Cultural Issues in Play Therapy [2 ed.] 1462546900, 9781462546909

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CULTURAL ISSUES IN PLAY THERAPY

ALSO FROM THE EDITORS Essentials of Play Therapy with Abused Children (DVD)

Eliana Gil The Healing Power of Play: Working with Abused Children

Eliana Gil Helping Abused and Traumatized Children: Integrating Directive and Nondirective Approaches

Eliana Gil Play in Family Therapy, Second Edition

Eliana Gil Play-Based Interventions for Childhood Anxieties, Fears, and Phobias

Edited by Athena A. Drewes and Charles E. Schaefer Play Therapy for Severe Psychological Trauma (DVD)

Eliana Gil Posttraumatic Play in Children: What Clinicians Need to Know

Eliana Gil Termination Challenges in Child Psychotherapy

Eliana Gil and David A. Crenshaw Treating Abused Adolescents

Eliana Gil Working with Children to Heal Interpersonal Trauma: The Power of Play

Edited by Eliana Gil Working with Children with Sexual Behavior Problems

Eliana Gil and Jennifer A. Shaw

CULTURAL ISSUES IN PLAY THERAPY SECOND EDITION

edited by Eliana Gil Athena A. Drewes Foreword by Robert Jason Grant

The Guilford Press New York

London

Copyright © 2021 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Names: Gil, Eliana, editor. | Drewes, Athena A., 1948– editor. Title: Cultural issues in play therapy / Eliana Gil, Athena A. Drewes. Description: Second edition. | New York : The Guilford Press, [2021] | Includes bibliographical references and index. Identifiers: LCCN 2021014449 | ISBN 9781462546909 (paperback) | ISBN 9781462546916 (hardcover) Subjects: LCSH: Play therapy. | Play therapy—Cross-cultural studies. | BISAC: PSYCHOLOGY / Psychotherapy / Child & Adolescent | PSYCHOLOGY / Ethnopsychology Classification: LCC RJ505.P6 C84 2021 | DDC 618.92/891653—dc23 LC record available at https://lccn.loc.gov/2021014449

To Eugenia Valero and Manuel Gil, my deceased parents, who were courageous immigrants and dared to dream and visualize a better world for their children.                         —E. G. To my best friend and the man with the sweetest heart, my husband, Dr. (Nelson) Keith Seibert. Thank you for being supportive, loving, and my partner on this amazing adventure of a lifetime together. And to my mother, Mariko Atheneos Drewes, a first-generation Greek American, who started me on my journey of exploring cultural diversity and understanding prejudice.                         —A. A. D.

About the Editors

Eliana Gil, PhD, RPT-S, ATS, is a founding partner and senior clinical and research consultant in a private group practice, the Gil Institute for Trauma Recovery and Education, in Fairfax, Virginia. Dr. Gil is an approved marriage and family therapy supervisor; a registered play therapist/supervisor; a registered art therapist; a Circle of Security–certified parent educator; and a Level II Theraplay provider. She is a former president of the Association for Play Therapy, which honored her with its Lifetime Achievement Award. Dr. Gil is the author of numerous publications on child abuse prevention and treatment. Originally from Guayaquil, Ecuador, she is bilingual and bicultural. Athena A. Drewes, PsyD, RPT-S, is a licensed psychologist, certified school psychologist, and registered play therapist and supervisor. Dr. Drewes is semiretired in Ocala, Florida. She has over 40 years of clinical and supervision experience, in school, outpatient, and inpatient settings, working with children and adolescents experiencing complex trauma and sexual abuse. She is a past board member of the Association for Play Therapy and a founder and president emeritus of the New York Association for Play Therapy. A frequently invited guest lecturer around the United States and internationally, Dr. Drewes has published 11 books on play therapy.

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Contributors

Rachel A. Altvater, PsyD, Owner and Psychologist, Creative Psychological Health Services, Baltimore, Maryland Peggy L. Ceballos, PhD, Associate Professor, Department of Counseling and Higher Education, University of North Texas, Denton, Texas Jamila Codrington, PhD, Supervising Psychologist, Astor Services for Children and Families, Bronx, New York Athena A. Drewes, PsyD, Founder and President Emeritus, New York Association for Play Therapy; Former Director, Association for Play Therapy, Ocala, Florida Eliana Gil, PhD, Founding Partner, Gil Institute for Trauma Recovery and Education, Fairfax, Virginia Myriam Goldin, LCSW, Founding Partner, Gil Institute for Trauma Recovery and Education, and Director, Starbright Training Institute for Child and Family Play Therapy, Fairfax, Virginia Cary M. Hamilton, MA, Director, Play Therapy, Antioch University Seattle, Seattle, Washington; Director, Olympia Therapy, Tumwater, Washington; Director, Playful Wisdom, Olympia, Washington Cathy A. Malchiodi, PhD, Founder and Executive Director, Trauma-Informed Practices and Expressive Arts Therapy Institute, Louisville, Kentucky Sarah Moran, MA, Senior Clinician, Olympia Therapy, Tumwater, Washington Phyllis Post, PhD, Professor, Department of Counseling, University of North Carolina at Charlotte, Charlotte, North Carolina Mónica Rodríguez, MEd, doctoral student, Department of Counseling and Higher Education, University of North Texas, Denton, Texas Quinn K. Smelser, PhD, LPC, RPT, private practice, Fairfax, Virginia viii

Foreword

A

subculture can be described as the way of life, rituals, and ideas of a particular group of people within a society that are different from the rest of that society, or as a cultural group within a larger culture, having beliefs or customs at variance with those of the larger culture. In this second edition of Cultural Issues in Play Therapy, Eliana Gil and Athena Drewes reference “subculture” as “a social group within a society that has a lifestyle distinct from the culture of society as a whole. A subculture subscribes to the main norms and values of mainstream society but may also have some norms and values that are unique to it.” Definitions of subculture can vary, but the main characteristic—a culture existing inside a greater culture—permeates most ideas of what defines subculture. When I began working with children and families affected by autism and developmental disorders, I did not conceptualize that I was entering into a subculture. At the time, I was focused on discovering treatment approaches (primarily as a play therapist) that would be impactful for these children and families. With my very first child client diagnosed with autism, I was in fact beginning my journey into the subculture of autism, and I have been traversing the canals of this unique culture ever since. I distinctly remember walking into a large meeting room inside a local church on a Saturday in March 2006. This was the regular monthly meeting of the Southwest Missouri Autism Network (SWAN), a large parent-created and parent-led support group that averaged around 50–60 parents per meeting. I had been contacted by the president of the group and asked to speak about play and children with autism. I had been working with children with autism for a while but had not branched out into the greater autism community, and this was one of my first experiences speaking to an autism group. ix

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Foreword

My content was well received, the process went smoothly, and I enjoyed the experience, but the most significant piece for me was the exposure to and awareness of this autism subculture that manifested very clearly before me. These parents shared a common awareness, concerns, and experiences. I remember phrases I overheard such as “That’s what autism moms do,” “The autism community,” “Our kids,” “My tribe,” and “How we do things.” The mission statement of SWAN that permeates their website, social media pages, and marketing materials communicates the essence of the community: • To encourage parents and caregivers of children and adults with autism everywhere. • To enlighten the public about the challenges and joys of parenting children and caring for loved ones with autism. • To exchange information, ideas, and experiences in a caring, safe, and supportive atmosphere. • To enrich the lives of our children through group activities, playdates, and public outings so that they can experience the joys of childhood that all children deserve. • To experience friendship, hope, encouragement, and joy along the way with other parents and providers who are also traveling on this journey called autism! Through the language, the camaraderie, the shared exchanges, the atmosphere, it was very clear this was a group of individuals who shared a passion, a way of life that identified outside of the greater culture—this was a fully realized subculture. Throughout the last several years I have been a full participant in the autism subculture: attending and participating in many resource fairs specifically designed for those with autism, participating in advocacy groups designed to promote the interests of those with autism, being on boards of nonprofit organizations devoted to autism causes, serving on school boards of private schools specifically created to educate children with autism, and helping families access services for children affected by autism. It’s not uncommon for parents to seek out professionals, schools, and programs based not on credentials, proximity, or cost but on experience working with children with autism—this awareness and understanding of “my child,” “my needs,” “my world,” supersedes other more typically assessed elements. The autism community created the term “neurotypical” to describe those who do not have autism. The term has emerged and is widely used and referenced. Judy Singer, a person with autism, coined the term “neurodiversity” in 1988. The autism community has advanced the terms “neurodiverse” and “neurodiversity” to promote recognizing a different way



Foreword xi

of thinking, processing, and responding that is not less but different, not a problem but an asset. The subculture that is autism is continually active in being recognized and valued. Many children who were diagnosed in the early 1990s are now adults and are speaking out and advocating for acceptance and rights in ways that have not been seen before. Their advocacy efforts are having an impact on the recognition and understanding of the subculture of autism and how it is beginning to change the larger culture. Autism leaders and influencers such as Dr. Stephen Mark Shore, Dani Bowman, and Aaron Likens routinely present and write about their experiences of being autistic and the culture of those with autism and how it differs from the greater neurotypical culture. When I developed AutPlay Therapy, an integrative family play therapy approach focused on working with children and families affected by autism, I was keenly aware that for providers part of the process of learning AutPlay would be understanding how families and children with autism are affected—how these families and children look different from the greater culture. Basically, what is the subculture they are navigating? Every AutPlay training covers this topic. As a play therapist working primarily with a specific subculture, I have become aware of a child’s subculture experiences as a context for play therapy treatment. If the awareness of the subculture is absent, the treatment will fall short. When I began working with children and families affected by autism, the play therapy community could be described as limited (at best) in recognizing, understanding, and working with these children. Many writings at the time suggested these children were the “exception” and play therapy would not work for them. This second edition of Cultural Issues in Play Therapy, which focuses more on subcultures, is very timely for understanding play therapy’s history with autism. As I look back through the years on the growth of play therapy for children with autism, I believe the early lack of presence was not because play therapy wasn’t viable (the same play therapy theories are implemented today with significant research and treatment outcome support), it was about play therapists not understanding the subculture of autism. Do play therapists understand subcultures? Have we done a sufficient job as a field to understand and address needs in the variety of cultural situations we encounter with our child clients? Are play therapists equipped to meet the challenges of being culturally aware and proficient? These are not only good questions but powerful questions—the types of questions that lead organizations and individuals to a higher level of comprehension and execution in delivering the best, most relevant treatment to their clients. For me to best serve and work with my clients with autism, I had to understand the culture these children lived in and their families’ way of life. Eliana Gil and Athena Drewes communicate this point well in their Introduction: “Our job is to suspend judgment, invite introspection and reflection,

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Foreword

address culture directly rather than avoid conversation, and help our clients view their culture as accessible, as well as include a plethora of resources.” What a great commentary from a much-needed book. I am confident readers can learn from and appreciate the work of all the contributors and the important topics highlighted. This book takes our play therapy community farther down the road of being subculture competent, and we are better for having this resource at our disposal.               Robert Jason Grant, EdD, LPC, RPT-S                Creator, AutPlay Therapy

Acknowledgments

T

hank you to Athena, whose idea it was to prepare a second edition to this book and who, as always, kept us on task and took care of a million different things. She is a pleasure to work with. I also want to thank our wonderful editor at The Guilford Press, Rochelle Serwator, for being a steadfast supporter of our work and for her willingness to consider the way we chose to conceptualize the second edition of our book.                            Eliana Gil

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Contents



Introduction: Redefining and Broadening the Definition of Culture

1

Eliana Gil and Athena A. Drewes

CHAPTER 1

Practicing Child-Centered Play Therapy from a Multicultural and Social Justice Framework

13

Peggy L. Ceballos, Phyllis Post, and Mónica Rodríguez

CHAPTER 2

White Privilege, Anti-Racism, and Promoting Positive Change in Play Therapy

32

Eliana Gil

CHAPTER 3

Culturally and Racially Attuned Play Therapy: Toward a Social Justice Approach

58

Jamila Codrington

CHAPTER 4

The Impact of Culture on Expressive Arts Therapy with Children

75

Cathy A. Malchiodi

CHAPTER 5

Exploring Gender and Sexuality Using Play Therapy

90

Quinn K. Smelser

CHAPTER 6

Providing Mental Health Services to Undocumented Families of Color in Our Current Culture Myriam Goldin and Eliana Gil

xv

111

xvi

CHAPTER 7

Contents

The Culture of Violence in Schools

131

Athena A. Drewes

CHAPTER 8

Filial Therapy with Hearing-Impaired Children

152

Cary M. Hamilton and Sarah Moran

CHAPTER 9

The Culture of Technology and Play Therapy

172

Rachel A. Altvater

APPENDIX A

Resources on Multicultural Play Therapy

191

APPENDIX B

Resources on Gender and Sexuality in Play Therapy

197

Index

Purchasers of this book can download chapters from the first edition on play therapy with major cultural groups—African Americans, Hispanics, Native Americans, and Asian Americans— at www.guilford.com/gil6-materials for personal use.

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Introduction Redefining and Broadening the Definition of Culture Eliana Gil Athena A. Drewes

T

he first edition of Cultural Issues in Play Therapy, published in 2005, was well received by mental health professionals working with children and families. It was an attempt to help play therapists take a broader view of culture in order to attain greater cultural competence and to lead them toward further dialogue. In that text we discussed the multidimensionality of culture and used Falicov’s definition of culture: Culture is those sets of shared world views, meanings, and adaptive behaviors derived from simultaneous membership and participation in a variety of contexts, such as language; rural, urban or suburban setting; race, ethnicity, and socioeconomic status; age, gender, religion, nationality; employment, education and occupation, political ideology, stage of acculturation. (1983, pp. xiv–xv, cited in Falicov, 1998, p. 14)

In our first edition, we focused primarily on race and ethnicity and included various chapters on utilizing a cross-cultural lens when doing play therapy with children and families from specific ethnic groups. Since that edition, the world has changed dramatically due to the COVID-19 pandemic and a renewed focus on systemic racism, societal injustice, and 1

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Cultural Issues in Play Therapy

inequality through the actions of Black Lives Matter following the killing of George Floyd and other Black men and women by police violence. There has also been an explosion of electronic and Internet advancements resulting in readily accessible global contact and exchange of ideas between cultures, along with subsequent Internet abuses, as well as the current technological imperatives of telehealth and virtual schooling. Consequently, we realized that subcultures have emerged that play therapists are actively working with, and that we felt were important to focus on in this edition rather than just update the first volume and its more traditional view of culture. Consequently, all the chapters in this volume are new, while readers can still access, for free, the four chapters from our first edition that focused on working with Black, Hispanic, Native American, and Asian children and families (see the box at the end of the table of contents). While the focus is primarily on subcultures, in light of recent developments, chapter authors have also worked to include pertinent issues such as racism and inequality and White privilege, as well as telehealth work (due to COVID19) to sensitize and raise issues for readers to consider and use in selfevaluation. A “subculture” can be defined as cultural patterns that set apart some segment of a society’s population. It can be based on age, ethnicity, residence, sexual orientation, occupation, and other factors (Papelirin, 2014). Thus, a subculture is a social group within a society that has a lifestyle distinct from the culture of society as a whole. A subculture subscribes to the main norms and values of mainstream society but may also have some norms and values that are unique to it. However, some subcultures may be regarded as deviant by the wider society or by those wielding power. Consequently, subcultures can be a way that groups in society who face little opportunity to succeed within a dominant culture can take back some power (Papelirin, 2014). In this second edition, we opted to expand our discussion to address subcultures that share a set of common beliefs, attitudes, behaviors, and preferences. We have also added a broader definition of culture so that cultural and racial considerations are addressed for the play therapist in order to enhance multicultural competence. We have chosen to deal with issues of the day, especially racial injustice. Our authors tackle difficult but timely topics and offer the reader a chance to become more aware of and sensitized to how race and culture impact our clients on a daily basis. Case examples within each chapter bring to life the challenges our clients face, but also those of the clinician in tackling sensitive and difficult to discuss topics. In Chapter 1 we see child-centered play therapy through the lens of a multicultural and social justice framework. The authors strongly state that multiculturalism cannot and should not be separated from social justice advocacy and illustrate through a case example. Chapter 2 gets to the heart



Introduction 3

of an often difficult-to-discuss, often overlooked but necessary topic, that of White privilege and anti-racism, in order to promote positive change within the field of child and play therapy. It is written with the goal of helping play therapists be more attuned and self-aware as they work with children and families of color. Chapter 3 raises the ethical mandate of play therapists to be culturally and racially attuned through the lens of social justice. This chapter is intended to explore the complex ways that race and culture influence the psychotherapy process with children and it provides practical ideas for implementing racially and culturally attuned play therapy. The author underscores how play therapists are agents of social justice, not just emotional and behavioral change within the therapeutic process. Chapter 4 looks deeply into how culture impacts expressive art therapy. The author posits that at the core is the notion that reparation and recovery are enhanced within relationships and recapitulated through experiences of choice when meaningful sharing of power and decision making are present, and that these principles resonate with the action-oriented nature of expressive arts therapy and play-based work. And she further asserts that an emphasis on sensitivity to cultural preferences for treatment and the effect of worldviews on attitudes toward health and wellness is essential to trauma-informed practice. Chapter 5 explores the subculture of children dealing with nonconforming and fluid gender and sexuality. The author presents an overview of how play therapy inherently encourages safe gender and sexuality exploration. The authors of Chapter 6 highlight the special life circumstances of immigrants who have crossed the border, the daily stressors they face, and the current escalation of danger, tension, and anxiety they experience. They further sensitize the reader to the levels of psychological stress, anxiety, fear, and cumulative trauma experienced by immigrants, described especially vividly in their case study. We see in Chapter 7 the culture of violence within the schools in the form of bullying and the racism expressed through punitive levels of school discipline toward Black and Brown children and high levels of suspensions and expulsions, creating a “school-toprison pipeline.” Solutions and alternatives are offered. Chapter 8 enlightens and sensitizes us to the Deaf community as a cultural and linguistic minority with its own history, art, customs, language, and social and athletic organizations, and how it differs from the larger, more dominant culture. Finally, Chapter 9 addresses how children and clinicians are consumed and inundated by technology in our digital world. The author stresses that it is imperative for play therapists to remain mindful of technological evolution and how it intersects with play therapy treatment. This is even more important now with the need for digital and virtual schooling due to the pandemic and the use of telehealth in therapy. Readers will also find useful two appendices at the end of the volume. Appendix A offers a rich listing of resources, including books, articles,

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organizations, podcasts, and websites touching on cultural and social justice issues. Appendix B, which is connected with Chapter 5, offers useful resources—organizations, books, and conferences—that focus on the subculture of the LGBTQ+ community. Our hope is that including this range of topics amplifies the concept of cultural differences and allows us to think about flexible borders that can be bridged with understanding, information, and sensitivity. It is our goal for play therapists to feel better able to address these new cultural paradigms in their work with children and families.

CULTURAL IDENTITY Many individuals limit their perception of culture in a rigid fashion. It is quite common for individuals to state, “I don’t really have a cultural background” when they hear their counterparts talk about their origins as German, Italian, Irish, or African. The reality is that we are all descendants of a birth country, and we can all trace our family heritage and lineage, now more than ever. In fact, there appears to be a rise in the popularity of television shows that trace the origins of famous people, as well as various viable applications (e.g., 23andMe), and programs (e.g., National Geographic) that encourage us to provide information or take a mouth swab to learn more about our heritage. More and more individuals have availed themselves of opportunities to seek more information about their backgrounds. I (E. G.) have a friend who proudly discusses his farming background as a subculture, a tightly knit community with a shared sense of seasonal organization around planting, harvesting, and taking goods to market. There are anxieties inherent in farming that include storms, droughts, fires, and the emergence of natural predators. Farmers work and compete hard, and their children are usually taught ethics involving hard work, rewards, and struggles. Children in farming communities tend to spend a lot of time outdoors, helping their families with feeding and cleaning and maintaining the environment. Thus, values are instilled early on. These children and families develop a cultural identity that can bring great pride to some, and embarrassment to others, and feelings that they may have missed out on broader childhood experiences. Nevertheless, children’s identity is formed by being exposed to very specific work ethics and goals, community, and family participation. Cultural identity is formed in everyone, but it may be encouraged more in some children than others. Some parents have strong positive memories of their upbringing, cultural lessons they were taught by their elders, experiences in their young lives, holiday traditions, or cooking and eating special ethnic foods. Other parents may feel cut off from their own family of



Introduction 5

origin and thus less familiar with, or interested in incorporating and passing on, cultural beliefs or values. Still others may simply not think about or discuss their own heritage often and may not have had opportunities to think about, identify, or express memories, thoughts, and associations with their cultural roots. We believe that when we are working with children and families part of the treatment strategy should include an invitation to explore culture, personal meanings, acculturation, and how culture plays a part in their current lives.

EXPLORING CULTURE ACTIVELY Gil (2003) devised a play genogram that allowed families to use miniatures (or other objects) to show their thoughts and feelings about everyone in the family, including themselves. The following slight variation allows family members to go deeper by focusing on their cultural identity. The clinician provides the graphic of a genogram, which includes boxes for males and circles for females (McGoldrick, Gerson, & Petry, 2008), and places to indicate the relationships among family members. Thus a typical genogram includes separations and divorces, whether people live together or are married, whether children are adopted, birth order, deaths, specific problems such as drug abuse or mental illness, and even whether relationships are emotionally close or distant, and whether there has been physical abuse or other forms of family violence. Once clinicians and families have an accurate genogram with significant people included, the invitation is to “find miniatures that best show the cultural lessons you were taught by everyone in the family. When you get to yourself, find a miniature that shows your cultural identity.” A colleague of mine (E. G.), Karen Pernet, has also devised an invitation asking children and/or families to build a sand tray that shows their cultural identity (Pernet, personal communication, 2020). The only obstacle to doing family genograms is a lack of imagination. For those therapists who do not own miniatures, this exercise can be done by asking them to go out into nature and pick things that might communicate their thoughts and feelings about family members, providing rocks and crystals, having people use collage materials, and possibly having people make an affective color code (picking a color to show each emotion) and asking children and/or their parents to color in the feelings they have toward everyone in their family including themselves. The idea we are proposing here is that redirecting people to reflect on the element of cultural identity, directly or through play, can be fruitful in therapy. Other ways of inviting individuals to learn more about their culture is asking about special foods, special colors, music, community, family

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Cultural Issues in Play Therapy

rituals, religious practices and holidays, and having a world map in your therapy space to help locate ancestral countries and immigration patterns, and so forth. Therapists are advised to do some research to learn more about families living in the urban or rural setting where the therapy practice is, personally attending religious events and forms of entertainment within the community, and even exploring clients’ political preferences. Our job is to suspend judgment, invite introspection and reflection, address culture directly rather than avoid conversation, and help our clients view their culture as accessible, as well as include a plethora of resources. The other issue that has always been significant in working with clients, some of whom are not seeking therapy voluntarily, is to understand their family values regarding helpers by exploring who they turn to for help when in trouble, what kind of help is available and/or provided in times of hardship, and how accessible those resources are. As clinicians, we might want to team up with people considered natural helpers to our clients, whether they be pastors, priests, rabbis, ministers, church elders, or religious leaders in any religion. There might also be family elders who are regularly consulted. There may be the incorporation of prayer or meditation or music. Families have usually created and relied on specific resources that might feel more natural and user-friendly than structured psychotherapy, and learning what those are can be viewed as respectful and inclusive of family values. The authors of this book assert that all clinical work should include some direct exploration of cultural values and functioning regarding family roles, physical discipline, affection, and the presence or absence of play or work patterns, as well as the role of family violence, drug abuse, pornography, closed family systems, and normalization of conflictual patterns of interaction. The authors also believe that professionals must do their part to become culturally sensitive and remain alert to issues of social injustice, racism, oppression, inequality, White privilege, and other social constructs that are inflicted on many families. Play therapists, like any other licensed mental health professionals, must prioritize the issue of difference or privilege from the outset. This is a pressing topic that needs a responsible clinical response, both when children or parents bring it into the session indirectly through their play behavior, storytelling, or personal interactions and, most importantly, when they may also not even choose to address it. Below is a case example of a child and family that I (E. G.) worked with who challenged me in more ways that I can say and brought the issues of addressing culture and race to the forefront in a variety of ways. This is one of the first cases that allowed me to think through an expanded role of the therapist—a role that incorporated a more confident stance on raising or responding to the issues of race and culture and asking the family to reconsider cultural biases and prejudices.



Introduction 7

CASE EXAMPLE Miranda was a 6-year-old partially hearing-impaired child who was placed in foster care due to neglect. The school found out that Miranda went home to an empty house after school hours, and that she cooked dinner for herself and put herself to bed. Miranda’s mother, Miraya, was a woman who had fled her country of origin to protect her daughter from her abusive husband as well as a violent neighborhood. Miranda’s hearing problem was a result of a severe beating to her head. Miraya was a cook in a restaurant and worked hard to gather the money to travel to the United States. She had a distant cousin who offered her a room until she could find a place of her own. Both Miraya and her cousin worked two, sometimes three shifts at a hotel and restaurant. They were unable to pay for a babysitter, and since Miranda had often been left alone when she was much younger, Miraya thought her daughter would be okay at her current age. And by all accounts Miranda seemed fine being alone, was used to making a sandwich for herself, and watched TV or read until she was tired. However, as Miraya found out, in the United States it was against the law to have an unattended child of her age. Thus, Miraya came home one day to find a police officer and a child protective services worker ready to take her daughter to foster care. Miranda was placed with a Korean foster family with two older girls and two parents. Miranda was then referred to therapy. The foster parents came into the intake and described a compliant, self-sufficient child. In fact, they were surprised at how resilient she was, adapting easily to her new room. Their only concern was that she didn’t interact with the two older girls and she kept to herself. They described her as “quiet and respectful.” I inquired about Miranda’s hearing loss and parents said that as long as she was looking at them, she understood what they said, and that they noticed she could hear better in her right ear. Individual treatment proceeded easily with this highly adaptable child. It was clear she was used to being alone and making few demands. I always sat to her right, and I agreed with foster parents that she seemed to read lips and spoke fairly well. I spoke with her in Spanish, her first language, and her English was improving as a result of her English immersion program. She seemed to like playing in solitary fashion and seemed unfamiliar with the array of toys in the play therapy office. She often asked what a specific toy was and how it was used. She said she didn’t usually “have time to play,” and her mother “didn’t have money to buy her toys.” She asked often when she would see her mother and go home again and seemed to understand that a judge would decide those things and that I was available to help her with whatever thoughts and feelings she was experiencing. Miranda volunteered little information spontaneously; however, when we did a family play genogram, she inserted a huge two-headed dragon for

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Cultural Issues in Play Therapy

her father and put a weapon in its hand. When I asked about the figure, she did not hesitate to say that her father hit her on her head with a bat and that she and her mom ran away from him because he was scary. When she motioned toward the right side of her head, I asked if he had hit her on her ear. Miranda said he had, and I asked if she heard differently on the ear that was hurt from the one that wasn’t. She said that was the case. I asked what that was like for her, and she said she didn’t like it and that her hearing loss reminded her of him. When I asked if it was a problem either in the foster home or school, she said that sometimes friends teased her because they had to repeat things for her. She said that her teacher sat her in the front row so that she could hear everything. She also noted it was easier for her to read my lips because I knew Spanish. Miranda did not seem to feel self-conscious about the hearing loss and was quick to point out when I did not hear her. I eventually told her that I also had a hearing loss because I had flown on an airplane when I was sick and my eardrum had burst. She was fascinated with this and sometimes tried asking something in my right and left ear to see the difference. I also mentioned to her that I got good at looking at people’s lips and trying to understand what they were saying. She said she could do that too, and we played two specific games. In one game we would sit with our backs to each other and listen and repeat what the other person said. We would count how many times we had to repeat it. In the second game, she would sit next to me, on the right and then on the left, and say something, and also said something while facing me. We took turns doing these games. I also brought in a microphone, and we practiced speaking into it and turning the volume up and down until we could hear. Somehow playing these games seemed to lighten these topics, and it seemed like a relief to her that we were speaking about them explicitly. At one point she asked if her foster parents knew that she could hear better in one ear. I suggested she ask them, which she did. She reported that they had not noticed anything and stated they had not been told (their effort to normalize the hearing loss). She seemed happy that they were not told and hadn’t noticed. She stated, “I don’t like everybody to know, only when I tell them.” She expressed anger that her dad had hit her so badly that all her life she would have to remember him. She was very adamant that she did not like him and never wanted to see him again. She began to have supervised visits and talked in Spanish with her mother, who seemed to ask tons of questions of Miranda about where she was, who was taking care of her, and so forth. The mother cried openly about wanting her daughter back in her care but appeared stymied when asked what changes she could make so that the child was not alone or had someone to help with caretaking when mother was working. The social worker had given Miranda’s mother some resources she could access at



Introduction 9

school, but Miraya was slow to talk to the school. She later confided to me that she thought the school was “mean to her” and acted like they thought the child was in a better home now. This might have just been the mother’s perception, or the teacher who had learned about this child being alone, might in fact have been judgmental toward Miraya. The supervisor of visits spoke enough Spanish to get by, but not enough Spanish to understand the conversations between mother and daughter. Some of what was being discussed however, was the mother’s disapproval of her daughter being with Korean parents. The overall treatment goal with Miranda was to provide supportive psychotherapy as she coped with being separated from her mother and being in a new home environment. Eventually, I was sure I would provide some reunification services as well. As I learned about her hearing loss, I specified a goal related to assessing how she experienced this and to see if she needed specific support or resources.

Culture-Specific Work About 3 months into therapy, I noticed some very specific behavior on Miranda’s part in which she took Asian miniature dolls and would stick them in the trash can before she started playing in the dollhouse or sand tray (her two favorite things to do). After observing this behavior a few times, I made it verbally explicit: “I notice that you take the small Asian figures and throw them in the trash can before you go on to play with other things in the room.” She nodded her head. Then I introduced the topic in the following dialogue with Miranda: “I’m wondering what it’s like for those little Asian dolls to be in the trash can. They look so small in there.” “It doesn’t matter. They are trash.” “The small Asian figures are trash?” “Yes, they are smelly, dirty people.” “These small Asian family members [mother, father, two girls] are smelly and dirty people?” “Yes! They are gross.” “Hmmm, I wonder where those ideas came from?” “My mom told me that they are tricky, not to listen to them, not to let them touch me, not to eat too much of their dirty foods.” “So, your mom has these strong ideas about Asian families.” “Yes, she doesn’t think I should be living with them. She thinks I should be with White people or with Spanish people.” “So, your mom does not want you to be with a Korean family.” “She says they are trash and should be put in trash cans and taken away.” “So, that’s what your mom thinks. What do you think?”

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“I think I want to go home with my mom. I’m scared of the tricky people.” “I see, so you’re scared now, and when you come into the room you want to put them in the trash like your mom says.” “Yeah.” “I wonder where your mom got those ideas about Korean people?” “I don’t know.” “Do you think she’s ever met any Korean people?” “I don’t know.” “Hmmmm. So, you might know more about Korean people than your mom does right now. Your mom might just be worried for you if she imagines they might trick or hurt you.” Silence. “Have you ever told your mom about your foster mom or dad?” “No, she doesn’t ask me . . . ” “And if you could tell her something about your foster mom, what would it be?” “I don’t know . . . she’s nice.” “What does she do that’s nice?” “She asks me about school, and she makes treats for me, and she reads us books at night.” “Oh, okay, so she sounds nice.” “Yeah.” “So, it sounds like some Korean moms are nice and read books and make treats.” “My mom says they are dirty and smell—” “Well, I’m not sure if your mom has ever spent time with Korean people, but tell me, do you notice any smells or dirtiness?” “Some of the food smells different, but it tastes good.” “Okay, so you notice smells but from good food.” “Yeah.” “So, you have found your Korean foster family seems to be different than what your mom thinks. You have gotten to know them and she has not.” “Yeah, but I don’t want to stay there.” “And I can imagine you being worried about that. You want to go home with Mom, and she wants you to come home to her.” She stopped putting the Asian miniature family in the trash after this discussion, and I often brought up how many similarities Korean and Latin families had: special foods, brown skin, their own religion and church, lots of family around them, and so forth. My next task was to meet with Mom and have the same conversation, which did not go as easily but had the same eventual outcome. Miraya understood that she was scared her child would be given to this new family



Introduction 11

and she was trying to create a negative narrative about them so her daughter did not get close to them. I understood her desperate attempt to keep her daughter close to her, and at the same time, I was able to communicate that she had inadvertently sent the message that all Koreans are dirty and smelly and basically “trash.” We talked about how U.S. people sometimes discriminate against Spanish-speaking people and how unfair it was. Miraya was able to identify many incidents of racism toward her. I asked her to consider how hurtful it was to her and whether she really needed to repeat this behavior toward others. She was also stunned to hear that her daughter was throwing toys in the trash, and said she had not intended for her to do that. Eventually, Miraya was able to appreciate that her daughter was in good caretaking hands, especially when a reunification plan was begun.

SUMMARY We have expanded the definition of culture to include subcultures in which children and families may be functioning. We have tried to move beyond limiting the term “culture” to ethnicity and have instead encouraged clinicians to invite culture into the play therapy office, to craft therapeutic dialogues, assessments, and games designed to identify and process issues around cultural identity, and provide a template of more active therapeutic curiosity around issues of prejudice and racism. Working with Miranda, two important issues emerged that were dealt with directly: her hearing loss and its impact on her self-esteem and social relationships, and issues of racism promoted by her mother. These both appeared to be issues that needed to be introduced directly in order to facilitate this client’s adaptation to her foster home and school.

