In my last blog (January 2018) I introduced you to Billy, an eight-year-old boy, who had experienced frightening and unpredictable childhood trauma and neglect. As a result, his brain was operating from a hyper aroused defensive position. I wrote that his brain frequently operated from the limbic and brain stem area causing him to swing into dysregulated trauma responses to his current environment, relationships and capacity to learn.

Billy and I worked together for 12 months using dramatherapy to help integrate his brain and implicitly held memories so that he could respond to current life experiences from a regulated place of being.

Our first task in supporting this was to support Billy to develop an emotional language and narrative for his experience.

Billy asked if we could play Emotional Bingo. This game has emotions depicted with a picture and a word, as you turn a card over if you have the emotion on your bingo card you cover it with a counter.

The use of games in therapy helps:

• the negotiation of difficult experiences that leads to mastery of stresses and traumas
• the motoric release of feelings and action
• the special relationship and rapport that develops with the therapist

Dramatherapists tend to look at games as a way of the client dramatically projecting and engaging with their internal world, at a distance which feels safe. Billy had an insecure and anxious attachment pattern, his feelings often felt overwhelming and he described his brain as ‘dying’ when things became too much. I wondered if his brain went into ‘freeze’ mode which may have been a repeat of his early trauma response to his overwhelming and confusing home life and experiences. Playing Emotional Bingo, enabled Billy to start to notice and name how he was feeling in response to our playing together. At times he was surprised at what he noticed, at the end of one of our sessions he picked up the ‘guilty’ card and told me that this was how he was feeling but that he did not know why, in a later session when leaving he picked up ‘angry,’ and ‘disappointed’. I wondered if in beginning to notice and name feelings in the here and now encounter we were also learning to recognise older more implicitly informed experiences belonging to Billy’s earlier life.

In infancy our capacity for understanding our self is shaped by the quality of interactions with our carer, by touch, gaze, through the use of symbols and then through the use of language. A child learns to understand and manage their internal experiences and place in the world through these numerous interactions. Billy had not experienced this in his early life. The parts of the brain which are most affected when this is absent are the pre-frontal cortex and the limbic system. The pre-frontal cortex helps us think, have empathy and manage feelings and the limbic system is where we hold our ideas about emotional safety and relationships. In therapy Billy was beginning to name experience, develop empathy and experience a safe and trusting therapeutic relationship.

The more relaxed Billy’s brain became the more he could think about how it might be working and what was happening when it wasn’t working. He also began to imagine what I might be feeling, picking Emotional Bingo cards for me and starting to notice our differences and similarities. We thought about how our brains worked and what happened when they felt frozen or overwhelmed.

To this end we used a marble run game, constructing a two-foot high structure of connected tubes with different blockers, pacers and enhancers in. We thought of this structure as the connection between the body and the brain, our marbles became our neurons firing through the brain. We noticed what happened when the brain became hyper aroused by overloading it with marbles, we noticed what happened when we placed marbles in slowly and then filmed it on a slow-motion camera setting, we noticed what happened when the marbles went in in a paced regulated manner. We continued to explore this over several sessions, I added some explanations around attachment, trauma and neuroscience at a pace I felt Billy could manage. Listening to these explanations Billy decided that, using the marble run, he would make a short four-minute film, entitled ‘Me and my Amazing Brain”

Alongside this, he started talking about his amazing brain on a weekly basis, noticing what he was managing at school and in relationship with his peers. He also began to understand when he started to become overwhelmed. I recommended a Sensory Attachment Assessment so that the system around Billy could also think more about his amazing brain and how to keep supporting and developing its growth.

At the end of Billy’s dramatherapy he asked that we make a certificate about his amazing brain and that he got to keep the four-minute film, Billy’s relationship with his brain was a long way from where it had started in those initial dramatherapy assessment sessions.

Sarah Mann Shaw

April 2018.

 Comments/feedback and observations on my work are always welcome – please feel free to message me.

Billy is eight, he is adopted. His early life was categorised by neglect, emotional and physical abuse, he frequently moved and at one point lived in a house with a pack of dogs amongst which he would crawl, dodging excrement and looking for food.

Billy was referred for dramatherapy, the hope was that a creative, non-overwhelming, more symbolic and playful intervention might help him make sense of his past experiences.

At the beginning of our work together Billy took the rubber brain off the shelf and began kicking it around the room. He told me that his brain was ‘stupid,’ ‘dumb’ and ‘didn’t work’. It deserved a ‘kicking’.

I asked in what ways it didn’t work and reflected that he seemed pretty angry with his brain. Billy told me that it couldn’t pay attention in class, it couldn’t think or remember things and that it made him feel bad.

