Abstract
In this article, Catherine Sori interviews Dr. Eliana Gil about her work with traumatized children and their families. Eliana Gil discusses her trauma-focused integrative play therapy model, and gives practical tips on how to use the model to improve practice with this population. This is the first of two articles from an interview with Dr. Eliana Gil.
Biography
Eliana Gil is known for her work in treating abused and traumatized children and their families. She offers comprehensive clinical training programs on topics such as assessing and treating traumatized children, using family play therapy in the treatment of children and families, art, and sandtray therapy. She has worked in child abuse agencies in both California and Virginia. She is currently in private practice at the Gil Center for Healing and Play, located in Fairfax, Virginia, a center that specializes in childhood trauma. She is a prolific author of numerous books, chapters, articles, and videos on topics including treating trauma in children and adolescents, family play therapy, expressive arts, and cultural issues in play therapy. She has a new book on problem sexual behaviors coming out, and is in the process of revising her classic book on family play therapy. Her credentials include being a registered art therapist, a registered play therapy supervisor, and a licensed marriage and family therapist. As an adjunct faculty member at Virginia Tech and George Washington Universities, she teaches classes in both play therapy and family therapy. She is the past president of the Association for Play therapy. She has served on the Board of the Directors for the National Resource Center on Child Sexual Abuse and the American Professional Society on the Abuse of Children. Thank you so much, Eliana! I am excited about this interview, and am hoping that this will be a way for many more professionals to understand how trauma affects children, and the importance of the work you are doing. After attending one of your workshops recently, I became fascinated with the integrated play therapy model you have developed, and what that looks like in your approach to treating traumatized children. Thank you! Would you like to start by sharing your credentials and what you are doing now? I started working in 1973 on the issues of child abuse, prevention, and treatment, and so that became a focal point for me very early on. I have stayed in that field, attended a lot of workshops and trainings, and read a lot. In addition, I have shared my experiences with people as I have worked in the field and have gathered clinical information and experience with children and with families. I am just amazed at how much opportunity there is right now from the different scientific advances that have occurred in the last 10 years or so. We are much better anchored in knowing how to be helpful than probably ever before, and at the same time recognizing that there is still so much work to be developed further.
There is so much new information that has been presented that challenges what we know about clinical practice. We need to stay current on topics because research is evolving very quickly, guiding ways to incorporate the things that we learn. I have always been someone who likes to take large pieces of data and then try to translate them and funnel them through some kind of lens of practicality, thinking, now that I know all of that, what do I say or do differently with the children and families I work with? An integrative approach probably makes the most sense for most of us at this point. There is a good deal of innovative work and good information if we are receptive to learning new things. I have always felt that it is important to maintain an open, receptive stance. I learned the importance of having specialized training to work with specific populations as a music therapist, and that is certainly true for counselors who want to work with traumatized children and their families. Can we talk about your Trauma-Focused Integrative Play Therapy (TFIPT) model? I know you have stated that this approach is “anchored in both hard science and trauma theory.” Can you say a little bit about that? Yes. Basically, the TFIPT is a model. It is a way of organizing the approaches that we have toward individuals who have been traumatized. When I say “hard science,” it really has to do with what we have come to understand about the impact of trauma. Starting with Judith Herman, and then Bessel van der Kolk and Allan Schorr, and so many other people who have advanced the notion that trauma impacts a person fully, on so many different levels. Because of that, it becomes necessary to provide an integrative or holistic approach. You cannot just be treating one piece of the person, the intellectual part, or the emotional part, or the physical part; therapy has to be a comprehensive effort. The contemporary focus on science has to do with the impact of trauma on brain functioning, and the way that trauma can create defensive strategies, such as dissociation; and how memory is encoded—whether it is implicit or explicit. Sometimes traumatic memories can become fragmented. These are principles in trauma theory about which most people are now pretty clear. However, we must understand the context when working with people who have their own phenomenological way of experiencing and resisting trauma. They may have their own specific defensive strategies, their own internal resources.
