appropriate nurturing touch and sexually arousing touch. If the child makes suggestive comments or touches you inappropriately, you can simply say; "I won't let you touch me there. You can touch me here and here and here" (hands, cheeks, shoulders, for example). You should avoid the kind of touch that seems to arouse the child but must continually seek ways to provide the child with the experience of appropriate touch.
REQUEST FOR ENLIGHTENMENT. The child may ask for information, not as a means of controlling the session, but because he has a genuine need for information. Theraplay techniques are held in abeyance until the therapist has met the need. Examples of this need would be if the child is uncertain about something important to his security, <'Will my mother pick me up today?" or if he is anxious about something that might happen to him, '<When I see the nurse, will she give me a shot?"
AN UNHAPPY EXPERIENCE. The child may tell an unhappy story, not so that the
session shall proceed according to his own rather than the therapist's plans,
but because he has a genuine need to express his unhappy feelings. For example,
many children living in inner cities experience violence every day. They often
hear gunfire, they see bullets fly through their windows, and they occasionally
witness the shooting deaths of relatives. Such children often have a desperate
need to talk about their experiences. Although Theraplay is not a "talking"
therapy, you must put aside your plan in order to listen to their stories and
help them deal with their fears. To do otherwise would be to fail to meet their
needs. Then you must decide whether to refer the child for further counseling
with someone who is trained to help children who have experienced trauma. If you
are qualified.to do so, you may combine that approach with a modified Theraplay
approach, as described in Chapter Nine.
Reflection Exercise #7
Online Continuing Education QUESTION
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