Treatment Issues

The first goal of therapy, no matter what the child’s age, is to establish a safe and trusting relationship. Other goals of play and art therapy are aimed at providing a nurturing atmosphere where the child can experiment with a wider repertoire of adaptive behavior, allowing the child an opportunity to be expressive with creative stimuli and supporting parental efforts at setting limits for acting-out behavior by providing alternative outlets for the child.

As Kyle attached to his foster mother, he also became stimulated sexually, which is not uncommon in children sexually abused at very young ages. He attempted to come into the bathroom when she was showering, and when she emerged wearing a towel, he would become excited and begin humping on her legs. He also became stimulated when she wore summer tops and shorts and would attempt to unbutton her blouse or French-kiss her. All of these behaviors were extremely unsettling, and his foster mother asked for help in setting limits without making him feel bad or inadvertently teaching him that sex is dirty. Using his terminology, I told Kyle that I wanted to talk about “boyfriends and girlfriends.” I provided anatomically correct dolls and asked, “What do boyfriends and girlfriends do?” Kyle asked if he could undress the dolls. He pulled on the boy dolls’ penises and stuck his fingers in the vaginas of the girl dolls. He positioned the dolls carefully, as if they were having sex.

He said, “They kiss.”

I told Kyle that when he and mommy play, they cannot play these games because mommies cannot do that with their little children. Mommies can do that only with daddies. He asked, “Then who can I do that with? You?” “No,” I said. “You can do that with the dolls. When you feel excited like that, you can play with the dolls.” In this way, I was putting words on his feelings for him (he gets “excited”), and I was providing him a time and a place where he could do this kind of play, which seemed essential to his ability to ultimately control his sexual impulses. Together, we dressed the dolls. At the end of the session, we brought in his foster mother and talked with her about what he and I discussed. I reminded Kyle that when he and mommy play, if he starts to feel excited, they have to stop playing. He cannot play like that with mommy or with other children. He can play with my dolls. I also reminded his foster mother that as soon as she notices his play becoming sexually charged, she needs to stop the play and remind him that they cannot play that game.

Language abilities at this stage are extremely limited. The parent must take total responsibility for keeping the child safe, for at this age the child is unable to identify or to learn about unsafe situations. The parent must be able to recognize unsafe situations or people. The parent must also learn that a child of 2 who is sexually or aggressively acting out cannot be left alone unsupervised with other children. This means “eyeball supervision.”

The child’s memory is not be aided by representations, symbols, or thoughts but is totally dependent upon perceptions and body movements. Therefore, an abused child may use the body to recreate the abuse, and this behavior, when acted out in inappropriate settings, must be stopped in a gentle but firm manner. The parent is most likely be the one to witness this behavior, so educating the parent is paramount. For example, a 2-year-old who takes off her clothes repeatedly and puts objects in her vagina should consistently have the clothes put back on and be given a firm “No!” The child should not be punished beyond this, for she is only repeating the behavior that has been learned without understanding why. As the child develops language, the parent may talk to her about it, but the response of “No” must be consistently repeated.

Any therapy with the child is primarily expressive in nature. A therapist trained in art and play therapy wants to offer the child opportunities for enactment through presentation of materials that invite repetition. Some of the toys, particularly the anatomically correct dolls, may appear to be stimulating to the child. However, they are not sexually stimulating to a child who does not already have that issue (Dawson, Vaughan, & Wagner, 1992; Sivan, Schor, Keoppl, & Noble, 1988). When a child appears to be sexually stimulated within the session, the therapist may want to steer the child toward the dolls, as it offers an opportunity for enactment in a safe way. Dolls, puppets, and, in particular, anatomically correct dolls can stimulate the kind of play that is useful toward the enactment of abusive situations (Klorer, 1995). Through repetition, the child can experiment with new modes of behavior or different outcomes. Children should not be allowed to remove their own clothes or act in a sexually provocative manner in the office but should be given dolls for this purpose.

The therapist wants to provide art materials for expressive purposes. Although the child may be only scribbling, the stories told about the scribbles may be meaningful. Play and drawing tap into primary process thinking, which helps the therapist understand the child’s mental representations of the event. Play and art provide opportunities for the child to reexamine, find new meaning for, reexperience, and rework the memory and the emotions associated with the trauma, independently of verbal processing.