REFERENCES Falicov, C. J. (1998). Latino families in therapy: A guide to multicultural practice. New York: Guilford Press. Gil, E. (2003). Individual and family play genograms. In C. F. Sori, L. Hecker, & M. E. Bachenberg (Eds.), The therapist’s notebook for children and adolescents (pp. 49–54). New York: Routledge. McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and intervention (4th ed.). New York: Norton. Papelirin, J. (2014). The growth of subcultures. Retrieved from https://prezi.com/wwlcvb2h4oih/the-growth-of-subcultures.

CHAP TER 1

Practicing Child-Centered Play Therapy from a Multicultural and Social Justice Framework Peggy L. Ceballos Phyllis Post Mónica Rodríguez

“M

ulticulturalism” as a concept refers to diversity in a community or society (Kirmayer, 2019). Within a larger context, multiculturalism cannot be a separated from the reinforcement of human rights to address oppressive factors (Kymlicka, 2007). In addition, the interconnectedness that globalization brings to our societies is requiring professions to address multicultural and social justice competencies to effectively respond to the needs of diversified communities. The emphasis on multiculturalism within the mental health field has been called the “fourth force” of counseling (Pedersen, 1991). This fourth force brought with it a new era of research on and conceptualization of multicultural contexts to create a new ethos for how mental health services are rendered. As the field continued to advance in this direction, it became clear that multiculturalism could not and should not be separated from social justice advocacy. Social justice advocacy became the fifth force of the counseling profession (Ratts, 2009). Whereas multiculturalism has been recognized as “a powerful force, not just for understanding . . . [others] but also for understanding ourselves” (Pedersen, 1991, p. 6), social justice advocacy has been conceptualized as considering the impact of oppressive factors, privilege, and discrimination 13

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on the mental health of clients with the end goal of creating equitable distribution of power and resources (Chang, Crethar, & Ratts, 2010; Ratts, Anthony, & Santos, 2010). More recently, Ratts, Singh, Nassar-McMillan, Butler, and McCullough (2016) revised the Multicultural and Social Justice Counseling Competencies to reflect the complexity inherent in understanding the intersectionality of identities and the crucial role that social justice advocacy plays in the mental health field. For play therapists, it is pivotal to address multiculturalism and social justice advocacy in their work because our societies will continue to diversify and be directly affected by globalization (Kirmayer, 2019). In the United States specifically, it is estimated that minority children already surpass the number of White children (Chappel, 2015). Systemic oppression places minority children at higher risk for academic challenges (Carey, Yee, & DeMatthews, 2018) and adverse childhood experiences (Wade, Shea, Rubin, & Wood, 2014). Due to these risk factors faced by minority children, play therapists have a responsibility to consider the effects of social oppression, socioeconomic stress, and political factors on the well-being of clients (Ceballos, Parikh, & Post, 2012; Davis & Pereira, 2014). This multicultural and social justice framework must be integrated into play therapists’ theoretical orientations. In the case of childcentered play therapy (CCPT) approaches, including child–parent relationship therapy (CPRT) and child–teacher relationship therapy (CTRT), it is pivotal to gain a deeper understanding of how to conceptualize and practice within a multicultural and social justice context.

CHILD-CENTERED THEORY: MULTICULTURALISM AND SOCIAL JUSTICE Child-centered play therapy emerged from Carl Rogers’s (1942) personcentered theory. Central to person-centered theory is the belief that each person has the innate capacity to self-actualize, or grow in a positive direction. In 1947, Virginia Axline started to conceptualize how person-centered principles applied when working with children. Axline (1969) believed that children have the capacity to engage in self-healing when given the opportunity to experience a safe relationship guided by the core conditions proposed by Rogers (1957): unconditional positive regard, genuineness, and accurate empathy. Following Axline’s work, several scholars in the field of play therapy continued to develop what is today known as CCPT (Ginott, 1961; Guerney, 2000; Landreth, 2012; Moustakas, 1953). Today CCPT has a strong body of research that supports its effectiveness with various child problem behaviors (Lin & Bratton, 2015). Additionally, CCPT research supports its effectiveness with children across cultures (e.g., Barcenas, 2017; Ceballos, Lin, Bratton, & Lindo, 2019; Gonzalez &



A Multicultural and Social Justice Framework 15

Bell, 2016; Post, Phipps, Camp, & Grybush, 2019). However, rendering culturally responsive CCPT requires practitioners to be intentionally mindful of the ways they integrate multiculturalism and social justice advocacy into their conceptualization and treatment planning for clients. Conceptualizing CCPT from a multicultural and social justice framework starts with a deeper understanding of how the theoretical tenets of CCPT can be understood from a context not bound up with Western culture. At the center of CCPT is the belief in the self-actualizing force (Landreth, 2012). Axline (1969) explained that children’s self-actualizing force is enacted to its fullest when optimal conditions are present. This belief comes directly from Rogers’s (1951) idea that the self-actualizing force is influenced by external factors. Specifically, Rogers (1951) stated, “The child will actualize himself, in spite of the pain which is often involved in these steps. Even when he does not, because of a variety of circumstances, exhibit growth . . . one may still rely on the fact that the tendency is present” (pp. 490–491, emphasis added). This statement indicates that while all children have the capacity for self-actualization and use it constantly to survive, a variety of circumstances can challenge their ability to access it fully. Thus, practitioners need to be aware of what these external forces are and how they are interacting with children’s ability to fully access their selfactualizing force. Self-actualization must be recognized within the cultural context of clients’ cultures, not therapists’ cultures. In addition, oppressive factors such as poverty, racism, and heterosexism affect children’s selfactualization process. Swan and Ceballos (2020) argued, “Given that the self-actualizing force is viewed as an internal drive to fulfillment, this process is selfdefined by the client and thus it must be understood from the client’s cultural background” (p. 6). For clients who adhere to a collectivistic culture, self-actualizing may be viewed as a process that is in harmony with interdependence instead of individualism. As a result, practitioners must be keenly aware of children’s cultural values and the effect these have on clients’ views of self and others. Thus, it is important to recognize clients’ experiences or views of self-actualization. Conditions of worth are another important concept within CCPT that needs to be viewed from a multicultural and social justice framework. Cornelius-White (2016) explains how the power differential that exists in society between the oppressed groups and the majority group creates conditions of worth. According to Rogers (1951), people develop conditions of worth based on the congruence between their real selves and external experiences. In other words, incongruence between self-concept and experience of who the society believes people represent creates socioemotional problems (Cooper, O’Hara, Schmid, & Bohart, 2013). To this end, oppressive factors such as discrimination or racism restrict individuals’ true expression of themselves (Cooper et al., 2013). When these forms

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of oppression are internalized (i.e., internalized oppression), conditions of worth are created. Two examples are Latinx children who believe that to be accepted they need to code-switch and act White and in the case of heterosexism, children who internalize that to be respected in school they need to behave differently from how they feel. When conceptualizing children’s conditions of worth, it is crucial to note the importance of accounting for the complexity of intersectionality of identities. For example, children can have identities that afford privileges as well as identities that bring oppressive experiences. From a CCPT perspective, it is important not to have preconceived notions of children based on their identities; instead, child-centered play therapists seek to be in psychological contact with children to understand their internal worlds. Children are the experts on their own experiences, and thus play therapists can understand conditions of worth only when they adopt cultural humility to learn from each child. For example, one child may experience poverty very differently from another child who shares the same cultural background; their conditions of worth around the oppressive experience may be different. This highlights the significance of the importance of the relationship between children and play therapists. The client–therapist relationship in CCPT is characterized by the nine conditions proposed by Axline (1969). These conditions create the boundaries of safe relationships in which children feel completely accepted and free to be real and to behave without conditions of worth. As children experience being fully accepted, the need for conditions of worth diminishes. In other words, as children feel unconditional acceptance from therapists, they learn that it is safe to be real and that they, for example, do not have to match the cultural norms of their therapists to be worthy of respect. This does not mean that it will be equally safe for children to be real within their environment outside of the therapeutic relationship. For example, transgender children may understand that being authentic outside of a therapeutic environment could place them at risk of being physically attacked. Even in this case, the fact that children can experience unconditional positive regard with therapists helps them; whereas before children were unconscious of their internalized oppression, now they can understand it as an external factor that does not have to define them. In this case, children may choose to behave in a different way to protect themselves, but not because they believe that something is wrong with their identities. Becoming aware of internalized oppressions helps unblock the self-actualizing force. This example also highlights the need to engage in advocacy with and on behalf of children. It is only by removing external barriers in society that clients will be able to have social environments with the optimal conditions to selfactualize. As Swan and Ceballos explained (2020): In an optimal therapeutic environment . . . clients are able to have more full range of access to their self-actualizing force and to more fluidly



A Multicultural and Social Justice Framework 17 rely on their internal valuing system. . . . Clients can begin to internalize awareness of limitations the environment may be placing on their self-actualizing process, which can then materialize into awareness of internalized conditions of worth and, with new awareness, develop into a sense of empowerment. (p. 10)

This empowerment can result in clients advocating for their rights and for more socially just environments. In addition, the relationship, as explained by Axline (1969), calls for play therapists to be genuine and to accept children unconditionally. These conditions can only be present when therapists have engaged with their own self-awareness. As social beings, we all grow up with unconscious biases as a result of being socialized in environments that send constant discriminatory messages against others and that have institutionalized oppressive systems. Cornelius-White (2016) emphasized the need for person-centered counselors to acknowledge their power and privileges and argues that without such acknowledgment, accurate empathy and acceptance cannot be provided to clients. Unawareness of privileges and power as therapists can indeed re-create oppressive relationships with our clients. Because of this, CCPT play therapists need to commit to a never-ending critical exploration of themselves. The importance of this critical self-exploration has been highlighted previously in the literature (Barstow, 2008).

CONSIDERATIONS FOR CCPT APPROACHES WITHIN A CULTURAL CONTEXT Previous meta-analyses have revealed that CCPT is appropriate and effective with externalizing and internalizing behaviors across cultures, has larger effect sizes than directive approaches, and that minority children exhibit greater benefit from CCPT than White children (Lin & Bratton, 2015; Bratton, Ray, Rhine, & Jones, 2005). Similarly, research shows strong support for the use of CPRT with parents from different cultures (e.g., Ceballos & Bratton, 2010; Sheely-Moore & Bratton, 2010; Glover & Landreth, 2000; Lee & Landreth, 2003) and CTRT with teachers and in schools with large populations of minority children (Post, Grybush, Elmandi, & Lockhart, 2020a, 2020b). While there is a robust body of research supporting the effectiveness of CCPT with minority children, play therapists need to practice CCPT with an understanding of the clients’ cultures. For example, I (P. L. C.) regularly work with Latinx children and parents and find that telling children, “Let’s do it together” or “Let’s figure it out together” may be more affirming than returning responsibility by saying, “In here that’s something you can do by yourself.” For children who live in cultures where individualization and independence are valued, returning responsibility by allowing the child to do it alone can be affirming, but this is not necessarily

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true for children whose cultures promote interdependence and collaboration. Scholars in the field of CCPT have acknowledged other differences, such as the need to introduce the playroom more intentionally the first time when working with Latinx children (Barcenas, 2017; Garza & Bratton, 2005) and having toys in the playroom that represent the clients’ culture (Hinman, 2003; O’Connor, 2005; Shen, 2016). It is equally important to be aware of how other cultural preferences may manifest within the therapeutic relationship with children and parents. For example, children’s preferences for large or small amounts of personal space, children’s familiarity or lack of familiarity with indoor versus outdoor play, and cultural messages about gender differences can affect the way children interact with play therapists and with the playroom. Other factors such as children’s or parents’ acculturation level (when this applies), clients’ level of racial identity development, and the need for linguistically diverse services affect the relationship with therapists and require them to be sensitive to issues of culture.

Child–Parent Relationship Therapy CPRT is based on the belief that secure parent–child relationships are necessary for children’s healthy socioemotional development; thus, CPRT focuses on strengthening parents’ empathy and ability to respond to children’s needs (Landreth & Bratton, 2020). In CPRT, parents learn the basic CCPT skills to use with their children in special playtimes at home. CPRT is grounded in the filial therapy model originally developed by Bernard Guerney in the early 1960s (Guerney, 1964). Researchers have conducted over 45 studies related to CPRT. Overall, results indicate CPRT is effective in increasing parental empathy, decreasing parental stress, and reducing child behavior problems across diverse populations and issues (Bratton, Landreth, & Lin, 2010). Additionally, multiple studies show CPRT’s efficacy across ethnic, socioeconomic, and cultural groups, including African American, Native American, Israeli, Latinx, and immigrants (Bratton et al., 2010). Minority families in the United States face discrimination (Krogstad & López, 2016; Pew Research Center, 2016) and are overrepresented in poverty (DeNavas-Walt & Proctor, 2016). According to Duncan and Johnson (2007), minority clients tend to mistrust mental health practitioners due to past negative experiences with the mental health system. Furthermore, using mental health services is not a common or accepted practice within many minority communities (Clement, Schauman, Graham, & Maggioni, 2015). CPRT can help reduce feelings of mistrust and disempowerment by positioning parents as the experts and as the agents of therapeutic change (Sheely-Moore, Ceballos, Yung-Wei, & Ogawa, 2019). Thus, CPRT can be a very affirming intervention when working with minority families.



A Multicultural and Social Justice Framework 19

However, play therapists need to deliver CPRT in culturally responsive ways that adapt and respect parents’ cultures. Sheely-Moore et al. (2019) list several cultural considerations when providing CPRT to minority families. Among them is attention to how different communities may view confidentiality; while for some cultural groups bringing extended families to group therapy from time to time is welcomed, for some other communities it is actually better to provide CPRT individually due to the high value they place on maintaining confidentiality related to family issues. Other considerations include (1) attending to linguistically diverse clients by translating handouts; (2) intentionally integrating important cultural concepts into the CPRT training (e.g., linking limit setting to the value of respeto when working with Latinx families); (3) having flexibility with the 10-week model as this format may not be feasible for some parents; and (4) having filial kits that have toys representative of the clients’ culture, ethnic and racial identities. In addition, just as when rendering CCPT, CPRT leaders need to be mindful of whether the specific skills we are teaching are congruent with the family’s cultural background and adapt accordingly. Similarly, it is important to be mindful of the oppressive factors that influence the parent–child relationship. For example, research shows that as poverty increases, parental stress increases and that poverty negatively affects family dynamics (Evans & Kim, 2013). This awareness must be accompanied by a social justice advocacy component by advocating with the parents as well as on behalf of parents. For example, the educational system in the United States is systematically oppressive to minority children and families (Milner & Laughter, 2014). When working with minority families, letting them know of their rights and engaging in conversations on how they can advocate at the school can be helpful.

Child–Teacher Relationship Therapy The application of CCPT interventions in schools, with both students and teachers, is essential if we hope to have an impact on minority group children. In their review of the literature about the impact of CCPT on marginalized children, Post et al. (2019) found that all of the intervention studies about the impact of CCPT were conducted in schools. They state, “this finding is noteworthy, though not surprising, because ethnic minority group children are more accessible in schools because they are less likely to use clinical mental health services” (Post et al., 2019, p. 93). When addressing the issues of minority-group children in schools, we cannot ignore the fact that exposure to abuse, loss, and violence (Wade et al., 2014) is common for many minority group children. Finkelhor, Turner, Shattuck, and Hambly (2013) reported that each year approximately 60% of children either experience or witness some form of violence and about 15% experience six or more incidences. Adverse childhood experiences (ACEs) that

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include abuse, neglect, and household dysfunction can affect the structure and function of the developing brain (Felitti et al., 1998). Although many factors contribute to higher ACEs scores, minority-group children who live in low-income homes (Wade et al., 2014) are most vulnerable. Students who have experienced ACEs may struggle to regulate their behaviors and emotions, be fearful of novel situations, be difficult to calm, and demonstrate aggression and impulsivity (Carvalho et al., 2019), which can result in lower performance on achievement tests and developmental delays when compared with children living in more privileged situations (Jaycox, Kataoka, Stein, Langley, & Wong, 2012). A supportive, positive relationship with an attentive and predictable adult is the number one protective factor for children who have experienced ACEs (Ludy-Dobson & Perry, 2010; Sciaraffa, Zeanah, & Zeanah, 2018). Teachers see children every day, and they can be that person to form relationships with students that mitigate the impact of ACEs and support students’ resilience and healthy development. CTRT (Sepulveda, Garza, & Morrison, 2011), an adaptation of CPRT (Landreth & Bratton, 2020), is a promising intervention to support children in schools. Using the same structure and model as CPRT, CTRT focuses on strengthening the relationship between teachers and students using their preexisting relationships. When working with teachers, understanding the cultural background of both the teachers and their students is critical. A component of the training must address the degree to which the trainers understand the teachers and the degree of understanding that the teachers have for the cultures of their students. To this point, CTRT leaders need to be sensitive to how the specific skills in the training are congruent or not with the teachers’ cultural backgrounds. Similarly, as with the parent–child relationship, it is important to be mindful of the oppressive factors that influence the teacher–child relationship. A developing body of research supports CTRT as an effective intervention to increase teachers’ ability to demonstrate relationship building skills (e.g., Hess, Post, & Flowers, 2005; Post et al., 2004; Sepulveda et al., 2011) and reduce students’ behavioral problems (e.g., Morrison, Bennett, & Bratton, 2011; Post, McAllister, Sheely, Hess, & Flowers, 2004). Recently, Post et al. (2020a, 2020b) conducted two studies that examined the impact of CTRT in a rural Title I school. In addition to the standard content of the CTRT program, the authors infused discussions about the impact of poverty, oppression, trauma, and social justice into the training. For example, discussions and experiential activities were included that focused on the impact of ACEs on the developing brains of children as well as the impact of institutional racism and poverty on children. The outcome of the qualitative pilot study, conducted with four kindergarten teachers, revealed that they found the training helpful and insightful and that CTRT program deepened their commitment to their work and to the skills they



A Multicultural and Social Justice Framework 21

learned. The following year, all teachers in the school participated in the CTRT training (Post et al., 2020b). The outcome indicated that the CTRT intervention had an impact on teachers’ attitudes about trauma-informed care, attitudes aligned with the values of CTRT, and most importantly, their ability to demonstrate the CTRT skills in their classrooms compared to a control group of teachers. The implications for emerging CTRT work include that it is an intervention that can focus on systemic change in schools that is sensitive to issues of culture, privilege, and oppression, as well as closely aligned with the values of trauma-informed care. Similarly, CPRT research supports its effectiveness as an intervention that can focus on systemic change in families by affecting the parent–child relationship. We need to embrace the fact that teachers and parents are essential caregivers for children of different cultural backgrounds, so we must make a concerted effort to ensure they are empowered with skills that help all children. Similarly, just as childcentered play therapists need to be sensitive to issues of poverty and oppression and aware of the intersectionality of children’s identities, teachers can be educated on these concepts to be better equipped to work with diverse students who face risk factors.

CONCEPTUALIZATION FROM A SOCIAL JUSTICE FRAMEWORK When conceptualizing cases, we recommend that child-centered play therapists intentionally attend to the effects that clients’ cultural background, intersectionality of identities, and exposure to oppressive factors have on the presenting concern. The following questions can help therapists to be mindful of these factors: • How do clients’ cultural identities contribute to their experience of privileges versus oppressive factors? • Have clients been exposed to discriminatory messages? Have they internalized these messages? Have these internalized messages become conditions of worth for the children? • How are oppressive factors challenging children’s abilities to fully engage in the self-actualization process? • Who has the power to remove or mitigate the effects of the identified oppressive factors? • What advocacy actions do you need to take as a play therapist outside of the work done in the playroom? The answers to these questions can help child-centered play therapists conceptualize children’s presenting problems more holistically and

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inform the type of advocacy needed when developing treatment plans. When deciding on type of advocacy, it is important for play therapists to be familiar with an advocacy model that can help them make decisions regarding advocacy actions. The American Counseling Association updated Advocacy Competency Domain (Toporek & Daniels, 2018) explains advocacy as an action that can happen in collaboration with clients and/or on behalf of clients at the micro or macro level. An example of a micro-level advocacy intervention with clients could be going to the school with parents to advocate for 504 plans. An example of macro-level interventions that play therapists could implement is to engage in social/ political advocacy targeting immigration laws that could help clients who do not have U.S. citizenship/residential documents. Another example could be for the play therapist to implement a schoolwide CTRT program that infuses concepts about privilege and oppression to create systemic changes in a school climate. Familiarizing oneself with the different types of advocacy work that one can do is important in eliminating systemic oppression. Below is a case study that exemplifies how the authors conceptualize and work with a child using CCPT in a way that is culturally responsive and that attends to the role of advocacy. In order to maintain the confidentiality of clients, we are presenting a case based on our work with different Latinx children.

CASE EXAMPLE Carlos is a 7-year-old bilingual Latinx boy referred to play therapy by his second-grade teacher. He is the third child to his biological parents and often perceives the need to compete with his siblings for attention. Carlos’s parents are both undocumented immigrants and moved to the United States when Carlos was 5 years old. Due to their undocumented status, Carlos has been warned to refrain from speaking to teachers or strangers about his family. He has an older brother in the fifth grade and an older sister in the third grade. All three children go to the same elementary school. His parents have a long-lasting marriage; however, they rarely spend long periods of time together because of their extensive work schedules. At times they struggle to provide the basic needs for the household and sometimes pick up part-time or temporary work aside from their primary jobs. Carlos’s maternal grandmother also lives in the household and provides most of the caregiving when his parents are out of the house. From his earliest age, Carlos was an easygoing and happy child with no behavioral concerns. However, upon entering kindergarten, Carlos began to exhibit significant tantrum behavior both at school and at home. During these tantrums, Carlos becomes emotionally dysregulated and often



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threatens to hurt himself or others in the classroom or family. Teachers found it difficult to respond to Carlos in a way that helped him regulate and refrain from his aggressive behaviors. Teachers attempted to contact Carlos’s parents and grandmother about his increasing tantrum behavior; however, all caregivers were Spanish speaking and limited in their English proficiency. Carlos’s brother was also struggling with behavioral concerns at school while his sister was experiencing isolation and social withdrawal. The play therapist was a bilingual school-hired counselor who went to the school twice a week to provide play therapy to children referred by teachers.

Conceptualization The play therapist’s decision to adapt the CCPT model for Carlos’s unique cultural context aligns with the growing literature that mentions the importance of recognizing and addressing the impact that culture, society, the environment, and other systems have on clients (Ceballos et al., 2012; Swan & Ceballos, 2020). Her conceptualization and adaptations for Carlos’s needs began with the introduction of the room. The play therapist was aware that a child’s experience of oppressive factors blocks his opportunity to release his innate capacity to self-heal and achieve self-actualization. Her decision to include the option to use both languages (English and Spanish) allowed Carlos to choose how he would like to express himself instead of feeling forced to speak in a language that he may not be able to fully understand. The play therapist contacted Carlos’s parents and grandmother to discuss how they experienced Carlos, and they spoke about the family’s barriers to accessing resources, their experience with the school system, and their parenting style. She now had a more in-depth picture of Carlos’s home and school life and how these factors have influenced him at school. Due to the parents’ and grandmother’s low proficiency in English, the play therapist asked Carlos’s family if they had anything they wanted her to communicate to the teacher. The family gave her a list of questions and concerns for the teacher. The play therapist met with the teacher to address the questions asked by Carlos’s family and to learn more from the teacher about her perception of Carlos’s situation. Following the updated American Counseling Association Competency Domains (Toporek & Daniels, 2018) the play therapist was working in the community/school/organization domain while collaborating with and on behalf of the family. This action helped bridge a gap in communication between Carlos’s family and the schoolteacher. Additionally, through contacting the family, she discovered that Carlos appeared to be navigating two different cultural worlds and two sets of values and norms. The family spoke extensively about their home

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life and expectations about interdependence, which were different from the expectations at school that focused on independence. Carlos may have experienced confusion from the mixed messages he received, which could have been intensified by his limited ability to communicate verbally with his teacher. These factors could have been contributing to the behavioral concerns in the classroom for which he was referred to play. Although his teachers were initially supportive, they felt frustrated with their inability to deescalate Carlos’s behavior during his aggressive episodes. He consistently heard his name being called throughout the day even when he thought he was following the rules. Rogers (1951) claimed that children are born with a need for positive regard. As a child, Carlos had a strong need for positive regard from others; however, he was mainly receiving conditional positive regard from his teachers. Carlos understood that he was only accepted by his teachers when he was behaving according to expectations that may have contradicted his family background, For example, he might have held the belief “I am worthy when I am working individually” or “I am worthy when I code switch,” which is contradictory to his collectivistic cultural background or family behavioral expectations; with relation to language, he might have held the belief “I am worthy when I speak English,” which is not his native language. These conditions of worth created incongruence between Carlos’s real self and ideal self, which triggered misbehaviors. In addition, within the cultural context of society, Carlos received other discriminatory messages. For example, Latinx families without citizenship/residential documents are often criminalized on a daily basis by being described with words such as “illegal” and “criminals.” Similarly, facing risk factors such as poverty did not provide the optimal environment for Carlos to fully enact his self-actualizing force. Moreover, because of societal pressures on boys to withhold feelings of sadness and fear, Carlos may have heard at home or at school that “boys don’t cry,” so his emotional expression of depression could have been expressed as externalized misbehaviors.

Beginning of Play Therapy The play therapist arrived at Carlos’s classroom for the first play therapy session. He seemed hesitant and unsure but followed the play therapist out of the class and into the playroom. The play therapist offered Carlos a choice of walking next to her or holding her hand as they walked to their destination. Carlos chose to walk quietly next to her until they entered the playroom. It would be important to allow Carlos the freedom to express himself in many of the ways that he would like. Since Carlos’s native language is Spanish, Carlos could choose to express himself in both English and Spanish. The play therapist followed the suggestion from Garza and Bratton (2005) of introducing the play therapy room in the following way:



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“This is our special playroom. In here you can say and do many things that you would like, and can also decide to speak English, Spanish or both.” “Este es el cuarto especial de jugar y aquí puedes hacer y decir muchas cosas que te gustan, aquí puedes escojer hablar Ingles, Español, o los dos.” The play therapist then matched and responded to the language that Carlos chose to speak, at times alternating between both languages following Carlos’s lead. Additionally, during the first few minutes of the session, the play therapist touched the toys in the room and encouraged the child to touch them. This action is a deviation from the original CCPT training model. However, in certain cultural contexts, Latinx immigrant families may have more authoritarian parenting styles. Thus, Latinx children may be hesitant to begin playing with the toys unless given specific permission to touch the toys (Barcenas, 2017). The play therapist responded to the unique cultural dynamics of Carlos and his family by adapting the model to allow him to experience freedom in the room. The playroom had a variety of toys representatives of Latinx cultures to allow Latinx children at the school to feel welcomed and at home in the playroom. Recognizing toys from his culture helped Carlos have a sense that in this room his culture was accepted. During the first four sessions, the play therapist established a safe relationship guided by Axline’s (1964) principles. As the play therapist helped Carlos feel safe and unconditionally accepted, Carlos started to trust the therapist. Slowly, Carlos started to be more relational by engaging the play therapist in his play.

MIDDLE OF PLAY SESSIONS As the therapy progressed, Carlos played out some of his concerns through play. Themes of safety and mastery seemed to become prevalent in his play. This could reflect the lack of safety his family experienced due to not having documents. For example, Carlos played that the police would come and take away the dinosaur’s father for “misbehaving,” which was followed by being afraid of the police because “they didn’t know who was bad or good.” Carlos also engaged in a lot of mastery play. He would decide to do things that were hard, such as putting the ring toss game far away. The theme of mastery could have reflected Carlos’s experience being in an English classroom and trying to learn a second language. It appeared that Carlos needed to play in ways that allowed him to feel capable (mastery) while also playing out his fear of the father being taken away (safety) in his attempt to make sense of his experience at home. The play therapist realized that one of the ways in which Carlos engaged her was by asking her to do things for him in the playroom. To honor his collectivistic culture, the play therapist would return responsibility by stating, “This is something we can figure out together” or “Hmm, let’s see, can you show me how can

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we do this?” These responses allowed Carlos to know that his collectivistic way of being was accepted in the playroom.

END OF THERAPY Toward the end of therapy, Carlos’s need for mastery appeared to diminish. During one of the last sessions, Carlos played that he was the police, and he put the play therapist in handcuffs saying, “You have been bad, and you must go to jail.” He then rescued the play therapist and said, “Go and hide. You are good.” It appeared that the safety concern continued to be important. Given the fact that his family continued to fear deportation, it is understandable that Carlos would continue this theme in his play. However, the therapist noticed that the intensity of his emotions when playing was lower compared to the beginning of therapy. Similarly, the play now ended with Dad being a “good person,” which could be due to Carlos’s ability to reject the external oppressive messages associated with being undocumented. Limit setting was more prevalent during the last part of therapy. For example, Carlos started to take sand out of the sandbox and tried to shoot the therapist. For the play therapist this became an opportunity to engage Carlos in practicing self-control by using limit setting as explained by Landreth (2012). As Carlos started to show self-control in the playroom, his teacher also reported that Carlos’s behavior in the classroom was getting noticeably better. Carlos’s mom was offered to participate in CPRT, but her work schedule did not allow her to join a group. Thus, the play therapist modified CPRT and provided eight individual session to Carlos’s mom and grandmother. This allowed for a better transition from the end of Carlos’s play therapy to the start of his special play times at home.

ADVOCACY While the play therapist adapted the session and the playroom to create a safe and nurturing environment for Carlos, the school environment continued to impact him in ways that created conditions of worth and therefore increased his level of incongruence. To help Carlos from a systemic perceptive and thus provide him an opportunity to release his capacity for growth, the play therapist worked on behalf of Carlos and involved his teacher. Providing the teacher with psychoeducation on how to work with the unique socioemotional needs of immigrant children fostered empathy from the teacher that allowed her to create a stronger relationship with Carlos. Additionally, exploring how symptoms of depression and anxiety manifest for boys provided clarity on Carlos’s aggressive behavior and what he was experiencing both at home and at school. The teacher participated



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in a small CTRT group that allowed her to learn classroom use of play therapy skills—such as paraphrasing, reflecting feelings, offering choices, and therapeutic limit setting—to help Carlos when he is upset and foster his own capacity to self-regulate. The teacher’s participation in CTRT was possible because the school administration decided to focus on systemic change in the school by offering CTRT to all teachers. The administration’s decision was due to advocacy from the play therapist, who explained how CTRT could help teachers work with all children in ways that could support children’s experiences with risk factors such as oppression, discrimination, and social injustices. The play therapist also worked with the parents and offered them resources in the community, including legal aid services to assist with their immigration status, an integrated health care center in the community that offered a variety of medical services, and physical addresses for different food pantries in the community.

CONCLUSION Becoming culturally responsive practitioners is a lifelong process that includes commitment to become aware of our own cultural background, privileged identities, and identities that bring oppressive experiences. As Cornelius-White (2016) explains, without self-awareness therapists cannot offer authentic empathy and genuineness; in fact, the lack of self-awareness on the part of therapists could risk re-creating oppressive systems within client–therapist relationships. Because of the importance of self-awareness, we recommend that child-centered play therapists seek continuing education opportunities to grow their multicultural and social justice knowledge and commit to a continuous self-reflective journey. In addition, as explained in the Multicultural and Social Justice Competencies (Ratts et al., 2016), therapists have an obligation to become knowledgeable about their clients’ cultures and aware of oppressive systems and their impact on clients’ well-being. Play therapists can intentionally seek opportunities for cultural immersion experiences that allow them to interact with people from different communities. In addition, keeping up with policies that affect clients’ socioemotional well-being and seeking opportunities to engage in advocacy at the community level can be very beneficial to understand clients’ experiences of oppression. All who touch the lives of children, especially of those who are exposed to oppression, poverty, and trauma, would benefit from interventions that allow the children to be empowered. Similarly, play therapists need to engage in advocacy to eliminate systemic barriers that challenge children’s and their families’ self-actualizing force. Child-centered play therapists can empower children by trusting them and allowing them to lead while also being intentional about addressing oppressive factors inside and outside of the playroom.

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Sheely-Moore, A., Ceballos, P., Yung-Wei, L., & Ogawa, Y. (2020). Culturally responsive Child Parent Relationship Therapy. In G. L. Landreth & S. L. Bratton (Eds.), Child–parent relationship therapy (CPRT) treatment manual: An evidence-based 10-session filial therapy model. New York: Routledge. Shen, Y. J. (2016). A descriptive study of school counselors’ play therapy experiences with the culturally diverse. International Journal of Play Therapy, 25, 54–63. Swan, A. M., & Ceballos, P. (2020). Person-centered conceptualization of multiculturalism and social justice in counseling. Person-Centered and Experiential Psychotherapies, 19(2), 154–167. Toporek, R. L., & Daniels, J. (2018). 2018 update and expansion of the 2003 ACA Advocacy Competencies: Honoring the work of the past and contextualizing the present. Retrieved from www.counseling.org/docs/default-source/competencies/ aca-advocacy-competencies-updated-may-2020.pdf?sfvrsn=f410212c_4. Wade, R., Jr., Shea, J. A., Rubin, D., & Wood, J. (2014). Adverse childhood experiences of low-income urban youth. Pediatrics, 134(1), e13–e20.