Probably the biggest question in the research field is how one particular trauma can overwhelm one child in one circumstance, and another child experiencing exactly the same thing will have a completely different response to the trauma, all the variables being as close as possible. We need to understand what it is about human biology, temperament, and all those very individualized features, that create stress resistance in some children and adults, while for others this ability to resist stress is a little more compromised. What creates those kinds of circumstances? I think there is an overriding interest on the impact of trauma in a very individualized way. Individual characteristics help us understand the impact of trauma and respond to each unique person according to his or her specific needs.
The other part is what we also need to understand how trauma can create difficulties in how people perceive things. For us as clinicians, engaging, inviting, and interacting with individuals who have histories of interpersonal trauma is a challenge. How do we create environments that welcome them, and environments that are receptive to their challenges, their defensive strategies, and their resources? We can optimize a positive experience. We can prepare them and move them beyond the particular ways in which trauma has affected them, where they begin to feel mastery and control. Many people can overcome traumatic experiences, and understanding the clinical approach that helps best is critical.
The model I use is trauma-informed first and foremost. It is based on years and years of working with children, and understanding that trauma and all of its repercussions present some very special challenges. The first goal is to create an atmosphere where a safe, healing process can occur. The model we use is based on Judith Herman’s foundational work on trauma, and her three phases of treatment. To this day, her work is a guiding force in terms of making sure that safety can occur first and foremost in any kind of clinical relationship. Sounds like safety is crucial to the relationship. Can you discuss how creating safety lowers the defense mechanisms you mentioned before, and how this focus can lead to better treatment outcomes? What that really means is that you give children time to anchor themselves in the setting, and in the relationship to the other person, before discussing topics that could be sensitive. Approaching trauma discussions prematurely could create enough stress to cause a withdrawal, or a compliance with a conversation that may not have substantive meaning. The phasing is really important. Some children may come in and just want to sit down and talk about past trauma, but this is rare. The important part of treatment is to just be inviting and engaging and connecting. The older I get, the more I realize the importance of being available to invite the client to have a relationship. When there has been interpersonal trauma, the relationship issues need to be explored, considering that abused children experienced pain within the context of an interpersonal relationship. When you invite a child into a clinical setting, it can appear dangerous. The child is with an unknown person, in a small room, and the door is closed. This is a place where child and clinician get to know each other, which again, may create a certain amount of anxiety. Counselors need to be aware that trauma repercussions really do play a part in establishing a therapy alliance.
That is why I thought Judith Herman’s work was so important. Early clinical understanding of trauma suggested that the therapist really had to get the person to talk immediately in detail about everything that had happened. Sometimes clinicians tried to push people to talk, and that created acute difficulties, such as the client withdrawing, because the exposure was too soon and occurred prior to the establishment of therapeutic safety.
In Herman’s model, the middle phase of therapy has to do with addressing the traumatic events. Another thing that I saw was that some were so cautious about not rushing into things or making people uncomfortable or withdrawn, that they avoided the whole topic completely. That sounds like there were two opposite poles on the spectrum of when and how to address trauma. Why do you think clinicians have difficulty with the timing of the discussion of trauma? I think there is clinical discomfort in addressing that area because some clinicians are unprepared to work with trauma. I know it is different right now, but when we were getting trained in the 60s and 70s, there was not enough information about trauma. We really did not know what to teach students when people started disclosing abuse, and in spite of our good intentions, we were uncertain how to respond to clients. Now there appears to be some consensus about what we do, and some consensus about what we do not do. There have been some really odd, random examples of clinical interventions that have been dangerous to people. We have to be cautious, client-oriented, first and foremost; and then at the same time, take in whatever new information becomes available. We may not be on the same page about how to address clinical issues; but at least we are on the same page that there is a kind of cluster of different areas to which we have to attend. I think that we have consensus areas in treatment that are really important and relevant.