For a child living in a secure family environment with a strong parental support system, therapy at this stage of development may be short term, with the understanding that further therapy may be needed as the child matures. However, one should not make the mistake of thinking that because there is no verbal or conscious memory, there has been no trauma. If the event is being symbolically reenacted in art or play, it suggests that there has in fact been severe trauma, and the child is using expressive means to gain mastery over the anxiety associated with the event. By providing an expressive outlet for this anxiety, the therapist is assisting the child in working through the trauma. The need to process verbally does not belong to the child of this age.

Carla, a 3-year-old, came into therapy because of suspicions of sexual abuse. Carla had shown a number of behavioral clues that indicated there was much trauma, although she could not disclose the nature of that trauma in any detail. Her behavior at home included excessive scrubbing of her genital area with a plastic doll brush; demonstration of sexual positions in her play with dolls; masturbation; sudden phobic fear of hair in her mouth; a sudden reaction to the point of nausea to any white, sticky food; and nightmares in which Carla would wake up screaming. She was able to disclose only that her dad “hurt my butt” and that “Daddy and a mean lady put fire in my butt.” Carla was a bright and precocious child but could never offer enough details to substantiate a child abuse case with the state’s protective services organization. In therapy, she appeared to be afraid to talk on some occasions, but on other occasions she appeared to dissociate. Always, Daddy’s name evoked anxiety for Carla. When I asked her about Daddy, she would sometimes make weird movements with her head and then stare off into space, suggestive of dissociation, or she would lie down on the floor and began writhing, as her eyes rolled around in her head. Other times she might run out of the room in distress or flit around from one activity to the next, seeming to illustrate the principle that you can’t hit a moving target (Walker, 1988). Carla would have been 2 years old at the time of the abuse, so her memories were preverbal, and hence she would not have access to descriptive words to convey exactly what happened. During the sensorimotor period, construction of mental structures is not aided by representations, symbols, or thoughts, but rather such schemes are totally dependent upon perceptions and body movements (Piaget & Inhelder, 1969). Her avoidance and dissociative behavior whenever Daddy’s name was mentioned and her vague admissions, along with sexual acting-out behavior, were such that sexual abuse with her father as perpetrator was highly suspected, and the immediate concern was to get legal intervention so that he would have no unsupervised visitation. Once this was accomplished, I felt that creating further trauma through “therapy” that attempted to get the child to remember and disclose details was not in Carla’s best interest at this time, since she was safe from further abuse. Because several months had gone by since Carla had seen her father, and her mother and she had moved to a new area, very little from their previous life was available anymore to stimulate memories, so she was becoming even less verbal about the memories. Consequently, a more subdued and nondirective approach to therapy was used, with unstructured playtime and art making available for her to choose and direct her own therapy.

Carla’s play therapy themes indicated a number of fears, including fears of monsters, spiders, the dark, and bad people. Ultimately, through repetition of themes, Carla was able to gain more control of her anxieties. Toward the end of therapy, play therapy themes began to take on a more positive character, such as sandtray themes of mother animals taking care of their baby animals and living “happily ever after.” Therapy was terminated when Carla turned 4. The decision to terminate was made when nightmares had ceased and Carla was generally observed to be less anxious and better able to cope with stressful situations. At that time, I recommended that further therapy would be warranted as Carla got older, almost inevitably at adolescence. For a period of time I became more directive, working with Carla on sexual abuse-prevention techniques through reading books about potentially abusive situations for animals and children, and having Carla repeat ways for the characters to stay safe. She also worked on the identification of simple feelings (happy, sad, scared) through drawings.

Awareness of other people’s feelings and the ability to identify specific situations that evoke different kinds of affective responses are important in learning prevention techniques. Although children are primarily egocentric, studies (Borke, 1971, 1972; Greenspan, 1979) suggest that children as young as 3 can differentiate between happy and unhappy feelings in other people. Games that allow the child an opportunity to learn simple feelings complement the treatment.

We can hope that children under age 2 or 3 forget their traumas. Terr (1985) suggested that some do so because of the massive repressions normal in the first years of life, and some because the trauma occurred at a time when the child had not yet acquired adequate words or symbols to represent and record the trauma. This has vast implications for the therapist working with children under the age of 3. It justifies the use of art and play therapy as the primary therapy and poses the question of whether it is even appropriate for the therapist to get children to talk about the abuse, for fear of leading them in a direction about which they are not able to process cognitively. Terr (1990) suggested that before about age 28 months, a child does not possess the mental capacity to take in, retain, or retrieve full traumatic images in words. Yet behavioral memory manifested in play is almost universal.