CHAP TER 2

White Privilege, Anti-Racism, and Promoting Positive Change in Play Therapy Eliana Gil

It has been said that to teach is to touch the future. Helping students to see the past more clearly, to understand and communicate with others more fully in the present, and to imagine the future more justly is to transform the world. There is nothing more hopeful than that. Is it better? My answer is: Not yet, but it could be. It’s up to us to make sure it is. I remain hopeful.                    —Beverly Daniel Tatum (2017)

Being courageous enough to reimagine the world as we know it will only deepen our genuine solidarity with those who are currently struggling to survive it. Instead of timidly admitting to our various privileges, let’s ask ourselves what a world where all Black lives matters everywhere would look like— and accept nothing else.                        —Momtaza M ehri (2020)

WHITE PRIVILEGE DEFINED AND EXPLORED: ANTI-RACISM ACTION “White privilege” has been defined as “an institutional (rather than personal) set of benefits granted to those of us who, by race, resemble the 32



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people who dominate the powerful positions in our institutions. . . . Having greater access to power and resources than people of color do” (Kendall, 2002, p. 1). DiAngelo (2016) asserts that “The term white privilege refers to rights, benefits, and resources that are purported to be shared by all but are only consistently available to the dominant group. The fact that an assumed right is not granted to everyone turns it into a privilege—an unearned advantage” (p. 60). Kendall (2013) states: White privilege has nothing to do with whether or not we are “good” people. We who are white can be jerks and still have white privileges; people of color can be wonderful individuals and not have them. Privileges are bestowed on us solely because of our race by the institutions with which we interact, not because we deserve them as individuals. We are sometimes granted opportunities because we, as individuals, deserve them; often we are granted them because we belong to one or more of the favored groups in our society. (p. 63)

Peggy McIntosh wrote an essay and working paper in 1988 and 1989 that became foundational to her later work. In 2019, she stated, “I have come to see white privilege as an invisible package of unearned assets which I can count on cashing in each day, but about which I was ‘meant’ to remain oblivious. White privilege is like an invisible weightless knapsack of special provisions, maps, passports, codebooks, visas, clothes, tools, and blank checks” (1990, p. 216). She also emphasized and cautioned that White privilege inherently includes advantages by noting, “As a white person, I realized I had been taught about racism as something that puts others at a disadvantage, but had been taught to see one of its corollary aspects, white privilege, which puts me at an advantage” (McIntosh, 1990). She goes on to say that the word “privilege” sounds limited to her and offers up an alternative: “the word ‘privilege’ now seems to me misleading. We usually think as privilege as being a favored state, whether earned or conferred by birth or luck. . . . Yet some of the conditions I have described here work systematically to over empower certain groups. Such privilege confers dominance because of one’s race or sex.” Thus, she offers up the terms “earned strength” and “unearned power.” The history of the United States has demonstrated racial inequality relentlessly, way after the ultimate violation of slavery. And although formal slavery did end, an informal type of oppression of BIPOC (Black, indigenous, and people of color) has continued for decades. Kendall (2002, pp. 2–3) lists the unequal institutional distribution of privilege, including (1) the U.S. Constitution’s confirmation of Black people as property; (2) Whites owning “land” that belonged to the native people; (3) the separation of Black families during slavery; (4) prohibiting Black children from learning to read; (5) removing Native American children from their land

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and homes and systematically removing their language; (6) laws that maintained the separation of Whites and Blacks; (7) the vote afforded White, not Black, women; (8) the manipulation of immigration laws to block people of color; (9) the removal of Japanese from their homes while taking their land and businesses; and (10) the use of affirmative action to promote opportunities for White women rather than people of color. BIPOC have never achieved the same rights as their White counterparts and remain in danger of being targeted and killed, disproportionately sent to prisons, and often kept from educational pursuits. There has never been an even playing field. The Black Lives Matter movement was formed to keep a spotlight on the lack of equality and reform and must be supported by the rest of us if we are ever to achieve the “land of the free, and the home of the brave” for all Americans. This organization is built on principles of nonviolence raised up by Martin Luther King, Jr., John Lewis, and Jim Clyburn, and yet many are easily swayed to renounce it for the incorrect assumption of its pursuit of violent tactics. And if there is any doubt about our collective history, there are countless historians who provide a full account with passion and historical acuity (Kendi, 2019). This chapter accepts that White privilege exists and persists, consciously or less so, and provides some thoughts on individual responsibility as we negotiate providing services to marginalized communities. As Stovall (2019) states, “From colonization to revolution, slavery to emancipation, O. J. to Obama, White America has engaged in an epic struggle to hide, avoid, and rationalize the glaring gulf between our egalitarian self-image and our repressive group behavior. And we aren’t fooling anyone. The confusion in white people’s hearts is the most poorly kept secret in the world” (p. 8). There has been a lot of discussion about racism, racist attitudes and policies, the complexity of thinking involved in White privilege, and the role that White individuals can play to move and push forward positive change. Some Blacks believe that White people have to discuss their privilege with each other, not attempt to explain this phenomenon to other racial groups, who are all too aware of the impact of privilege. On a recent episode of Call & Response: Comedian & Correspondent on The Daily Show with Trevor Noah, Dulcé Sloan explains why White people need to stop asking Black people to educate them, and instead, discuss and own up to their White privilege and do the work of dismantling oppressive behaviors. My goal in this chapter is to acknowledge the privilege (or unearned power) afforded to those of us who were born with and live in white skin, and how that privilege might be acknowledged and addressed in our work as play therapists with clients, as well as the platforms we have as authors, teachers, consultants, and supervisors. Acknowledging White privilege is insufficient—a false exercise—unless it is followed by action. I also agree that we can’t make this topic a reductionist one that ends up focusing on individual action exclusively. Mehri urges follow-up action after self-reflection,



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stating, “Unlearning personal prejudices should coincide with undoing the structures, logics, and economic arrangements that perpetuate antiblackness” (p. 3). I don’t think individual and systemic action are mutually exclusive—our efforts must occur on parallel dimensions. This topic must be woven into our personal and professional work broadly and with persistence, and even though I may currently have more questions and thoughts than specific answers, I encourage our community of White professional clinicians to dig deep, take the first, second, or third steps to become more personally and professionally responsible and accountable, embrace activism in whatever dosages are feasible, and continue to generate conversation and introspection that might provide a foundation for a realistic and sustainable plan of action. Every discourse on this topic begins with self-evaluation, which McIntosh (1990) describes as an elusive subject: “The pressure to avoid it is great, for in facing it, I must give up the myth of meritocracy.” It’s tempting to sit back and ask, “What can I possibly do or say?” and yet that attitude keeps us static. We need to jump in and do either private or public internal and external work designed to advance the transformations that have started to emerge and form. And yet this first step is not always easily approached: “For most white people, whiteness is a minefield—a topic to gloss over, a mask to hide behind, a shame to cringe over, maybe a tool to use, a weapon to hurt with, or be hurt by. Certainly nothing to muse about publicly” (Stovall, 2019, p. 10). Because long-lasting, concrete changes take time and concerted effort and have a tendency to elicit both supportive and adversarial responses, our work will need to be task focused and stubborn. It will be important for all of us to do better, and to do better permanently, not only in enthusiastic spurts responsive to social climate—too often vibrant flames wither away to small embers that historically fade with time. Steps have to be taken and retaken, and lead to a range of small and large actions, taken immediately or planned over time. We also can’t stop at honest selfevaluation. As Mehri (2020) asserts, “The mainstreaming of anti-racist discourse is causing many people to question their own position in the world. As welcome as this is, let’s not stop at self-reflection. Unlearning personal prejudices should coincide with undoing the structures, logics and economic arrangements that perpetuate global anti-blackness” (p. 3). Each of us has our own personal history, heritage, and basic understandings of the personal and situational factors and traditions that have contributed to our growth and development and that constitute the essence of who we are. Many of us have been, or are, highly receptive to the influences and multilayered messages of community, dominant culture, and gender, as well as spiritual, social, religious, economic, and familial nuances that shape our individuality and our values. And regardless of all the external underpinnings, we live in a White body and that body communicates privilege, whether we acknowledge it, try to manage and mediate it, feel

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ambivalent or guilty about it, or have occasion to reap the benefits of this higher status awarded to us. The truth is that White play therapists must rise to the occasion in whatever ways they fathom or design. There will be missteps, false starts, downright errors along the way, and yet persistence and internal and external work must continue if we are to become culturally responsible, provide support to our BIPOC colleagues, and work directly with our White, Brown, and Black clients and their families, one client at a time. Our job is to advocate for reflection, discussion, and values clarification. This is not a time to feel weary (although we do), or to feel discouraged (in spite of worrying that there’s nothing each of us can do), or to give up (being in lockdown does not help). Let’s rally and have frank discussions with each other and with our clients, and then activate as many changes as we can. As Saad (2020) states, “Doing this work and going into the truth blasts away all the lies and games, giving you a real opportunity to create change. There is no safety in this work. There is no clean, comfortable, or convenient way to dismantle a violent system of oppression. You must roll up your sleeves and get down into the ugly, fertile dirt” (p. 199). If you are not BIPOC and/or have not had the experience of you or your loved ones being singled out, judged, or treated differentially due to your skin color, it’s impossible to know what it’s like to live in daily fear, or to knock on doors that don’t open, or to be turned away without being heard (see, e.g., McIntosh, 1990, for her list of the daily effects of White privilege). As White individuals, we don’t have similar experiences based on racial discrimination alone, and it’s hard to imagine circumstances, microaggressions, and abuse such as the ones that happen to BIPOC daily. As privileged or empowered people, we may not have to sit down and try to explain to our children why our people are targeted, abused, tortured, or killed. There is a YouTube clip called Black Parents Explain How to Deal with the Police, and when I watched it, I felt the sense of my White privilege in that I never had to tell my kids about this. I cringed as I watched these loving parents trying to explain to their children what they needed to do to remain safe: They had to be compliant, keep quiet, and show their hands at all times. They emphasized that any sudden moves on their part could be misinterpreted or used as an excuse for abusive behavior. I never had that conversation with my children, although I am now informed by the danger that my Black son-in-law describes to me and his recurrent nightmares of being arrested, isolated, and unable to return back to society to continue his life. I also fear for my nephew, who is one of the sweetest, most gentle humans I know, but his appearance as a Brown Hispanic youth with a penchant for tattoos could elicit negative responses from others based solely on his appearance. We also don’t know the price that people of color pay, and have paid, to push back against policies and systems that have felt



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inaccessible. And yet the fight has paid off for many, and there is a growing number of BIPOC professionals who are in positions of leadership, and who have prioritized changing those very systems that were difficult to penetrate. The perseverance of BIPOC in spite of numerous historical starts and stops is remarkable.

MY PERSONAL AND PROFESSIONAL FIRST-STEP EVALUATION REGARDING WHITE PRIVILEGE I share my story as a way of asserting that we must all explore our relationship to racism, equity, and diversity. For mental health professionals, it is absolutely the smallest first step that can be taken. Our histories might afford us some points of connection, a way to detect even the smallest hint of what our BIPOC colleagues may experience. These are not shared to proclaim any kind of special status or to inflate my own entitlement to render an opinion, only to demonstrate the kinds of issues that might be worthwhile for all of us to explore if we haven’t done that before. I have struggled for decades about using the term “person of color.” I am a Latina immigrant, bilingual and bicultural, straddling two worlds without fitting completely into either. I have felt like an outsider from time to time, and yet (as I have recently admitted to myself), I do live in White skin, thus I am “white passing.” This skin color has always been singled out in my Latin American culture: “Que blanquita que es tu hija” was a common comment I overheard made to my mother (translation: “Your daughter is so white”). In my birth country of Ecuador, there are nicknames for just about everyone—“the skinny one,” “the chubby one,” “the one with a big nose”—and they include references to skin color such as que tostadito (translation: “You are Brown like the color of toast”) or negrito (“Your color is black”). It is built into our culture, so much so that no one thinks twice about using those terms, and they are usually considered terms of affection! In addition to running commentaries based on skin color, I began to notice differences in the way I was treated when with darker-skinned relatives, even as a young child. This concept of “colorism” was first coined in 1983 by Alice Walker, but when I was a child, it had no name. It was a series of experiences that taught me about inequity. Kendi (2019) urges us all to “first recognize that Light people and Dark people are two distinct racialized groups shaped by their own histories” (p. 109). He also states, “When the gains of a multicolored race disproportionately flow to Light people and the losses disproportionately flow to Dark people, inequities between the races mirror inequities within the races” (2019, p. 111). A very powerful and distressing experience in my life has been to sense and feel the ways in which my sister and I are treated differentially when it

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comes to skin color: I am obviously White and she is obviously a beautiful shade of brown. We are treated differently in our country of origin, and we are treated differently in the United States. She and I have discussed this on the surface, but we have both been protective in our conversations. We have also discussed this in reference to her brown-skinned children, who experience profiling and microaggressions all the time due to their appearance alone. All this to say, it becomes very useful to evaluate the impact of these experiences on your inner sense of self as well as others and to pursue some type of action designed to develop and grow anti-racist ideas about light and dark people. As DiAngelo (2018) states, “If they ‘pass’ as white, they will still have a white experience externally. If they look white, the default assumption will be that they are white and thus they will be responded to as white” (p. 18). I have felt the annoying sting (as opposed to the painful abuse that BIPOC experience) of unintentional statements people make that I view as care-less or thought-less but that are obviously emerging from a place of discomfort with race and diversity. Those comments typically include statements such as “You don’t look Latin!!” or “We need someone Hispanic on the panel, but we’d rather have someone who looks Hispanic.” When people make those statements directly to me, I always say, “What does a Latin or Hispanic person look like?” or “How does one look or not look Hispanic?” There are many people walking around with White skin who are from other cultures and races, and who share histories of cultural marginalization or historical oppression and who have diverse immigration stories. My personal experience, like yours, provided me with formative information about race and diversity. First and foremost, I had a nanny throughout my childhood who was Black and Ecuadorian. Her name was Manoni, and she was a second mother to my brothers and myself—I feel fortunate to have developed early attachment bonds with this tender, caring Black woman. We loved her deeply and felt tremendous grief when she left our home in the United States in order to marry a White man and move to a southern state—my mother worried for Manoni until the end of her life, often talking about last having contact with her during the civil rights unrest and hoping that she was safe. Other than this relationship with Manoni, I did not encounter many Black people in my youth, except in a small town on the beaches of Ecuador where some Africans had settled. Some of you may have noticed that our Ecuadorian soccer team has a substantial number of Black athletes, and they tend to come from one particular village, called Esmeraldas. My impression was that Esmeraldeños were happy, loved their beautiful village near the ocean, and danced with glee on streets and parks filled with lively music. They seemed happy-go-lucky and proud, selling beautiful arts and crafts. They reminded me of the villagers in the high country of Quito, where many Indigenous Indians lived. My



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impression was that our native Indians were creative, artistic, and lived in harmony. I will never forget the foods and colors of this part of my country. What I missed as a child was seeing or understanding the grave inequities that were not visible to me: the lack of education offered to children, the lack of health providers, the diseases that went untreated and took many lives, and the lack of financial resources that existed. Some of this has changed over the years, but a lot of it continues. Most of the racism I learned about in Ecuador was against Asians. There was one whole section of town where Asian (mostly Chinese) people lived, and I remember driving by there as a child and asking why all the Chinese were gathered in one spot. I don’t remember the answer, but I do remember the racist jokes and comments that permeated the topic. Like many marginalized people, neither Africans nor Chinese came into the larger city too much. They were likely never invited and might have understood deep down that they were not welcome. One of my girl cousins fell in love with a Chinese boy. I remember the drama and secrecy surrounding this event, and eventually I heard she ran away with him. On one of my visits to Ecuador, in my early twenties, I saw her father at a gathering, I asked him about her and how she was doing. He looked grim as he said, “I don’t know anyone by that name,” and he walked away. I agree that children are not color blind, rather they can notice and feel differences and even comment on those perceived differences. What children don’t have when they are very young is a tendency to think negatively about skin color. Those negative associations regarding skin color develop over time as a result of many variables, including guidance from parents, caretakers, teachers, and friends. All this is to say, racism and anti-racism must be discussed with children as early as possible. As Oscar Hammerstein wrote in the musical South Pacific, “You’ve got to be taught to hate and fear, you’ve got to be taught from year to year, it’s got to be drummed in your dear little ear, you’ve got to be carefully taught.” Ibram Kendi has written a book for babies called Anti-Racist Baby (a companion book to How to Be an Antiracist) to address this issue as early as possible. I realized as an adult that racism can be instilled (or not instilled) in you, and my racist beliefs were buried deep. At one point during my graduate training, a paper on racism and discrimination allowed me to recognize and then create an action plan to decrease the prejudice about Chinese people that I had carried inside me for years. My plan had to be concrete and specific, and it required personal investment to change, but the first and smallest step was pausing long enough to explore the thoughts and feelings that were stored. The second and smallest step is making a commitment and investment in changing deeply rooted responses, thoughts, and attitudes that have been percolating quietly for years and have silently influenced past actions. Developing a blueprint and goal setting are critical steps once racism is acknowledged and examined.

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We all need to explore our formative experiences regarding race, culture, and class, as well as the deficits in our education. This honest action can allow us to develop a renewed or fortified sense of clarity so that we can better support our BIPOC friends and colleagues, and for whom the world is inherently different on the basis of skin color. In other words, we need to understand the phrase “driving while Black” as indicative of the inherent threats that Black and Brown individuals feel. We can’t be held back by a feeling in ourselves or others that “it’s too little, too late.” I have heard commentaries such as “Welcome to the table, better late than never,” or “Thanks for catching up.” These comments are important and correct. We have not been privy to what BIPOC have experienced for the past 400plus years as they fought for equity and were shut down over and over again. Even as we Whites develop a sense of wanting to join in, discovering (or rediscovering) this issue or being willing to explore it more deeply and actively, African Americans have lived this painful struggle daily. The conversation about racial injustice and inequity immediately leads to introspection about reparation and what the government can do, what society’s educational and social institutions can do, and what each of us can do to ensure that we use this moment in time to clarify our path of support and personal action. John McWhorter recently wrote a scathing rebuke of a book called White Fragility by Robin DiAngelo, stating, “White Fragility is, in the end, about how to make certain educated white readers feel better about themselves” (2020). I honestly disagree because I think that exploring this issue initially tears down our carefully protected image of not being personally involved in anything racist, and it is far cry from feeling better. The reality is that we all have layers of racism, and acknowledging them is the only way forward on a personal level. Choosing to turn reflection into action in all the intersections of our lives is yet another move forward. McWhorter points out many other concerns that he has about this book, especially because it has been well received and influential. His criticism resonates with McIntosh’s early concerns that defining White privilege inherently suggests White empowerment over others. McWhorter cautions White people about the privilege dichotomy, stating, “DiAngelo’s outlook rests upon a depiction of Black people as endlessly delicate poster children within this self-gratifying fantasy about how white America needs to think . . . or better, stop thinking. Her answer to White fragility, in other words, entails an elaborate and pitilessly dehumanizing condescension toward Black people. . . . and becoming racist in a whole new way.” When I read this statement, it takes my breath away because it presents a powerful perspective that I must recognize, respect, and learn from. At the same time, DiAngelo was the first person to bring this matter to the forefront, and her leadership and boldness cannot be overlooked. Her work caused thousands of people to become more introspective and accountable, and that is an



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important contribution. Thinking about White privilege is a small first step that requires subsequent actions to address it each and every time it rises up in our personal and professional lives. One thing we can all do without hesitation is to proclaim that Black Lives Matter, in recognition of the movement to dismantle racist capitalism, racist policies that marginalize and abuse BIPOC, and efforts to uphold the values of this country that are stated but not yet realized. And as mental health professionals we have to look at access issues, types of therapies provided, and the critical issues that affect Brown and Black children, who are disproportionately reported for child abuse and taken into the foster care system, where they sometimes age out.

WHITE PRIVILEGE IN MENTAL HEALTH The mental health profession is an elite, privileged institution crafted in such a way as to make entry somewhat daunting. Not only do you need to have abundant financial resources, you need to have the time to undertake a long course of study, something that is not possible for many young people of color, who must often prioritize earning money, supporting their families and fleeing dangerous social environments in order to avoid violence, drug addiction, homelessness, and other social ills linked to poverty, lack of access to health services, and lack of resources. Not everyone has the means or desire to postpone life in the pursuit of mental health education and licensure demands. In their insightful and provocative book on the field of family therapy, McGoldrick and Hardy (2019) state, “Family therapy has been structured in ways to support the dominant value system. And again, like other institutions of our society, our field has evolved many conceptualizations and practices that keep invisible certain hidden organizing principles of our lives, including social class, race, gender, sexual orientation, and religion” (p. xii). And as Stovall (2019) notes, “Ironically—or not—the field dedicated to uncovering, understanding, and repairing our dysfunctional patterns can’t perceive the white elephant in the room. Having put numerous other social and racial groups under the microscope, psychotherapy continues to resist turning an eye inward to the group behavior of white people as white people” (p. 12). These statements apply to many of us as child and family play therapists. The mental health profession has been dominated by a rigid hierarchy, sexism, and a closed system. The Diagnostic and Statistical Manual of Mental Disorders, which has provided a classification system for mental illness, has also been subject to large social blunders. Homosexuality, for example, was initially categorized as a disorder warranting specific therapies to turn homosexuals into heterosexuals (these “conversion therapies” have been debunked and the clinical categorization changed to dysphoric

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homosexuality). The diagnostic term “borderline personality disorder” consistently overlooked the tremendous import of childhood trauma. The category of posttraumatic stress disorder was developed for survivors of war and rape, and yet it’s often superimposed on children’s maltreatment by shortsighted authors who fail to consider the need to shift to a more socially responsible categorization in which the role of adverse experiences in childhood can be highlighted. Efforts to include the category of developmental trauma disorder as distinct from posttraumatic stress disorder have been underway for years. Though the mental health profession has evolved and continues to do so, albeit at a snail’s pace, it must renew its efforts to respond to social constructs. The mental health profession as a whole must make a focused examination of how BIPOC clients are welcomed, how they are assessed, what kinds of treatment approaches work, and how to integrate our knowledge about social oppression and racism into the therapy work we do in order to elevate our services to the best of our abilities. Interestingly, there have been attempts to include diagnostic categories such as “extreme prejudice,” and these have been rejected (Stovall, 2019). The mental health field is replete with examples of exclusion, of arduous membership requirements, and of White privilege. Inclusion practices have been sluggish in most agencies and institutions, and even when people of color are included, leadership roles are often difficult to obtain. Most private practices make efforts to hire with equity, and yet many organizations still have a very White appearance, which we need to commit to changing and improving. The reality is that many clients who are referred to mental health services by social services departments are people of color, and they are more likely to receive therapy services from White therapists unless services are being provided in new agencies designed with equity and social justice in mind (Chicago Minds is an example of one such agency).

HOW WHITE PRIVILEGE CAN ENTER THE PLAY THERAPY OFFICE As White therapists, how many of us take the time to address White privilege or Whiteness in general in our therapy work? And once we take a look inward, how many of us follow up with specific actions? Do we prepare our offices to manifest inclusion: to show that we welcome people of color? Do we check in with our clients directly about what it’s like to see someone who is not of their own color or race, especially marginalized groups? Should we be doing this or simply ignoring the fact that we are meeting people from a position of privilege? How was this issue addressed or ignored in our graduate programs, in our supervision, in our trainings and workshops? How do we move forward with the concept that we have to do better?



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Maya Angelou asserts the importance of self-exploration that precedes clarity and action: “I did then what I knew how to do. Now that I know better, I do better.” Stovall asserts, “A white person can drastically decrease their racist behaviors and increase their willingness to undermine white supremacy long before their racist thoughts and feelings subside. If you want—and that’s a big ‘if’—to change the ways your actions are influenced by racial bias, conscious or not, then increasing your awareness of your bias and decreasing its influence over your behavior is a skill you can fairly easily learn and practice” (2019, p. 16). Let’s discuss what doing better in a focused way might encompass. A foundational action is to become better informed, be reflective, and then make a plan that makes sense for you and the systems that you’re able to influence. Introspection without action is shortsighted.

White Play Therapists Doing Better and an Anti-Racist Plan Changing your behaviors can start immediately after reflection has identified vulnerable areas. “Psychotherapy is always about behavior change, and behavior change can happen long before psychological healing is complete” (Stovall, 2019, p. 16). There are many components that have been articulated (see, e.g., Codrington, Chapter 3, this volume). First, let’s start with environmental changes to our play therapy offices. The waiting rooms, offices, administrative offices, and general space must manifest diversity in order to welcome people of all colors and races, as well as clients who experience a sense of being marginalized or different from others. We need to send the message to our White clientele that we promote diversity and equity. I have consulted with play therapists who tell me that they serve a mostly White population so there is no need for them to look at environmental messages. However, White child and adult clients come to therapy with their own racial biases and prejudices. Creating an inclusive environment challenges many underlying prejudices and racist beliefs and serves as a way for White play therapists to send important messages in subliminal ways. These messages could elicit overt responses that can then be a bridge to dialogues. There will be great opportunities for more direct discussion if the messages are visible and flush out ideas and values that can be addressed in therapy. Because children often learn prejudice from their caretakers or environments or experiences, we can take action by attending to the environment. Artwork, posters, decorations, libraries—all can be reviewed for either neutrality or exclusion. Let’s scan our environment and see what messages we are sending about race, racism, prejudice, or privilege. By narrowing the focus and using this lens, you will have the opportunity for a more mindful and purposeful environment for your child and adult clients.

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Marketing and advertising materials should also be overtly anti-racist, and I believe that drafting statements of support, joining our Black and Brown communities as allies, conveys an important message. I recently found a sample of an anti-racist statement on the website of a group called SMARTmoves. The shorter version reads “SMARTmoves, LLC stands in partnership and solidarity with activists, organizers, and BIPOC (Black, Indigenous, People of Color) protesting systems of oppression, racism, and institutional violence that cause trauma to Black and Brown bodies across our country.” The longer statement is available on their site. This resonated with me and will serve as inspiration for our own public statement. As Kendall (2013) states so aptly, “We are all continually working at the personal, the interpersonal, and the organizational levels,” and we have to address all levels (p. 158). The play therapy office must be multicultural by design. I recognize that it can be difficult to locate diverse miniatures that show people of color in an array of roles and functions. We have to prioritize this area of inclusion, locating primarily African American, Hispanic, Asian, Indigenous, or Caribbean symbols and ensuring that our toys, games, and miniatures are reflective of inclusivity. There is a larger discussion going on right now about taking down statues of Confederate leaders, for example. Think about what we say to children of color about why those statues are there in the first place. Why are we lifting up these individuals who were on the wrong side of history and who fought hard to preserve slavery in our country? Might it not be better to have symbols that represent heroes of color? And there are hundreds of them, we just don’t hear about them in school. Every year when Black History Month happens, I wonder how my education could have withheld information, creating and prioritizing institutional White privilege? My hope is that education representative of our full history will be implemented—again, better late than never. We can play a small part in our play therapy offices, prioritizing a representative sample of racial, ethnic, and cultural diversity; sensitivity to marginalized populations; and inclusivity. Our work environment includes therapists, administrative staff, and others who are the face of our agency. We can’t look away from recruitment and hiring practices that are color blind. There are well-trained and talented play therapists of color, and we must make every effort to invite them into our group practices. I don’t think it’s acceptable to have all-White therapists in agencies that are serving diverse populations. The arguments that “we only see White folks,” or “Black and Brown people don’t apply” are not viable defenses. Play therapists of color need to be part of every mental health organization, and we must make every effort to recruit interns and residents of color, as well as licensed mental health professionals of color by seeking them out, and inviting them in, with assertion and persistence, as well as equal pay.



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It is abundantly clear that BIPOC often don’t have the same access to services afforded to others who may have insurance, employee assistance programs at their work sites, and personal transportation, as well as more freedom to move around outside institutions and systems that might pathologize people of color. For example, it is very well known, as mentioned earlier, that Black and Brown children are more likely to be reported for child abuse than their White counterparts. White people with resources can hire power-attorneys to defend them in civil and criminal courts. Thus Black and Brown people are overrepresented in juvenile detentions and prisons. Given these disadvantages faced by BIPOC, mental health groups or agencies have to loosen rigid boundaries that might create barriers to accessing or maintaining services. This might include providing home visits, finding sites that are on bus routes, and doing longer sessions less frequently. White play therapists can design an economic and administrative plan that might make access paths less convoluted, providing sliding-scale fees and pro bono opportunities, creating an internship program that allows for play therapists of color to receive supervision and training at lower costs, and prioritizing diversity and inclusion rather than shying away from creating a diverse work force. I do want to state that matching clients and therapists exclusively by race, gender, or culture is not always successful. As a Latin therapist, I have had some referrals where the client prefers to be seen by someone of another race or culture than the one the client and I share because they imagine that the therapy will be less fraught with learned or embedded lessons of culture. One Latin American woman said to me, “You’re obviously from a different class than I am, and I would be more comfortable with a White therapist who doesn’t have that background.” I honored her request, respecting and accepting her decision. For those of us who have visibility as trainers or workshop providers, authors, or other disseminators of information, we must ensure that these forums are anti-racist in content and process. How often do discussions of race, equity, diversity, access to services, and modifications in treatment approaches appear in mainstream workshop presentations? How often is racism articulated during trainings to mental health professionals? And I ask readers to think about their experiences prior to the recent upsurge in culture-specific panels and training programs. This is an area all of us can improve on, ensuring that our presentations are inclusive of these relevant and critical issues that often remain in the background. The most relevant issue of all for play therapists is how to consider the impact of Whiteness, privilege, and racism on the therapy we deliver and the opportunities we have in our connection to our child clients and their parents, whether they are White or BIPOC. We need to become part of the solution, not part of the problem of mindless status quo. We are in a unique position to educate clients and their families and respond to children’s

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issues surrounding racial differences. I believe we should all participate in providing anti-racist interactions with the families we serve.

Whiteness and White Privilege (or Power) in the Play Therapy Office I think this is a complex issue for mental health professionals, who are often in a position of power with their clients. This could not be more evident than when therapists are working with court-mandated clients, who are not seeking out therapy voluntarily but may have to cooperate by checking off boxes in order to have the courts provide them with a positive outcome. The most common situation, in my experience, is children who are in the foster care system and whose parents may have a limited capacity to meet all the demands placed on them by the courts. Case in point: when children are placed in foster care, the courts and social workers from the department of family services usually require parents to have a living environment with separate bedrooms for their children. One such family I worked with found it near impossible to find a four-bedroom apartment that would allow each child his or her own space. Putting children in separate bedrooms is a requirement of returning children back home that often doesn’t fit with the reality of parents who have multiple jobs to make ends meet, or who may wish to have a family bed. We need to be open to considering that other cultures function differently and some parents prefer the physical closeness of their family at night and feel better able to be protective if all children are in the same bed. Unless there are concerns about sexual abuse, children and parents who are not in the system often find the family bed comfortable and desirable. Parents may also be mandated to attend therapy sessions with their children, and the times that are usually available may necessitate the parent missing work and putting his or her job in jeopardy. Thus, the White perspective shapes underlying beliefs about what constitutes safety for children of color whose parents may not have adequate financial or physical resources. We need to be open to considering that other cultures function differently from the Western culture and that our position of power shapes how we view differences and how we set requirements for nonvoluntary clients. So many BIPOC families are petrified to lose their children to a child welfare system that wields tremendous power. We are often in a position to advocate for our clients with social service agencies and judicial institutions. Mental health professionals are in the business of giving advice and trying to find ways to improve family functioning. Again, unless there are questions about child maltreatment, parents may speak louder, grab their kids to get their attention, or be a little more gruff with them based on their own upbringing. This doesn’t mean they are not good parents, it means that they may not view their behaviors as out of the ordinary. We need to



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concede that our lens of privilege often creates rigid standards and expectations that all parents must follow. I believe that it can be very helpful to show alternative behaviors and remain open to the possibility that different parenting styles may be “good enough,” rather than trying to impose unrealistic expectations. It’s critical for mental health professionals to maintain a cross-cultural lens with a commitment to providing tangible help, which includes deep listening as well as flexibility and creativity. I don’t believe our educational institutions prepare us well enough regarding cultural responsibility to our clients, although the literature has provided many talking points and several clinicians have focused their careers on this topic. Real help is help that responds to people’s needs, not someone else’s impression of what people need. Real help is also responsive to clients’ preferences, so that therapists are not forced on them and they don’t have the ability to choose who they work with, or who they feel best sees and empathizes with them.