Gil’s TFIPT Model
How does your TFIPT model incorporate all of this information? I am particularly curious about how your model integrates play therapy. The TFIPT model was an attempt to take this trauma-informed material and organize it so that there was attention to pacing and phasing of treatment, with an attention to safety in particular. One critical factor when working with children is the integration of child-friendly interventions. That is why it is called “Trauma-Focused Integrated Play Therapy,” because it gives us an opportunity to look at how play therapy actually can be engaging, and inviting, and helpful to children enough, so that they make an investment in their own recovery process. We have to be informed about play therapy, the directive and the nondirective approaches, and how children may actually guide this process if we are really paying attention to what their needs are. It sounds like clinicians are advised to pick up cues from the child in order to decide the best type of play therapy to use in session. And that is the best way—to let the child guide the process? Yes. I always think it is funny when people consistently ask me, “What kind of play therapist are you?” I believe it depends on the child I am working with. It is really the child who is going to require me to be one way or another. So I have to be pretty well versed in both directive and nondirective strategies, and be conversant with those fields enough to be able to shift and function in either one or the other, based on the child’s needs. The children are really who I am most interested in; I pay attention to how they negotiate for what they need. They are good at letting you know what seems to be helpful to them by their behavior and their investment in what they are doing. Listening to all this, it makes me wonder if the field of individual child treatment—whether it is play therapy or someone from a more psychiatric position—is ahead of the fields of family counseling and family therapy in addressing childhood abuse and trauma. How do you see it? As a family therapist, it has been interesting to watch the evolution of what therapists become interested in, such as attachment, or trauma or domestic violence. Some family therapists take an issue and then develop a model around it: for example, domestic violence. So, in that area there has been some movement. In the area of childhood trauma, the most visible models appear to be the brief therapists. I just saw something called “Trauma without Drama,” that offered a one-session treatment for childhood trauma. The emphasis is how to get past trauma more quickly by doing these interesting family therapy interventions. And that worries me. But there have been some good family therapists working in the field of trauma, Marsha Scheinberg, Peter Frankel, and Mary Jo Barrett, for example. Yes, Mary Jo Barrett. Mary Jo has been wonderful! And Yvonne Dolan looks at trauma using an Ericksonian point of view. So, there are a handful of family therapists interested in trauma. As pervasive as childhood trauma is, and as much as one would assume that it is seen within the context of families, it is interesting that there has not been more leadership from the family field. So the trends that you are seeing in the field are toward brief therapies for the treatment of childhood trauma. I think there is such a push in managed care that fits with the more postmodern theories, especially a solution-focused approach. This trend would be counter to doing longer, more in-depth individual treatment with children. It also seems to go back to the research from about 15 years ago, about how children are excluded so often from family sessions, in large part due to perceived inadequacy of their training. If people are not trained to work with children in general, they certainly are not going to be trained to work with children who have experienced trauma. Absolutely. I agree. Some people avoid certain topics. For example, if a child starts talking about biting or hitting, or being beaten, therapists may not want to delve into the subject. They may just avoid that issue and move on to emphasize something else. Specialized interest and training is really required. The signs of abuse may be there, but unless somebody is trained to know what those are, they may not necessarily look in that direction. I totally agree that specialized training is essential first to be able to recognize abuse, then to know how to create a sensitive and caring environment before beginning to address any trauma, and then to engage children in effective play therapy techniques. Your TFIPT model is a sensitive approach that reflects this specialized training and provides a guide for clinicians to do meaningful work with these clients. Can you discuss the phases of the model, and how to implement the model in practice? Yes. There are three phases of treatment, and the first phase is on safety. This is the time, I always say, when the clinician is