David A. Crenshaw, Ph.D., ABPP, RPT-SFounder, Rhinebeck Child & Family Center, LLC

Clinical Director, Children’s Home of PoughkeepsieFaculty Associate, Johns Hopkins University

www.childtherapytechniques.comdacrenshaw@childrenshome.us

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Our Own Internal WorkWe can’t begin to access the

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

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Creating a Safe Place

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

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Exploring the Internal Space

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

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Relational World of the Child

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

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Safety via Symbolic Play

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

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Questions to Important to DismissFreud spent 30 minutes a day after seeing his

patients to examine the reactions stirred in him as a result of his interactions with his patients. Children, certainly aggressive and sexualized children, stir a wide range or emotional reactions in us—what do we do with that?

Do we push it away, do we bury it, or do we examine it? Do we travel at a velocity that doesn’t allow for pause, let alone stop, to reflect, to learn, and to face our own vulnerabilities?

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Questions that can Make or Unmake the TherapistInstead of growing from such encounters with

our child clients, a cumulative residue of unexamined feelings and reactions develops and compounds. What is the result—the impact on our psychic, our spirit, our health? Do we value ourselves enough to even care?

Are we so use to putting ourselves in a secondary role that we don’t even notice? What other questions do you regard as too important to dismiss?

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Honoring our Own, Unique form of Genius (David Whyte)Residing within, is a deep well of previous

intuitions, inherited wisdom, and strengths because by definition we all are here today because we came from a long line of survivors. This well can only be accessed by listening carefully, ever so carefully, to the deep silences that speak volumes when we are attuned to our internal well of unique genius. When fully attuned we will be guided to the path of our star, the star we were born to follow, the star to which we belong.

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Diagnostics of an Unhealthy Way of BeingImpatience with the rest of the world

that is not charging around like we are!

The feeling that the only legitimate players are the ones traveling at the same velocity we are!

When we play back the message on our answering machine and we sound like we are half-dead!

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Diagnostics: ContinuedWhen we get a new referral, and we say: “Oh

dear God why me?”

When we think the session is about over and we look at our watch and it is only 10 minutes into the session!

What are some other diagnostics of an unhealthy way of living and being for those of us doing this work?

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Robert Brooks

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

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Kenneth V. Hardy

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

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Walter Bonime, M.D.

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

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Bruce Perry

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

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Predatory, Aggressive BehaviorsIn a group of boys living in a RTC whose past

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

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James Garbarino

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

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Attachment Research

Edward Tronick, Attachment researcher at Harvard University

The “Still Face” Experiment

Attachment IssuesResults indicated that boys with disorganized

attachment and children with ambivalent attachment reported a higher level of externalizing problems then did secure children. Moreover, disorganized children also reported a higher level of internalizing problems than secure children.

 Canadian Journal of Behavioural Science. 38(2),

Apr 2006, 142-157. 

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Right Orbital Prefrontal Cortex

Gender Differences Contrary to the differential

socialization hypothesis, the results showed substantial gender differences in the prevalence of physical aggression at 17 months of age, with 5% of boys but only 1% of girls manifesting physically aggressive behaviors on a frequent basis.

Developmental Psychology. 2007, 43(1) 13-26

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Temperament and Harsh ParentingOur results suggest that a

behaviorally uninhibited temperament, CU features, and attitudes favoring harsh parenting are all important for understanding the development of aggression in preschool children.

Journal of Child and Family Studies. 2006, 15(6) 745-756

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Ways of Viewing AggressionReactive

Proactive

Ross Green’s work: Neurodevelopmental deficits underlying rigidity and low frustration tolerance

“Any child will do well if they can.” Ross Greene

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Another Prism for Viewing AggressionImpulsive/Reactive Aggression (Ross Greene)Hot Rage—Invisible wounds to the soul

(Hardy, Garbarino, Crenshaw)Cold Rage—Bruce Perry and Kenneth Hardy

(dehumanized loss)In the latter two, research emphasizes the

need for empathy based treatments, particularly with kids who have psychopathic traits who have a remarkable lack of capacity to perceive the emotional distress of a victim.

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RevengeImpact on resilience

“When you start out on a journey of revenge, dig two graves—one for your enemy and one for yourself.” Native American

“An eye for an eye makes the whole world blind.” Gandhi

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Child Responsive Therapy (CRT)An integrative approach in which the response of

the therapist is based on empathic attunement with the child. The therapist responds to the cues of the child in an dynamic interplay over the course of the therapy and even within a given session to determine whether to support or to challenge, whether to gratify or frustrate, whether to strengthen coping or explore deeper issues depending on what this particular child needs at the particular place and point in time.

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1. Making Therapy a Safe Place 1) Rituals mutually decided in early sessions;

2) Calming Symbol3) Photograph Album Metaphor (Joyce Mills)

4) Wave Breathing (Kevin O’Connor)

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2. Modulating Affect1) Downsizing;2) Addressing the hostile attribution bias by working on social and cognitive distortions;

3) Enlisting Humor as an Ally;4) CBT (Child-Friendly) Strategies (Janine Shelby)

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3. Teaching the “Language of Feelings”1) The Heartfelt Feelings Coloring

Card Strategies (HFCCS Expressive Cards)*

2) Psychoeducational Tools such as the Heartfelt Feelings Strategies (HFS) (Riviere, Goodyear-Brown, Kaduson, Crenshaw); Feelings Map (Drewes); Feelings Charades (O’Connor)

* Available: www.astorservices.org/heartfelt-feelings-manual.php

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30HFCCS available for purchase from http://www.astorservices.org/heartfelt-feelings-manual.php

4. Accessing the Inner World

1) Three Step Drawing Strategy2) Overidentification with the

Aggressor3) HFCCS Relational Cards4) Inside/Outside (James)5) Symbol Association Therapy

Strategies (SATS-C) available from the Self-Esteem Shop—my profits go to “Ivy’s Fund” at the Children’s Home. 31

5. “Tickling” the Self-Observer

1) Projective Storytelling and Drawing Techniques;

2) Building the Reflective Function (Fonagy);

3) Building the Frontal Lobe, the Executive Functions (van der Kolk)

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6. Addressing the Invisible Wounds

1) Crucial Importance of Empathy-Based Treatments;

2) Wounds in the family system;3) Wounds due to disrupted attachment;

4) Wounds related to cultural factors

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7. Trauma-Informed Therapy Strategies when Indicated

“The soul would have no rainbow if the eyes had no tears.” Native American

Creating the Trauma Narrative in Symbolic PlayCase Examples of Pre-verbal Trauma

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8. Crucial Importance of a Resilience/Strengths Based Mindset

A Mountain of Strengths

Helping Hand

Robert Brooks: “The birds need a home too.”

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9. Facilitating HopeA “delicate operation”

Pacing and timing are of utmost importance

Goal: To honor strengths without trivializing suffering—a delicate balance requiring attunement and sensitivity on the part of the therapist.

How hope can be dangerous36

10. Preparing for Termination Attunement to the importance to the child;

Expressed in Metaphor;Counting Down;Album with Letter;Talk Show;One Last Conversation

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