Children Who Act Out Racist Beliefs in the Play Therapy Office I will end this chapter by discussing one of my most pressing concerns: beginning a dialogue among play therapists about how we respond to overt or covert racism in the play therapy office. In order to have us consider the complexities of what children can bring to our offices, I will offer the following scenarios for the reader to consider in terms of the play therapist’s potential responses, all of which have occurred, although the specifics are changed to protect confidentiality: • “I will be the police, you be a Black guy and I will chase you.” A little 6-year-old White boy wanted to play dress-up and found a sheriff’s badge and gun inside a holster. “Awesome,” he said as he put on the badge and holster. “Now you be a Black guy and I will chase you and try to catch and kill you!!” • “My mom says I don’t have to listen to you because you aren’t like me.” A 10-year-old African American child referred for “antisocial behavior” in school came in to see me with a pretty feisty attitude. When we started to talk about school, and what was going on, I suggested that we talk about how her anger builds and then how she lets it out. At one point she looked at me and said loudly, “I don’t have to listen to you because you aren’t like me.” She went on to say that all the White people in her school were against her and she hated them! • “My grandpa says White people have better brains than Black or Brown people.” A 9-year-old White boy was referred for aggressive

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behavior with peers. When we started talking about his brain and how he needed to stop and make better choices, he turned to me earnestly and said, “My grandpa says White people have better brains than Black or Brown people.” • “Those people don’t work, they’re lazy, they’re on food stamps and we’re paying for them to eat.” An Asian boy of 12 was doing some artwork and making a family portrait. He talked about how his family worked all the time and said that he and his brothers had to help them all the time. Then unexpectedly as he kept drawing he said, “My friend is Spanish and those people don’t work, they’re lazy, they’re on food stamps, and we’re paying for them to eat.” • “My dad buys guns and he says we have to be ready for the new war with Blacks.” An 11-year-old White boy who was referred for aggressive behaviors at school and at home seemed obsessed with weapons and ammunition, eventually saying, “My dad has lots of guns, he buys lots of guns.” He added, “My dad says we have to be ready for the new war with Blacks and if we don’t win, they will, and we will have to do what they say!” • “She doesn’t know anything, she’s from a different place.” This was a comment made by a 12-year-old White boy after a woman wearing a hijab in the waiting room asked him to please keep his voice down. This boy, who was struggling with oppositional behaviors, came into my office in an agitated state and ranted for a while about how nobody tells him what to do except his father! He then added, “And she doesn’t know anything, she’s from a different place, she doesn’t even belong here and she can’t even speak English good!” • “I wish they would go home. They get special attention from the coach.” This example comes from an African American child who started up a friendly soccer game in the hallway of my office with a Hispanic child who was my client. When I went out to the hallway and asked my client to come in, the African American child said loudly, “He’s a cheater, he needs to go back to where he came from. He thinks he’s all that, and he’s not!!” When my client came into the office, he seemed upset and told me that he had just been to a soccer tournament the past weekend and that the losing team had chided his team by calling out “Go back home, go back home.” This child then cried a little telling me that sometimes he wished his parents had stayed in his native country because he was not wanted here. • “That kid is a faggot, he’s weird, I have to show him who’s the boss.” A White boy of 12 is referred by his school for bullying a peer who



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has recently come out as gay. This 12-year-old seems preoccupied with his gay peer, someone who has been a friend of his since they were children.

BECOMING ANTI-RACIST IN PLAY THERAPY To be anti-racist, words must be followed with action. So action begins with the way you advertise and market your services, actively defining the scope of these services, inclusivity and diversity among providers, and interest in issues relevant to BIPOC families. In addition, an intake procedure should include questions about issues of oppression and racism and whether there is an active component of that in the referral. Discussing the availability of therapists of color is critical, and when White clients state a preference for White therapists, this must be openly discussed. The office must reflect the consistent presence of anti-racism, and people of all colors, genders, and ethnicities should feel valued and treated with respect. Signs of inclusivity should pepper the environment and seek to make all clients feel welcome. Services should be defined to address diversity. A White therapist should inquire what it’s like for BIPOC to be talking with someone outside their race or culture. This dialogue should occur throughout treatment, not just at intake. The therapist should use a broad lens to elicit and try to understand the client’s experience and constantly consider multiple layers when making recommendations. The White therapist should also advocate for positive changes in service delivery, calling out policies that might inadvertently or purposely have racial overtones. And White and BIPOC play therapists should consider how to respond to prickly situations that occur in the play therapy office and whether it is wise or appropriate to remain silent or simply reflect what the child is doing. In the brief vignettes provided earlier, the challenge is to work with the material that is brought into the room because it indicates what’s on the child’s mind. However, I encourage play therapists to pause and consider options that might include amplifying the metaphor or pursuing a dialogue that might allow for sharing of alternate perspectives. I don’t feel that I can tell you what to do, as our theoretical orientations may be different and our approaches vary based on training, experience, and personal explorations, and many other variables. However, I do encourage you to pause, reflect, and explore. Whether you are able to respond in the moment, bring a thoughtful response to your next session, or contact the parents or the school the child attends, it seems undeniable that this is a time for action, because inaction has not served us well in the past. As mentioned prior, “I’m not racist” implies inaction. “I am anti-racist” implies action. Most importantly, because children generally don’t arrive at racist thoughts and feelings on their own, it is critical to invite parents in to

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engage in an open discussion of the lessons they are teaching their children about racial differences, or the lessons they may want to convey to them in general, about empathy and sensitivity to others who feel marginalized or different. I have worked with parents with whom the topic of racism is charged and dialogues are not easy. However, I have always felt it my responsibility to talk with parents about the lessons children are learning, who their influences are, and whether these lessons are causing confusion, anger, or social difficulty, or whether they are helping children achieve success in their environments. When considering responses to play that demonstrates racism or prejudices, I suggest thinking about responses along a continuum. The first response can always be child-centered, providing a reflective statement about what the play therapist sees or hears. Child-centered play therapists provide unconditional acceptance of the child as s/he is. The play is simply observed and the child is seen and heard without judgment. Play therapists can also consider the phase of treatment. Early on, child-centered work can help establish a therapy relationship of unconditional acceptance, trust, and warmth. Subsequent interactions can include entering the metaphor and exploring the thoughts and feelings of characters in the play, or asking children to give voice to what characters are experiencing. Moving along on this continuum, therapists can suggest different story lines, provide psychoeducation embedded in the story, or make definitive statements that might cause children to pause and reflect about their perceptions. The age of the child also makes a difference. With much younger children, the play therapist might want to speak with parents about themes that suggest confusion about racism. The play therapist may need to engage with parents about psychoeducation. My best suggestion to play therapists facing racism in their offices does not include specific responses. Instead, my suggestion is to become thoughtful and purposeful about what kind of response to provide, something that may or may not align with the theories we use to guide our work. Here are some possible responses to the vignettes above: • “I will be the police, you be a Black guy and I will chase you.” Some play therapists may want to play out this scenario and reflect the child’s feelings back to him. However, because I knew this child fairly well, and he had a history of witnessing domestic violence, I felt that I wanted to take a more definitive stance with him. My response was “You know what, not even in pretend play do I want to act out something killing someone else because their skin color is Black.” I also went on to include some more psychoeducation, including that police officers are usually good people trying to help, that a small group of police officers do kill Black people, and that this is a very serious problem. A lot of play therapists will take exception to this approach, finding it



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more appropriate to allow the child to play out the scenario that’s on his mind. “This is pretend play,” someone might argue, and play therapists are unconditional witnesses and understand that play is not literal. See where you stand on this question. • “My mom says I don’t have to listen to you because you aren’t like me.” I think this child is experiencing prejudice and racism in her school, both by the teacher and her peers. I think it’s important to apologize and state the obvious, “You’re right that I’m not exactly like you, at least our skin color is different, we are different sizes and ages, and have had different lives so far. I’m really sorry that you’re having trouble at school with the White kids and teachers, and maybe together we can figure out what you can do about that besides striking out.” The child was frustrated and said, “Nothing works. They don’t like me cuz I’m Black.” I responded, “I’m so sorry that you have met White people you think don’t like you because you’re Black. After we talk some more about examples and what to do, I am going to check back with the school and see what they can do differently.” I went on to say, “I won’t tell them that I know you at all, I will just ask if the school has considered talking with the children and parents about diversity and strategizing ways for children to feel more safe within the school environment.” • “My grandpa says White people have better brains than Black or Brown people.” This is definitely a racist statement about White superiority. Does a White play therapist reflect what the child has said (“So your grandfather thinks that White people have better brains than Black or Brown people”) or you challenge the statement in some way: “What do you think about what your grandfather thinks?” or “Hmmm, I didn’t know that brains are different in people of different skin colors. . . . I wonder if that’s true.” As you can see, responses can occur along a continuum from knee-jerk responses to taking a definitive stand. In this case, the child loved and respected his grandfather, and yet it was important to do or say something. What would you consider an appropriate thing to say? This might be an appropriate time to talk with the grandfather, although some of these conversations hit a dead end when racist belief systems have become central organizing principles for individuals. I don’t want to assume I have responses everyone will like. I do hope that these vignettes give us all a chance to reflect and imagine what our responses might include, whether they are given or not. • “Those people don’t work, they’re lazy, they’re on food stamps and we’re paying for them to eat.” This statement is obviously racist and based on some stereotypes that have been presented in movies, television, books, and so forth. The so-called “laziness” of Mexicans is even romanticized at

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times, as part of a panorama of Mexican life. Depictions of sleeping or resting men with huge colorful straw hats are plentiful in stories and movies. The reality of course is much different. I started with “What’s your Mexican friend’s name?” “Carlos.” “Carlos. I have a cousin with that name. What do you like about your friend?” The child talked about many things the two friends had in common. “Have you ever been to Carlos’s house?” “Yeah, sometimes I go to his house for dinner and he comes to my house too. I even spent the night at his house once.” “Sounds like you two are good friends!” “Yep, he’s cool.” “What do his parents do for work?” The child reported a lot of information: “Mom cleans houses and makes a lot of money, and then she also takes care of two babies during the day!” “Wow,” I commented. “Sounds like Carlos’s mom has two jobs, not just one job . . . I guess there’s nothing lazy about her.” The child did not respond. I then asked about Carlos’s dad and the child client said, “I’ve never met him, he drives trucks and he only comes home now and then.” “Ooof,” I said. “Driving trucks is a tough job. You have to stay awake long hours and sit in your chair and keep yourself from getting bored. Sounds like Carlos’s dad is a hardworking dad.” “Yeah,” he said. My last comment was “A lot of people talk about Mexicans being lazy and such, but sounds like you know a Mexican family that is quite the opposite of that.” “Yeah,” he commented, “Carlos is cool.” He added, “Yeah, not everything you hear about Mexican people is true, sometimes you can make up your own mind based on what you know.” • “My dad buys guns and he says we have to be ready for the new war with Blacks.” Although this example seems improbable, there are likely many children living in families where parents are obsessed with White supremacy, violence, and narratives about an impending second civil war. What do we do in these situations? Talking to the parents may get us nowhere, and yet we have a child client who we can hypothesize is being affected by his environment. Can we possibly move the needle on his anxiety and aggression without addressing the issue directly with his parent? And will the parent be responsive to anyone telling him how to raise his children? Sometimes outside interventions can make parents dig in more. At what point can we intervene when the parents are providing for the basic



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needs of their children but are filling their heads and hearts with fear and violence? What are your thoughts here? • “She doesn’t know anything, she’s from a different place.” “What did the lady in the waiting room ask you to do?” I asked quietly. “She told me to be more quiet.” “Oh,” I said, “that sounds like what happened a while back when someone else asked you to keep your voice down in the waiting room.” “Yeah,” he agreed sheepishly. “That made you really mad today, didn’t it?” “Yeah.” “What was it about today that made you so mad?” “Cuz she embarrassed me in front of that boy that was out there.” “Oh,” I said, “so you got embarrassed that your voice was too loud.” “Yeah.” “I hate being embarrassed in public, that can make me feel really bad.” “What do you know about people who wear head coverings?” I asked. “Nothing,” she said. “Well I can tell you that she is a very peaceful and quiet mom, and she’s usually praying in the waiting room while she waits. You probably distracted her from praying.” “Oh,” my client said. “And one other thing I can tell you,” I added. “That lady and her family have been here since she was a little girl. She is American just like you. An immigrant, just like you.” The child looked at me and then said, “I know, I didn’t mean it, I was just mad.” “That’s okay,” I said, “I just wanted you to know that sometimes people look different because of their clothes or skin color, but they are just as American (and human) as you are and I am, even though we are all immigrants from other countries.” When the child walked out of my office, he went up to the mom and apologized. The mom took his hand and thanked him and told him not to worry. • “I wish they would go home. They get special attention from the coach.” I spent the session talking with this child about his immigration to this country and his biculturalism. In addition, this child was feeling very distraught at encountering negative thoughts and feelings from his White peers. “I think they’re mad because they don’t know how to play soccer too good.” I agreed that soccer is not the most favorite sport in the United States. He also felt bad that his coach and team, who had won the tournament, had to get on the bus and leave before the trophy ceremony because the children (and their parents) were so mean to them and started chanting “Go home.” I empathized with him about how bad that must have

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felt—that those on the other team were sore losers, and that he couldn’t celebrate his victory in the usual way. We had a long conversation followed up with a family therapy session where everyone in the family could talk about their hopes and dreams coming to this country, and the disappointment and fear they were filled with to be here during this current phase in our history. The grief and fear were palpable in the room as family members talked about the racism they faced daily and the ways they felt beaten down and hopeless. A multifamily therapy group was organized on the topic of racism and acculturation to give parents a sense that they were not alone. Five families were able to join and speak together, creating a sense of hope and future orientation. • “That kid is a faggot, he’s weird, I have to show him who’s the boss.” This was a tough case because the 12-year-old White boy, Derreck, had also been sexually abused by a teenage babysitter when he was 8 years old, and his trauma experience had left him feeling vulnerable, confused, and scared of his own sexuality. Apparently the babysitter had groomed Derreck by engaging him in fun games about undressing, mutual masturbation, and skinny-dipping, which then had turned to aggressive actions, including forced sexual assault. Derreck spent 1 full year in silence before imploding and telling his parents what had occurred. The friend he was now targeting had told his parents when the babysitter had made his first approach to him, and Derreck was angry that his friend had been able to avoid the teen’s sexual assault. Derreck’s parents were homophobic, which also did not help the situation. In fact, Derreck’s paternal uncle had been rejected by his family for being homosexual. Thus Derreck did not have a way to sort out his various deeply felt responses to his traumatic experience and his friend’s coming out. Derreck’s father had added insult to injury by chiding Derreck for “letting” the babysitter abuse him. The therapy with Derreck was long-term and included trauma-specific work that led to the creation of his own self-empathy. Once he was able to regard himself with kindness, acknowledging his victimization was not an act of weakness on his part, he began to break free of some of his intense feelings toward his friend Mark. I did take a strong stand with this child about his bullying as well as his negative feelings toward Mark based on his sexual preference. I also took a strong position with his parents, especially his father. I provided information to them in a calm but unapologetic way and recruited their aid in helping their child. Derreck’s dad proved to be incredibly wed to his beliefs about homosexuality and used his religious beliefs to condemn homosexual acts. Our conversations were intense and direct, and yet we both persevered: Derreck’s father was ultimately devoted to his son and his son’s health and healing. Derreck’s mother was supportive and loving. Eventually the two were receptive to coaching that allowed them to



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deliver strong, supportive messages about Mark, the neighbor child who had grown up with Derreck, as well as the religion that encouraged kindness and acceptance. In addition, our conversations on religion identified many messages about compassion and forgiveness that both parents felt they could promote. This case stands in my memory as one of the most challenging and rewarding cases I’ve ever seen.

SUMMARY White privilege, or “unearned power,” inhabits our psyches whether it’s consciously acknowledged or not. It may be something we have explored in the context of maturation, or something we have dismissed without too much thought. It might also be something that comes to the surface and shocks us at times, or something we’ve done battle with over the years. It tends to emerge and form during our childhood, shaped by parental messages initially, and later by direct experiences, peer pressure, social interactions, and so forth. It is also shaped by the games we play, the movies and television we watch, and social media. The only unacceptable response to our long-overdue urgency about racism in this country is to do nothing! As I’ve stated many ways, the very smallest first step is to understand ourselves. In fact, Sue (2015) lists potentially positive actions that include self-exploration, acknowledgment of racial biases, comfort discussing topics of race and racism, validating and facilitating discussion of emotions and their meaning, avoiding silence, not letting conflicts fester, and understanding differences in communication styles, to name a few. Play therapists and other mental health professionals have a responsibility to themselves and the profession to take stock of their attitudes and beliefs, because whatever degree of racism we have, anti-racist positions must be developed, planned, and articulated in thought and deed. A workbook is available to help us all consider our racial identities and, most important, learn to be an advocate and an ally for our Brown and Black colleagues and for our White, Brown and Black clients and their parents (Singh, 2019). Saad’s book (2020) also guides us in identifying commitment areas and crafting plans. I particularly resonated with her challenge to us all to become “good ancestors.” This chapter considers anti-racism in our advertising and marketing, in the shaping of our work environments, in the selection of our art and toys and books, and in the way we train therapists and design and deliver therapy services to our clients. In addition, play therapists are often privy to the inner workings of children’s thoughts by observing their play. It is in this uncensored expression that they allow us to understand what is on their minds, how they make sense of things, and what they are struggling with.

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Because I am encouraging you to take an anti-racist position directly with your White and BIPOC clients and their families, I have provided you with a number of case illustrations that clearly demonstrate that we must remain alert to the development and expression of racism in children and provide them with experiences that can elicit reflection. Just how to do that will be subject to debate, but my hope is that you will pause and explore the many options we have at our disposal, do your own work confronting this issue, and avoid inaction. In addition, I encourage you and your colleagues to brainstorm how to approach all the various ways that “business as usual” may include racist policies and practices and reimagine how to convert anti-racist ideals into a proactive design that is visible in all our professional intersections. Saad’s words (2020) inspire me: “Antiracism is not about perfectionism. It is about the intention to help create change met with the consistent commitment to keep learning, keep showing up, and keep doing what is necessary so that BIPOC can live with dignity and equity” (p. 200). Her book is a useful blueprint for making and following concrete commitments.

REFERENCES DiAngelo, R. (2016). What does it mean to be white?: Developing white racial literacy. New York: Peter Lang. DiAngelo, R. (2018). White fragility: Why it’s so hard for white people to talk about racism. Boston: Beacon Press. Kendall, F. E. (2002). Understanding White privilege. Retrieved from www.goldenbridgesschool.org/uploads/1/9/5/4/19541249/understanding_white_ privilege_-_kendall_edited.pdf. Kendall, F. E. (2013). Understanding white privilege: Creating pathways to authentic relationships across race (2nd ed.). New York: Routledge. Kendi, I. X. (2019). How to be an anti-racist. New York: One World. McGoldrick, M., & Hardy, K. V. (Eds.). (2019). Revisioning family therapy: Addressing diversity in clinical practice (3rd ed.). New York: Guilford Press. McIntosh, P. (1988). White privilege and male privilege: A personal account of coming to see correspondences through work in women’s studies (Working Paper 189, Wellesley Center for Women). Retrieved from https://nationalseedproject.org/ images/documents/White_ Privilege_ and_ Male_ Privilege_ Personal_ AccountPeggy_McIntosh.pdf. McIntosh, P. (2019). White privilege and male privilege: A personal account of coming to see correspondences through work in Women’s Studies. In M. McGoldrick & K. V. Hardy (Eds.), Re-visioning family therapy: Addressing diversity in clinical practice (3rd ed., pp. 215–225). New York: Guilford Press. McWhorter, J. (2020). The dehumanizing condescension of white fragility. Retrieved from www.theatlantic.com/ideas/archive/2020/07/dehumanizing-condescencion-white-fragility/614146. Mehri, M. (2020). Anti-racism requires so much more than “checking your privilege.” Retrieved from www.theguardian.com/commentisfree/2020/jul/07/anti-racismchecking-privilege-anti-blackness.



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Saad, L. F. (2020). Me and white supremacy: Combat racism, change the world, and become a good ancestor. Naperville, IL: Sourcebooks. Singh, A. A. (2019). The racial healing handbook: Practical activities to help you challenge privilege, confront systemic racism, and engage in collective healing. Oakland, CA: New Harbinger. Stovall, N. (2019). Whiteness on the couch. Retrieved from https://longreads. com/2019/08/12/whiteness-on-the-couch. Sue, D. W. (2015). Race talk and the conspiracy of silence: Understanding and facilitating difficult dialogues on race. New York: Wiley. Tatum, B. D. (2017). Why are all the black kids sitting together in the cafeteria?: And other conversations about race (20th anniversary ed.) New York: Basic Books.

CHAP TER 3

Culturally and Racially Attuned Play Therapy Toward a Social Justice Approach Jamila Codrington

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ll children have beautifully rich cultural identities cultivated through socialization that influence their everyday lives, their functioning, and their experiences in therapy. Despite their tender age, they enter the psychotherapeutic process with social class experiences, racial histories, religious orientations, gender and sexual orientations, and a variety of other cultural dynamics that contribute to themes that inadvertently play out in therapy. While they may not be equally salient for each child, each source of identity or sociodemographic is a viable option to further align ourselves with our clients and leverage their cultural strengths to facilitate the therapeutic process. This is the case regardless of whether there are race-related or cultural aspects of the presenting problem in therapy. Being culturally and racially responsive to our clients is an ethical obligation in the mental health profession, regardless of age. However, students and professionals alike are rarely taught what this means for children. For example, the American Psychological Association Ethics Code (1992) and the “Guidelines for Providers of Psychological Services to Ethnic, Linguistic, and Culturally Diverse Populations” (1993) offer clear guidance for avoiding a Eurocentric or monolithic perspective in working with these individuals, but the pragmatic application to the context of play is much more elusive. Despite the lack of a universal, clear set of standards for cultural competence in play therapy, we must do more than give lip service to 58



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concepts like celebrating diversity (e.g., through multicultural play therapy materials). This chapter is intended to explore the complex ways that race and culture influence the psychotherapy process with children and provide practical ideas for implementing racially and culturally attuned play therapy. Additionally, this chapter takes a slight departure from the existent (albeit limited) literature on cultural issues in play therapy by exploring how play therapy can be utilized as a vehicle for the empowerment of children from marginalized and oppressed cultural groups. In this vein, play therapists are viewed as agents of social justice and not just emotional/ behavioral change within the therapeutic process. Much of what I discuss in this chapter has been taught to me, through trial and error, by the beautifully diverse children that I have treated within my clinical practice in New York City. I have attempted to adapt my traditional training and understanding of “cultural competence” to their unique cultural nuances and developmental level, and they have taught me valuable lessons. My goal is to offer anecdotal insights and practical examples to help raise awareness of the multifarious ways that play therapists can be culturally and racially attuned, rather than offer prescriptive techniques or empirically based methods for various racial or ethnic groups. From their inception, ethical guidelines and standards on “culturally competent counseling” have emphasized the importance of therapists grounding themselves in the social and political history of the cultural group with which they are working (Lee, 2008). To elucidate this concept, consider the population of African American children and the groundbreaking “Doll Test” by psychologists Kenneth and Mamie Phipps Clark in the 1940s. The Clarks set out to study the psychological effects of segregation on African American children by asking these young subjects to identify both the race of the dolls and which color doll they preferred. Although the dolls were identical except for color, a majority of the children preferred the White doll over the Black doll and assigned positive characteristics to the White doll. The majority pointed to the White doll when asked “Which is the nice doll?,” “Which is the pretty doll?,” and “Which doll has a nice color?” The majority of children pointed to the Black doll when asked, “Which is the bad doll?” and “Which is the ugly doll?”; they also rejected playing with the Black doll (Suggs, 2019). The experiment yielded statements like “the Black doll is a nigger,” and some children were even unresponsive, ran out of the room, or started to cry when asked which doll looked like them. Not only were these children (as young as age 3) aware of their racial status, but they attributed negative characteristics to being Black and became upset when they had to identify the Black doll they had rejected, which looked most like them (Suggs, 2019). In Dr. Kenneth Clark’s words, this was a “disturbing” finding that indicated that even young children’s sense of worth and self-esteem is

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impacted by the racism of American society (Suggs, 2019). The Clarks concluded that Black children formed a racial identity or consciousness by the age of 3 and attached negative traits to their own identity, and that “prejudice, discrimination, and segregation” created a feeling of inferiority among Black children and damaged their self-esteem (Suggs, 2019). This profoundly influential psychological research study was used over a decade later in the 1954 Brown v. Board of Education Supreme Court case to support desegregation in the U.S. school system. Many individuals assume that with time, American society becomes increasingly progressive and that African American children should have a more positive attitude toward their own race since the segregation era has ended. However, the original 1947 Doll Test study by the Clarks was replicated in 2005 by Kiri Davis, a young high school student from New York, and her findings (presented in the award-winning video A Girl Like Me) were essentially the same as the Clarks’ original study (Edney, 2006). The majority of African American children tested still retained negative attitudes toward children with black and brown skin. CNN also commissioned a replication of the Clarks’ study in 2010 by the University of Chicago child psychologist Margaret Beale Spencer. The pilot study showed that both White and Black children (from New York and Georgia; ages 4–5 and 9–10) had a “White bias” (Billante & Hadad, 2010). White children generally identified the color of their own skin with positive attributes and darker skin with negative attributes. Black children, as a whole, also demonstrated bias toward Whiteness, but not as much as White children (Billante & Hadad, 2010). One might also assume that children’s stereotypical notions about race might evolve as they get older and develop more sophisticated thinking. However, Spencer found in the study that children’s ideas about race changed little from age 5 to age 10 (Billante & Hadad, 2010). These findings remind us that the ugly myth of Black inferiority is insidious and ever present in the lives of children living in the United States. It is not a vestige of the old “Jim Crow South.” This myth is perpetuated through the subtleties of language, which is encoded with cultural values, beliefs, and attitudes. Language is loaded with proverbs, sayings, expressions, and idioms that are encrypted with value-based messages around race, the most salient sociodemographic and dominant organizing factor in American society. Each negative statement sends messages about Blackness and could potentially have a strong, damaging impact on the self-esteem of a developing child. As play therapists, we have a valuable opportunity and responsibility to address this for children of African descent. Moreover, all children, regardless of cultural background, have a right to therapeutic interventions that are not only effective but grounded in their historical and contemporary sociopolitical realities.



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PATHWAYS TOWARD CULTURALLY AND RACIALLY ATTUNED PLAY THERAPY The major thrust behind a racially and culturally attuned play therapy approach lies in the stance of the therapist. It is a deliberate adoption of specific modes of thinking and attitudes that require ongoing practice, more so than concrete skills or interventions that one learns and attempts to master. This section offers considerations for the primary conceptual building blocks of the process of attuning one’s self to race and culture as a play therapist. Seven major concepts are presented: (1) grounding oneself in sociopolitical history, (2) adopting a social justice agenda, (3) breaking free of cultural encapsulation, (4) decolonizing Western play therapy methods, (5) dismantling internalized oppression, (6) understanding biculturalism in immigrant children, and (7) processing race-based stress and racial trauma with youth of color. The discussion of these seven concepts is followed by a case study with sample interventions.

Grounding Oneself in Sociopolitical History The introduction to this chapter was historical and racially loaded by design. Becoming a play therapist who can effectively manage the nuances of culture and race that enter the psychotherapy process with children requires recognition of a few basic premises. First, we must educate ourselves about the sociopolitical histories of our client population, particularly with children of color affiliated with oppressed cultural groups. Most often, these children need support navigating their racially and culturally loaded experiences, both overt and covert. Play therapy is a platform through which this type of support can be provided, as long as play therapists can envision themselves and their work within a social justice agenda.

Adopting a Social Justice Agenda Regardless of one’s cultural identity and sociopolitical history, the merits of social justice work for play therapists must be considered. In general, social justice work involves addressing the advantages and disadvantages that exist in society, challenging power relations, making justice and human rights a personal and interpersonal concern, and promoting liberation from unjust social, political, and economic conditions. Indeed, play therapists, like other therapists, have a professional and ethical responsibility to facilitate change based on a well-developed conceptualization of the problem that is aligned with the realities of clients’ sociopolitical lives. Although social justice issues cannot be addressed through play therapy alone, play therapists can take some first steps through a simple

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commitment to creating egalitarian relationships with their young clients. Through self-reflection and openly processing your relationship with the children whom you work, you can raise your consciousness about power dynamics in your own clinical work and begin to equalize power inequities that exist within therapist–client relationships. Regardless of the cultural identity of yourself or your client, you can routinely ask yourself: Who holds the power and privilege in my relationship with my client? How do I negotiate this from session to session? What are the values and intentions that inform my play therapy work? Do I challenge institutional policies that punish my client’s family for systemic problems (e.g., terminating clients for “noncompliance” without considering barriers to transportation, child care, and flexible work schedules that are faced by lowincome, disadvantaged, and underresourced families)? How do I function as a gatekeeper to much-needed services? What are the social and political factors that influence where I position my clinical practice? Can I do more to serve underserved populations? Am I searching for openings to honor the wisdom of my client (vs. rushing in with my own clinical opinion) and collaboratively drawing out and utilizing my client’s cultural assets toward the achievement of treatment goals? How can I effectively engage in advocacy to give voice to disempowered play therapy clients or help them develop their own advocacy skills (in their school, family household, and community)? Play therapists can also take on a social justice agenda in their clinical work by engaging in what Frantz Fanon (1986) referred to as “conscienciser,” the process of bringing to consciousness the unconscious in order to free clients from their unconscious desires and orient them toward social change. In line with Fanon’s thinking, play therapists can ask themselves: To what extent do I conceptualize client problems in relation to their sociopolitical history (e.g., of oppression) and incorporate this understanding into therapeutic conversations? Are there times in which I operate under the guise of neutrality (Prilleltensky & Nelson, 2002), assuming and communicating objective interpretations of client behavior when in actuality I am influenced by stereotypic notions? Particularly for clients with cultural histories of colonization, we should ask ourselves: How does my use of the colonizer’s language and concepts impact clients’ consciousness? Such questioning (common within liberation psychology, community psychology, and narrative, feminist, and multicultural counseling approaches) helps to integrate a social justice philosophical framework into our day-to-day office work and serves as stepping-stones as we journey into social change agents as play therapists. We do not all have to possess a radical social justice agenda that is played out on the big stage. Taking small social justice initiatives based on an underlying commitment to equity, empowerment, and social responsibility is indeed a step in the right direction for play therapists.



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Breaking Free of Cultural Encapsulation Additionally, we must explore our own cultural encapsulation as play therapists. The modality of play is not immune to cultural encapsulation. All therapists have cultural identities that influence expectations of children based on what we construe to be “normal” childhood behavior and development, modes of play we choose to engage in, and so forth. Across all therapeutic approaches, clinicians run the risk of being culturally encapsulated, where they lack an understanding of or ignore clients’ cultural values, beliefs, and attitudes and are biased toward their own worldview. Culturally encapsulated play therapists may inadvertently rely entirely on their own internalized values about what play therapy approaches are good for their clients—a response that is consistent with their cultural context and lacks understanding of the clients’ view of the world. We are responsible for practicing with an understanding of the depth of our cultural blind spots and proceeding with unwavering humility.

Decolonizing Play Therapy Methods In nearly every modality of therapy lies the possibility of racial and cultural impasses—play therapy notwithstanding. One theme that runs through racial and cultural impasses in play therapy is the violation of cultural norms for collectivist cultures. Collectivist (non-Western) cultures typically have cooperativeness and harmony with one’s environment as key elements of their worldview. A nondirective (client-centered) play therapist who gives the child from a collectivist culture an unstructured space to play and create freely and expects him or her to engage in the activity independently might be unwittingly forcing the child to violate cultural norms. It may be considered impolite for a person of lesser social status (e.g., a child) to call attention to oneself when in the presence of a higher status person (e.g., adult/therapist). Or the child may be raised under the cultural idiom “Children should be seen and not heard.” In all of these situations, a child from a collectivist culture may respond passively due to the strongly held expectation that the therapist will take an active role in leading the session. This can then put the child at risk of being labeled “nonresponsive,” “resistant,” or “highly defended” in a Western model. Play therapists may misinterpret client dynamics as intrapsychic factors when they are more reflective of cultural values, worldviews, or patterns of communication. To address this, it is important that play therapists invite children and/ or their parents to talk about their comfort level and expectations with respect to level of participation in the session and the flow of communication. This is especially important if the therapist–client dyad is cross-racial/ cross-cultural. If the therapist and client are of different racial backgrounds, then there is a greater risk that their respective sociopolitical histories of

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domination and subjugation may enter the therapeutic relationship and cause an impasse (Helms & Cook, 1999). Western values are embedded within traditional play therapy techniques. Only through intentionally uncovering these values can play therapists build more effective therapeutic relationships and interventions necessary for working with children from collectivist/non-Western cultural groups and dismantling issues of power and privilege.

Dismantling Internalized Racial Oppression We must embrace the reality that race is the single most salient cultural identity in the United States. Children from oppressed racial groups within the United States do not develop in a neutral environment. Their identities are shaped in response to racial oppression. They grow up within a complex socialization process in which they are exposed to social scripts that indoctrinate them on their position in the world based on the existent racial hierarchy. Culturally and racially responsive play therapists work to understand the role that racial hierarchies play in structuring the social world of children. They recognize that decision-making power in peer groups (e.g., who gets to go first, select the play activity), conflictual interpersonal experiences, and allocation of resources (e.g., toys, snacks) can all be influenced by the same racial hierarchies that govern society. Children’s peer groups are often a social microcosm of the macrocosm—a smaller representation of the social order in the world at large. Children from oppressed racial groups also tend to grow up receiving blatant and hidden negative societal messages about their own racial identity. For example, I have had African American children convey to me that they have been told they were “ugly,” teased, and called negative names because of their darker skin color. Others have had the experience or perception of their teacher not liking them or thinking they weren’t capable academically because they were “Black.” Examples of internalized racial oppression within Latinx children include colorism (in which children with darker skin tones believed that siblings of lighter hues were given preferential treatment by their parent), and heightened self–other comparisons based on skin color, hair texture, and other facial characteristics. Such colorism, in which there is favorable treatment given to people of lighter skin color within the same ethnic or racial group, is common within Afro-Latinx communities (Quiros & Dawson, 2013). There are countless examples in my clinical practice of children making statements at a very young age (as early as 5 years old) evidencing the internalization of racial oppression and prevailing societal messaging. Typically, this is reflected in aspirations to have physical characteristics that are closer to the White dominant culture (e.g., “I am too brown,” “I wish I had silky hair”) versus those with which they were naturally born.