In terms of memory, a child is more likely to remember a single traumatic episode than repeated trauma. In a singular event the child does not have the foresight to activate defenses that would help in coping with the fear. Events that occur over time, however, stimulate defenses such as denial, splitting, self-anesthesia, and dissociation (Terr, 1990). Certainly in Carla’s case, dissociation appeared to be activated as a defense. Her abuse was suspected to have been repeated over a number of months, and hence she was able to anticipate its occurrence with her visits to her father. She learned to activate her defensive coping strategies in order to tolerate her fear, and she showed evidence of being severely distressed and disturbed. Always, we need to remember that the defenses the child has employed have served the child well.

Nurturance often becomes a primary issue in therapy for children of this age, and the therapist may also need to educate the parent about how to nurture the child. Parents who were not nurtured themselves may not know how important this is. The therapist may need to take an active nurturing role with the child, including hugging, rocking, and holding. For children with sexual abuse histories, touch is a very sensitive issue. The therapist should be open to touch but should allow the child to control when and how touch happens. Because of the interactive nature of art and play therapy, the therapist can test out the child’s receptivity to touch through the exchange of art materials or dolls. For very young children, the therapist might walk with his or her hand to the side and see if the child grasps it. In time, the child may initiate lap sitting or snuggling. The therapist should be aware that a child of this age may confuse sexuality and nurturing and be ever on the lookout for moments when this confusion is occurring in order to help the child understand sexual feelings. Providing appropriate boundaries is crucial.

I walked into the waiting room to meet my new client, a 3-year-old who had been placed in a foster home only 2 weeks earlier. Renita ran toward me and hugged my legs as I entered the room. She was tiny for her age and could hug only as high as my knees. I turned to her social worker and asked if Renita always greeted strangers in this manner. He did not know.

Inside my office, Renita and I sat at the art table. Renita asked where I lived. I reflected the question back to her. “Nowhere,” she answered. She said she used to live with her real mom and did not know why she doesn’t live there anymore. As we were talking, she scribbled with markers on the paper available. She could not name her scribbles, as a typical 3-year-old would be able to, and did not know her colors. She filled the paper with heavy-pressured lines and dots. After drawing, she explored the rest of the room with me and discovered the dollhouse, sandtray, puppets, and dolls. She moved quickly from toy to toy, not seeming to enjoy the play, but wanting to cover as much territory as possible.

When there were five minutes remaining in the session, we put away the toys she used and I gave her a sticker. She ran to the sticker drawer and began taking things out of the drawer. I told her she could not do this and told her it was time to go but that I would get to see her next week. Renita got very clingy and sad, and big tears flowed down her tiny face. She climbed up onto my lap and cried.

I reassured her that I would see her again and walked her out to the waiting room. As soon as I let go of her hand, she ran back into my office. I went to get her, but this time I carried her out and brought her to her social worker.

There was little information about Renita’s history. When a child this young comes into foster care, it is often because of extreme neglect. The details and extent of abuse come much later, in bits and pieces, through the child’s behavior and play.

Renita began to form a more genuine attachment to me in the ensuing weeks. The first play ritual that she established was with the Co-Oper Band. Renita was in control of the Band. When we got inside of it together, she pulled away and came toward me only a few feet before pulling back again. Each time she’d come toward me, she said in a singsongy voice, “I want YOU!” but then would pull back before she got too close. Then she began wrapping herself up in the Band, twirling toward me and getting all tangled, while saying, “I want you, I want you, I want you, I want you, I want YOU!”

At this point she would be all tangled up very close to me. Possibly because of the closeness this game allowed, this ritual led to playing “Baby.” Of course, Renita assigned herself to the role of the baby, and I was the mommy. I had to be clear with the boundaries of this game, as I did not want Renita to begin regressing at home or in her daycare, so I was careful to define the parameters of the play area, and when we moved back to the art area I always reminded her that she was no longer a baby but was big girl Renita again. This helped her to differentiate between the game and reality.

