Is Play Therapy Enough?

Working with children who have been exposed to trauma has been a difficult topic to tackle for most therapists because as with adult therapies there are a variety of methods available when treating children, each with their own sets of advantages and disadvantages. Another difficulty is that children have not yet developed the level of insight and objectivity needed when working with adults using therapies such as CBT or Psychodynamic therapies for example, making it difficult to gauge whether one is achieving anything. Children can also create or exaggerate on existing stories, occasionally unsure of the difference between fantasy and reality.

Is play therapy enough? One of the main premises in play therapy is reaching underlying and not easily accessible emotions, using indirect methods that make children feel more comfortable (www.playtherapy.co.za). This method allows children to begin to open up and express themselves through games. Is expression per se or on its own enough though? Evidence based therapies, such as CBT and others, tend to have clear step by step programs and techniques for eliciting real and permanent change in behaviour and cognitive processing? 

According to studies Psychodynamic therapy for children affected by trauma appears to be quite effective. This form of therapy is based largely on the developing and strengthening of relationships in the child’s life and includes the family, particularly the parents in the healing process. “A core aspect of psychodynamic psychotherapies is that the ultimate goal is to promote personality coherence and healthy development rather than to alleviate symptom severity alone” (Foa, Keane, Friedman & Cohen, 2009; 586). This form of therapy appears to be aimed at a more sustainable approach to childhood trauma focusing on long-term mental wellbeing, whereas play therapy appears to be more focused on expression.

From a systemic perspective, when working with children one should always aim to incorporate their parents and family as much as possible, you cannot heal a child in isolation as they are part of a larger system on which they are dependent. To effect real change the system needs to be incorporated (http://ecosystemic-psychology.org.za/). However, when using play therapy the child and therapist work alone, is this really the most effective means of working through trauma? Especially when one considers the fact that a child will spend one hour a week with their therapist playing, and the rest of the week with their family, surely their family should be involved and at least educated as to effective support strategies for their child.

Children have not yet fully developed the ability to articulate what they feel or even why they feel the way they do; “toys are a child’s words and playing is their conversation” (http://pegasus.cc.ucf.edu/~drbryce/Play%20Therapy%20Techniques.pdf). Professionals have to look to the games children play to discover the story a child is trying to tell you. This becomes especially difficult when one is attempting to make an assessment of a child’s safety and it comes down to deciphering what is fantasy and what is reality. The interpretation made by a therapist can have severe and far reaching consequences in the child’s life, even legal cases in instances of suspected abuse, adding pressure to make the correct assessment. Is the analysis of a repetitive pattern of play really sufficient in determining whether or not a child is being abused or is unsafe in their home environment? There are a variety of influences that can inform the games that a child plays including, but not limited to, games learnt from other children, television programs, computer games and the internet. How can we be sure that the story we are being told is rooted in reality?

Generally it seems to be accepted as axiomatic that play therapy is the method of choice to deal with childhood trauma. However, it is fair to say that play therapy actually needs considerably closer, scientific scrutiny, and a sound evidence base, before the widespread use of the modality is justified.

Hanover Park: How do we end the vicious cycle of gang violence?

Description and history

Hanover Park is a predominantly coloured community in the Western Cape. This community has been plagued by gang violence for over a decade. There are two main gangs in the area namely the Americans and the Mongrels and most of the violence between these gangs has erupted as a result of territory (turf) wars. Since these turf wars have started, the Mongrels have split, creating another gang known as the Laughing boys. These turf wars affect the entire community.