working behind the scenes by exploring what kind of environment the children are in, and what their support systems are. In terms of community, for example, are the children attending a good school setting, and is there a professional involved in their lives? Who are their helpers? What are their resources? What are their strengths? The focus initially is on safety, and determining the risk factors in the family. You want to help children become as comfortable as possible. That means approaching the parents initially, because sometimes they have the notion that they constantly have to be prodding their kids with, “Tell her this,” “Tell her that,” and “Don’t forget to say this.” Parents come in and say, “Well, let me tell you what he did this week.” Just getting them out of that mind-set so they understand that we are not going to focus a lot on problems initially, other than trying to effect what is going on with the child, is first and foremost. Initially, we want parents to begin to look at their children as healthy. I have this form I have parents fill out, because they always want to report what their child has done wrong. The first question is, “What delights you about your child?” and “What kinds of signs did you observe that gave you the feeling that your child is really making progress?” That is wonderful! So you initially focus on finding the “positives” rather than reporting behavioral problems as the parent is accustomed to doing. You are setting up a different interaction from the beginning by changing the pattern, encouraging the parent to view the child differently. Right. So we orient them toward the child’s strengths. Then the last item on this paper is, “Were there any concerns that you want me to know about?” So there is a little bit of coaching just to help the parents set the safe environment, decreasing the risk factors if they exist, and building alliances. That is the first phase of treatment. Obviously, in the therapy sessions, it is creating this “safe environment” that we hear about all the time, which has so many different variables to it. Consistency is vital in the therapy environment, and predictability—making sure that children clearly know what is going to happen every time they come to see you, and that they are somewhat in charge, except for areas where you might need to set limits to keep them safe. That can take a while, too. Sometimes people think you can do that in one or two sessions; it can take 3–4 months for a child really to feel safe, and also for the parallel process of safety to occur in their home environment. Sufficient changes must occur in order for children to feel they are going to develop safety and security with their primary caretakers. May I clarify? Is it in this first phase of treatment that you primarily do nondirective play? Yes, absolutely. That has been my philosophy for quite a long time. First of all, you need to give the kids a way to find their own healing resources if they can do that. If you are directing, there is not enough opportunity for children to express what their needs might be. They might, for example, take a baby doll that is in a crib, and play with it in such a way to show you what their concerns are. If they rip all the clothes off of it right away, and begin stabbing the doll with a pen, they are obviously communicating something to you that is really important. You have got to give them a choice to do those things so you can see what is on their minds and what they might be able to show you, rather than simply saying, “Oh, here is the baby doll. Why don’t we take her clothes off and give her a bath.” When you are directing the play, the child really does not have the opportunity that might be there when they look at something and they have an intuitive response to it. I always start with nondirective play. I really believe that giving the children space and not making a lot of demands allows them to externalize what might be on their minds, and also to come to use their own reparative mechanisms, which they are going to be able to incorporate. And that is what I think is really important. You take the demands away, and you will see them go toward something reparative, and you give them an opportunity to show you what might be on their mind.
That reparative process is different for each child. And I never know what it is going to be ahead of time. I never know what it is in the room that might prompt the child to do something that has a reparative dimension to it. If that is what they begin to do, then you have to back off and let them continue to do that. After the safety-building phase of treatment where they had a chance to do nondirective therapy, you might see that instead of approaching the things that are on their mind and using play and our relationship as a way to begin to process it, they do the opposite. They avoid everything that could have something to do with what happened that would be helpful for them in terms of externalizing things.