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Given that their developing identities are malleable, like wet clay on a potter’s wheel, children are susceptible to internalizing the negative societal definitions about who they are. This can be very damaging to their selfconcept and self-esteem. To elucidate this connection, it is helpful to take a fresh look at the early writings of Lev Vygotsky. In the early 20th century, Vygotsky presented a paradigm shift in the understanding of human development by challenging acultural, individualistic theories and positing that human thought is fundamentally dependent on the sociocultural context (Holzman, 2009). Vygotsky challenged the distinctions and boundaries within the mainstream cognitive psychology theories of the day, particularly the notion of a fixed identity and presumption of a split between cognitions and emotions, the psychological and the social, and the child and the environment (Holzman 2009). Vygotsky posited that these are false dualities, and that instead, the relationship was more complex and interconnected, with psychological processes being constructed by children’s interface with their environment. In this light, we can understand the power of negative societal messages on children’s development of self-concept and self-esteem. More importantly, because play with others is a primary site for children to experience their social life, play therapy is a powerful opportunity to influence the developing consciousness of the child and potentially reprogram negative societal messages. Play therapy is a creative environment for enacting Vygotsky’s concept of the “zone of proximal development,” the distance between what a child can do without help (actual competence level) and the potential developmental level with the assistance of someone with more knowledge or skill (Vygotsky, 1978). Play therapists can support and stretch children to do what is beyond them—not just in problem-solving tasks, but in making sense of the world and making meaning of their social interactions. A radical application of this concept is the notion that play therapists can support the transformation of children’s racial consciousness and help them think of themselves beyond the limitations that society has placed on them. In essence, play therapy can function as a child’s process of becoming. The idea of culturally affirming play therapy as a Vygotskian tool to advance children’s development of a positive self-concept and racial/ ethnic pride is discussed in further detail later in this chapter within the case study.

Understanding Biculturalism for Immigrant Children Acculturation, cross-cultural, and bilingualism research has suggested that most immigrant children, particularly first and second generation, are constantly frame switching culturally between the demands of their heritage culture and the mainstream culture across the major contexts in their lives: home and school. They are not only facing challenges inherent

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in development trajectories during this period of development, but also those posed by the differing expectations of their two cultures. The constant shifting between cultural cognitive schemas may have the potential to influence play therapy experiences and outcomes. However, literature examining contributors to biculturalism is minimal. Given the high and growing contingency of immigrant youth in the United States, having a better understanding of how culture and the dynamics of biculturalism inform play therapy interventions to support immigrant youth is critical. To increase awareness, play therapists must develop a sensitivity to and curiosity about the linguistic and transnational experiences of immigrant children and their families. Additionally, play therapists must interrogate traditional Western approaches to play therapy and develop creative strategies for addressing the unique stressors related to traumatic moves and separation from family members, fear of deportation of undocumented family members, and acculturation and cross-cultural adaptation within the context of play.

Processing Race-Based Stress and Racial Trauma with Youth of Color Systemic racism against the Black community within the United States has historically plagued our nation. The year 2020 has seen countless days of civil unrest and worldwide protests related to systemic racism and police brutality, sparked by the killing of George Floyd by a Minneapolis police officer. Children are not immune to the virus of racism, and they are often exposed to vivid images of police brutality and racial unrest. One 6-yearold Black client in my practice verbalized that she was “scared” because there was “so much going on in the world.” Although she was unable to name it as police brutality, protests, or looting, she was gripped with fear after seeing burning buildings from rioting in her New York City neighborhood and overhearing her teenage sister talk about the death of Black people (including George Floyd) at the hands of police. I have observed other children develop fear that negative race-related events may happen personally to them, anxiety about being outside in their own community, or difficulties with sleeping, eating, or reactions to loud sounds or sudden movements. These experiences are not uncommon. Witnessing or hearing about racism, discrimination, or structural prejudice can have a profound impact on the mental health of those vicariously exposed to these events (Carter, 2007). Such racial trauma impacts entire communities, including children. Despite the resilience of the community, family, or caregiver, they can easily transmit implicit and explicit social messages to children in an attempt to ensure their safety. This poses yet another challenge, as social messages related to preparing children for discriminatory experiences may have unintended negative consequences. Children who receive these social



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messages and also consume negative imagery of racial violence and racial unrest may experience traumatic stress responses. Common traumatic stress reactions reflecting racial trauma include increased vigilance, suspicion, and sensitivity to threat, as well as aggression and a sense of a foreshortened future (Comas-Díaz, 2016). Unfortunately, these traumatic stress reactions are exacerbated by the cumulative impact of exposure to multiple traumas, making youth in low-income urban communities particularly vulnerable given that these environments pose increased risk for community violence and victimization (Wade, Shea, Rubin, & Wood, 2014). Although all children (regardless of racial or ethnic background) can experience traumatic stress resulting from the direct experience or viewing of traumatic events related to racism against people of color, children from racial minority groups (e.g., Black and Latinx) may be more susceptible (Harrell, 2000). Therefore, as play therapists, it is important for us to consider specific interventions for addressing race-based stress and racial trauma for youth of color. How can we help these children contend with the psychological impact of repeated exposure to trauma-related media stories stemming from racism? First, play therapists need to understand that children need adult guidance in navigating racism in the media and in their daily experience and cultural history. That adult guidance is not merely a job for parents or educators, but also for therapists, who are particularly skilled in processing difficult and complex emotional material and treating traumatic stress reactions. Once this concept is embraced and conveyed to the client, play therapists must create a psychologically safe environment for children to process racially traumatic events by identifying and removing potential triggers or trauma reminders (e.g., loud noises in the case of police shooting) that may undermine psychological safety. Affective regulation skills should also be taught and practiced so that children have a game plan for how to reestablish psychological safety should they be triggered and experience traumatic stress reactions. Play therapists can explore narrative techniques to give youth of color who are managing race-based stress or racial trauma a safe space to process complex and difficult emotions through the co-construction of stories. Positive and affirming stories and experiences that validate their racial identity and cultural history are particularly helpful for countering themes of feeling devalued, as these stories are often left out of the media.

CULTURALLY AFFIRMING PLAY THERAPY INTERVENTIONS Culturally affirming play therapy is a powerful medium of empowerment, particularly for children of oppressed racial or cultural groups, as it serves

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as a means for them to act as their own agents of social change and social justice. While there are a number of play therapy interventions and techniques that can be utilized inside of the aforementioned conceptualizations, those highlighted below reflect a few that I find to be most invaluable based on firsthand evidence.

Sharing Cultural Expressions In attempts to decolonize Western play-based modalities and interventions, it is important to engage in the process of allowing children of color to share cultural expressions and norms that are indigenous to their own cultural group, using cultural traditions throughout the therapeutic process. With a pair of siblings that I treated for traumatic grief (sudden loss of their father and grandmother within 6 months), we incorporated their Africancentered value of ancestral veneration into the therapeutic work. Our puppet play included puppets who represented their ancestors, and the motifs were centered around a remembrance of their loved ones. Those puppets who represented the ancestors were incorporated into a closing ritual for each therapy session, in which the children, mother, and myself would “get low” (dance to the ground) and slowly come back up to symbolically reflect the connection with ancestors who were buried in the ground and had the ability to rise and visit the family as spirits. Dancing was also integrated as it represented a culturally syntonic coping mechanism for this Caribbean family. The family tradition of honoring ancestors by giving them a food offering on a table was incorporated into play therapy by helping the children plan a meal for their ancestors’ birthday and the anniversary of their deaths. They used play food objects and engaged in a remembrance of their ancestors’ favorite things to eat.

Culturally Aligned Biblio/Poetry Therapy Biblio/poetry therapy, in which books and poetry are used as a part of the therapeutic journey, provides a powerful entry point to culturally affirming play therapy. In the course of my career, I’ve sought out beautifully designed books with children of color as the main character to help reinforce my clients’ sense of self-worth. There are numerous books specific to particular racial or ethnic groups (e.g., children of African and Latin American descent) and genders to help them understand and love who they are at an early age, integrate history and culture together to educate them about their heritage, and emphasize the process of discovering the unique beauty in each young person and celebrating cultural characteristics (e.g., skin color, hair texture) through positive and inspiring affirmations (e.g., “I am enough,” “I’m Black and beautiful”).



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Restorying Identity through Dramatic Play Children can take on the roles of characters from the literature or their own lived experiences in improvised play and be supported in a process of discovery. I have used this form of dramatic play to enable children from oppressed cultural groups to try on other definitions of themselves and not limit themselves to narrowly defined stereotypes or negative conceptualizations of self. It helps to support a corrective experience, particularly for children of color, who have come to believe, accept, and live out the negative societal messages that misshape their identity and contribute to cultural misorientation (Kambon, 2003). This intervention rejects the notion that identity is fixed and draws on the notion that racial identity (in particular) is enacted as roles that are socially constructed, performed, embodied, and internalized within the ecological environment. By engaging with these roles, we may disrupt rigid notions of race and move toward a social justice approach to play therapy.

Racial/Cultural Identity Exploration through Doll Play and Puppet Theater Children often love to use dolls and puppets to play out their daily life experiences and inner world, including their dreams, their joys, their hurts, and their sorrows. Children also project their beliefs about self onto dolls and puppets, including the complexity of their thoughts in relation to their identity development. Thus, doll and puppet play, like the dramatic play method, can be a powerful technique to help children express the different parts of themselves. They can act out through each doll or puppet character the wide range of emotions, thoughts and perceptions that they pick up about their racial and cultural selves through their socialization process. They can explore, reimagine, and restory any negative elements of their self-concept or base of their self-worth, so that it is not derived from what they hear or see from others, but based on their true selves within. This process is particularly important for children of color, who are more susceptible to low self-worth and self-esteem based on negative stereotypes and messaging that exist about their cultural group. With this in mind, children should not only have dolls or puppets that look like them, but a range of multiethnic dolls and puppets that can be used to play out various racial or cultural identity and self-esteem issues. The prevailing thought might be that cultural similar dolls and puppets are preferred, as they do a better job of building clients’ self-esteem. However, we want to first offer a broad selection of play materials in order to give children permission to play out the complexities of race and racial identity, akin to how a projective test is designed to present ambiguous stimuli to draw out

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a subject’s personality. The goal is to use a range of ethnically and racially diverse dolls and puppets as a landscape for children to project and explore their internalized perceptions of beauty, sense of inclusion and belonging in the world, racial or cultural identity, and self-esteem and racial/cultural pride. To elucidate this technique along with a few other methods discussed in this chapter, I present below (with pseudonyms) a case study from several years ago within my clinical practice.

CASE EXAMPLE Tamara, a 7-year-old African American girl, was referred to therapy by her mother due to angry and acting-out behavior at school, as well as aggression toward peers. Shortly before her intake session, Tamara had a critical incident in which she cut the hair of a classmate (Kerry) with a pair of scissors during art class. Tamara’s mother, Ms. Wilson, described Tamara as a strong-willed child who did not listen to teachers. Socially, she was very selective about her friends, having clear thoughts about who she should and should not be nice to, and taking advantage of students who were nice to her by doing mean things to them. Additionally, Tamara was pulling out her hair. At the time of intake, Ms. Wilson conveyed no race-related behaviors or dynamics. Tamara was diagnosed with Disruptive Behavior Disorder not otherwise specified (DSM-IV) and admitted into outpatient care. The first few sessions after intake focused on exploring the nature of Tamara’s peer conflicts and disruptive classroom behavior: drawing techniques were used, and Tamara drew herself and her friends, noting which ones she disliked. This was the first entry point to exploring racial dynamics. I made available multicultural crayons with a variety of skin tones and asked Tamara to use them to portray her classmates, coming as close to how they looked as possible. In addition to processing her peer relationships through the drawings, I invited Tamara to tell me about the skin color and cultural background of her classmates. This simple culturally relevant assessment technique opened up the door for interesting data to be revealed. Tamara conveyed that she disliked the two other students of color (Indian and Asian) in her class and that she really wanted to be close friends with Kerry, the classmate whose hair she cut. Tamara described Kerry as popular and White, and drew her with yellow (blond) hair. Tamara classified herself as African American and drew herself with a crayon that closely resembled her light-brown skin tone. Given these budding racial themes, I asked Ms. Wilson about whether she had ever engaged in discussions with Tamara about race and ethnicity. Ms. Wilson conveyed that she had, and that Tamara knows she is African American but confuses nationality with ethnicity (i.e., she did not believe an Asian boy in her class could be American because his parents spoke another language).



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Over the course of the next few sessions, I engaged Tamara in nondirective doll play. There were multiethnic dolls for her to choose from, and notably, Black dolls with different skin complexions. She began to evidence a growing preference for the White and lighter-skinned Black dolls over the darker-skinned Black dolls during play therapy. After a solid therapeutic relationship was built, I inquired about Tamara’s selections of dolls at the start of the play session and provided a behavioral observation that she tended to like to play with the White and lighter-skinned dolls. Tamara conveyed that lighter skin is better than darker skin. Even through the dramatic play, Tamara was unable to engage in any further dialogue about why she believed this to be the case. However, the theme of her doll play involved peer conflict in which the darker-skinned doll acted subservient to the lighter-skinned doll, and the lighter-skinned doll bossed around the darker-skinned doll. When these themes were discussed with Ms. Wilson, she acknowledged that she did not know how to discuss these racially loaded issues with Tamara at home. As a pathway to treating the disruptive behavior, therapy initially focused on helping Tamara to explore her negative views about darker skin (which she possessed as an African American) and admiration for White standards of beauty (i.e., long, silky, blond hair), which emerged early on in the doll play. Therapy also focused on increasing her awareness of the relationship between these perceptions and her friendship patterns and peer conflict. Simultaneous collateral work with her mother focused on providing psychoeducation about cultivating healthy racial identity development in children and increasing her comfort level and skill in talking with Tamara about race. It was also important to assist Ms. Wilson in finding better ways to manage Tamara’s hair-pulling behavior, as she attempted to control this by threatening to punish her by sending her to school with an Afro if she did not stop the behavior. Through the evolving doll play, which became slightly more directive over time, Tamara was prompted to use the characters to act out the parts of their made-up personalities that she liked and disliked. Then Tamara was prompted to use herself as one of the doll characters and act out the parts of herself that she liked and disliked. In a breakthrough session, Tamara was able to disclose through the dramatic doll play that she felt she had no real friends and wished she had long blond hair like Kerry. I then began to incorporate bibliotherapy into sessions and integrate her mother into therapy on a biweekly basis to help develop a positive racial identity through reading books that celebrated uniqueness, brown skin, and kinky hair and had affirmations related to self-love and acceptance. Ms. Wilson was invited to expand on these themes by helping Tamara create a daily affirmation that she can say to herself in the mirror while getting dressed for school each morning (e.g., “I am smart,” “I am beautiful,” “I am loved”). These positive affirmations were then integrated back into the

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dramatic doll play with prompts for Tamara to act out scenes in which the characters were being smart, beautiful, and loving. After eleven sessions, Ms. Wilson came into session excited to report that Tamara drew a picture at home of someone with brown-colored skin for the very first time (without prompting). As a result of her collateral work, Ms. Wilson was also able to refrain from threatening Tamara with having to wear her natural hair (Afro style) to school as a punishment for pulling out her hair. She removed the long extension braids from Tamara’s hair and encouraged her to go to school with her own natural hair, which Tamara hesitantly agreed to do. Tamara eventually stopped pulling out her hair and began to feel more accepting of her natural, shorter hair. These shifts were considered significant breakthroughs in Tamara’s development of a positive self-concept and racial identity. Simultaneously, Tamara began to evidence less bossy and aggressive behavior toward her classmates. She still had limited friends because of her reputation in the class, but she evidenced less of a desire to be best friends with Kerry and was able to diversify her playmates at recess. The process of using drawing exercises (aided by multicultural crayons) to assess the racial nuances of the presenting problem, and doll play and bibliotherapy techniques to explore, challenge, and re-story perceptions of self and others rooted in race ultimately proved to be effective in minimizing problem behaviors in the classroom. The above vignette of Tamara is not uncommon in my clinical practice. Anecdotally, many children of color have come into therapy evidencing “typical” disruptive behavior and mood disorder symptoms on the surface, but after utilizing racially and culturally attuned assessment and play therapy techniques, the race-based and cultural dynamics of the presenting problem begin to emerge. Given the disruptive behaviors and peer conflict, one might have attempted to treat Tamara’s case using empirically based cognitive-behavioral play therapy techniques to help develop her social skills and problem-solving abilities. Learning to problem-solve, engage in healthy conflict resolution with peers, and effectively interact in the classroom are important skills for all children. However, when the behavioral problems are not simply the result of a skill deficiency but rooted in themes of cross-racial and cultural interactions, adoption and internalization of societal messages about beauty and worth, and a lack of a true sense of belonging as a racial other in the classroom, traditional skill-based techniques can fall flat.

CONCLUSION Race and culture are seldomly formally discussed in the modality of play therapy. Often, play therapy is taught and written about in the existent literature from a color-blind perspective, as if somehow play transcends



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difference, othering, and power and privilege dynamics in the therapist– client dyad. It does not. As we embrace a social justice agenda, we are in a better position to see opportunities that are often missed and to connect play therapy with the empowerment and healthy racial and cultural identity development of children—particularly those from oppressed cultural groups. In doing so, we must refrain from “how-to” instructions for working with particular racial and cultural groups and formulate a rich, more nuanced approach that is guided by principles of grounding oneself in sociopolitical history, adopting a social justice agenda, breaking free of cultural encapsulation, decolonizing Western play therapy methods, dismantling internalized oppression, understanding biculturalism in immigrant children, and processing race-based stress and racial trauma with youth of color. As therapists work with children to express and transform their emotions and experiences through play, they are urged to adopt a strengthbased stance that is racially and culturally attuned. They are encouraged to be curious about and respond to children’s lived experiences in a racialized world and as members of their unique cultural groups. Only when this is done can play therapists truly move from being well intentioned to being effective in facilitating growth and healing among diverse populations.

REFERENCES American Psychological Association. (1992). Ethical principles of psychologists and code of conduct. American Psychologist, 47, 1597–1611. American Psychological Association. (1993). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48(1), 45–48. Billante, J., & Hadad, C. (2010, May 14). Study: White and black children biased toward lighter skin. Retrieved from www.cnn.com/2010/US/05/13/doll.study/ index.html. Carter, R. T. (2007). Racism and psychological and emotional injury: Recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13–105. Comas-Díaz, L. (2016). Racial trauma recovery: A race-informed therapeutic approach to racial wounds. In A. N. Alvarez, C. T. H. Liang, & H. A. Neville (Eds.), The cost of racism for people of color: Contextualizing experiences of discrimination (pp. 249–272). Washington, DC: American Psychological Association. Edney, H. T. (2006, August 16). New “doll test” produces ugly results, Baltimore Times. Fanon, F. (1986). Black skin, white masks (C. L. Markmann, Trans.). London: Pluto Press. Harrell, S. P. (2000). A multidimensional conceptualization of racism-related stress: Implications for the well-being of people of color. American Journal of Orthopsychiatry, 70(1), 42–57. Helms, J. E., & Cook, D. A. (1999). Using race and culture in counseling and psychotherapy: Theory and process. Boston: Allyn & Bacon.

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Holzman, L. (2009). Vygotsky at work and play. New York: Routledge. Kambon, K. K. K. (2003). Cultural misorientation: The greatest threat to the survival of the black race in the 21st century. Tallahassee, FL: Nubian Nation. Lee, C. C. (2008). Elements of culturally competent counseling (ACAPCD-24). Alexandria, VA: American Counseling Association. Prilleltensky, I., & Nelson, G. (2002). Doing psychology critically: Making a difference in diverse settings. London: Palgrave Macmillan. Quiros, L., & Dawson, B. A. (2013). The color paradigm: The impact of colorism on the racial identity and identification of Latinas. Journal of Human Behavior in the Social Environment, 23, 287–297. Suggs, E. (2019, February 1). Mamie and Kenneth Clark used toys in a test that helped to overturn U.S. school segregation law. Retrieved from www.ajc.com/news/ mamie-and-kenneth-clark-doll-test-challenged-attitudes-segregation/gGknWIaYpKa1Yh9Oqs6hjL. Vygotsky, L. S. (1978). Mind in society. Cambridge, MA: Harvard University Press. Wade, R., Shea, J. A., Rubin, D., & Wood, J. (2014). Adverse childhood experiences of low-income urban youth. Pediatrics, 134(1), e13–e20.

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The Impact of Culture on Expressive Arts Therapy with Children Cathy A. Malchiodi

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sychologists, counselors, social workers, play therapists, and other helping professionals often utilize creative interventions in their work with children. Expressive arts therapy—the purposeful and integrative application of visual art, music, dance/movement, dramatic enactment, creative writing, and imaginative play—is a largely nonverbal, sensory-based way to encourage self-expression of thoughts, feelings and perceptions (Malchiodi, 2020). This approach is action oriented and taps implicit, embodied experiences that can defy expression through verbal therapy or logic. For this reason, it is often used with children in a variety of settings, including psychiatric, medical, community, and educational (Malchiodi, 2006, 2007, 2011b). This chapter explores the basic principles of expressive arts therapy with children with an emphasis on culture and, in particular, social justice and intersectionality in trauma-informed practice.

WHAT IS EXPRESSIVE ARTS THERAPY? Many play therapists use arts-based approaches in their work with children and often refer to expressive arts methods as part of the larger array of play-based practices. However, expressive arts therapy brings a slightly different component to treatment than play therapy or than simply completing an art task, engaging in movement, or participating in dramatic 75

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enactment. It focuses on purposeful ways to help children specifically communicate experiences and engage in reparative experiences through arts-based imagination. By definition, it is an integrative approach that purposively combines two or more art forms to address individual needs and treatment goals (Malchiodi, 2006, 2020). For example, a practitioner may begin a session with movement that may become the inspiration for creating a drawing or painting or using drums or instruments to make sounds. Depending on the individual, this may lead to generating a narrative through storytelling, puppet play, or creative writing. Play is often involved when applying expressive arts with children because any type of arts experience generally capitalizes on spontaneous responses that include playfulness and imagination. Because humans have an extensively documented history of using the arts for self-expression, self-regulation, reparation, and commemoration, culture is particularly central to the practice of expressive arts (Malchiodi, 2007). Image making, ritual, movement, dramatic enactment, imaginative play, music, and storytelling are repeatedly cited as ways we humans make experiences and events special and address loss, disaster, and traumatic events, even as a form of preventative and reparative treatment (Dissanayake, 1995). Perry (2014) summarizes these ethnological findings from a modern-day, neurobiology-informed perspective: “Amid the current pressure for ‘evidence-based practice’ parameters, we should remind ourselves that the most powerful evidence is that which comes from hundreds of separate cultures across the thousands of generations independently converging on rhythm, touch, storytelling, and reconnection to community . . . as the core ingredients to coping and healing from trauma” (p. xii). In my work with children who have experienced acute or chronic trauma, the integrative synergy of the arts is a requisite for addressing traumatic stress with most children as well as adults, families, groups, and communities. Because expressive arts themselves are deeply intertwined with cultural traditions related to ethnicity and community, it is essential that therapists using expressive arts approaches with children understand these relationships in order to provide effective and responsible treatment, particularly when it comes to trauma.

TRAUMA-INFORMED EXPRESSIVE ARTS THERAPY AND HEALING-CENTERED ENGAGEMENT Trauma-informed practice is a term used to describe current thinking and best practices with individuals, families, and groups when it comes to traumatic stress. It emerged over the course of decades from many important models and foundations. Trauma-informed practice is based on the idea that most children, adults, and families who seek care have experienced a



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significant traumatic event at some point in their lives (Substance Abuse and Mental Health Services Administration, 2019). The development of the National Center for Trauma-Informed Care (2019) in 2011 in the United States also marked growing recognition of the impact of psychological trauma and its important role in health care services in general. In brief, the trauma-informed model of care encourages practitioners to consider how traumatic experiences may impact people throughout the lifespan, how these experiences may contribute to a variety of emotional, physical, and cognitive problems, and if trauma reactions are present, how to reduce those reactions through best current practices. When it comes to cultural factors, trauma-informed practice is a model that invites the individual, family, group, or community to become a participant in sessions and to collaborate in therapy, and intervention reflects cultural preferences and worldviews. I believe the core the idea that reparation and recovery are enhanced within relationships and are recapitulated through experiences of choice and when meaningful sharing of power and decision making are present; these principles resonate with the action-oriented nature of expressive arts therapy and play-based work. Trauma-informed practice also emphasizes that sensitivity to cultural preferences for treatment and worldviews of health and wellness are essential. For example, this includes developing collaborative relationships with other systems with the individual’s consent (e.g., working with tribal health care systems and healing traditions for Native Americans or including clergy when needed for spiritual support of individuals). Additionally, traumainformed practice values traditional cultural connections and practices, the importance of gender, age, and socioeconomic influences, and historical and intergenerational trauma. Trauma-Informed Expressive Arts Therapy is a framework for practice that I developed over two decades of work with children, adults, and families (Malchiodi, 2011a, 2020). In brief, it emphasizes approaches that underscore the neurobiology of traumatic stress and the importance of self-regulation, safety, and body’s experience of trauma. Because personal preferences and cultural beliefs and traditions are key to trauma-informed practice, this framework also emphasizes the central role of culture and personal preferences in how psychotherapy is delivered and co-created between client and therapist: Expressive arts therapy respects the individual’s preferences for selfexpression, particularly of trauma narratives. Trauma-informed practice emphasizes the role of individuals in their own treatment and their preferences for participation. These preferences are determined by culture, previous experiences, worldviews, values, and other dynamics. Arts-based approaches offer a variety of ways for expressing “what happened,” dependent on the individual’s comfort level with self-expression.

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Cultural Issues in Play Therapy These therapies also respect the use of personal metaphors and symbols that allow individuals to control how they communicate sensitive experiences. (Malchiodi, 2020, p. 41)

The concept of “healing centered engagement” (Ginright, 2018) is an important part of trauma-informed expressive arts therapy and proposes that individuals be viewed through wider lenses of not only culture but also social justice and intersectionality. Simply put, social justice is based on the principles of human rights and equality and how these are manifested in the everyday lives of people at every level of society. Intersectionality is a slightly more complicated domain to articulate. By its most basic definition, it is defined as the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group. It is also defined as creating overlapping and interdependent systems of discrimination or disadvantage. Healing-centered engagement brings these two concepts, social justice and intersectionality, into practice to underscore the role of control, power, and inequality in not only the individual’s life, but also within systems such as schools, health care settings, mental health agencies, institutions, and other environments (Malchiodi, 2020). Within this framework, therapists also are asked to become conscious of the multiple intersections of issues and dynamics that impact an individual child such as racism, sexism, ableism, classism, prejudice, and gender as well as hunger, homelessness, poverty, and even environmental stresses, including climate change. In other words, when children exist within toxic systems, dynamics, and living conditions, trauma-informed intervention cannot truly be effective if these issues are left unacknowledged. While it makes sense that therapists continue their dedication to resolving symptoms (anger, anxiety, fear), healingcentered engagement moves the pendulum toward a focus on strengthening what supports well-being (hope, imagination, trust, aspirations) inclusive of social justice issues and intersectionality. In brief, it shifts the perspective from “what happened to you” to “what’s resilient about you” when it comes to working with children and families.

A FOUR-PART EXPRESSIVE ARTS THERAPY MODEL FOR CULTURALLY RELEVANT PRACTICE Because the expressive arts provide a unique context for psychotherapeutic engagement, it is important to also have a framework that defines these approaches within the arts themselves. When I considered the principles found in both trauma-informed practice and healing-centered engagement with individuals, families, and groups, I also began to examine the cultural basis for applying expressive arts to trauma intervention (Malchiodi, 2020).



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Because expressive arts therapy emphasizes the centrality of the person, it is the person who derives meaning from creative expressions in contrast to the therapist providing interpretation. Individual meaning making not only is seen as a function of personality, but also includes the community, culture, and global environment within which the person exists. For several decades I have taken a similar position on how mental health professionals generally view drawings and expressive arts as solely representations of the self. With regard to children’s drawings, I said, “Although children bring their own unique thoughts, perceptions and feelings into their creative work, their art expressions may be influenced by the environment in which they draw or the materials with which they create. The impact of the therapeutic relationship is equally important, issues of safety and trust and the therapist’s enthusiasm, knowledge and respect” (Malchiodi, 1998, p. 40). Children’s art expressions as well as their musicality, movement, stories, and enactments actually communicate a worldview that is also impacted by family and caregivers, neighborhood, and environment. This does not mean that an individual’s creative expressions do not represent personal emotional, cognitive, or physical experiences, but it is important to keep in mind that any communication includes elements that are beyond the person and are inclusive of other factors. Rather than use neuroscience as a framework, I look to cultural anthropology and the contributions of indigenous people for answers about what we humans have found to be “healing practices.” These practices materialized in the form of rituals, traditions, conventions, procedures, and ceremonies in response to individual and collective experiences of trauma and loss (Malchiodi, 2006, 2012, 2020). Traumatized individuals, including children, I have worked with over decades often already have some identifiable capacities for repair. These are universal approaches found throughout human behavior across all cultures that have yet to be fully acknowledged and integrated into trauma-informed systems of clinical and community practices. I believe that they form as strong a foundation as science for what we define as “best practices” in addressing mental health challenges. As a result, I arrived at this model for clinical practice that places them into four major categories or phenomena: movement, sound, storytelling, and silence, explained as follows when working with children (see Figure 4.1).

Movement Movement is a foundation for almost all expressive arts and healing practices and is central to cultures throughout history. By some accounts, it is an experience that has helped humanity to develop empathy and adaptation to the environment because of its emphasis on interconnectedness, rhythm, and synchrony. Movement includes gesture, dance, sensory integration activities, yoga, tai chi, and cultural practices such as the Polynesian hula,

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the Aboriginal Australian corroboree, Maori Haka, or Native American Sundance that also have spiritual components.

Sound Music and music making are arts-based wellness practices across cultures, but they also fall into the broader category of sound. Music can influence and impact emotions quickly and effectively, encourage movement and speech, and generally enliven individuals. Singing (whether individually or in a group) and playing musical instruments are expressive arts approaches; there is also chanting, praying, and recital of verse or stories, sound vibrations, and listening.

Storytelling Storytelling is often perceived as a language-driven activity, and with children, listen to or creating stories often comes to mind. But stories are also communicated in many ways through expressive arts and play-based experiences. Visual art (drawing, painting, clay work, collage, photography, and film) are forms of graphic or symbolic storytelling through images; play, and particularly sand tray work with miniatures, conveys narratives. Any form of dramatic enactment, performance, role play, and improvisation communicates stories. In particular, cultural ceremonies and rituals that include movement, sound, imagery, and language have a similar function.

Silence Silence, the final category, emphasizes the way many expressive arts can quiet the mind and regulate the body. We most often think of silence in the form of contemplative practices such as mindfulness and meditation. With children, activities such as art making can be a source of mindful focus; mindful movements such as yoga fall into this category. Also, attending and witnessing theater performances and art objects in museums often involve silence as a core experience and are a form of focused contemplation. (Note that although I have identified four distinct categories, there are overlapping functions due to characteristics of the arts themselves. For more detailed information, see Malchiodi, 2019, 2020.) These four categories form a basis for understanding children’s preferences for various expressive arts experiences as well as determining any culturally relevant arts-based practices they already know. For example, children may have learned self-soothing or regulating songs or dance sequences from their community. Storytelling may be part of the oral traditions of their families and have specific themes or applications; there may also be

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SOUND SINGING DRUMMING PLAYING INSTRUMENTS HUMMING CHANTING PRAYER VIBRATION LISTENING

MOVEMENT

DANCING YOGA BILATERAL MOVEMENT SENSORY INTEGRATION ENERGY ARTS CULTURAL PRACTICES LABYRINTH PLAY

ENACTMENT DRAMA ROLE PLAY IMPROVISATION VISUAL ART CREATIVE WRITING LYRICS JOURNALING EMBODIED NARRATIVES CEREMONIES/RITUALS

STORYTELLING

STORYTELLING

MINDFULNESS MEDITATION CONTEMPLATION ART MAKING YOGA LABYRINTH WALKING FELT SENSE INTEROCEPTION WITNESSING ARTS

SILENCE

SILENCE

FIGURE 4.1.  Four-part model for arts-based healing practices. From Malchiodi (2020, p. 61). Copyright © 2020 The Guilford Press. Reprinted by permission.

SOUND

MOVEMENT

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certain symbols used through images or art expression that are culturally relevant for each child. These categories of expression may also affect children’s willingness to share and communicate aspects of the self through expressive arts to varying degrees, depending on what is learned through cultural experiences involving creative expression and how it is learned. Rules about the content used in expressive arts can also be culture specific. For example, in Australian Aboriginal communities, children still learn specific symbols for making human figures (a half-doughnut shape) and other objects from their elders and use these concepts in storytelling and enactments. These symbols are traditions handed down for generations whose meanings are recognized by this particular group of individuals—in this case, the Aboriginal community. Children are taught to portray people in a seated position and in a shape commonly accepted within the culture as that which represents “person.” In the United States, some Native American children who grow up within tribal communities also learn to draw symbols that are reflective of their cultural rituals; if they move from their tribal communities to attend public school, they may adopt the drawing conventions of peers unless the original symbols they learned are reinforced or practiced.