One of the most frightening aspects is that members lure children into their gangs with promises of a better lifestyle and more money. One of the initiation programmes is for a new gang member to shoot a member of the opposite gang (dead) in order to prove their worthiness in the gang. As recently as a few weeks ago, a nine year old child was taught to use a gun and shot and killed an adult for one hundred rand. Because of the nature of the crime, the child will not be released from police custody (http://www.eyewitnessnews.co.za/Story.aspx?Id=66966)

The gangs prey on the weak and vulnerable in the community taking advantage of poverty, addiction unstable home environments, absent fathers and the like. Families are being paid up to four and a half thousand rand a night to house the gangster’s drugs and whatever else they need to store. The people chosen are usually selected as they seem least likely to be suspected by police, and are often not in a financial position to say no. They suddenly have access to a lot of money and a lot of drugs, mainly tik, and begin to indulge themselves. Their addiction and dependence on the income from the gangsters is how they become trapped.

Families are also given money by the gangsters so that their sons can go and kill a ‘target.’ Because the families are not in a position to refuse, they support and encourage their children in the gangster’s requests. To kill another human, a teenage boy’s family is paid up to one thousand rand. Families sell their daughters to the gangsters for the protection of their daughter and the family as a whole, as well as the money that they so desperately need to survive.

Taxis and their drivers operate under gangs as well. Often they will have what is termed a ‘taxi queen.’ A taxi queen is a girl that the taxi driver uses as a prostitute. This is appealing to the girls especially in the context of poverty because this man is making them feel special he has a car and buys them nice things. These girls can be as young as eleven years old.

Current situation

Since October 2010 the gangs have been relatively peaceful as a result of a peace treaty that was signed. However, this treaty did not last and turf wars have recently restarted in Hanover Park. Since May 2011 at least four gang related deaths have been reported, two of which occurred in the space of a week. This Monday (8^th of August 2011) gangsters were searching for and chasing a teenage boy that had been labelled a target, and shot him dead. Children have to walk home from school and various other places in the afternoon amidst a full blown gang war.

Interdicts are legal sanctions prohibiting the behaviour of one person against another. Interdicts are usually employed in spousal relationships against abuse. Currently police stations are filled with people waiting to get interdicts, what is frightening is that these interdicts are acquired by parents against their own children. A large majority of parents in the community are afraid of their own sons, because of their gang involvement and their dependence on tik (http://www.thefreedictionary.com/interdict).

Tik makes people very volatile, it is a stimulant and thus keeps one awake for extended periods of time, when on tik people don’t eat and feel nauseous when they do, people on tik lose interest in maintaining their lives. It is thus understandable that parents feel frightened of their children. Especially when an addiction to tik is paired with gang involvement, aggression and a gun (http://www.12steptreatmentcentres.com/TIK_CRYSTAL_METH_DRUG_ABUSE_SOUTH_AFRICA_79.asp).

The nature of the turf wars are such that shoot outs start up randomly throughout Hanover Park, in the midst of innocent community members and children. The residents have to take cover for fear of ricochet bullets and wait for the shooting to stop. Community members are not supposed leave their homes after six o’clock in the evening for their own safety. The community is in a state of hyper-vigilance, as there is no certainty as to where and when the next shoot out will erupt and who will be in danger. This state of hyper-vigilance has been observed even prior to this recent outburst of gang violence.

 Potential psychological effects

Hyper-vigilance falls under the subsection of hyper-arousal in the DSM-IV-TR definition of Posttraumatic stress disorder, and is to be expected given the circumstances. The same is true for intrusion and constriction. Posttraumatic stress disorder is manageable provided that the person begins to feel safe and is in no immediate threat. The people of Hanover Park and people in other communities undergoing similar experiences do not feel safe, and live in constant fear. In these circumstances how does one even begin to correct the damage of this continuous trauma?