Billy’s early experiences were of a frightening and unpredictable world around him. The absence of a consistently safe and trusting other meant that Billy’s attachment pattern was insecure in nature, moving between a desire to be in control of those around him as a way of avoiding feeling vulnerable; to an embodied sense of fear and anxiety.

Billy’s sensory, implicitly held memories were intense and this makes complete sense when we think about brain development. Billy’s early trauma and neglect experiences will have been remembered… just not through words.

The first part of the brain to come on line is the brain stem which begins development in utero, it is the part of the brain responsible for keeping the child alive when in danger and for basic functions such as heart rate, respiration, swallow reflexes etc. The limbic brain starts to come on line at the age of nine months and is responsible for the development of emotional maturity, behaviour control and the ability to have healthy relationships. The emotional centre of the brain, the amygdala, lies deep in the limbic brain, and relies on signals to manage potential threat. If the signals received indicate threat, then powerful stress hormones including cortisol and adrenaline are released to increase the heart rate, blood pressure and rate of breathing, this all prepares our body to have a fight, flight or freeze response to the perceived danger. In normal circumstances once the danger has passed the body returns to its normal state. But when recovery is blocked, the body is triggered to defend itself from that which makes it feel agitated and aroused. Cortisol is a stress hormone, the amounts that are produced in infants who have been abused and/or neglected can become toxic to their developing brains.

The third part of the brain to come on line is called the cortical brain, it is responsible for learning, language, reflection, morality, processing information and planning.

The development of an integrated brain is blocked in circumstances of prolonged trauma and in the absence of a safe other to protect the child and to enable them to regulate their responses and construct a narrative to explain the danger and support their recovery from it.

Billy’s brain was still operating from a hyper-aroused sense, alert to sensory triggers of traumatic memories that meant that he could not relax or be too open to new learning experiences. Billy’s brain had not found a way to regulate and to make a coherent sense of overwhelming sensory experiences and triggers.

I felt that we needed to work on extending his window of tolerance.

Each child has a unique window of tolerance, when they are within it they can think, love, learn, empathise, be playful, explore, reflect and use words to describe their feelings. When they are pushed out of their window of tolerance either to the upper level, hyper arousal or the lower level, hypo arousal the thinking brain, goes off line and disconnects from the other parts of the brain leaving the limbic and brain stem experiencing neuro chemical changes, swinging into distress, fear and activating the move into hyper-arousal and trauma responses of fight, flight, freeze, flop or flail.

The nature of our work together, was how to encourage Billy and his brain to be more integrated and operate more from within his window of tolerance. To do this we had to focus on

• the quality of our therapeutic relationship to support Billy’s experience of me as a safe and trusting other
• develop a narrative to organise and make sense of his early experiences.
• To respond to Billy’s controlling, shame based behaviour through empathic relational and attuned responses
• To encourage joy and delight in Billy’s exploration of himself through dramatherapy

At the end of our session Billy said that he needed to keep his ‘brain on a lead so that it did not run away from him’. I thought Billy and his brain needed help making friends…. I asked if he would like to explore this in his sessions with me he nodded and grinned.

Look out for my next blog which will explore some of the ways we worked together to support Billy’s brain’s integration

Sarah Mann Shaw

January 2018

Ricky was five when he was referred for a dramatherapy assessment. He was a child of dual heritage who had been with his adopted parents since he was three. Ricky had experienced difficult attachment experiences with his birth mum, who had a mental health diagnosis and who had experienced severe domestic violence. His birth father had been diagnosed with a personality disorder and had been dependent on Class A drugs. Ricky’s start in life had been characterised by unpredictable, chaotic and frightening relationships and experiences. When moved into foster care at 10 months of age he was already exhibiting fearful behaviours, screaming, demonstrating clawing movements, tears. His adoptive parents noticed that Ricky still presented with some unusual behaviours and wondered if therapy could support him and them in understanding and responding to him.

Ricky entered the therapy room with his adopted mum. He wanted to tell me a story he said. He set a home where a black mummy doll lived with her son; Ricky told me that ‘there was no daddy’. Every now and again a knight visited the little boy and his mum. Using the little knight puppet Ricky showed me how it would attack the little boy’s heart with a great sword, Ricky told me how much this hurt the little boy’s heart.