EXPRESSIVE ARTS AS A CULTURAL LENS FOR PLAY THERAPISTS While expressive arts therapy with children is a complex topic, there are several areas that help to clarify cultural elements, including the impact of social influences and intersectionality. For play therapists who are less familiar with expressive arts, these are good starting places for viewing children’s creative output because these three areas form a foundation for applying expressive arts within play therapy practice: (1) expressive arts as nonverbal expression; (2) expressive arts as metaphor; and (3) expressive arts making as sensory-based experiences.

Expressive Arts as Nonverbal Expressions Many years ago, I worked as an art and play therapist in a domestic violence shelter for women and their children. My very first child client was a 6-year-old Vietnamese boy, Tao, whose family had recently moved to the United States. Unfortunately, the father was extremely violent to Tao and his mother, forcing her and her children to seek safety and help at the shelter. Tao and I could not communicate verbally with each other; he spoke very little English, and I knew no Vietnamese. However, when he saw a basket of felt marking pens and white paper on the table, he immediately began to draw. His first image was of a large face with eyes, rudimentary nose, and



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a downturned mouth; the most remarkable features were the large tears he drew in black marker flowing from the face’s eyes. He pushed the drawing toward me and whispered something in Vietnamese. I acknowledged his drawing—pointing toward it, making a sad face, and tracing my cheeks where he drew tears on his drawing’s face. He nodded affirmatively and then took his pen and scribbled across the face as if to scratch out the tears; he also drew over the downturned mouth, adding an upturned line over it. Later in the week, with the help of a bilingual social worker, Tao told me more about his drawing. He said that because he, his younger brother, and his mother had left his father, he was now the “man in the family.” Although the face in the picture was originally sad and tearful, Tao felt that he had to be strong for his mother and brother because he was now the oldest male in the family, and he stated, “I cannot cry, because I have to take care of my family now.” His drawing was a representation of both his sadness and his expected role and responsibilities as the oldest boy in the family. This experience taught me that when words are impossible due to language barriers, visual expression is a useful form of nonverbal communication. It is also a powerful example of the intersectionality present in Tao’s life story. Once unpacked I learned that he had not only endured being a child witness to violence and the subsequent responsibilities in his family; he also had intergenerational trauma embedded in his family’s background. In working with the bilingual social worker and Tao in additional art and play therapy sessions, I also learned his mother and father endured horrific conditions in their homeland, experiences that caused them to leave their country on a small boat. During that escape and eventual immigration, they witnessed people sicken and die. In fact, they lost what was their only child at the time and had to watch their baby’s body be tossed into the ocean. These additional events and more were key to a more traumainformed, intersectional understanding of Tao’s images and particularly the significant social events that formed his family’s history of trauma. Although a difference in verbal language is one scenario where visual art allows for self-expression, there are other circumstances when expressive arts can be equally effective. Children may be told or believe that they should not speak about certain events or feelings, but they may be able to express these experiences through art. In some cultures, open expression of emotions is not considered appropriate; in other contexts (especially when abuse or neglect has occurred), children may also learn from parents, other family members, or the community not to talk about specific experiences, or may believe that speaking is not safe or desirable. Another brief case summary illustrates this point. Tom, an 11-yearold Navajo boy, resided on a reservation with his mother and grandparents. Tom’s 16-year-old brother had been in an automobile accident and died from brain and spinal cord injuries. Shortly after his brother’s death,

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Tom’s teachers referred him for a psychiatric evaluation because he became extremely agitated and cried often during class. His mother also reported that he had difficulty sleeping; she believed that he was visited by “night spirits,” which caused him to scream almost every night. Tom and his mother left the reservation to seek help through a Native American health center in the nearest large city. After evaluating Tom, the center staff felt that they did not have the services necessary to help him and his mother. They recommended that Tom go to a children’s psychiatric unit to receive a more complete evaluation, as well as art and play therapy. After an assessment of Tom’s symptoms was made by a child psychiatrist, I saw Tom and his mother for an initial session. Tom spoke openly about his nightmares and his difficulty in staying asleep because, as he said, he feared “ghosts and spirits” were after him. However, after a short while, he felt uncomfortable about saying any more and became quiet and withdrawn. In brief, there was a taboo among the tribe on speaking openly about deceased persons—in this case, Tom’s brother. However, at the suggestion of the Native American health center, Tom was able to draw pictures about his feelings, his traumatic experiences, and eventually even the death of his brother—including what his brother looked like “dead” and the subsequent funeral. During this time, a local medicine man was also consulted and performed a ceremony to aid Tom in his recovery process and to help his mother grieve for the loss of her son. Tom’s treatment included both antidepressant medication and art therapy. By the end of 5 months, his depression and anxiety were considerably reduced, and he and his mother returned to their community.

Expressive Arts as Implicit Communications Like play therapy, expressive art therapy offers children the opportunity to use metaphor through nonverbal expression as well as narratives about their creative work. In terms of the four categories of healing practice, art expression and dramatic enactment are most closely aligned with storytelling; in particular, art is a way to generate tangible symbols. Both of these expressive arts can also serve as metaphoric communications for experiences that a child may feel uncomfortable speaking about because of beliefs or messages from family or community. Rousseau, Lacroix, Bagilishya, and Heusch (2003) conducted a study with immigrant and refugee children in Canada that I have always found fascinating. Their investigation helps to clarify how art can relay metaphors through image and subsequent storytelling. They asked children to “tell the story of a character of their choice (human or not) who experienced migration in four stages: the past (life in the homeland before migration), the trip itself, the arrival in the host country, and the future” (p. 3). The children drew pictures and later talked and wrote about each of the



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drawings. Children who had multiple traumas and losses had difficulties in both drawing the past and projecting themselves into the future. Those who managed to portray images for each of the four stages structured their drawings and stories around three main themes: family, friends, and myths about their home culture. The researchers concluded from this pilot study and a subsequent study that significant metaphors from a child’s culture were helpful in assimilating past experiences with present and future events. They also observed that newly arrived immigrant and refugee children used references to myths and tales from their home culture, their host country, and the cultures of their classmates. When a child predominantly adopted references from the host country, the child might be borrowing a “false self.” One of the strengths of expressive arts in therapy is their ability to enhance and encourage storytelling through image, gesture, writing and enactment. For example, enactments about a drawing, painting, or clay sculpture need not be literal to be therapeutic; in fact, children who have had severe multiple traumas generally only find it possible to communicate imaginative stories when trust and the beginnings of attachment are established between therapist and child. The narrative or enactment is often a communication of children’s distressing experiences—and, in trauma-informed practice, coping skills and strengths. By working with these communications as metaphors, the therapist not only can assist a child, but also can begin to understand the cultural influences behind the stories told.

Expressive Arts as Sensory-Based Experiences Neuroscience is currently informing the field of mental health about why activities such as drawing are important tools in work with children, particularly those who have experienced trauma (Malchiodi, 2011b). Expressive arts may be especially helpful with traumatized children who experience symptoms of traumatic stress. For these children, the sensory—tactile and visual—aspects of expressive arts, along with strategic interventions, may provide an effective combination in the reduction of traumatic stress (Malchiodi, 2020). Since many of the children therapists see have had experiences of domestic or societal violence, physical or sexual abuse, loss, immigration, homelessness, or multiple foster care situations, expressive arts can be an effective means to ameliorate psychological trauma because of their unique capacity to support communication about implicit memories of feelings, perceptions, and events. What I continue to find impressive about expressive arts is their ability to stimulate children to respond in ways that mirror dynamics occurring in a variety of environments outside the psychotherapeutic setting and particularly within significant interpersonal and caregiver relationships. For example, children who have experienced neglect or poverty often react to

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art or play materials with specific behaviors and for often idiosyncratic reasons. Many chronically neglected children may hoard items in the therapy room and even ask to take supplies with them, just as they may hoard or want to take extra food if offered; this is not pathology, it is a demonstration of adaptive coping necessary for survival. In my work in domestic violence shelters, safe houses, and shelters for homeless persons, I learned that even an accidental spill of paint across the table might cause children to reexperience violent incidents that had happened at home when a cereal bowl was dropped on the floor or a glass of milk was tipped over. Because of previous verbal or physical punishment, children, may show the same sort of hypervigilance, fear, and anxiety in a therapy setting that they display in their families after certain incidents have triggered violent reactions from parents or caretakers (Malchiodi, 1997, 2020). These manifestations truly can convey not only the intersectionality of children’s experiences of trauma, but also the interpersonal and social factors that impact their daily lives outside the play therapy room.

CULTURALLY SENSITIVE EXPRESSIVE ARTS THERAPY Although there is still much to learn about how culture influences expressive arts therapy with children, there are several aspects that culturally sensitive therapists can take into consideration to exercise their own “cautious enterprise.” Because most play therapists find it easiest to apply art expression and storytelling in their work with children, this section focuses on the use of drawings from a culturally sensitive perspective. Overall, therapists should view children’s art expressions as cultural expressions that reflect a wide range of personal and unique experiences. That is, drawings or other art products cannot be viewed solely as representations of emotions or disorders; nor can they be understood simply through the lens of ethnicity, race, socioeconomic status, family, gender, peers, or media. In taking a culturally sensitive stance toward art expressions, it is more important that therapists view the child’s creative work contextually and as being reflective of a variety of aspects of culture, environment, relationships, development, and personality. Therapists must also be sensitive to how they initiate art expression as therapy with children. For example, for some children a nondirective approach (“Draw anything you want to”) may be threatening and counterproductive to developing trust and establishing a safe, comfortable environment for creative expression. Some children may prefer copying images or tracing to doing something original, particularly if their cultural experiences have dictated this as the preferred way to draw or create. This “art behavior” should be accepted and understood as part of who the children are. Others may find craft work more desirable because it is an art form



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that is recognized, has been previously experienced, or recalls memories of success or self-esteem. Although a therapist may focus on a variety of topics in culturally sensitive art therapy with children, some specific directives are helpful. The following are just a few themes that therapists can use to get a sense of children’s cultural backgrounds: • “Draw a picture of your home.” Because “home” may mean anything from an actual house to an apartment, or even a shelter for homeless persons or a street dwelling, it is important to request a drawing of “your home” rather than “your house.” Therapists may want to ask children, “What makes it special?” or “What don’t you like about it?” Drawings of “your room,” “the shelter,” or “your neighborhood” can also help therapists understand more about the context in which their child clients live. I have often asked children to make me a map of their neighborhood, community, tribal reservation, or apartment complex in order to help me learn more about their family lives, extended families, and social setting. • “Draw a picture of your favorite heroes, or favorite storybook, folktale, or cartoon characters.” Along the same line, a therapist may ask a child to draw or create an image from clay of a scene from a favorite story or folktale. Clay figures allow the child or therapist to enact stories or scenarios through movement. • “Draw a picture of how birthdays [or another event] are celebrated in your home or with your family.” Children may also be asked to include anything that makes a birthday special, such as certain foods or decorations. This directive generally stimulates memories of family rituals, customs, and values. Finally, it is also important to consider if art-based assessments actually support culturally sensitive evaluation and subsequent intervention. Most traditional projective tasks, such as a drawing of a house, tree, and person, have not been standardized as assessments from a cultural perspective; the available research is not applicable within a multicultural framework and often comes from studies conducted many decades ago. Therefore, when inviting children to participate in these types of directives, they are generally more useful as ways to engage children in storytelling through image and verbal communication with the therapist. For all of the art-based activities mentioned, therapists should have on hand materials that support and nurture creativity with children of various cultures. For example, there are “multicultural” crayons, felt markers, and clay that come in a range of skin tones approximating skin colors. Photo collage materials should reflect as wide a variety of cross-cultural images as

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possible, including ethnicities, families, lifestyles, and beliefs. Craft materials such as fabric, yarn, beads, or other objects may be helpful in stimulating some children whose experiences with art have evolved around fabric decoration, jewelry making, or traditional needle arts. The overall caveat is to be aware that children, because of cultural influences, may need a wide range of expressive arts media and materials to inspire and stimulate their creative process in therapy.

CONCLUSION Respecting the uniqueness of each individual is a core value of expressive arts therapy; this includes the impact of culture in all its dimensions. The psychotherapeutic goal is to first understand the world in which children live and the challenges they face and then to co-create meaningful artsbased experiences that respond to that reality. When it comes to trauma, it is essential to shape expressive arts interventions to support each child’s capacity for imaginative actions that they may have lost due to adversity, while remaining conscious of the impact of the larger communities in which they live, the societal factors of their daily lives, and the intersectionality they bring to sessions. Ultimately, this requires that the therapist possess a humble and respectful attitude; adopt principles of trauma-informed practice and healing-centered engagement; and maintain a genuine curiosity about the rich complexities of child clients seen in treatment.

REFERENCES Dissanayake, E. (1995). What is art for? Seattle: University of Washington Press. Ginwright, S. (2018, May 31). The future of healing: Shifting from trauma informed care to healing centered engagement. Retrieved from https://medium.com/@ ginwright/the-future-of-healing-shifting-from-trauma-informed-care-to-healingcentered-engagement-634f557ce69c. Malchiodi, C. A. (1997). Breaking the silence: Art therapy with children from violent homes (2nd ed.). Bristol, PA: Brunner/Mazel. Malchiodi, C. A. (1998). Understanding children’s drawings. New York: Guilford Press. Malchiodi, C. A. (2006). Expressive therapies. New York: Guilford Press. Malchiodi, C. A. (2007). The art therapy sourcebook. New York: McGraw-Hill. Malchiodi, C. A. (2011a). Trauma-informed expressive arts therapy. Retrieved January 31, 2011, from www.cathymalchiodi.com. Malchiodi, C. A. (Ed.). (2011b). Handbook of art therapy (2nd ed.). New York: Guilford Press. Malchiodi, C. A. (2012). Introduction to art therapy in health care settings. In C. A. Malchiodi (Ed.), Art therapy and health care (pp. 1–12). New York: Guilford Press. Malchiodi, C. A. (2019, September 24). Expressive arts therapy is a culturally relevant practice. Psychology Today Online. Retrieved from www.psychologytoday.com/



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us/blog/arts-and-health/201909/expressive-arts-therapy-is-culturally-relevantpractice. Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. New York: Guilford Press. National Center for Trauma-Informed Care. (2019). Purpose and mission statement. Retrieved from https://tash.org/nctic. Perry, B. D. (2014). Foreword. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. ix–xi). New York: Guilford Press. Rousseau, C., Lacroix, L., Bagilishya, D., & Heusch, N. (2003). Working with myths: Creative expression workshops for immigrant and refugee children in a school setting. Art Therapy: Journal of the American Art Therapy Association, 20(1), 3–10. Substance Abuse and Mental Health Services Administration. (2019). Trauma-informed care in behavioral health services. Retrieved from https://store.sam-hsa.gov/system/files/sma14-4816.pdf.

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Exploring Gender and Sexuality Using Play Therapy Quinn K. Smelser

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ery few studies examining gender and sexuality exist in the play therapy literature. Until roughly 20 years ago, research almost completely neglected this aspect of client diversity, especially for children. Most literature deemed gender and sexual identity issues as taboo even though they can have a tremendous social and psychological impact on a child and family. In the past, clinical attention to aspects of gender variance in children included conversion therapies and encouraging families and clinicians to redirect and shape children’s interest in or concerns about gender fluidity. Research, assessment, and treatment approaches have emerged in the last decades, and the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community is now a subculture, with its own political voice, social presence, and ability to offer immediate feedback to global concerns regarding gender and sexual identity issues. In fact, the information on this topic is evolving quickly, and clinicians need to stay abreast of developments to understand the most appropriate terminology to use, but more importantly, how to craft treatment goals and approaches that are ethical, affirmative, and informed. Though ignoring the role of child gender and sexual identity development may hinder a child’s growth, very few articles and little research has focused specifically on best practices for allowing children to safely explore their gender and sexual identity in play therapy. This chapter presents an overview of how play therapy inherently encourages safe gender 90



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and sexuality exploration. Strategies for letting the child lead in the playroom, creating a safe space for exploration, and working with families are highlighted, as well as the many worries, biases, and arguments around sexual and gender identity issues with children. Finally, a case study that illustrates techniques and considerations for trauma is presented, and an argument is made for better advocacy for the needs of these children and their families.

WELL-BEING OF LGBTQ YOUTH BY THE NUMBERS Attachment and parenting research repeatedly shows the vital role that parents and caregivers play in scaffolding and supporting the healthy development of children and adolescents. However, parents and professionals alike may feel uncertain how to support, discuss, or raise the issue of healthy sexual development, and this becomes more challenging when children and adolescents have identities falling outside of what is considered “heteronormative”1 or “gender binary.”2 For the last decade, the Human Rights Campaign has commissioned a number of surveys in conjunction with the University of Connecticut to understand the mental health and well-being of LGBTQ youth and their families. In the Human Rights Campaign’s LGBTQ Youth Report (2018), only 24% of LGBTQ youth felt that they could be themselves at home, and 48% said that their families made them feel bad for their identity. For many of these youth, the sentiment shared by one teen is a daily reality (Human Rights Campaign, 2018, p. 5P): “I’m not out to my parents for safety reasons. If they found out I was gay, they would kick me out or force me into conversion therapy.” Child therapists and development researchers know the socioemotional, mental, and physical health effects caused by a child fearing for their safety in their home (van der Kolk, 2016). The mental and physical health disparities between LGBTQ youth and others are alarming (Human Rights Campaign, 2018; American Academy of Child and Adolescent Psychiatry, 2012). These youth are twice as likely to be bullied, and 26% say that their biggest daily problems are bullying, fear about their identity, and not feeling accepted by their families. Non-LGBTQ youth mostly report being worried about grades and getting into trouble at school (Human Rights Campaign, 2018). It is no wonder that 85% of LGBTQ youth rate their stress as higher than 5 on a 1–5 1 Heteronormative

attitudes assume that heterosexuality is the default sexual orientation instead of one of many possibilities. This belief also assumes that the default relationship is between two people of “opposite” genders. 2 “Gender binary” assumes there are only two distinct, opposite genders—male and female. Gender actually falls on a spectrum with a range of expression.

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scale and 77% say they have frequently felt down or depressed in the last year (Human Rights Campaign, 2018). However, only 41% of these youth reported seeing a counselor. At school, only 27% of LGBTQ youth say they can be themselves, mainly because of fear of bullying, peer rejection, and not knowing if it is safe to discuss their identity with a school counselor (Human Rights Campaign, 2018). According to the Centers for Disease Control and Prevention, in 2019 suicide was the third leading cause of death in the United States for persons between the ages of 10 and 14 and the second leading cause for people between the ages of 15 and 24. Due largely to feeling unaccepted and experiencing prejudice against their identity, lesbian, gay, and bisexual youth are two to five times as likely to attempt suicide as their peers (Centers for Disease Control and Prevention, 2019). They are also more likely to experience depression or anxiety, and use substances to cope (Human Rights Campaign, 2018; Centers for Disease Control and Prevention, 2019). Further, 20–40% of all homeless youth in this country identify as LGBTQ (Centers for Disease Control and Prevention, 2019). If there is any hope of lowering these numbers, mental health professionals, including play therapists, must examine their own biases, seek supervision and training to better understand sexual and gender identity development, and develop consistent best practices for therapy with LGBTQ children and adolescents. They must also be open to discussing sexual and gender identity development with children and adolescents, provide psychoeducation for teachers, parents, and other youth, and become advocates for these children and families (Human Rights Campaign, 2018).

EXAMINING BIASES In 2015, the Obama administration supported the end of the use of conversion therapy, the practice of “repairing” someone’s identity, because it was a treatment that lacked evidence and actually caused harm (Adelson & Knight, 2015). The American Psychiatric Association (2018) warned that conversion therapies might result in further depression, anxiety, and selfharm. Additionally, the American Psychiatric Association noted that “therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient” (2018). The American Psychiatric Association, the American Medical Association, the American Academy of Pediatrics, and the American Counseling Association have made similar statements regarding the use of conversion therapy. The Association for Play Therapy’s best practices guidelines (2019) state that play therapists must respect individual differences and cultural diversity—the LGBTQ community is most definitely a diverse subculture



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of the mainstream culture. One way play therapists become culturally competent is by actively identifying their own beliefs and values and being careful not to force those beliefs onto the child and family (Association for Play Therapy, 2019). Play therapists need to self-evaluate, recognize areas of competence, and seek out training and continuing education to keep current on research about populations they work with (Association for Play Therapy, 2019). Yet many therapists and play therapists tend to refer LGBTQ families and children elsewhere, or they shy away from training programs that focus on this aspect of identity. Most importantly for this work, play therapists must explore the gender and sexual orientation biases they carry as people, another area outlined in the Association for Play Therapy’s best-practices statement (2019). In addition, play therapists must recognize that even if sexual and gender variance are not the reason a child is referred, the topic may present itself in therapy sessions and play therapists must be receptive to the child client’s personal exploration, and any concurrent worries or concerns.

GENDER AND SEXUAL IDENTITY DEVELOPMENT In order to examine one’s own beliefs about LGBTQ identities, it’s fundamental to have a basic understanding of gender and sexual identity development, in spite of the fact that this area is not always incorporated into clinical training. Just like cognitive or socioemotional development or any other aspect of identity, these pieces of one’s identity are not a person’s choice. There is no single developmental pathway for LGBTQ identity development, a process that unfolds over the many years of childhood and adolescence (Bonfatto & Crasnow, 2018). The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) removed “gender identity disorder” and replaced it with “gender dysphoria” for children, adolescents, and adults. This represented a step toward removing stigma and ideas of choice and single developmental trajectories, ending the pathologizing of aspects of identity, and stopping attempts to “cure” people in the LGBTQ community. As part of this shift, DSM-5 also separated the concepts of gender and sexuality. Additionally, there was more language included around gender and sexuality exploration being relatively normal at different ages of development. Gender identity development begins around age 3, an age at which many play therapists start seeing children (Ray, 2016). At this age, children are curious about differences in body parts and body functioning between boys and girls. Most children at this age view gender as something that cannot be changed (gender binary) as well as something mostly observed through differences in appearance—boys as “handsome,” girls as “pretty” (Halim, Gutierrez, Bryant, Arredondo, & Takesako, 2018). Children

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largely depend on what’s learned or witnessed in their environment for this knowledge (Ray, 2016). Sexual play is normal at this stage of development, when it is infrequent, spontaneous, and occurring between children who are the same age and know each other well. As children grow to ages 4, 5, and 6, they largely see gender identity as based on differences in genitalia and as something that is constant/unchangeable (views often held by uninformed adults as well around topics introduced in this chapter). Children at this point in early childhood might ask questions about where babies come from or why people have different body parts, and might also engage in masturbation from time to time because they are discovering that touching themselves feels good (Ray, 2016). A child in early or middle childhood will explore behaviors outside of what society expects of the sex they were assigned at birth. Some refer to this behavior as gender nonconforming or gender expansive.3 These behaviors do not mean that the child is transgender. Feminist and queer theories speak to gender as a socially created institution with power inequalities. Further, theorists, therapists, and advocates point out that gender fluidity has been around universally for centuries, as seen in Joan of Arc, Amelia Earhart, and Rebecca’s Daughters. Experts agree that by adolescence, fluidity in gender identity begins to solidify (Olson, n.d.). As will be outlined later in this chapter, the question of whether or not a child is “in a phase” cannot fully be known until late childhood or early adolescence. While gender identity involves who you are and how you feel or identify in your body, sexual identity is about who you love and are attracted too. A great tool for identifying these differences is shown in Figure 5.1. This is a visual graphic that many therapists keep up on the wall in their playrooms to help children begin to understand aspects of their identity or of the identity of someone in their family. By middle childhood, ages 9 to 11, kids begin to really learn about sexuality and what intercourse is, and begin to identify sexual or affectional orientation identities (Ray, 2016). Adolescence is also when sexual identity orientation begins to take shape, though aspects of sexual feelings occur in infancy (American Academy of Child and Adolescent Psychiatry, 2012). Sexual identity and sexual development both have psychological, social, and biological components (American Academy of Child and Adolescent Psychiatry, 2012). There is empirical evidence now supporting the notion that neuroendocrine, neuroanatomy, and genetic factors all influence sexual orientation. There is no evidence to support the belief that social learning or visibility of homosexual adults has any bearing on developing 3 Gender

expansive” is preferred over “gender nonconforming.” “Gender expansive” describes people’s gender expression more broadly than “gender binary.” “Nonconforming” has negatively connotations because it implies that there is something people should be conforming to and are not.



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FIGURE 5.1. The Gender Unicorn. From Trans Student Educational Resources (www.transstudent.org/gender).

a homosexual identity (American Academy of Child and Adolescent Psychiatry, 2012). Sexual identity development begins as varying expressions of gender role behavior with females displaying more fluidity in gender role behaviors and sexual orientation identification (American Academy of Child and Adolescent Psychiatry, 2012). Cass (1979) outlined a stage model for homosexual identity development in which individuals progress (or do not fully progress). These are first identity confusion, then identity comparison, then identity tolerance, acceptance, pride, and synthesis. When a child reaches adolescence, they might have already begun to cycle through these stages. Another popular model across the lifespan for sexual identity development is D’Augelli’s (1994) model. In this model a person exits a heterosexual identity, then develops a lesbian, gay, or bisexual (LGB) identity, then a social LGB identity, and then an identity as an LGB child within their families of origin. Identity as an LGB child potentially changes a person’s relationship with their parents/caregivers. From there, a person develops intimacy as an LGB person and finally enters an LGB community or subculture (D’Augelli, 1994). Through these stages of development, an LGB

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person will likely encounter myriad issues for clinical intervention—all of them a result of the effects of stigma, biases, peer and family rejection, internalized prejudice, and bullying (American Academy of Child and Adolescent Psychiatry, 2012).

INTRODUCING GENDER AND SEXUALITY IN THE PLAYROOM For some clinicians, broaching the topic of gender and sexuality in a session with an adult client can bring hesitation and fear, partly because of their own values or ideas, but more so because of the lack of discussion of these topics in professional arenas. Thinking of tackling this topic with a child amplifies that fear and can even result in accusations of ethical violations, debate, and arguments (Barron & Capous-Desyllas, 2017). However, as previously discussed, gender and sexual identity development are a part of childhood. Part of gender identity developing around age 2 or 3 means that children begin to see the expression of gender through toys and clothes, though the deeper meaning of gender expression and identification is not yet defined (Grossman & D’Augelli, 2007), but it might begin to be explored through play behaviors. Barron and Capous-Desyllas (2017) described gender identity as being part of a biosocial paradigm where society expects behaviors to align with socialized gender roles and with genitalia assigned at birth. While some psychodynamic authors acknowledge that play allows a child to freely express their gender and that children who experience gender dysphoria are suffering, they still suggest that play behaviors consistently falling outside of the gender binary are indications of psychopathology (Meersand & Gilmore, 2018). These authors encourage the play therapist to have an attitude of exploration, but their suggestions do not affirm the child’s experience. Play therapy should be a space that is free of social norms and full of acceptance, making it compatible for exploring types of families, and sexual and gender identity. The child-centered play therapist has to do very little to bring the topic into the playroom. Play almost inherently encourages identity exploration as the play therapist lets the child lead in labeling toys, in dressing up in any ways they might need, listening to stories told from a first-person perspective, and in offering a nonjudgmental and fully accepting attitude toward the child. Stutey, Klein, Henninger, Crethar, and Hammer (2020) recommended play therapists create a space for gender to be a fluid concept in the playroom by not using gendered language when grabbing a toy and/or being aware of one’s own gender stereotypes. These authors state that a therapist can follow the lead of the child if the child uses a gendered pronoun and that the play therapist should not separate toys by gender-role category but



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rather create an affirmative playroom where children can express themselves in whatever way they need (Stutey et al., 2020). Allowing gender fluidity in a playroom is key for any child, and especially for a child who has disclosed a feeling of being in the wrong body or having a gender identity that does not match their sexual assignment at birth (Olson, n.d.). With trust and acceptance built between the play therapist and child clients, children can use play as a language to express their feelings, needs, and phenomenological experience, while role-playing solutions or ideas that they might not have the flexibility or space to create outside of the playroom.

BEST PRACTICES FOR LGBTQ CHILDREN IN PLAY THERAPY As part of the growing emphasis on social justice and diversity within counseling and play therapy, attention to best practices with gender diverse adults has increased, but little of this attention has focused specifically on working with children (Puszczyk & Czajeczny, 2017), and there has been even less attention in the field of play therapy. Little play therapy literature discusses the constructs of gender identity versus sexual identity development in the playroom. Very little research has focused on best practices to allow children to safely explore their sexual and gender identity in therapy (American Academy of Child and Adolescent Psychiatry, 2012). The American Academy of Child and Adolescent Psychiatry (2012) put forth nine principles for working with LGBT youth: 1. Getting an age-appropriate psychosexual development assessment. 2. Considering issues of confidentiality within the family system (for possible family rejection or alienation). 3. Exploring family dynamics in relation to the youth’s cultural values. 4. Assessing for situations that commonly occur with LGBTQ youth, including bullying, suicidality, risky behaviors, and substance abuse, and providing psychoeducation around sexually transmitted disease. 5. Fostering healthy psychosexual development. 6. Understanding that conversion therapy lacks any empirical support and could be harmful. 7. Staying up to date on evidence surrounding choosing treatments for gender discordance that differ based on the child’s age. 8. Consulting with schools, community agencies, and other providers to advocate for unique needs of the youth. 9. Being aware of community and professional resources for LGBTQ youth.

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The American School Counselor Association details practice guidelines for professional school counselors working with LGBTQ youth. Similarly, the American Psychological Association has Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients; Guidelines for Psychological Practice with Transgender and Gender Nonconforming People; and a Toolbox to Promote Healthy LGBTQ Youth (all of these can be found in the resources list in Appendix B, this volume). Wren (2019) argues for flexibility, multiple points of decision making, consulting with multiple professionals, psychoeducation, understanding family and social contexts, and awareness of power and voice in order to operate as professionals in the best interest of LGBTQ youth and families. All of these practice parameters and recommendations involve supporting both the youth and the family by creating an affirmative environment, understanding the role of prejudice and bullying in the child’s environment, assessing for trauma reactions, being knowledgeable about resources for the child, working with other professionals, getting a full psychological evaluation if the situation warrants it, knowing the family’s comfort level with the topic (because helping a youth be “out” with their family may not be in the best choice for the child’s safety), advocating for the child in other settings, and being flexible in your approach. As a counterpart to the guidelines informing best practices for the related professions mentioned above, I propose the following as best practices for play therapists working with LGBTQ youth and families: 1.  Examine your own beliefs and biases to determine if you are the best fit for this youth. Everyone comes to therapy with beliefs and biases, whether they are the therapist or the client. Even well-meaning allies who are not a part of the LGBTQ community have biases and are not always aware of their heterosexual or cisgender privilege. Adelson and Knight (2015) caution therapists to allow the child to “discover and be accepted for who they are” rather than imposing our own beliefs and values on the child, even if well intended and nondiscriminatory. Therapists can play an exceptional role in the lives of LGBTQ youth if they are truly child centered and flexible in their approach (Adelson & Knight, 2015). 2.  Seek psychoeducation and supervision before and while working with LGBTQ youth. Exploring your own biases and beliefs involves seeking supervision to better look at these values with objectivity and psychoeducation to immerse yourself in LGBTQ communities and resources. 3.  Create an affirming environment. The American Medical Association stated that an affirmative space can alleviate emotional disturbances for LGBTQ youth as these spaces can be hard to find (Adelson & Knight, 2015; Human Rights Campaign, 2018; Olson, n.d.). This means ensuring



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that your physical space and the psychological and emotional space you hold should be affirming. Toys in the playroom are the child’s words and should allow the child to be themselves in play (Landreth, 2012). Affirming playrooms should have sand tray figurines representing gender-stereotypical figures, gender-nonconforming figures, and figures with dual identities or dual characteristics (i.e., a mermaid); a wide variety of dress-up clothes, toy vehicles, superheroes and action figures; and a dollhouse and dolls that are conducive to all forms of gender expression and sexual identity and allow for the creation of all types of families. Further, displaying safe-space triangles4 in the playroom as well as in your agency’s waiting room can alert clients to the fact that this space aims to affirm their identities. If you are able to provide them in your clinical practice, gender-neutral bathrooms send a message of inclusivity and acceptance. Agency paperwork should also be gender affirmative and include spaces for legal name and name the child goes by as well as pronouns used. The term “preferred pronouns” implies that a person’s gender is a choice. Remember that pronouns are never “preferred,” they just are. While the use of the term “preferred pronouns” is common, it is incorrect and should be avoided and/or constructively corrected when used by others. The therapist can ask the child for pronouns, and if they ask why, he or she or they can simply say, “I ask all kids I work with that question.” 4.  Assess at both the child and family levels. When receiving a referral that involves a child who is struggling with either gender or sexual identity questions, it is important to assess differentially what might best serve the child and what might best serve the family. This allows clinicians to see how comfortable the child and the family are together and separately. Additionally, assessing for past traumas that the child or family have experienced is relevant. Further, it is best practice to have a relationship with a psychologist or psychiatrist who can do a psychiatric evaluation and assess psychosexual development while affirming the child’s identity. This means clinicians are well served to develop and maintain a referral database of LGBTQ-informed and -affirming providers with whom you also have relationships. 5.  Find other providers, communities, and resources. Part of the clinical work is providing a safe space for LGBTQ youth, which involves knowing which providers—general practitioners, psychiatrists, psychologists, family advocates, social workers, and others—can offer an identity-confirming 4 A

safe-space triangle is an internationally recognized symbol that educators, therapists, and others display to show that it is safe for those from marginalized communities to talk to them. Safe spaces and people do not engage in violence, hate speech, harassment or discrimination.