Long term effects of continuous trauma on the community

Possible long term effects of continuous trauma on the community of Hanover Park include but are not limited to; flattened/inappropriate affect, dissociation, hyper-vigilance, sleep disturbances, hyper arousal and eating disorders. Learning difficulties amongst children exposed to trauma are common, which may account for a high academic failure rate in these communities. Children that have been exposed to trauma are often very hyperactive, causing them to be ‘problem’ children. The behaviour associated with ‘problem’ children can often lead to abuse of the children on the part of the parents as they do not know how to handle their children for a number of reasons, firstly ‘problem’ children are difficult to handle for any parent let alone parents living in Hanover Park under constant stress, secondly the parents are likely to be traumatised themselves as a result of their own experiences within the community which is likely to impair their judgement, trauma can often lead to substance abuse which also impairs ones judgement and is commonly related to child abuse, and lastly the parents in Hanover Park more often than not  have not had good role models as far as parenting is concerned (http://www.monash.ac.za/tyronepretorius/fortitude-and-violence-in-adolescents.pdf).

Ineffective parenting styles and the community environment can lead members to seek safety and security for themselves and their families, especially young boys and men, making them vulnerable to recruitment by older gang members.

The recruitment of younger members into gangs allows the gangs to continue, as they use the younger members to commit their crimes, as they are not eligible for prosecution. In so doing allowing the violence to continue, which in turn continues to traumatise the community and so the cycle continues.

Can this be rectified? Can we expect change in an environment that while begging for it, enables things to continue?

Speaking to members of the community has revealed that more often than not family members are well aware of the gang status of their children, and protect them and their identity, so that they are neither discovered nor arrested. Some community members also leave their houses open or unlocked allowing gangsters to use their homes as storage points and hiding places for guns or drugs or whatever else they might need them for. It is these sorts of behaviours that enable gangs and gang violence to continue in the community of Hanover Park. It seems unrealistic to expect change in this community as the community itself is enabling the gangs and gang violence to continue.

What sorts of interventions have the power to illicit possible long term change in Hanover Park and similar communities? Where and how would one begin especially when the effect of continuous trauma on the community members themselves is taken into account?

Osama Bin Ladens’ Death: Psychologically traumatic or relieving?

When a person experiences a traumatic event they can begin to question the status of the world, sometimes changing it from a safe and friendly place to a scary and uncertain one.  It has been suggested by researchers that if the perpetrator is held accountable or captured there can be a reduction in the symptoms of PTSD as they have gained closer from the event.  After the killing of Osama bin Laden, one wonders if the same will happen for the survivors, and people affected by 9/11.  http://www.rcpsych.ac.uk/mentalhealthinfo/problems/ptsd/posttraumaticstressdisorder.aspx

It has been found that if a person who experiences a traumatic event is involved in restorative justice there is quicker recovery or a greater chance at recovery as there is an opportunity to address the perpetrator and gain closure.http://www.restorativejustice.org/RJOB/restorative-justice2019s-impact-on-participants2019-psychological-and-physical-health Restorative Justice is the process in which  the survivor gives the perpetrator tasks to do that will allow the survivor to get a sense of justice. A good example of this is the Amy Biehl Foundationhttp://www.amybiehl.org/amy.php , where the murderers who killed Amy were required to work in her organisation.  In this way the perpetrators were able to feel that they had amended for their actions and the people affected felt that they had received a sense of justice.Will people affected by 9/11 be able to get this sense of Justice after the killing of bin Laden by US military?http://books.google.co.za/books?hl=en&lr=&id=zZXyBALVs7EC&oi=fnd&pg=PA1&dq=Factors+aiding+the+recovery+of+PTSD&ots=Jk6A0x1Pm-&sig=HAx724YX2IoVeytAJkftCsNvi84#v=onepage&q&f=false

This question has many confounding factors to consider.  Firstly, because America waged war in the efforts to find Osama they lost around a 1000 US military soldiers http://abcnews.go.com/Politics/1000-us-military-casualties-sept-11-inspired-war/story?id=9986252.  This contributes to the increase in people suffering from loss due to the effects of 9/11, as many families have had to suffer while their loved ones were at war.This begs the question, how many lives was bin Laden’s worth?