The first time she played “Baby,” Renita enacted the movements of an 8-month-old baby who has just mastered crawling toward things and reaching for what she wants. Her enactments were an almost perfect replication. Children often reenact an age at which their basic needs were not sufficiently met. They seem to know instinctively what it is that they missed and need. She crawled toward “mommy,” and I reached out my arms toward her. She reached for the bottle, and I fed her. She cuddled close to me, and I rocked her. Renita always controlled the amount of touching that happened, and she seemed to crave the physical contact. Renita did not tire of this game easily. She was ensuring that her unmet nurtur- ance needs were satisfied. After several weeks of “Baby,” Renita’s baby movements became more like a 1-year-old. She pulled herself up as if she were beginning to learn to walk. Her movements were strikingly realistic. In this phase, she explored more autonomously away from “mommy.” She would crawl behind the dollhouse and play “Where’s baby?” through the windows. She played “peek-a- boo.” She would walk toward the sandtray toys, speaking baby talk, and pick up toys that looked interesting, as if she were discovering them for the first time.

After about 5 months of working together, Renita came into her session and wanted to play “Baby” again. She sat on my lap with the bottle and cuddled close to me. She whined, “I want my mommy,” so I fed her and held her. She wanted to be very close. Suddenly, she got up off my lap and said in her regular voice, “Now I a little kid. I’m 3.” The 3-year-old stirred the sand and pretended to make popsicles for her and her mommy.

After several minutes of being 3, she announced, “Now I going to be the daddy and you be the mommy.” The daddy made food in the sandtray, fed the baby doll, and put the baby doll to bed. The daddy, mommy, and doll went on a car trip. When we returned, he gave the baby a bath, brushed her teeth, and put her to bed. “Now we go to bed,” Renita announced. I lay back on the beanbag chair I was sitting on, and Renita lay next to me. “Go to sleep!” Renita demanded. I pretended to be asleep. Suddenly, Renita started to get sexually stimulated. She began breathing heavier, ran her fingers softly along my neck and shoulder, and kissed me quickly on the lips, all in a matter of two seconds. I was startled, sat up immediately, and told Renita that we could not play that game. I told her adults cannot play that game with children. Renita looked confused and hurt.

I told her that when she wants to play that game, she can use my anatomical dolls. I asked if she wanted them, and she said yes. Renita took the dolls and said, “Him going to hump her.” She began with the adult male and female dolls, undid the man’s pants, and said, “Him put his dick in her and hump her.” She very carefully put the male doll’s penis into the female’s vagina and began pushing on his buttocks rhythmically with her hand. She then repeated this with the child dolls.

After we put the dolls away and moved back to the art table, I sat down and said I wanted to tell her something. Again I told her that adults and children cannot play that game. We can play “Baby,” and I can hold her and feed her, but we cannot play adult games. Renita looked very sad and rejected. In future sessions, I was more aware of the potential for her to misperceive situations and set firmer boundaries on our play. Renita learned that when she feels that kind of excitement she can use the dolls to play.

This was a highly sexualized child who likely received affectionate touches only during abuse. I needed to help her understand the feelings that were activated in her body so that she could begin to differentiate the two. Her confusion of nurturing and sexuality was understandable and quite complex for a child of this age to understand. I talked at length to her foster mother about her own interactions with Renita, as I correctly assumed that if it happened in my office it was happening elsewhere. I made suggestions as to how to set limits when Renita appeared to be confused. I suggested that she allow Renita to touch her own genitals when alone in her bed, but not at other times. When goodnight kisses took on a sexual nuance,

I suggested the foster mother tell Renita that mothers and daughters do not kiss like that.

When working with a child of a very young age, or an older child who is functioning emotionally at a regressed stage of development because of past deprivation and abuse, one immediately needs to assess the possibility of working with the parents or guardians to help them learn to deal with behaviors as they arise. Because the parents are most likely to witness the acting-out behavior, it is almost impossible to have an effect on behavior without their help. Finding a consistent reaction to behavior helps the child learn what is appropriate and inappropriate. This then coincides with the therapist’s expressive work, wherein we attempt to help the child understand the feelings that accompany the behavior. This is accomplished through following the child’s lead in terms of choices of materials and types of interaction, such as movement, art, and play. The therapist needs to put words on feelings for the child of this age as they are being expressed, remembering, however, that the need to process verbally does not belong to the child. As the child matures, he or she will be able to make more use of symbolism in art and play.

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