Ricky fetched the doctor’s kit from the side of my room; taking on the role of doctor he tried to mend the little boy’s heart. When the doctor looked closely at the place where the little boys heart should have been he declared that ‘it was gone!’ I wondered where the little boy’s heart had gone. Ricky knew the answer, ‘it’s at the bottom of a deep ocean, and only a diver can get it.’ We looked around my room for a toy that could become a diver and reclaim the lost heart. To each suggestion I made Ricky gave an empathic ‘No’, there was nothing and no one who could help.

Going back to the doll’s house he showed me again and again how the knight would come and attack the space where the little boy’s heart should have been. The mummy puppet asked why the knight was so angry. The knight told her that as a baby he had cried and cried and no one had come and now he was cross.

Ricky was telling me that it was not safe to have a heart that just got hurt over and over again, better to hide it at the bottom of a deep ocean where no one could harm it. Of course Ricky could not find a diver in my room to retrieve his heart, he did not know me well enough, he did not know if he could trust me and so he needed to stay in charge and keep his heart hidden and protected. He had also not experienced a safe and trusting adult in infancy and so had not internalised a representation of a ‘good enough other’ who could help Ricky know about feeling safe, loved , protected from harm and cared for.

Over the following sessions Ricky and I continued to engage with dramatic play in the therapy room. This theory understands that in all play there is a process of dramatic projection; that in the process of play the child engages in the placing of themselves, parts of themselves and their feelings onto objects that are then engaged with in play. The dramatherapist supports the child in the process of play and in the encouraging of the telling of a metaphorical story through the use of symbolic objects which hold projected meaning for the child. This process enables the child to engage in difficult, themes, feelings at an emotional distance that feels safe enough to encourage engagement and exploration.

Dramatic Play was a natural language for Ricky; it gave him words and actions to convey the meaning of his experiences. Over the following sessions Ricky and I played lots of games together in which themes of significance were explored; power versus powerlessness, the lack of a safe and trusted helper, hyper arousal and fear, the potential of gaze to contaminate and turn someone ‘bad’. Ricky’s play was focused on what Bion (In Symington 1996) terms the nameless dread, it was attachment related and focused on the trauma of his experiences at a time when he was powerless to protect himself in anyway other than through psychological defence.

Overtime his metaphorical narratives worked on in therapy developed more coherence, he became less hyper aroused, his stories developed with an emotional narrative, he overcame difficulties, his play was populated with friends and helpers, he became more robust. Some way into his therapy Ricky came into the room with his mum. ‘Tell Sarah what you told me’ said mum. ‘Sarah’ said Ricky, ‘I have got a heart now.’  ‘That’s great’ I said, ‘and how is that?’ ‘Good’ he said ‘I have a heart because I have someone to love,’   Ricky pointed at his adopted mum.

Ricky had reclaimed his heart and he knew how to use it. Dramatherapy and psychotherapy are powerful therapeutic interventions, that with Ricky, supported the development of a good enough attachment. How great is that!

Sarah Mann Shaw

November 2016.

References:

Bion W. In Symington J (1996) The Clinical thinking of Wilfred Bion ( Makers of Modern Psychotherapy) Routledge London

Felix is five, he is now adopted. He has experienced early childhood trauma, he had a mother who was unable to attach to him in a secure and loving way, as both she and Felix had lived with perpetual domestic violence.

The impact of such an experience on the developing infant’s body and brain is profound. We know that when the primary care giver is unable to provide a warm safe and loving bond with the infant then these children grow up with real difficulties in trusting others to help make their world safe. They are unable to regulate what they feel inside, often feeling anxious and on the alert for any possible real or imagined signs of danger. Their brains are wired to decode anything which might trigger a threat. Sometimes these triggers are external, as in noises, movements, facial expressions, sometimes they are internal, a raise in body heat, feeling anxious or excited. Without the experience of a safe and loving other the child has little capacity to make sense of these stimuli and to soothe himself. Without the feeling of being understood, of knowing that trauma induced terror can be managed with the help of a regulating other these children often remain, anxious or aggressive or controlling, their brains and body’s operate from a sense of fear rather than a sense of hope… the hope that there is someone else who can help.

Such was the case with Felix, he had a traumatised brain and really needed to know that his new mum and dad were resourced and robust and could help him figure things out and feel safe in the world.

Felix and his new mum came for dramatherapy. Felix liked to play and he was good at it. His mum was good at watching and joining in when Felix needed her to. Felix loved to play with action figures; he told me that their job was to save the world from the bad man figure. He told me that the bad man was scary, he wanted to attack people all the time, and that he wanted all the action figures to feel as angry as him.

Felix built a castle and filled it with toys, play food and dolls house beds. He told me that this is where the action figures would learn not to be angry. ‘How long would that take?’ I wondered, his answer ‘two weeks!’ They would be helped by a superhero who had already worked out not to be angry.