Secondly, the positive effects of finding Bin Laden could be confounded by the fact that the American military took 10 years to find Osama Bin Laden, therefore, many people who have suffered from the psychological impact of 9/11 may have moved on. However, with the hype and publicity of bin Laden’s killing they might start re-experiencing the memories of 9/11. Although some could find the killing of Osama a way to gain closure, for some it could simply bring back old memories of a difficult and traumatic time.http://www.theeastafrican.co.ke/news/Bin+Laden+killing+justice+for+1998+bombing+victims+Kenya/-/2558/1154760/-/w13jkv/-/

Lastly, because Osama bin Laden refused to be detained he was killed. This makes it impossible for those members of the public who wanted insight into the motives, to gain an understanding of his various behaviours and actions. If Osama had been captured and stood trial some of these questions might have been answered, allowing those people to gain understanding or attempt to engage in restorative justice.http://www.internationalpeaceandconflict.org/profiles/blogs/killing-osama-bin-laden

The question of the psychological impact of bin Laden’s death on those who were affected by terrorist attacks is a complex investigation with many factors to consider.  Here some of these factors have been discussed briefly, but unless more research is done the exact therapeutic benefits of this will be unknown.

So in your opinion, will the Killing of Osama Bin Laden lead to the relief of psychological trauma related symptoms, for those affected by various terror attacks, such as 9/11?

The Consumer Protection Act: How does this effect medical practitioner, psychologists and counsellors?

The consumer protection act that has recently been implemented in South Africa protects buyers from multiple adverse situations, by giving them a legal foot to stand on. http://www.iol.co.za/news/south-africa/how-the-new-consumer-law-protects-you-1.1020996 . How does this act affect service providers such as medical practitioners, psychologist, and counsellors?

According to the act section 54 a consumer has the right to good quality services, in a timely manner, with the expected quality agreed to by the provider and consumer, without any property being harmed while the service is being provided.  If the service provider does not comply with this the consumer has the right to request the service provider to fix the problems or to refund the consumer a reasonable portion of the price paid. http://www.michalsons.co.za/wp-content/uploads/2009/04/consumer_protection_act_68_2008.pdf  http://www.iol.co.za/news/south-africa/consumer-protection-act-explained-1.1041008

If one were to literally translate this into the medical practice context, it paints a disturbing and scary picture for psychologists.  It implies that should a client not be happy with the services that they receive in therapy, they will be entitled to get the services that they demand or a partial refund.  The nature of receiving services from a psychologist is a complex and multidimensional process; it requires both the consumer and the practitioner to become involved in a changing relationship.  Unfortunately there is no guarantee that such services with be effective as there is no one formulae that can be applied to all consumers.  Therefore does this new act leave psychologists and counsellor in murky water where they can expect an increase in law suits?

Although the consumer protection act from the outside creates a concern surrounding an increase in litigation in the medical field, all hope is not lost. According to Dinnie (2009) if consumers (patients) are unhappy with the services that they receive in the medical context they will be better off relying on the common law, as a partial refund of the services will not cover all the expenses to allow the consumer to seek additional medical help.  For example if a consumer undergoes surgery and is not happy with the results, if they claim under the new consumer protection act, they will be allowed a partial refund or the same surgeon fixing the problem.  If the client was to claim a partial refund this would not cover the expenses to allow the consumer to seek additional medical help. The consumer would be better off relying on the common law, where they would be able to claim more for the incident, by suing for negligence and malpractice.  In the mental healthcare although nothing concrete has been written one would think that the same would apply, thus not changing the legal umbrella that we are currently under. http://www.sajbl.org.za/index.php/sajbl/article/viewFile/62/48 http://proffessa.co.za/articles/how-will-the-new-consumer-protection-act-affect-your-medical-practice/

In conjunction with the above, it has been determined by the minister that the consumer protection act is applicable only to those companies that are above the threshold of two million annual turnovers.  This means that the smaller practices are not affected by the new consumer protection act. http://www.polity.org.za/article/consumer-protection-act-682008-determination-of-threshold-in-terms-of-the-act-gazette-no-34181-notice-294-2011-04-01 . http://us-cdn.creamermedia.co.za/assets/articles/attachments/32645_n294.pdf  

The fear of having an increase in litigation, in medical practices due to this new act is unfounded.  If the client decides to use the consumer protection act the medical practice would need to have an annual turnover of above two million rand for the act to apply. Resulting in only the bigger practices being affected by it; however consumers are more likely to sue for negligence and malpractice (in the common law) than the new consumer protection act.