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space. This means getting to know agencies, organizations, and other community resources and attending conferences, workshops, festivals, parades, and other events that support LGBTQ youth. Much of the time gender issues are, perhaps understandably, expressed in physical complaints from a child such as stomachaches, headaches, or unusual body movements. This is sometimes because of the experience of feeling disembodied and should be evaluated by a medical professional to rule out medical concerns or conditions. Connecting LGBTQ youth and their families with community-based support groups, affirming providers, and advocacy groups can remove feelings of isolation and increase social support. Increasing connections and social support is a protective factor for mental well-being. 6.  Let the child lead. Child-centered play therapy can be very effective for LGBTQ youth as play therapists have a unique ability to enter and understand the world of a child. LGBTQ youth frequently report rarely feeling understood and accepted. Letting the child lead is one of Axline’s (1969) eight basic principles of nondirective play therapy. Additionally, unqualified acceptance of the LGBTQ child, not attempting to hurry their process, and creating a feeling of sensitivity and permissiveness are a few other nondirective principles (Axline, 1969) that can be very powerful for children exploring gender and sexuality. Depending on the age and needs of the child, some psychoeducation about different kinds of bodies, people, and families might also be warranted. Books and resources that can assist in this are listed in Appendix B. Educating and assisting children in building up internal and external resources to cope with bullying (both in and outside their families) is also crucial should the child’s play show that this is needed. 7.  Work with families. Mental health professionals understand the critical nature of a secure attachment figure in a child’s life (Bowlby, 1982), and caregivers need to understand this as well. A child’s sense of self-worth, emotion regulation abilities, and style of interaction with others are just a few things that tie back to having an adult who provides physical, psychological, and emotional safety in a child’s environment (Sroufe, 2005). Supportive and accepting families are critical for LGBTQ youth to develop greater self-esteem and resilience and have lower rates of stress and depression, homelessness, and substance use (Human Rights Campaign, 2018). Play therapists can explore and encourage the family in supporting the child’s identity and expression. It is important to note that clinicians might need to proceed slowly here because there is also grief work that might be needed in the family. Barron and Capous-Desyllas (2017) speak to the family’s transition process relevant to gender. Parents and caregivers may need help processing feelings of anger, sadness, disgust, anxiety, or denial about



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losing their psychological expectations for their child’s gender or sexual identity development. Often well-intentioned parents can move too quickly to socially transition their child or to support their early adolescent’s romantic interests (Langton, Wren, & Carmichael, 2019). Olson recommends taking a weekend (or whatever amount of time they need) and allowing a child to fully test out their social gender expression. Play therapists can guide parents in thinking about different aspects of revealing a child’s identity to loved ones, schoolteachers, and others. Similarly, therapists can refer families to other providers to discuss medical or physical interventions without insistence that these be the first step (Langton et al., 2019; Olson, n.d.). Lack of best practices such as these can cause changes for the child and the family that are too rapid and do not allow space for looking at the entire context of the child and the family system (Adelson & Knight, 2015; Langton et al., 2019; Olson, n.d.). 8.  Consider traumatic material. Creating an affirming space for the child also entails creating a safe therapeutic relationship built on respect and awareness that many LGBTQ youth, especially those in foster care, have experienced trauma and oppression (Human Rights Campaign, 2018). LGBTQ youth who are in the foster care system have likely been rejected and thrown out by their family of origin. Harassment, stigma, violence, and family rejection are traumas that LGBTQ youth disproportionately face (Human Rights Campaign, 2018). Further, many parents and caregivers express fear that prior trauma, specifically sexual abuse, causes LGBTQ identity. Not only is it important to reiterate that there is no empirical evidence of this, but also that thinking in such ways pathologizes identity (American Academy of Child and Adolescent Psychiatry, 2012). Trauma-informed play therapists understand the impacts of trauma on brain development (Gaskill & Perry, 2014). These effects can lead to depression, substance use, risky behaviors, homelessness, and suicide, especially as LGBTQ children face further traumatic experiences such as discrimination and oppression. These effects of trauma can be reduced by promoting trauma-informed and LGBTQ-affirmative procedures and policies at an individual and organizational level as well as collaborating with other professionals, tailoring practices to meet the unique needs of each child, understanding triggers, involving families, and building community for families and children. 9.  Be flexible. Many experts agree that flexibility is critical to working with youth exploring gender and sexual identity fluidity or concerns (Adelson & Knight, 2015; Olson, n.d.). Gender and sexual expression exist along a spectrum (American Academy of Child and Adolescent Psychiatry, 2012). Not all trans individuals want to fully transition medically. Trans

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children, teens, and adults might not be “trapped in a body they hate,” and they might also identify as heterosexual. Remembering that childhood and adolescence are periods in development where youth are supposed to be exploring and understand gender and sexual identity and allowing for myriad narratives to exist are extremely important tenets of this work. 10.  Advocate. Not only should play therapists advocate for their individual clients and families, they must also think about advocacy beyond the playroom. Identifying oneself as an ally of LGBTQ persons is only the first step in a lifelong process of fighting for equity and eliminating oppression. De Graaf, Manjra, Hames, and Zitz (2019) found that minorities account for fewer than 10% of those who access gender identity development services. The Human Rights Campaign (2018) found that four out of five LGBTQ youth experience racism in addition to other forms of discrimination about their identities. This potentially heightens the risk for LGBTQ youth experiencing trauma. Armed with this knowledge, therapists should use their positions to advocate for nondiscrimination in their communities and states and at the national policy level.

CASE EXAMPLE Olive was referred to our trauma center after her mom searched for play therapists in the area who were knowledgeable about trauma and gender identity issues. Her mother stated that she did not know if her divorce from her ex-husband nearly 4 years ago might be contributing to her daughter’s increasing displays of anxiety at home and at school. She also did not know if her 7-year-old daughter wanted to be referred to as “daughter” or as a “she” as Olive had recently begun stating things like “I’m just Olive, I’m not a he or she.” Olive was also more and more inclined to dress in a gender neutral way rather than dressing as a girl and wanted a very short haircut. Lately, her mother reported, Olive was really struggling when it was the time of the week to go to her dad’s apartment for weekly visitation even though the mom and her ex-husband had a very strong co-parenting relationship with little conflict. Olive had become very clingy, not wanting to leave the house, go to school, or go anywhere else. Her dad was also present for the intake appointment and confirmed that he had recently experienced Olive as very clingy and wanting to spend an increasing amount of time with her older brother, who was 10 years old and was not always enthused about entertaining his little sister. Her mother reported that at her Montessori school, Olive was shutting down and not speaking from time to time. She was leaving school complaining of bad stomachaches and headaches and had developed twitches and other body movements for which doctors could not find a physiological



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explanation. She was also getting in trouble for going into the girls’ bathroom while her appearance was becoming more and more masculine. This was all very confusing for Olive, and she would come home and cry unconsolably. Both parents were uncertain if they should continue to try to socially transition Olive to expressing her gender as male, if she was experiencing the effects of trauma or bullying, or if she simply had increasing anxiety, something that was present on Dad’s side of the family. Let’s take a look at the best practices for play therapists working with LGBTQ youth and families as applied to the case of Olive. 1.  Examine your own beliefs and biases to determine if you are the best fit for this youth. Before my work began with Olive and many of the LGBTQ youth and young adults I have worked with, I had already confronted what it means to carry heteronormative and cisgender privilege. I had volunteered for nearly a decade with the Human Rights Campaign, an organization that became near and dear to my heart. Growing up I witnessed the impact discrimination and bullying had on LGBTQ family members as well as on one of my closest mentors and friends. I continue to seek supervision, volunteer, and work as an ally in the LGBTQ community. 2.  Seek psychoeducation and supervision before and while working with LGBTQ youth. Early in my career as a play therapist, I became interested in why issues of culture and diversity were not discussed more in the play therapy arena. They were definitely highlighted in my training and supervision as a counselor, but less so in this space. So, I began to go to trainings and conferences specific to LGBTQ populations to see how to best serve these youth with the skills I had as a play therapist. I also spoke with my colleagues who do identify as part of the LGBTQ community to better understand possible needs. I have now started to present at these same conferences and continue to consult with other professionals in the field. Through books, websites, organizations, and agencies that have been recommended to me, I have done research and increased my knowledge base. 3.  Create an affirming environment. Because of my volunteer work, I already had safe-space triangles on display in my playroom, I had a whiteboard that kids sometimes wrote their pronouns or pronouns they wanted to be called on that day, and the lobby of our space had signage indicating that all races, genders, sizes, bodies, sexualities, religions, and so forth were welcome in the space. The building did not, however, have genderneutral bathrooms. All of our paperwork had been created to be LGBTQ affirming with the help of the Human Rights Campaign’s “All Children, All Families” program. There was one instance in Olive’s case where another child’s parent

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asked intrusive questions about Olive’s gender despite all of these things. This parent also tried to impart his religious knowledge onto Olive’s mother. Once I was informed of this, I worked with our partners at the center, and the therapist worked with this parent to have him apologize to Olive’s mother and agree to not speak this way to anyone in the lobby again. 4.  Assess at both the child and family levels. During my intake session with Olive’s parents, I could tell that they were already on board and comfortable with whatever they needed to do to help Olive be whomever she wanted to be. If anything, I had to slow Olive’s mom down some in not forcing a gender transition too soon. When I met with Olive, I introduced her to the playroom as I do every child, and I stated that I see kids who have big feelings of all kinds or who have had bad things happen to them or who feel funny in their bodies to allow space for her to know that these things were safe to talk about in here. As I began nondirective play therapy sessions with Olive, I observed how shy and anxious she was by her quiet but frantic spurts of indecisive playing with everything in the room. She was especially interested in the dress-up clothes, and this is something that continued through our sessions together. 5.  Find other providers, communities, and resources. I have a number of contacts I have amassed over the years who all work with LGBTQ youth in different capacities. In Olive’s case, I contacted a medical doctor based in New England whom I got to know at the Human Rights Campaign’s Time to Thrive Conference. Specifically, I wanted to inquire more about his thoughts regarding her lack of expression of being in the wrong body and her somatic complaints and to know how he might proceed. Further, I gave Olive’s parents contact information for a psychiatrist in the area who I knew worked from an affirmative mindset for gender-expansive or gender-discordant children, just in case they decided they wanted to look into medication for severe anxiety. Olive already had an LGBTQ-friendly general practitioner who had ruled out any possible underlying physical condition and who was willing, if needed, to help with a medical transition down the road. In addition to medical and mental health practitioners, I began to give Olive’s mom information about various parent and child community support groups to decrease their feelings of being different and alone. Still today, Olive and her family attend cookouts, family camps, and various events with friends they have made through these groups. One of the biggest and most important groups that Olive joined was a mixed martial arts class, something that her mom and dad thought might help her when I recommended finding ways she could move her body either in sports or



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dancing to help her feel more in her body and empower her over her anxiety struggles. 6.  Let the child lead. Most of our time together I used a nondirective approach with Olive as she began to do the work she needed in the playroom. As our therapeutic relationship developed, Olive would draw pictures of herself, and sometimes she would identify the picture as a male, sometimes as a female, sometimes just as “Olive.” I worked to make sure I did not assign a gender to any toys or pictures or miniatures in the playroom until she did. Eventually, Olive spontaneously told me one day while playing with the sand tray that she was a girl and that “sometimes people think I’m a boy.” I was able to reflect her feelings of confusion, frustration, and sadness, to which she replied, “but you know I’m a girl and a she.” From then on, I was able to check in each week and reflect that I remembered she had told me that sometimes people thought she was a boy, and inquire how she was feeling about that on the day of the session? Most of the time she would just shrug her shoulders and say something to the effect of “it’s fine, I’m a girl,” and move right along playing. All of this happened with me following her lead. I am still amazed each time I see the power of play therapy work in this way. The other thing that evolved from me following her lead was a yearlong series of dress-up play that I think contained much of her gender exploration material (as does Dr. Eliana Gil, with whom I consulted on this). Every week, Olive would dress me up as something hysterical and ask me to go to the lobby to “see what people say.” At first, I thought this was just her testing the limits of the trust built in our relationship, but I after a few times, I knew from the intensity in her play that it ran much deeper. One of these times Olive dressed me up, she also gave me a toy sword and water gun because, she said, I “would need to protect” myself from the “kinds of things people might say about [me].” I did this for a number of weeks trying to reflect what I thought her experience was by saying I might be scared what people thought of me, I might feel badly, I might feel confused, and so forth. This went on for months until one session when Olive decided she wanted to dress up with me and have us both go to the lobby together. She said she was doing so because she “didn’t want me to have to be by myself anymore.” This remains one of the most powerful sessions I have had with a child in child-centered play therapy. Olive was able to project her experience onto me as the play therapist and it eventually empowered her to try on the same feelings around her appearance and internal experience. Eventually, Olive wanted to go out to the lobby dressed up on her own. A few times people and other children in the lobby would say things like “look at that funny boy” and Olive would say directly to them, “Nope, I am a girl.”

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7.  Work with families. Just as I had followed her lead in the playroom, I was able to begin to teach Olive’s mom, dad, and brother how to do the same. Olive’s mom was often in the waiting room, and I worked with Olive’s mom on play therapy-based language to use to engage with Olive and I when Olive would send me to the waiting room each session. In this way, Olive could see that her mother could create the same safety I was creating around her feelings of looking different than what people expected. I also worked with Olive’s parents on helping them educate their extended families on how to be affirming and nonjudgmental with Olive. 8.  Consider traumatic material. Olive also began to play out the different kinds of families in her life—her dad at his apartment, her mom with her new boyfriend—and each time she did this, no traumatic material seemed to be present in her play (Gil, 2017). She did seem to want to process her parents being divorced through some of her play, but she seemed to be needing to do so at her current developmental stage. Moreover, the posttrauma play she did exhibit had to do with the many invalidating experiences she had had due to her gender expression. This was evident in the protection needed in her dress-up play as well as in her play with miniatures, who often had to be disguised or hidden in the sand tray because if not, “people would see what they looked like and not like them.” 9.  Be flexible. The fact that myself, her parents, her school system, and her doctors exhibited acceptance and flexibility was very critical to Olive’s ability to increase coping strategies as needed. Olive did not immediately need to transition in gender, but she also did not need to change her appearance based on the socialized ideas carried by people in her life. She simply needed to have a safe space to explore and role-play while learning to access her inner resources to help her feel comfortable in her body (van der Kolk, 2016). When we terminated our counseling relationship, Olive was working her way up toward a purple belt in mixed martial arts, she was excelling again at school, she rarely had episodes of crippling anxiety, and her somatic complaints had disappeared. She still has her short haircut and still dresses in clothes that are neutral in color and shape, and she still wants to be called Olive and a girl. Later in her life, this may or may not change, but flexibility will allow for her to develop as she needs to. 10.  Advocate. Throughout the 3 years I worked with Olive, I spoke with her school principal and teachers to ensure that she would be protected from being harassed about the bathroom she was using as well as to aid the teachers in helping her with anxiety. I worked with the school counselor to help the counselor give psychoeducational lessons to the teachers and students at the school as the counselor reported a number of students who identified along the gender or sexuality spectrum. Further, I tried to



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help write letters to local policy makers whenever Olive’s mom forwarded something she was working on as an advocate. I also corrected my colleagues at the center I worked at whenever they misgendered Olive or one of my other clients (in front of the child). I consulted (and still do) when other professionals are struggling with how best to help an LGBTQ child.

RECOMMENDATIONS FOR RESEARCH AND ADVOCACY Most of the experimental studies put forth that provide the evidentiary research base for play therapy analyze its effectiveness for the treatment of aggressive and disruptive behaviors in children (Ray, 2011). Researchers also explored sexual abuse, trauma, parent–child relationship, anxiety, depression, self-efficacy, academic achievement, and medical issues. In all domains studied, play therapy was found to be effective (Ray, 2011) and is now considered an evidence-based treatment (Association for Play Therapy, 2015). There is fairly extensive research on gender differences in play themes, but this still assumes the gender binary—male, female (Holmberg, Benedict, & Hynan, 1998; Stutey et al., 2020). Much more research is needed to assess the best play therapy practices for LGBTQ children. A best practices document for addressing gender and sexual identity issues in the playroom, supported by the play therapy field, could better support play therapists in broaching the subject. Art therapy techniques are also frequently used in play therapy, and research should assess to what extent children use art versus the toys in the playroom to express gender and sexual identity themes. Almost all professional organizations for mental health professionals recognize the emergence of a clearly defined subculture regarding LGBTQ clients and they promote well-informed advocacy efforts. Play therapists must advocate for those in oppressed communities, not only for each individual client’s needs, but also on a state and national level. Only 19 states have anti-bullying legislation to protect LGBTQ students (Human Rights Campaign, 2018). In schools, 51% of transgender youth cannot use the bathroom that matches their gender identity and of those, 65% try not to go to the bathroom at all while they are in school. Most of us cannot imagine such a thing. Some of the responsibility for positive change is in our hands. Loue (2013) urged the field of social work to see more than the binary categories of sex and gender “to understand that the constructs of sex, gender, gender role, gender presentation, and sexual orientation exist along a spectrum and that sexuality and all of its various dimensions encompass the discovery of pleasure as well as the experiences of pain” (p. xi). Counselors, psychologists, social workers, and play therapists all need to move in this direction and recognize the nuances of working with

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nonbinary or gender-fluid children, whether it is a presenting problem or it emerges during the course of therapy.

CONCLUSION Play therapy is a space that is ideally free of social norms. Because children “play out” their “lived experiences” (Landreth, 2012, p. 15) they feel more “in control of the play and thus move out of the passive role of having been ‘done to’ and into the active role of being the ‘doer’ ” (Landreth, 2012, pp. 31–32). This feeling of gaining control in the playroom can diminish the number of out-of-control behaviors a child may display outside of the playroom. It also allows a child who is contorting themselves to fit within social norms to safely expand and explore things in the world outside of the playroom. Finally, play therapists must be aware of the polarized responses of religious groups and others, political happenings, current terminology, data around LGBTQ youth well-being, and ongoing advocacy opportunities to best support LGBTQ youth and their families.

REFERENCES Adelson, S., & Knight, K. (2015, May 1). The right therapy for LGBT youth. Washington Post. Retrieved from www.washingtonpost.com/opinions/the-right-therapyfor-lgbt-youth/2015/05/01/b43965e6-eeb4-11e4-8666-a1d756d0218e_ story. html. American Academy of Child and Adolescent Psychiatry. (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 51(9), 957–974. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. American Psychiatric Association. (2018, December). Position statement on conversion therapy and LGBTQ patients. Washington, DC: American Psychiatric Association, Council on Minority Mental Health and Health Disparities. Association for Play Therapy. (2019). Play therapy best practices: Clinical, professional and ethical issues. Clovis, CA: Author. Retrieved from https://cdn.ymaws.com/ www.a4pt.org/resource/resmgr/publications/best_practices_-_sept_ 2019.pdf. Axline, V. M. (1969). Play therapy. New York: Ballantine Books. Barron, C., & Capous-Desyllas, M. (2017). Transgressing the gendered norms in childhood: Understanding transgender children and their families. Journal of GLBT Family Studies, 13(5), 407–438. Bonfatto, M., & Crasnow, E. (2018). Gender/ed identities: An overview of our current work as child psychotherapists in the Gender Identity Development Service. Journal of Child Psychotherapy, 44(1), 29–46. Bowlby, J. (1982). Attachment and loss: Retrospect and prospect. American Journal of Orthopsychiatry, 52(4), 664–678.



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Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4(3), 219–235. Centers for Disease Control and Prevention. (2019, April 19). Data and statistics on children’s mental health. Retrieved from www.cdc.gov/childrensmentalhealth/ data.html. D’Augelli, A. R. (1994). Identity development and sexual orientation: Toward a model of lesbian, gay, and bisexual development. In E. J. Trickett, R. J. Watts, & D. Birman (Eds.), Human diversity: Perspectives on people in context (pp. 312–333). San Francisco: Jossey-Bass. De Graaf, N. M., Manjra, I. I., Hames, A., & Zitz, C. (2019). Thinking about ethnicity and gender diversity in children and young people. Clinical Child Psychology and Psychiatry, 24(2), 291–303. Gaskill, R. L., & Perry, B. D. (2014). The neurobiological power of play: Using the neurosequential model of therapeutics to guide play in the healing process. In C. A. Malchiodi & D. A. Crenshaw (Eds.), Creative arts and play therapy for attachment problems (pp. 178–196). New York: Guilford Press. Gil, E. (2017). Posttraumatic play in children: What clinicians need to know. New York: Guilford Press. Grossman, A. H., & D’Augelli, A. R. (2007). Trans-gender youth and life-threatening behaviors. Suicide and Life-Threatening Behavior, 37, 527–537. Halim, M. L. D., Gutierrez, B. C., Bryant, D. N., Arredondo, M., & Takesako, K. (2018). Gender is what you look like: Emerging gender identities in young children and preoccupation with appearance. Self and Identity, 17(4), 455–466. Holmberg, J. R., Benedict, H. E., & Hynan, L. S. (1998). Gender differences in children’s play therapy themes: Comparisons of children with a history of attachment disturbance or exposure to violence. International Journal of Play Therapy, 7(2), 67–92. Human Rights Campaign. (2018). LGBTQ Youth Report. Retrieved from https://assets2. Human Rights Campaign.org/files/assets/resources/2018-YouthReport-NoVid. pdf?_ga=2.100195614.1891233465.1588530798-2052278531.1588530798. Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York: Routledge. Langton, T., Wren, B., & Carmichael, P. (2019). Seeing the child in context: Supporting gender diverse children and their families in multiple ways: An introduction to this special edition. Clinical Child Psychology and Psychiatry, 24(2), 199–202. Loue, S. (2013). Expressive therapies for sexual issues: A social work perspective. New York: Springer. Meersand, P., & Gilmore, K. J. (2018). Play therapy: A psychodynamic primer for the treatment of young children. Arlington, VA: American Psychiatric Association. Olson, J. (n.d.). Ask the expert: Is my child transgender? Washington, DC: Human Rights Campaign. Retrieved from www.Human Rights Campaign.org/resources/ transgender-children-youth-ask-the-expert-is-my-child-transgender. Puszczyk, M., & Czajeczny, D. (2017). Gender dysphoria and gender variance in children: Diagnostic and therapeutic controversies. Archives of Psychiatry and Psychotherapy, 3, 234–242. Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York: Routledge. Ray, D. C. (2016). A therapist’s guide to child development: The extraordinarily normal years. New York: Routledge. Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth to adulthood. Attachment and Human Development, 7(4), 349–367.

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Stutey, D. M., Klein, D. E., Henninger, J., Crethar, H. C., & Hammer, T. R. (2020). Examining gender in play therapy. International Journal of Play Therapy, 29(1), 20–32. van der Kolk, B. (2016). The body keeps the score: Brain, mind and body in the healing of trauma. New York: Penguin Books. Wren, B. (2019). Ethical issues arising in the provision of medical interventions for gender diverse children and adolescents. Clinical Child Psychology and Psychiatry, 24(2), 203–222.

CHAP TER 6

Providing Mental Health Services to Undocumented Families of Color in Our Current Culture Myriam Goldin Eliana Gil

Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!               —E mma L azarus , “The New Colossus”

T

hese words, inscribed on the base of the Statue of Liberty, serve as a clear welcome to all immigrants and a reminder to all U.S. citizens about the core values and principles that our forefathers established and defended. And yet the words seem hollow during our contemporary culture of divisiveness, bipartisanship, and what some have called tribalism. In fact, the U.S. government and some residents appear ambivalent about the passionate message inscribed on the statue as more and more public dissent occurs about immigrants in the United States. In a country once called a “melting pot” with pride, current discourse includes references to immigrants as criminals and a drain on the U.S. job market and general quality of life. In fact, immigrants of color are considered by many to be threatening trespassers, and there is a strong outcry for speedy deportation, 111

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reinforced strong boundaries, and a less and less obtainable path to citizenship. The racism and distrust that underlie current views about immigrants apply to both undocumented immigrants and those who use the appropriate channels, although the clamor has been stronger about the “caravans” of undocumented Central American and Mexican immigrants approaching the U.S. borders, usually seeking amnesty. There is no denying that past administration policies, hastily undertaken and loosely implemented, have posed a significant threat to the safety of the immigrants we welcomed, protected, and assisted in another era: (1) the policy of separation of parents from their children at the border in order to deter immigrants from coming to the United States; and (2) the careless, irresponsible, and abusive ways that this policy has been implemented, resulting in several deaths, as well as neglect and physical and sexual abuse. Reports of children “lost” in the shuffle and a lack of documentation and planning for reunification further traumatize immigrant families often fleeing endangered and impoverished native lands. Soboroff (2020) does not mince words when he states, “The Trump administration’s deliberate and systematic separation of thousands of migrant children from their parents was, according to humanitarian groups and child welfare experts, an unparalleled abuse of the human rights of children” (p. xv). This reality prompted Soboroff to chronicle how the border atrocities began and how they emerged after Trump’s policy change in 2018. Taking a slightly different angle, Lopez (2019) wrote his book to enlighten readers as to the “deep sense of the brutality of our current methods of immigration enforcement, especially immigration raids. These enforcement tactics are militarized and violent, with little regard to the physical and psychological damage done to those at whom they are directed, and their families, or their communities” (p. 15). Although the political context for the current crisis for immigrant families is beyond the scope of this chapter, it is virtually impossible to talk about immigrant challenges without making note of the political context in which this problem emerged as well as how it is allowed to persist in silence, out of sight, with these noteworthy exceptions and exceptional exposés. Providing undocumented immigrants with mental health services has always been a compelling issue. Clinicians must gain a deep understanding of the issues facing immigrants in order to craft relevant, concrete, and truly helpful responses. This chapter highlights the special life circumstances of immigrants who have crossed the border, the daily stressors they face, and the current escalation of danger, tension, and anxiety they experience. In addition, immigrants often suffer from the after-effects of past and current traumas. We explore what happens when immigrants seek out or are referred (or mandated) for mental health services for an array of traumarelated behavioral, emotional, or social concerns either for themselves or their children



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MULTICULTURAL ISSUES IN TREATMENT Psychological Stress Adult immigrants, unaccompanied youth, and families with children endure multiple psychological stressors when coming to the United States. Their decision to leave their countries often stems from multiple survival needs: securing work opportunities that provide economic relief; escaping desperate conditions of poverty; flight from community and interpersonal violence; and/or reunification with loved ones and restoration of family connection and support. Migrating to another country can be highly challenging even when done legally and motivated by positive educational and professional opportunities. Most immigrants confront stressors regarding differences in cultural values and language, multidimensional acculturation issues, intergenerational conflicts, potential changes in gender roles, a new set of imposed rules and regulations, and loneliness and isolation (American Psychological Association Presidential Task Force on Immigration, 2013). Immigrants from Central America, Mexico, and other countries have been crossing the border to the United States for many years. However, the psychological stress on immigrants becomes more intense when they have experienced physical, emotional, or environmental traumas in their countries of origin and then face additional traumatic experiences during their perilous journeys or upon entry to the United States, which now routinely includes detainment by the U.S. Customs and Border Protection agency. Since 2018, news organizations as well as advocacy groups have shown the American public and the world at large the outrageous conditions that Hispanic immigrants have endured when detained by U.S. Customs and Border Protection. The steady number of unaccompanied youth coming to the United States in the last few years highlights the dangerous lives that they are trying to leave behind. In the report Vulnerable but Not Broken (Paris et al., 2018), the authors document the harsh struggles that many Central American minors face in their countries and their need to receive protection, not deportation, in the United States. These youths share narratives of abandonment, extreme poverty, exposure to severe violence, child physical, emotional, and sexual abuse, neglect, trafficking, and sexual exploitation. In other words, the main driving force behind the unaccompanied youth’s journeys is escaping life-threatening conditions. They come to the United States hoping to start a new life and/or reunite with parents or other relatives after years of separation. The literature suggests that despite the exposure to high levels of distress, unaccompanied youth show the capacity for resilience and positive long-term adjustment (Paris et al., 2018).

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The Needs of Vulnerable Children and Youth The findings of studies on the mental health status of unaccompanied youth from troubled regions of the world coincide with emerging research results in the United States which suggest that unaccompanied children and youth experience high levels of anxiety, depression, psychosomatic complaints, posttraumatic stress symptoms, and suicidal ideation (American Psychological Association Presidential Task Force on Immigration, 2013). Noticeable among research data is the fact that unaccompanied youth from Central America show posttraumatic stress disorder symptomatology (intrusive thoughts, nightmares, hypervigilance, and poor concentration) at high rates that coincide with the experiences of children coming from war zones (Stringer, 2019). Youth escaping familial and community trauma often encounter additional traumatic events during their journeys and when apprehended in detention centers. When they are released to family members or the foster care system, they often struggle with developing or reestablishing an attachment to parents and caregivers, externalizing their emotional needs by misbehaving and somehow increasing their chances for revictimization (Paris et al., 2018). It is worth mentioning that these youth and their parents develop protective distrust, finding it near impossible to trust the clinicians, caretakers, teachers, and child advocates they meet because their experiences are full of broken promises, lack of continuity of care, and unpredictable shifts in their status. The process of trusting adults is even more complicated when early interpersonal trauma has created a worldview that keeps expectations low and self-protection high. The U.S. Department of Health and Human Services (HHS) published a report dated September 2019 detailing the challenges that care provider facilities faced when trying to address the mental health needs of children in HHS’s custody. The report outlines myriad difficulties encountered when trying to meet the mental health needs of youth with trauma histories in general, and more specifically the developmental and attachment needs of children under 12 years of age. The Office of Refugee Resettlement (ORR), which implements the Unaccompanied Alien Children Program, found itself responsible for many young children separated from their parents and caregivers after the Department of Homeland Security formally adopted the “zero-tolerance policy” in May 2018. This policy criminalized the actions of all adults attempting illegal entry into the United States and developed the inhumane policy of separating even infants from their parents and placing them in the care of ORR (U.S. Department of Health and Human Services, 2019). This report candidly describes the disheartening findings regarding vulnerable children who could not speak or advocate for themselves and felt suddenly abandoned by their parents. The report also specifies how the



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clinical staff assigned as caretakers for these children felt woefully unable to reassure or comfort them, or provide for their needs. Additionally, children who could not put words to their distress developed a range of dysregulated emotions and behaviors that required more developmentally sensitive interventions. Caretakers felt overwhelmed and unprepared to face the impact of imposed policy decisions. Clinicians reported that the longer the children stayed in these facilities the more stressed, anxious, frustrated, and behaviorally dysregulated they became. Self-harm and suicidal ideation reportedly increased as children felt hopeless and disillusioned after more days passed without their loved ones. When required to transfer children to therapeutic placements that could serve higher mental health needs, clinicians found limited options in the community, once again highlighting the lack of planning prior to decision making. Many children remained in their facilities despite showing signs of more serious mental health needs and perceived lack of safety. Children stayed in custody prior to June 2018 an average of 55–58 days. These numbers increased to an average of 93 days from June to December 2018 and finally declined to 48 days by April 2019 as government policies shifted. Clinicians from the detainment facilities stated that they held caseloads of over 25 children in spite of the fact that regulations required a facility-wide staffing ratio of one mental health clinician for every 12 children. The HHS report summarized concerning and disturbing findings regarding the well-being of children in custody (U.S. Department of Health and Human Services, 2019). The American Civil Liberties Union recently made public the disturbing news that the Trump administration had separated an additional 1,556 immigrant children from their parents at the U.S.–Mexico border. The total number of children separated from their parents is estimated at 4,256. The report indicated that the majority of these children were under the age of 12, and more than 200 were 5 years old or younger (Sacchetti, 2019).

Sociocultural Factors Group studies on sociocultural factors affecting Hispanic immigrants, such as familismo, simpatia, and respeto (family, sympathy, and respect), have shown that these sociocultural values are protective factors in the overall psychological health of Hispanic immigrants. However, a recent study on trauma and cultural values in the health of recently immigrated families (Mercado, Venta, Henderson, & Pimentel, 2019) concluded that traumarelated symptoms highly impacted the health and emotional well-being of adults and children entering the United States and that the inherent protective factors in the Hispanic culture did not ameliorate their self-reported health concerns or emotional well-being. The findings in this study were significant in that the data is assessed within 24 hours of families entering

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the United States and included the assessment of posttraumatic stress symptoms and trauma exposure, underscoring the inclusion of mental health symptoms in the overall assessment of health (Mercado et al., 2019). The reoccurrence of traumatic events also has a cumulative effect on individuals who have already been exposed to trauma, rendering them further debilitated and vulnerable, overriding whatever coping strategies might be available. Adults, youth, and children clearly face far-reaching challenges at each stage of their migration process, and these difficulties increase exponentially when unresolved trauma becomes activated by trauma reminders and inescapable experiences of pervasive helplessness and loss of control. Immigrants are confronted by the day-to day postmigration macro- and microaggressions they experience, including discrimination and exclusion, which also intensify the risk of trauma and its consequences, as bodily responses of feeling threatened and powerless are activated (Perriera & Ornelas, 2013).

UNIQUE CHALLENGES IN PROVIDING MENTAL HEALTH SERVICES Immigrant children, youth, and adults end up feeling like second-class citizens, insecure about where they belong (Stringer, 2019). The sense of danger becomes even more pronounced as families prepare for the worst, making contingency separation plans with their children in the event that parents are detained. The impact on young children can’t be overstated as they do not have the developmental capacity to conceive of being separated from their loved ones. They suffer from high levels of fear, anxiety, and somatic symptoms, and the overall experience that “something bad” is going to happen. And yet, fear and anxiety about seeking help are often set aside, particularly when mothers are encouraged to seek help by teachers or social workers from their children’s school (Stringer, 2019). As mothers have direct experience with mental health services provided by sensitive professionals, they may even accept supportive services for themselves.