It was a really hard job for the action figures to learn to have other feelings, they learnt how to be sad when the ‘bad man’ attacked their safe castle, they learnt to trust the superhero figure to protect them when the bad man attacked, eventually they learnt that having friends made them feel happy. They learnt to choose which friends might be the best ones to help.

One session Felix asked me to pick up the bad man figure and chase the two action figures that he would hold around the therapy room. We played chase for about thirty seconds. At first Felix looked delighted with the game but then quickly realised that this wasn’t so good, throwing his action figures to the floor he ran into his mum’s lap.

1. She held him tight and told the bad man to ‘clear off, there was no way’ he ‘was having her son’. Felix snuggled into his mums lap and gazed at her. She gazed back lovingly. ‘Can we go home now?’ Felix said.

We cleared up the space together, and I commented on how well at playing Felix was and how good his mum was at sorting out bad men in the play. Felix grinned at me ‘See you next week Sarah’ he said as he left, hand in hand with his mum.

Felix had just had a reparative experience of accessing other to help; he had found other and had trusted that she could help. That trust had been beautifully responded to by his new mum.

Felix continues to enjoy his dramatherapy sessions.

Welcome to my first blog as a dramatherapist and child and adolescent psychotherapist. I really love what I do so that’s what I am going to write about, interesting then that my first blog is addressing Encopresis and Dramatherapy!

 This is because I had a recent enquiry from a parent who was dismayed to find small rounded stools in her child’s bedroom, she felt that they looked as if they had been ‘played with’, and as she explored her child’s room found other evidence of smearing. Another parent has recently expressed horror at finding containers in her child’s room which had been used to hold wee and poo.

‘Why are they doing this?’ both parents exclaimed,

 ‘Is it just defiance?’

Encopresis is the soiling of underwear with stool by children who are past the age of toilet training. Because each child achieves bowel control at his or her own rate, medical professionals do not consider stool soiling to be a medical condition unless the child is at least 4 years old. Both these children were older, they knew how and when to use the toilet but they weren’t.

My response was to think about how to help the parents tackle this issue and to look at it in the child’s therapy session  

We do have to think about the practical issue how to help our children manage their relationships with their bodies; do they need the loo?, is it hard to go to the loo?,  are they constipated, going to the toilet too late? etc.

Secondly is to think about it as an expression of worry or anxiety rather than defiance or a layer of ‘horrible’ behaviour. I remember when I was small that just outside the bathroom we had a poster of a tiger in long grass, the kind of poster where the eyes follow you. I was terrified. I had a very active imagination and was convinced that the tiger knew all my misdemeanours and one evening would get me! I used to wake my sister in the middle of the night to go to the toilet with me; if she refused I would crawl on my belly under the picture trying to avoid the tiger’s gaze! This went on for weeks until my mum realised that there was a problem and I plucked up courage to tell her and the poster was moved. That night I went to the toilet without any problems.

Be curious, what might your child be worried about?

Your child may also like the texture so what could you substitute poo with.  Can they play with clay, use finger paints at home, find other ways to get the same texture and feel?

Although it may look and feel revolting to you I am sure you know that it is important not to show this to your child but to think with them about what might help and to reassure them.

In dramatherapy one of these children was playing with dinosaurs and had created a world in which the smallest dinosaur was king, everyone was very gracious to this King and he was gracious back. This is nice, I thought, lots of positive reflections between the dinosaur characters, and then the little King was placed on the head of a much taller dinosaur by the boy in therapy. The little boy started to make thumping and whooshing noises. I wondered what was happening.

‘He is pooing and weeing all over the dinosaur’s head,’ he said.

We made the noises of pooing and weeing together and laughed at the skill of each other’s trumpy sounds. Then I asked what had caused the little dinosaur to poo and wee on the big dinosaur’s head.

‘Oh’, the little boy said, ‘he’s really scared and when he’s scared he can’t hold it in anymore. Commenting on the world the dinosaur lived in I asked if there was anyone who could help the little dinosaur with this dilemma.

The little boy nodded and manipulated a long necked Dinosaur to bring the little dinosaur back down to the ground. Then he used other dinosaurs to come up to the little King, one by one each said

‘I do that too sometimes when I am scared.’

In recognising, naming and normalising both fear and response the little dinosaur was able to reunited with his community without shame..

The little boy left the session laughing and was greeted with a big hug from his mum.

Next week his mum told me that there had been no more problems ‘in that area’.

Next time: Dramatherapy and Release – Enuresis within a trauma frame of reference.

Comments really welcome.