For more information about relevant issues in psychology see www.traumatrainingonline.com

A Closer Look at the Japanese Earthquake, Tsunami and now nuclear radiation threats.

The Tsunami in Japan has resulted in worldwide concern; this has increased with the additional threats of nuclear radiation.  http://www.worldnewsco.com/news/japan-tsunami-radiation-threat.  Due to these contamination effecting a larger population and having potentially devastating effect on the Aid workers, creating a whole new dimension the to an already horrific natural disaster. The nuclear threats pose not only physical concerns but can increase the potential psychological problems of survivors developing PTSD and secondary traumatisation for Aid workers. http://www.newsweek.com/2011/04/10/too-much-trauma.html

The psychological impact after the Japanese Tsunami has been predicted to look rather dismal. Psychologists say that there is a 25% chance of survivors developing PTSD after the initial Tsunami. This percentage is likely to increase with the threats of nuclear radiation http://blisstree.com/feel/scary-psychological-effects-of-japans-earthquake-tsunami-and-nuclear-disaster/

Psychologists might estimate high rates of survivors developing PTSD after a critical incident, however it was shown that during the 9/11 attack on the world trade centres, people were not as likely to have developed PTSD as predicted. Resulting in many researchers to begin investigating the resilience of people and what helps survivors in such circumstances.  Resulting in the development of Psychological first aid, (see previous post) http://www.stockholmresilience.org/research/whatisresilience.4.aeea46911a3127427980004249.htmlhttp://ptsd.about.com/od/causesanddevelopment/a/Sept11_PTSD.htm

Although, the Tsunami is very different to the 9/11 attack, I think that as mental health workers we should be weary when estimating the extent to which PTSD might occur as to avoid the effects of a self-fulfilling prophecy. http://www.suite101.com/content/selffulfilling-prophecies-a15843 .If psychologists warn the survivors of the Tsunami about a potential at developing PTSD following the disaster and state the high probability of them developing the disorder, a self-fulfilling prophecy could occur, where more people develop PTSD due to them believing it is out of their control, because of what psychologists have said.

The risk of the survivors developing PTSD has already been discussed however, a real concern is the mental health of Aid workers, as they risk developing secondary traumatisation, which is also known as Vicarious trauma http://www.buzzle.com/editorials/6-27-2006-100635.asp.  Vicarious trauma is when a person witnesses a disaster and starts to develop an adverse reaction to the event, which holds many similar symptoms to PTSD.  This is found when people who are not directly affected by the disaster such as observers, Aid workers, rescuers, or even people watching on TV, start developing PTSD symptoms from what they have witnessed of a disaster.  http://www.uic.edu/orgs/convening/vicariou.htm . 

The prevalence of vicarious trauma is increased when rescuers have an increase in risk of their own life and wellbeing; hence the situation as it stands in Japan is affecting more than just the survivors.  With the nuclear radiation threats both the health and psychological states of Aid workers are now important components to consider, as the probability of them developing vicarious trauma is increased.http://www.headington-institute.org/Default.aspx?tabid=2649

As mental health workers responding to this crisis, it is important to remember the cumulative effect of this particular natural disaster. The initial earthquake, Tsunami and now the nuclear radiation threats accumulate and affect the mental health of the survivors.  Along with the survivors needs its necessary to investigate the effects of responding to this disaster as Aid workers and the real concern of Aid workers developing vicarious trauma.