Then you begin to move into Phase 2, where I use what Nathan Ackerman used to call “tickling the defenses.” Is there a way that I can make this an easier bridge for them to cross? So, you begin laying down a different way to work that depends on the child and what his specific needs might be. There was this one child, for example, who had a traumatic event occur in a house, and the dollhouse was something that he avoided. He would come in, and he had this little ritual where he would always sit on this tiny little stool with his back to the dollhouse. I thought that was just brilliant, in terms of him showing, “I want that stuff behind me. I don’t want to look at that stuff.” However, after a period of time, it was very clear that this avoidance was also not letting him move on. He had developed selective mutism, another form of wanting to have control over what we do and do not do. So 1 week when he came in, I took a blanket and I put it over the dollhouse. He had a way of coming in and scanning that dollhouse right away. He came in and he looked at it, and right away, he pointed and grunted at it. So, he noticed it. That is called tickling the defenses from my point of view. It is really making explicit what he was doing, which was not wanting to see it. After he pointed at it and grunted, he went over and pulled the blanket off. Now, of course, once he pulled the blanket off, he faced the dollhouse. Once he began to face it, he actually began to move things into the dollhouse. And then his posttraumatic play started. That really illustrates how the treatment has to be tailored to the unique needs of each child. That is an example. Again, it is so unique to the child, and what you might think of doing. On occasion, I have done a smaller thing, which is to bring some kind of toy more to the forefront, and to leave it in the center of the room. Then whenever we walk in the child notices it. That sometimes is enough to begin to “tickle their defenses.” So that part occurs, but then in the middle phase of treatment, at some point, the child really has to be able to address the trauma in some way. Here is a phrase that I always say to them: “You can talk to me, or you can show me in whatever way you wish, how you think or feel about what happened.” Just adding that, “or show me in whatever way” gives them a chance to say, “Well, then I’m going to make a picture about it,” or they are going to do a sand tray about it, or they are going to go into the dollhouse. They are going to kind of reenact something for you to see, but it is going to be bears and dinosaurs, it is not going to be a mom and dad. I think this is an important piece. When we limit what we expect from children to only verbal communications, I think we do them and us a disservice.
Now on to the second goal of treatment, which is actually processing those traumas, looking at what the child thinks and feels about it. And processing either directly, verbally, or it is done in some kind of play therapy, just processing it on some level. Now, a lot of people believe that processing the trauma always has to be a conscious process. That if a child tells a story, any kind of story, it might somehow be a metaphor for what happened. Somehow, you immediately have to connect it to reality—to the traumatic events in their lives. And again, I just think that may be too much. Let us say a child was using a bear as the father, and the bear is growling and is kicking down the door. There is a baby skunk that is hiding under the bed. If you immediately say, “Oh, so you must be afraid of your father,” it is like busting through all of their defensive strategies. The purpose of play is actually to create that safe enough distance from this, so the child can begin to look at it, but look at it in a way that does not feel so scary. On occasion, I hear people say right away, “You are the skunk and the skunk is afraid of the bear” or “Somebody needs to tell that bear to stop being so mean.” Clinicians want to “fix things,” but that goes too far beyond where the child is, and what she may be capable of accepting consciously. The whole notion of meeting the child where the child is, really leads the way. This is a very different approach from people who feel that you need to get them to talk about the trauma as soon as possible; otherwise, you are colluding with denial, which is not healthy. I do agree with those basic principles. But there is a real difference in terms of how you facilitate trauma processing. Everybody agrees that we have to help people process the trauma so it does not overwhelm them, or they feel as if they cannot ever speak about it without becoming overwhelmed. We all agree on that, it is just how do we get to that point? Some people want to really go in there with no holds barred, but most people do not. Also, I think that it is really important to give children some psychoeducation, but I do not want to do that before I hear how they experienced their trauma. Then the psychoeducation I give them is not just general information, but is tailored specifically for them.
