Theraplay with a Difficult Twelve-Year Old Boy

Pirjo Tuovila
Specialist in Developmental and Educational Psychology Tampere, Finland


As part of my final exam to be a Theraplay Trainer/Supervisor, I was asked to reflect upon my most difficult client and describe my work with him.

Erik is a 12-year-old Romany boy who has lived in a children’s home for 18 months. He is by far the most difficult client I have had to date.

Erik’s mother immigrated with him to Sweden when he was a baby. Erik’s mother then remarried and relocated to Tampere, Finland, and he now has three younger half-siblings. He has a diagnosis of Hyperkinetic Conduct Disorder and Non-Organic Encopresis. His behavior became so unpredictable and problematic that his mother could no longer handle him and she reluctantly agreed for him to be taken into care at the children’s home. Erik has been to the children’s psychiatric clinic, both at the outpatients’ department and on the ward, because of severe behavior problems, smearing, self destruction, violence and impulsiveness. He gets excited in a split second, is aggressive, very controlling, lacks selfregulation and self-protection. He continues to smear and badly soil his clothes and person. Currently he is in special education but missed school almost the whole of last year. In the children’s home the caregivers frequently had to resort to holding and restraining him, especially at the beginning. While this is now rare, he still has big problems in relating to other people and interacting with them, and these problems emerge more or less on a daily basis.

The children’s home asked me to start therapy, because I was ”their last hope”. We have met 1-2 times per week, 11 times in all so far. Erik’s primary caregiver Sonja has participated in all the sessions. The MIM, done with his previous two primary caregivers from the children’s home, showed quite clearly the degree of Erik’s disruptiveness, dissociation and restlessness. In treatment, I have emphasized all of the dimensions, but my first objective was to start building a connection to him—to get him engaged. This very aggressive boy presented a physical challenge, too, but that in fact provided a good starting point for building the connection. While in the hospital, he had participated in Theraplay groups, and he thought I had copied some of the games from the hospital, such as blowing cotton balls and blanket cradling. He also told me that in the hospital he had always blown the cotton balls a long distance, and did not play the game of blowing to the others’ hands. From the very beginning, I felt it important to aim at adult leadership – although in Erik’s case this resembles more or less “rope dancing” because of his explosive aggression – while nurturing him with touch and feeding.

The first three sessions were very difficult. Erik did not want to come to therapy; he had to be brought to his first session by force. He was shouting and attacked me, and several times he even tried to escape. I had to use everything in my power-- be inventive, use my voice and body, give him goodies—to keep him with me. The children’s home, too, tried to bribe Erik by arranging something nice for him after every third therapy session. I felt conflicted about using bribery to get him to therapy. However, we managed to do some games and Erik seemed to enjoy them. Warm towels and foot massage have proven to be good nurturing activities when we have managed to persuade Erik to try them.

Erik had a very strong need to be in control. In his book The boy who was raised as a dog (2006, Basic Books) Dr. Bruce Perry points out that a traumatized child must be allowed to maintain control in therapy. However, I felt it important for Erik to be challenged to trust me so that he can learn that things can go well even if he is not in charge all the time. I took the middle position that occasionally one must let the child feel that he has a say in matters and the right to make decisions. So, I sometimes took his suggestion for a game, or modified his suggestion to make it a new game.

At first Erik did not trust Sonja and me at all. He simply grabbed the goodies and rushed out of the room, or just went through things in the basket and took what he wanted. I then decided to put the goodies in my pocket. One game that worked well was to have him guess the different flavors of snacks; Erik was able to accept Sonja’s feeding him in that way. Now he actually asks for the treats, although he still occasionally takes them without permission, if he can. Feeding has an extraordinary impact on him, as does getting lots and lots of goodies. It seems to develop in him a basic trust of us adults. I also give him “provisions” when he leaves – one or two crackers or biscuits.

Initially it was very difficult for Erik to let me touch him, but now it goes well and he himself touches me, lets his feet rest on my lap, touches my hands, lets me hold him in a good way. He will go near Sonja, cuddle up near her and let her hug him. Erik’s relationship with this skillful primary caregiver is good and he has even crocheted a cap for her at school!

Erik does not want us to apply cream or lotion to his skin, except on his feet. ”I don’t want any pampering, I just want my (birth) mother, I’m bad”, he once said. An interactive method such as Theraplay changes our conception of good and bad, and the bad can be made into something good. We have used scented talc powder (because of his habit of smearing, Erik often smells bad) and have then sniffed him. For the last two sessions I have detected no odor! We have also used warm towels every time, and Erik can say where we should place them. He has wanted them on his bare back in the last two sessions. I have tried to maximize the amount of touching in various ways, and have also used many strong physical games: thumb wrestling, arm wrestling, sailor wrestling, fencing, Spiderman (something that was created between me and Erik), and finding Erik´s and Sonja´s feet, elbows or knees under a blanket.