For more information on the different reactions to trauma look at www.traumatrainingonline.com

How Should Mental Health Workers Provide Effective Psychological Aid in the Wake of Massive Natural Disasters?

As humans we have developed various technologies to be able to predict events happening on our earth. However, we are still unable to predict natural disasters, or create effective pre-warning systems that provide adequate time for people to successfully evacuate, resulting in many natural disasters having catastrophic effects. When these extraordinary events happen people from all over the world flock to the affected area, in the hope that they can help make the situation marginally better.

Since 9/11 the concept of Psychological First Aid (Psychological First Aid Field Operations Guide) has become widely accepted as an adjunct to the usual aid and rescue efforts. Its purpose is to assist individuals and communities cope with the massive psychological trauma that is usually associated with large scale disasters.

Psychological First Aid is firstly a response to the immediate needs of the survivors of a disaster before any counselling or mental help is given. These initial needs are usually for safety and protection and for reconnecting with family, before seeking professional help. The main purpose of Psychological First Aid is to set up a social support and resource system in the wake of a natural disaster, instead of merely providing one on one counselling. The need for counselling is usually not a priority shortly after the initial impact, and becomes relevant only later on when the more primary needs have been met, and it becomes evident that mental health issues are at stake.

Prior to the development of Psychological First Aid,  various techniques had been used as part of this immediate psychological response, the most popular being Critical Incident Stress Debriefing (CISD) which falls under the umbrella term of Critical Incident Stress Management (CISM). Although their efficacy is widely questioned, these techniques are still in common use today, when natural disasters strike, mainly because it is an easy recipe to follow in response to trauma. It has been particularly popular with volunteer counsellors.

CISD is a seven step debriefing method, where the facilitator goes through each phase sequentially with the client, which can also be conducted in a group setting (http://www.info-trauma.org/flash/media-e/mitchellCriticalIncidentStressDebriefing.pdf ). The phases of CISD are as follows; the facilitator begins with an assessment of the survivor’s situation, then any immediate safety concerns are removed, the facilitator then gathers the facts from the client, and then explores the feelings and symptoms that the client is experiencing, after which the facilitator begins to teach healthy coping strategies and then re-enters the client back into their environment. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VH7-3XG84F4-&_user=10&_coverDate=01%2F02%2F2000&_rdoc=1&_fmt=high&_orig=browse&_origin=browse&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=76e308ea061eab5502ff10e5a60e0f78

This technique (CISD) was designed to help reduce the long term effects of trauma and ultimately decrease the development of PTSD. However, the effectiveness of this method has been questioned by various authors with some arguing that the impact of CISD can increase the possibility of developing PTSD, as they can be re-traumatised as a result of too much processing of the event too soon after the incident has occurred. http://goliath.ecnext.com/coms2/gi_0199-10209751/Psychological-debriefing-may-not-be.html

Research shows that when a person experiences a traumatic event it is stored as a visual memory, which takes time to be encoded into words. Using this research of McNally, Bryant & Ehlers (2003) argue that people who talk about the incident immediately after a traumatic experience, may not yet have finished encoding the event into words. In many cases this results in some individuals compounding their traumatic memories. The normal processing of the event has been rushed, causing them to have a higher chance of developing PTSD (nspb.net/index.php/nspb/article/view/34/31).

As this debate presently stands people are moving away from using CISD to using Psychological First Aid. However, mental health aid workers are still confused about what is the most effective method to use in this field.  This confusion is only compounded in the wake of the Japanese Tsunami. When and how do you think mental health workers should respond specifically to the Japanese Tsunami, and generally to future natural disasters? http://healthland.time.com/2011/03/14/tending-to-japans-psychological-scars-what-hurts-what-helps/

Additional links:

http://www.ncjrs.gov/App/publications/abstract.aspx?ID=122816

http://www.aaets.org/article54.htm

For more information visit Trauma Training Online at http://www.traumatrainingonline.com/