All these are really juggling acts in a way to try to figure out how to do this. I think that sometimes we have this notion and we just go for it, as opposed to really stopping and thinking about all the implications of doing something like that, and whether there is another way to advance our therapy goals. Also, I am really conscious of the fact that, especially older kids often will nod their heads and say, yes, I feel this, or no, I do not feel that. But that does not necessarily mean that it is an accurate representation. It could also be that they want to comply, and they want to make you happy, and they want to do the things that you are telling them are so important to them. You may get cooperation but you may not really get substantive or meaningful work from older children. For the therapist, you can leave the room and say, “OK, I checked that off.” You did that and we are done and we are moving right along, but the child is in a whole other place. Again, this points to the importance of being trained to work with children who have experienced trauma. We should allow children to get there gradually, on their own timetable… Exactly! Then you offer them opportunities for expression through the materials that you have. You being there, and the relationship that you have, and the safety that you have established is so vital. Then you can give them that opportunity, when they are ready, to begin to express the trauma metaphorically. Again, that is the difference in this integrative approach. Sometimes people push, but the child just may not be ready. I really think we have to be cautious. The caution comes from understanding the mechanics of how trauma really affects the whole person, especially young kids who do not have the sophisticated kind of defenses that adults may have. We really have to be careful of our implied authority with children.
Then after the trauma-processing period of time, you move into the third phase of treatment. This phase has to do with getting children ready to go out into the world again, where they can use the skills they have learned. In essence, they have organized themselves, are functioning better, and have learned coping strategies. They go back out into the world with a certain amount of trust that these events may not happen to them again in the future. I learned a really bad lesson early on about telling children, “This will never happen to you again.” Sure enough, a couple of children were re-abused. I was devastated that abuse reoccurred and that I had given naïve reassurance. Now I say that hopefully this is something that will never happen to you again, this usually does not happen over and over again, and that not all men are going to be hurtful to you. You kind of need to cross your fingers and say, “Gee, I hope that it doesn’t happen to you again.” And kids have to go from thinking, it could happen to me tonight, tomorrow, next week, next month; to thinking, OK, well maybe it is not going to happen to me again. And so that is the best that you can do in this very dangerous world that we live in. If it were to happen again, I would bet those children would feel more empowered to do something quickly… Yes. I think just giving them the sense that they can talk to someone about it specifically is important, or knowing they can go somewhere. I did work with this one little girl that had been abused and she was very little, I think four or something like that. She had been traumatized. She had been sexually abused by someone in her family, an extended family member. We worked together I think for a year. She really got a sense of mastery in the sense that she knew what to do and she always knew what was not OK. She would tell people that it was not OK to do this or that. At the age of 5, a man actually got out of his car to kidnap her. She was running ahead of her mother; when her mother was not there and she was just trying to make her way back, the car stopped. She ended up kicking this person and yelling really, really loud, and that got the attention of someone who lived on the other side of the street. The details are a little foggy now because this was a while ago. But, in any case, the guy got back into his car and took off. As the car was taking off this little girl actually looked at the numbers on the license plate, and she remembered these three particular numbers. Then the mom came and got her and she said to her mom, “I want to see Dr. Gil.” It was so funny because they lived in the neighborhood of my office, and she walked in and the woman in the front desk buzzed me, and I said that I was free and to come on in. She ran and jumped on top of my desk and she just said to me in a really loud voice, “I did it! I said NO! And I screamed. And nobody can hurt me today.” Oh my goodness! It was so exciting, and it was a moment in time, some 30 years ago now, I never forgot because of the sense of mastery she had. Now she was really lucky. He could have covered her mouth and then who knows what might have happened. I had never taught her about a way to kick anybody. We had talked a lot about using her voice. She had used one of those little microphones and would scream, “No!!!” But to have her be able to do that, it was just one of those moments were you just think, OK, there is something about her recovery process that allowed her to feel this. She had a lot of mastery over that particular experience. They were actually able to capture that guy because she remembered the numbers. Oh my! That is just incredible! It was really an exciting experience; it was incredible and yet very sad. Honestly, I have had moments like that in which you just think, thank God; I could not have plotted this out. It is just pretty amazing. It certainly is amazing. What a positive note on which to end. You are doing incredible work that is so inspiring! Thank you, Eliana, for taking the time to share your perspectives on the topic of treating traumatized children in general, and more specifically on your TFIPT model. I look forward to talking with you more about the importance of the neurosequential model and how you integrate that in your approach.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.