Erik is quite ambivalent in many respects, and he clearly enjoys certain things even though he does not quite allow them to happen. The same is true about his coming to therapy. During his sixth session, he asked how much time we had left for playing and then said, “Great, that much time!” When he had his eighth session, however, he again did not come in at first, but only came a little later with another caregiver. Erik often thinks of a condition just when he should already be leaving for therapy, and if the condition is not met, we are in trouble. Currently such problems seem to have disappeared and he comes to therapy quite willingly together with Sonja.

Dr. Donald Kalsched describes in his book The Inner World of Trauma, Archetypal Defenses of the Personal Spirit (1996, Routledge) the dissociation caused by trauma and the development of a self care system which protects the self. Erik sometimes has attacks during which he is out of contact, he keeps moving about, makes sounds, talks nonsense, is restless and may also get a fit of rage quite suddenly. When this happens, he may try to attack me and/or may leave the room and run out of the building. It seems to me that these attacks are dissociative states. The self-protecting system can be seen in that Erik finds it very difficult to let anyone come close to him. He does not trust anyone and does not allow himself good things. Consequently, he undermines himself by destroying new and potentially good relationships. The self-protecting system aims at preventing the child from being once again traumatized by other people, and the child achieves this by not letting anyone come close. When he has allowed another person to come close to him, in the next moment or in the next session he will withdraw again, since closeness and trust are too threatening for him. Shame reactions are quick and strong. On the other hand, Erik has a sense of humor and he is able to laugh at himself, too.

I always combine Theraplay with Daniel Hughes’ Dyadic Developmental Psychotherapy (DDP) with clients who are in care. I began adding DDP at the fifth session with Erik. Hughes speaks of allowing the child to express his feelings to stop the therapy if he finds something in the session to be too hard or stressful. Erik found all topics to be difficult and did not want to talk about anything with me. For example, I said to him that he has had a hard life, and he screamed at me that HE HAD NOT! In the tenth session he actually attacked me in a major way, which had not happened for a long time. We were talking about his aggression and how sometimes people who are aggressive have seen or been the subject of a lot of aggression themselves. He became quite angry with me and shouted that his mother has not hit him, while attacking me.

On the other hand, we have already been able to talk quite a lot about trust and how it has increased. Sonja has quoted some good examples of greater trust: on one occasion Erik called her “mother”. On another occasion he had been leaning against his floorball racket and had said, “Look, how much I trust this racket, I’ve been playing floorball for nine years, and already I trust my racket.” Sonja in turn asked Erik if he trusted adults. “When I’ve spent nine years with you, then I will trust you.” Now, he often says he will not speak to me, but then proceeds to do it anyway. He no longer demands things from Sonja, but asks for whatever he wants. He has visited the Eden Spa with Sonja and has gone into the children’s pool with her. In therapy, too, Erik may sometimes act like a small baby, he will talk baby talk, cuddle up in Sonja´s lap and say, “Now this baby will learn how to drink.”

In the ninth session Erik, in a happy mood, tells us about his dream. He has been on the Titanic and has sunk into the sea. His African brother has come to save him and has said, “Keep struggling and jump!” and Erik has struggled hard, jumped and has succeeded in getting to the surface. We talk a bit more about the dream and what it could mean. Erik himself is a bit dark-skinned and may therefore trust dark-skinned people more than white. He laughs about the African brother in the dream and he ponders how he was able to breathe under water. Here, too, we can see Kalsched’s idea of a self care system and of how the creation of a therapeutic relationship and trust is often followed by a meaningful dream. Erik does not usually have dreams. With the help of therapy, haunting images can change into protective ones. Erik’s sense of humor could be seen in his words to me at the end of our last session. When he was leaving, he smiled and asked, “Who’s going to be your next victim, I want to see that.”

In all, we have progressed quite well. The primary caregiver Sonja is very skillful, and she says she can see that Erik’s attachment relationship with her has grown to be stronger. Rushing and nonsensical speech have diminished, and there is more trust. However, Erik will probably be permanently placed at the children’s home as his behavior is still too difficult for his mother to handle. While Sonja is currently his primary caregiver, he is likely to experience other carers in the remaining time he will spend there.
In conclusion, here is a list of some points which I have found useful in treating seriously traumatized, spontaneous children:

  • Be ready for anything.
  • Do not expect to achieve changes quickly.
  • Be prepared for setbacks.
  • Use feeding as much as possible.
  • Maximize touch.
  • Improvise a lot.
  • Use your own person extensively, in multiple and creative ways
  • Be physical and strong; physical challenges help in building the connection and engagement.
  • Be gentle; plan games in which you can nurture the child and use touching.
  • In taking the lead use your imagination.

 

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