Culturally Sensitive Mental Health Approaches Over the past two decades, mental health professionals have been required to obtain education about the provision of culturally sensitive therapeutic approaches and become culturally competent to work with diverse populations. In fact, becoming a culturally competent mental health professional is necessary and critical to providing assistance to immigrant families in crisis. What follow are some of the relevant issues that might emerge in the context of working with Hispanic immigrants in our current climate, with



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suggestions for maintaining cross-cultural and trauma-informed lenses when we conduct assessments and design individualized treatment plans.

The Concept of Mental Health Treatment and Principles of Trauma Treatment Our Western culture mostly encourages and supports mental health service delivery, particularly to high-risk children and families. It’s important to pause and consider that what is normative in our culture may feel foreign and uncomfortable to others. In fact, most Latin American and Hispanic cultures seem to rely more on the concept of prayer and seeking guidance from God than on turning to mental health professionals. And while psychologists, counselors, social workers, and child therapists may be plentiful in the United States, these professions are fairly new and still unfamiliar in Latin and Central American countries, particularly among the poor. So when children and their families are identified in schools, medical offices, or in other environments, they may approach helpers with trepidation and anticipatory anxiety about what it might mean to interact with a host of professionals in their new country. And even when children and their parents have been familiar with mental health services as an option, they may advocate for a very brief treatment so that their children are not reminded of painful events. The adage “let them forget” traumatic events is very prominent among immigrant populations, along with the belief that difficult experiences prepare and strengthen you for a harsh world filled with danger and exploitation. Clinicians must immediately face these cultural beliefs and make efforts to clarify what might be necessary for these immigrants’ children and to help them view the practice of providing mental health as useful for mitigating the long-term effects of childhood trauma. On many occasions, parents may also fail to recognize that their children’s behaviors serve as red flags for their underlying suffering. A child may become aggressive and impulsive as a result of trauma, and parents may view this as a somewhat positive response—a sign that the child is developing necessary ways to protect himself. Children will manifest a broad range of symptoms depending on the gravity and chronicity of trauma events, developmental age at time of trauma, and cognitive and perceptual capacities, as well as social and environmental factors, such as the presence of a protective other. Despite these differences, the trauma research agrees that trauma processing is necessary for ameliorating long-term effects and is best achieved by providing clients with both expressive and verbal therapies as well as a combination of brain- and body-based approaches that target the whole brain and its connection to the body. Bruce Perry’s neurosequential model of therapeutics (2009) guides clinicians to consider children’s needs using a “bottom-up approach” that attends to the development of the lower

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parts of the brain first in order to provide the physiological and emotional regulation needed for accessing higher areas of the brain. In our opinion, providing trauma-focused cognitive-behavioral therapy, the current treatment of choice for trauma, is advisable when children are able to receive cognitive information, that is, after they are regulated and can attend to and integrate this important psychoeducational information (Cohen, Mannarino, & Deblinger, 2006). Trauma-focused work, by definition, attends to traumatic experiences, although approaches vary. There is general agreement that therapy relationships and safety must be achieved first if therapy is to proceed to traumaspecific work, which always includes helping children, youth, and adults clarify and understand their thoughts, feelings, sensations, responses; identify areas of cognitive confusion and discuss and correct them; help children to identify, express, and regulate emotions and self-soothe, developing healthy alternative coping strategies; experience mastery through controlled recall; and organize a narrative that provides closure and an orientation toward the present and future. In addition, the National Child Traumatic Stress Network encourages clinicians to address the areas of attachment, emotional and behavioral dysregulation, sensorimotor developmental problems, somatization, increased medical problems, dissociation, and self-esteem. The following case presentation captures the journey of Ramira, who fled her country of origin, crossed the U.S. border, and eventually had her children removed from her by a court of law.

CASE EXAMPLE Ramira was a 36-year-old mother of five: 21-year-old Estela; 18-year-old Raul; and 9-, 7-, and 5-year-old daughters Melinda, Paulina, and Ariel. Her older two children had stayed in El Salvador, Melinda and Paulina made the journey with Mom at ages 4 and 2, and Ariel was born in the United States, 1 month after she crossed the border. Melinda was referred to treatment because she disclosed sexual abuse by Ramira’s 20-year-old boyfriend, Oscar. At her elementary school, Melinda was under the guidance counselor’s supervision because she was often hungry, unkempt, and fatigued. The school had suspicions that things were not good at home but had little success reaching Ramira for a meeting. Melinda and Paulina were referred to therapy and lived together in one foster home. The third child, Ariel, had a number of chronic and immediate medical issues, not the least of which was malnutrition, and she had required hospitalization and a specialized foster home. Melinda and Paulina’s foster mother, June, arranged transportation for the two girls to and from appointments.



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Background Information Ramira was one of seven children born into a very poor family in El Salvador. She recounted that she left home at 14 with a boy who liked her. Ramira says that this boy was the first one to talk to her and ask her about her likes and dislikes. She remembers him treating her well. This boyfriend was a gang member and was killed within 1 year of their baby being born. Ramira was quick to point out that “no one noticed” that she had left home and that it took almost 2 years for her mother to try to find her and make her come home. Ramira says she was never really cared for in her own home: “There were too many of us and as soon as we were about 6, she put us to work.” Work consisted of going out into busy streets to beg for food or money. Other times work consisted of watching her siblings for days at a time. She said her older brothers and sisters left as soon as they could, and she had lost touch with virtually everyone in her family. She says she always heard talk of the United States and she made it her goal to get out, although she had no clear vision of what that would mean. Ramira told me that her mother “lent her” to an older man when she was 9 years old. She was raped, although she remembers her mother giving her a bath and a good meal when she came back. After that first time, there were about 10 or more men who paid her mother to have sex with her. She noted that it “hurt just once,” and after that, she didn’t care if it happened or didn’t. She said that some of the men treated her roughly, one covering her face with a pillow until she passed out, but when she woke up, he was gone and she didn’t think much of it. She noticed that her mother was happier when she had some money in her purse, although she used most of it for alcohol. Ramira remembers asking her mother if there was someone she could go with so they could have a good dinner. She recalled feeling hungry and crying herself to sleep many nights. She also confided that as she got older, she would trade sex for food or money. She noted that men just hung out in this one place waiting for girls to come to them. Ramira was a product of her impoverished, neglectful, violent, and perilous childhood. Her parents expected Ramira to help them survive from the time she was able to walk and talk. Ramira describes begging with her parents, and then alone, in the middle of traffic. The parents drank a lot and left the children alone much of the time. When Ramira had her first two children, there was little bonding, and she remembers them staying in the house with other family members when they were small. She doesn’t remember how she decided to come to the United States or why she didn’t bring her two oldest children with her. She remembered hearing from other women that if she was able to have children in the United States, that those children would be born American and then she could stay. Ramira prostituted herself to gather enough money to pay someone to hide her in a truck and cross the border. She followed a

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group of people off the truck, and a man grabbed her by the arm and took her and her children with him. That man became her pimp and provided her with a room in a house with other immigrants who appeared to get by selling drugs and prostituting women and teens. Eventually, Ramira became pregnant and miscarried after a routine beating and being thrown down the stairs. As Ramira spoke, she told of these and other sad and horrendous events as if they had happened to someone else, not her. She expressed little emotion and simply said, “My life was just like everybody else, nothing different or special.” She also reported feeling no love or affection for her parents or anyone else in her life, except two of her five children. She said that she didn’t know where her older children were and had very little contact with them after they left and went to live with a distant cousin. She also seemed disinterested in her youngest child, who had medical problems, saying she couldn’t afford a sick baby and didn’t know how to take care of her. She seemed quite invested in her two little girls, Melinda and Paulina, describing them as “sweet and affectionate” and herself as “very interested in taking care” of them. As Ramira described her relationship to the girls, it was clear there was a role reversal and they were her caretakers and protectors. When I (E. G.) asked Ramira about the sexual abuse allegations, she said she found it hard to believe since she always had sex with Oscar whenever he wanted. She did note that Oscar liked the children in bed with them as they had sex, and Ramira noticed that they covered their eyes and ears. When I asked if she was ever able to tell Oscar no when she didn’t want to have sex, or when the children were in the bed, she looked at me with a blank look. “If I said no, he would find someone else. I like him to be with me because he’s good to me, never hits me, has a car, and sometimes cooks for us.” She volunteered that he was “very nice” to her daughters and they liked him and almost always wanted to go out with him. He also bought them presents almost daily, and the girls looked forward to his coming home at night. I asked if she believed the abuse had happened, and she was careful with her language, “I think he might have played with them in the bed, maybe with their clothes off, I had seen him do that, but I don’t think he abused them.” I later found out that the fact that he was kind and playful with the girls negated her belief that what he had done was “abuse.” Eventually, she did admit that she would rather he “play” with her, but she could see how the girls’ bodies were much cuter than her own and at least he wasn’t going out to the streets to find prostitutes.

Special Considerations More often than not, immigrants are fleeing to this country because they come to view it as a “safe haven,” a place where they might have more



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opportunities and make more money. It’s fair to say that many immigrants from developing countries arrive in the United States without a clear plan for how they will survive. But these days, word of mouth travels fast, and immigrants move to cities where other immigrants from their countries have fared well, or at least better than they do in their own countries. Immigrants from developing countries have been raised in conditions of poverty, and they have experienced many adverse experiences in their childhood that are normalized. Too often, women have histories of rape and exploitation and have been forced into lives in which they feel helpless and see few options. Domestic violence and physical and sexual abuse may go undetected in their countries, so much so that women may prepare their children for different forms of exploitation because these traumatic experiences become normalized and expectable. I remember Ramira saying, “We women know that these are just things that happen, we move on, we stand up and clean up, and we keep moving.” One of the first issues in working with immigrant parents is that too often they don’t understand why people are reacting to events that in their own lives are considered perfectly normal. Parents are viewed as nonprotective from the get-go because they don’t recognize that they have a role in keeping their children safe. In fact, from Ramira’s point of view, her boyfriend, Oscar, was a good man, and they all had to be of service to him out of gratitude and to survive. Too often immigrant parents are held to a standard that they have no way of meeting. Their histories have taught them a different way of life, and judged by U.S. standards, they fall very short. As a matter of fact, parents such as Ramira can be viewed harshly without using the lens of personal history and context. Empathy is a very necessary clinical skill when working with uneducated, traumatized, surviving parents like Ramira. At the same time, if we can help family members change their life views and prioritize self-esteem, confidence, self-efficiency, and safety, it’s possible to break cycles of violence and empower women and children to live better lives. The issue of child sexuality is starkly different in the United States than in some other countries where sex exploitation and slavery begin at very young ages. In fact, many countries seem to prioritize virgin children, and exploitation of childhood is rampant. When parents have had these histories of exploitation themselves, it’s practically impossible for them to envision something different. Ramira could not understand why child protective services social workers and the judge she faced considered her as responsible and guilty as Oscar. In fact, the judge treated her harshly for continuing to have contact with Oscar in jail, and for pleading his case, claiming that her daughters had liked him and been comfortable around him and often asked him to play with them. “He never hit them or hurt them,” she cried in Court, which further convinced the judge that the children needed to remain in foster care. Ramira would later tell me, sobbing,

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that she had met many women whose children were never returned to them and who got adopted by Americans. “I will die without them,” she cried, but whenever she tried to explain why, she inevitably talked about their caretaking of her, not what she hoped for them. This case ended like many others that we have worked with: child protective services imposed a number of conditions that Ramira could not meet, and with a public defender appointed the morning of the hearing for termination of parental rights, her children were removed from her, swiftly and definitively, after the mandatory time period to give Ramira every chance to show she could be a safe and appropriate person. And yes, the court had ample evidence of Ramira’s noncooperation. What was not as visible was her love for her children and her utter lack of preparedness to take care of them, given her own trauma history. She had never experienced love, nurturance, caretaking, or any encouragement whatsoever, and she was hard-pressed to truly manifest her love to her children in a protective way. One of the most heartbreaking family therapy sessions occurred during this family’s final goodbye session: everyone was inconsolable and confused, even though the girls had been in placement 1½ years and were thriving with their foster family. They just kept begging their mom to please take care of herself, to eat well, to keep her job so she could keep the little room where she was currently living. And of course Melinda swore on a Bible she brought to the last meeting as a gift for her mother that she would come find her when she could. Ramira vowed to keep the same phone number and to wait for her children to find her, in the state where they all resided.

Treatment Plan Melinda’s Individual Therapy Melinda was indeed quite pseudomature for her 9 years of age, and she spent the first few months in therapy telling me how wonderful her mother was and how Oscar had not done anything bad to her. I (E. G.) mostly listened and told Melinda that lots of children tell me how much they love the person who touched them inappropriately. I told her I understood how much she loved her mom and Oscar. She also talked about regrets at telling the school counselor what was going on, and I told her I thought she had done the right thing by telling even though she might regret it at the moment. She was very slow to trust, and in every visit with her mom, her mom encouraged her to tell me specific things. Once when she blurted out that Oscar had never put his penis inside her, I commented that she hadn’t mentioned that before and I wondered what happened to cause her to report



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this to me. She put her head down and whispered that her mother wanted her to tell me that. I commented on how hard it must be to be carrying messages from her mother to me. As time went by and I built trust with Melinda, she told me that she told her mom to please tell me stuff directly. I (E. G.) did mostly child-centered play therapy with Melinda, informed by Judith Herman’s phases of treatment (Herman, 1997), while another therapist (M. G.) worked with Ramira. Melinda had never really had much experience with playing, feeling a little guilty, it seemed, for having fun from time to time. During the first 3 months, she explored almost every toy in the play therapy office, doing regressive play (water splashing), finger painting, and building structures with cardboard boxes. In addition, although she initially made a face at the baby dolls, she later approached them with great interest, at times bathing them, drying them with a soft towel, and putting talcum powder on them. “This smells so good,” she would say, and I remember sending home a small bottle of Johnson’s baby powder with her, which she thoroughly enjoyed. Later in therapy, when she played with the baby dolls she noticed their genitals were male and female. “Is this okay to look at?” she asked. I told her these were dolls that looked like real babies with their body parts of boys and girls. “So there’s nothing wrong with looking?” I responded that she could look at all the body parts of the dolls. “Oscar asked me to look at his privates.” “Oh,” I responded, “Oscar asked you to look at his privates.” She blushed and turned away from me. I said, “Sometimes grown-ups make mistakes. Oscar should have kept his privates private instead of asking you to look.” She turned around. “That’s funny, privates are private!” “Yes,” I responded, “that’s why we cover them up with diapers or underwear or bathing suits.” She didn’t say anything for a while and kept playing with the baby, then she said, “It was ugly and big . . . it was scary. I didn’t like to look at it.” I told her I was so glad she felt comfortable telling me how she felt and I understood how she might feel that way. “Have you ever seen one?” she asked, and I said, “Yes, but only when I was a grown-up.” “Was it still ugly?” “Well,” I said, “it is definitely different than our bodies.” She smiled a little. These conversations were brief and to the point and only occurred in the context of playing. They also gave way to later conversations about the difference between having sex and making love for grown-ups. The relationship-building (first) phase of our therapy allowed her to move into

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phase 2 (trauma work). She chose a combination of posttraumatic play and spontaneous verbal communication to show myriad difficult experiences, including witnessing her mother being raped and beaten, hiding under cardboard boxes, drinking so much alcohol that she passed out, and enduring beatings at the hands of multiple men. She paced herself carefully in the middle phase of treatment, using dolls to play out these horrendous scenes, and afterward she had the habit of wanting me to read a book to her and sitting close to me. As the sessions progressed, we were able to direct the abusers to stop, she was able to design a jailhouse for them, and she sent her mother to therapy to learn how to take care of children. “I think my mom will have more children,” she would say in a hushed voice, and then add, “I sure hope she learns how to take care of them.” Thus, the sexual abuse took precedence sometimes and the loss of her mother other times. She was doing the work she needed in her own special way. At times I was able to provide psychoeducation, which she was able to integrate when provided in small doses. The plan with Melinda was simple from the start: Because her abuse had occurred in the context of important relationships, my focus was on establishing a corrective relational experience with her. In order to do that, I prioritized her feelings of safety and creating a predictable, consistent environment. I also began to notice and make explicit her affective range. Melinda was quite regulated most of the time and exhibited more internalizing than externalizing behaviors, with a tendency to become sad and withdrawn when she felt frustrated or worried about her life and her future. The bulk of her worried feelings were about her mother. My work with Melinda was also slow and deliberate. I was very aware of her worry and concern for her mother, and the transition she was making from parentified child who took care of her mother and younger sisters to a child capable of receiving the care and attention of her foster mother. In fact, she once confided that it was nice her foster mother was now taking care of her sister Paulina because she now had much more time to do fun stuff that she liked. Letting go of taking care of her mother was a more monumental task: she eventually grew to believe that her mother had a therapist, a church, and a social worker looking out for her and this made her feel better. Eventually she stopped withdrawing from the foster mother (believing that she was being disloyal to her mother) and began to allow the foster mother to get emotionally closer. The foster mother was quite eager to work with me, and I met with her once every 2 weeks to review some homework suggestions. In fact, the child’s school and home environment provided consistency and attention, and as a result, Melinda was able to develop feelings of safety and connection. She often spoke about her “team of helpers,” and her mother’s team as well. Child-centered play therapy was a viable choice for establishing safety and allowing Melinda to regain some personal control. This child had been



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parentified from early in her life, and she showed great interest in playing freely and engaging in different types of play therapy including art, constructive play, dollhouse play, baby play (as mentioned earlier), and board games. I had two very distinct roles with this child—as her therapist and as her advocate, trying to ensure that Melinda had few surprises, knew who to go to when she had questions, and was kept informed about the legal process regarding Oscar, as well as some of the court conditions imposed on her mother. Melinda seemed to be realistic in her anticipation that she might not return home. Once she confided that her mother “needed to grow up and learn to take care of herself” before she could be a good mom to Melinda and Paulina. In fact, Melinda would often talk about how her foster mother always talked to her, tucked her into bed at night, read to her, made sure she did her homework, and made her food for breakfast and lunch! When she played mother and baby, the foster mother was always her guide. Melinda was learning by contrast how neglected she had been in the past. She also missed her mother and Oscar and her baby sister terribly. She said she had never met her older siblings but wondered what their life was like back in El Salvador. Once we established a stable foundational relationship, she naturally moved to utilizing posttraumatic play and I followed (Gil, 2017). During this middle phase of treatment I offered Melinda a range of directive, expressive techniques to draw, make stories, use puppets, and communicate some of her memories about her life. Some of those she embraced fully, others she quickly avoided, and we put them on a “list of activities” for the future. In the middle phase of treatment, I did a little writing project called “What we know about each other so far.” She wrote down, “You are nice, you are patient, you are not mean, you like spending time with me, you have lots of hair colors, and you like fruit.” I wrote down, “You are a kind person, you worry about your mom every day, you like your sister and you like that you don’t have to worry about her, you are confused about your feelings about Oscar, you miss eating pupusas, you’re afraid you’re forgetting Spanish and like to practice with me, and you hope you get to live with your mom again. Oh, and your favorite color is lavender.” After we made these lists, I told her that I wanted to use some of the time we spent together to help her with her worries about her mom as well as her confusion about her feelings about Oscar and what he had done to her body. We thus began to spend about half our sessions on the help I wanted to provide with the feelings and thoughts that caused her distress. We began by addressing her worries about her mom and then moved to her showing me what had happened with Oscar and talking about her confusing feelings of liking him and feeling badly that he was in jail.

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Systemic Work In addition to the very important issues addressed in individual therapy, there were parallel ongoing legal issues that loomed heavily, like a cloud hovering overhead, with little movement in any apparent direction. In addition, it was important for the children’s and mother’s therapists to maintain communication with each other as well as the school and the child protective services worker (and later the adoption worker). The children’s visits went from supervised to unsupervised and then back to supervised when Ramira began to encourage them to lie about what Oscar had done. In addition, Ramira maintained contact with Oscar and appeared more empathetic toward him than toward her children. Her social worker gave her directives to attend parenting classes and a group for mothers of sexually abused children, find a job and an apartment, and attend supervised visits with her children weekly. She was unable to complete these tasks, claiming transportation issues, illness, or lack of guidance about how to proceed. Her attendance at her own therapy was spotty, and I (M. G.) noted a lack of insight into the impact of sexual abuse on her children. Ramira was frank with her therapist, stating that most little girls learn about sex from older men and that it didn’t necessarily hurt them in any significant way. She even defended Oscar by saying that he had not penetrated Melinda, so it could have been much worse.

Ramira’s Individual Therapy I (M. G.) followed the same trajectory in Ramira’s treatment that was followed in Melinda’s, first establishing a safe and trustworthy position with her and later beginning to gently challenge many of her cognitive distortions. Ramira’s belief system suggested that she viewed this world as a place where bad things happen and where she had a compromised sense of personal agency. Her history, her lack of a loving childhood or protective parents, survival skills, and lack of education had left her incapable of understanding that her children needed unique attention and caretaking. In fact, she viewed herself and her children as equal: survivors trying to get ahead, unable to take control by making good decisions, lacking options, and unable to envision a different life, free of violence and exploitation. She frequently alluded to Oscar as someone who had improved their lives and stated how much the girls liked him and sought him out. She claimed his predatory grooming behavior toward the girls was in fact viewed by them all as welcome attention and caretaking. She never fully understood my role as her therapist and kept telling me things she wanted me to tell the judge. She also kept important information from me when she thought it would put her in a bad light. I tried to reinforce even the slightest efforts on her part (to get a job, find housing), but



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her focus on Oscar and his well-being seemed to override everything else, especially beginning to think about her children’s needs. She definitely felt wronged, and at one point expressed anger at her daughter for ruining her life by talking about their private lives to strangers at school. We made limited progress due to many factors, not the least of which was that Ramira was overwhelmed by feeling alone again. Her early unmet needs seemed to guide her decisions and loyalty to Oscar. We were never able to increase her awareness of her own trauma, and it was clear she had learned that women have to be strong and move on. Immigrants from developing countries often flee their difficult environments looking for something better. Unfortunately, they are also often ill prepared to negotiate the demands of a more structured life in the United States. They have histories of intense and chronic trauma, they lack education or skills to compete in a workforce, and they gather with other immigrants who might settle into dysfunctional lifestyles. Their childhood development has been stark and their attachment to parents fleeting, and their survival needs overrule everything else. U.S. standards of childrearing are often unfamiliar and exacting, and their children are viewed as high risk by our social service agencies. Children of color are much more likely than others to be reported for social services interventions. When agencies do intervene, they often find just cause to engage in protective action or provide multiple types of assistance to strengthen families. Unfortunately, when parents are not able or willing to make important changes in their behaviors and standards of care, their children can be permanently removed.

SUMMARY The United States once valued and prioritized the integration of immigrants from all over the world. In fact, the Statue of Liberty stands as a reminder of this country’s inclusionary policies. However, immigration reform has been articulated as a critical government priority without any substantial positive changes. In fact, the separation of parents and children at the border as a deterrent has been widely criticized and has caused an urgent situation in which immigrant children are transported to shelters and foster homes across the United States, with many reports of children who are physically and sexually abused. Reported deaths have also occurred along with an acknowledgment from social service agencies that there is no accurate data keeping that will enable the reunification of these families. In addition to immigrating into an unwelcoming country, immigrant parents and children, especially women, face great peril in their journey across the border, vulnerable to the financial, physical, and sexual exploitation of others. In fact, many families remain vulnerable to coyotes who

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charge them unseemly amounts of money and who might take children and youth into human trafficking as sex slaves. Those who do make it into this country encounter harsh realities and disappointments. Often work is not readily available and wages are low. Parents may inadvertently break U.S. laws as they leave their children unattended in favor of working to make money or by repeating the patterns of their childhood, like leaving children to fend for themselves. Immigrants may also live in crowded apartments and fear being discovered by immigration officers or angry landlords. Thus the level of stress can be tremendous, and lives with high levels of fear and anxiety become normalized. When children go to U.S. schools, they may be identified as neglected or abused. Parents may be unable to attend parent conferences, which further singles them out for concern. Children may be suffering from posttraumatic stress either as a result of specific incidents of physical and sexual abuse during their journeys or because they are living disorganized lives with limited resources, guidance, or protection. Clinicians working with immigrant populations must skillfully maneuver therapeutic needs while advocating for safe and nurturing life conditions. Many competing and challenging issues persist, particularly because many immigrant families are identified by social service agencies and mandated into treatment. Suspicious and distrustful of outside assistance and the dangers that could ensue, they rarely seek help voluntarily. Mental health professionals must proceed carefully and with focused sensitivity in order to avoid placing undue stress on already debilitated parents and children. Special attention must be given to understanding disparate cultural experiences in which trauma is rampant—a familiar experience that has become normalized. Parents may not believe that free choices are possible and may not fully understand the implications of their behavior. A mother who tells her child to keep quiet when a child discloses sexual abuse by a landlord may not grasp the concept of free choice, that is, that she is entitled to protect her children without losing her living accommodations. She may have endured similar experiences and may regard them as something that children must endure in silence. Her child’s disclosure could cause them to be thrown out on the street, or worse, elicit the attention of protective services workers, who are gravely distrusted due to their ability to take children out of the care of their parents. Clinicians must inform parents that options exist, but education is best provided while empathizing with their own victimization and expectation of limited options. The levels of psychological stress, anxiety, fear, and cumulative trauma experienced by immigrant families of color are often beyond description and belief. However, clinicians must make every effort to show empathy and understanding, and provide respectful guidance. Clinical approaches must be patient, and clinicians must become trustworthy by seeking ways to help concretely, often advocating for supportive community services. Trauma work must be undertaken gradually and only once therapeutic



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trust, safety, and predictability have been established, and approaches must be relevant and designed to challenge the normalization of victimhood, encouraging a shift in perspective so that clients can begin to feel more safety, even in an unsafe and unwelcoming current social climate. The case illustration provided above clearly documents the challenges that many undocumented immigrants face when they move to the United States. Ramira’s severe childhood relational trauma in her country of origin left her with profound early unmet emotional needs. She did not experience loving and protective parents, and she learned to normalize interactions between adult males and girls in ways that impacted her thoughts and perceptions about appropriate and inappropriate sexual touching, lack of supervision, and expressions of care. Child protective services were justifiably concerned about Ramira’s capacity to take care of her young children and took appropriate action to protect them. However, we struggled to advocate for Ramira given her history, her compromised caretaking, and her unmet needs. Ramira’s behaviors need to be viewed contextually and culturally. We must continue to identify and develop resources that are responsive to the challenges of cultures that do not support women and children and perpetuate intergenerational trauma. As mental health professionals, it is our job to be both trustworthy clinicians and strong advocates for our clients. As clinicians, we have to keep our goals realistic and work hard to set a predictable and safe context where clients can feel heard and respected. As advocates, we have to constantly articulate and highlight the social and family contexts that interferes with safe parental functioning while at the same time negotiating and prioritizing the needs of at-risk children.

REFERENCES American Psychological Association Presidential Task Force on Immigration. (2013). Working with immigrant-origin clients: An update for mental health professionals. Washington, DC: American Psychological Association. Retrieved from www. apa.org/topics/immigration/immigration-report-professionals.pdf. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York: Guilford Press. Gil, E. (2017). Posttraumatic play in children: What clinicians should know. New York: Guilford Press. Herman, J. (1997). Trauma and recovery: The aftermath of violence, from domestic abuse to political terror. New York: Basic Books. Lopez, W. D. (2019). Separated: Family and community in the aftermath of an immigration raid. Baltimore: John Hopkins University Press. Mercado, A., Venta, A., Henderson, C., & Pimentel, N. (2019). Trauma and cultural values in the health of recently immigrated families. Journal of Health Psychology. [Epub ahead of print] Paris, M., Antuña, C., Baily, C. D. R., Hass, G. A., Muñiz de la Peña, C., Silva, M. A., et al. (2018). Vulnerable but not broken: Psychosocial challenges and resilience

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pathways among unaccompanied children from Central America. New Haven, CT: Immigration Psychology Working Group. Retrieved from www.nwirp.org/ wp-content/uploads/ 2018/08/Vulnerable-But-Not-Broken.pdf. Perreira, K., & Ornelas, I. (2013). Painful passages: Traumatic experiences and posttraumatic stress among immigrant Latino adolescents and their primary caregivers. International Migration Review, 47(4), 976–1005. Retrieved from www. ncbi.nlm.nih.gov/pmc/articles/PMC3875301. Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical application of the Neurosequential Model of Therapeutics. Journal of Loss and Trauma, 14, 240–255. Sacchetti, M. (2019). ACLU says 1,500 more migrant children were taken from parents by the Trump administration. Washington Post. Retrieved from www.washingtonpost.com/immigration/aclu-says-1500-more-migrant-children-were-takenfrom-parents-y-trump-administration/2019/10/24/d014f818-f6aa-11e9-a285882a8e386a96_story.html. Soboroff, J. (2020). Separated: Inside an American tragedy. New York: HarperColllins. Stringer, H. (2019). Tackling the escalating immigration crisis: Psychologists are partnering with each other and those in other disciplines to address the mental health needs of Central Americans seeking refuge and asylum in the United States. Retrieved from www.apa.org/monitor/2019/09/immigration-crisis. U.S. Department of Health and Human Services, Office of the Inspector General. (2019). Care provider facilities described challenges addressing mental health needs of children in HHS custody. Retrieved from https://oig.hhs.gov/oei/reports/ oei-09-18-00431.asp.

CHAP TER 7

The Culture of Violence in Schools Athena A. Drewes

S

chool violence and bullying are not new phenomena (Hymel & Swearer, 2015). But public concern over the culture of violence in the United States has increased dramatically since the 1990s, owing in large part to the tragic deaths of our youth by suicide or murder, or from racial inequality and police violence, and the growing numbers of school shootings, starting with the Columbine massacre in 1998 (Cullen, 2009). Today bullying permeates popular culture through reality TV and violent video games, along with violence in the United States increasing substantially over the past few years (the death of George Floyd, protests and riots, isolation, anger and depression due to COVID-19, lack of background checks, etc.) (Farrell, Thompson, Curran, & Sullivan, 2020; Menesini & Salmivialli, 2017). The causes of violence are extremely complicated, with an intricate interaction between poverty, racism, drugs and alcohol, loss of employment, inadequate handgun regulation, lack of personal opportunity and responsibility, disinvestment in schools, and family violence (Menesini & Salmivialli, 2017; Paolini, 2020). Consequently, it is not surprising that the level of violence in public schools is increasing as well. In the last decade, punitive and racist approaches within the criminal justice systems have moved into our schools. Children of color are removed from the school environment and are being funneled into a one-way path toward prison. The “School-to-Prison Pipeline” is one of the most urgent challenges in education today (Mallet, 2016). “School-to-prison pipeline” 131

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is a term used to describe the alarming number of Black and Brown children funneled directly and indirectly from schools into our prisons. It starts with the high level of suspensions and expulsions, with disproportionately punitive levels of school discipline toward these children (Oluo, 2019). Students suspended from school are more likely to have to repeat that entire year, or may choose to drop out entirely. Black students make up only 16% of school populations, and yet 31% of students who are suspended and 40% of students who are expelled are Black. Black students are 3.5 times more likely to be suspended than White students. And 70% of students who are arrested in school and referred to law enforcement are Black (Amurao, 2013; Oluo, 2019). Growing violence, bullying, and chaos in classrooms have become a regular part of the school day for an increasing number of students. The pioneering work of Olweus (2001) has defined bullying as a subcategory of interpersonal aggression, which is characterized by intentionality, repetition, and an imbalance of power (derived from physical strength, social status in the group or from the group targeting of a single person, as well as knowing a person’s vulnerabilities and using this knowledge to harm him or her), with abuse of power being a primary distinction between bullying and other forms of aggression (Hymel & Swearer, 2015; Menesini & Salmivalli, 2017). This abuse of power can take the form of hitting or kicking, or damaging a victim’s property (physical bullying); verbal taunts, name-calling, and threats (verbal bullying); exclusion, humiliation, and rumor spreading (relational or social bullying); or electronic harassment using texts, emails, or online media (cyberbullying). Although physical and cyberbullying are often of greatest concern, social and verbal bulling are the more common forms experienced by students (Menesini & Salmivalli, 2017). Creating safe, supportive schools is essential to ensuring students’ academic and social success. Critical components include creating environments in which youth feel safe, connected, valued, and responsible for their behavior and education aimed at preventing violence in all forms including bullying, aggressive classroom behavior, racial bias, gun use, and organized gang activity (Furlong, Felix, Sharkey, & Larson, 2005; Oluo, 2019). School districts must take a systemic approach, address deeper causes of defiant and antisocial behavior in Black and Brown youth that lead to the school-to-prison pipeline (Oluo, 2019), expand immediate school actions, offer training and skills development and racism awareness training, along with depathologizing of Black children, and be proactive as well as reactive (Lunenburg, 2010; Oluo, 2019). Racial biases of school administrators and staff need to be addressed. Race is a deciding factor in how and whether students are disciplined and how harshly they are punished, correlated with how many Black children are in a school and not with the level of drug or delinquency problems at a school (Nelson & Lind, 2015; Oluo, 2019). Studies have shown that teachers are more likely to anticipate trouble from Black and Brown children and to view the play of Black and Brown children



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as aggression (Oluo, 2019). So cultural sensitivity, and not pathologizing of Black children is necessary.

PREVALENCE OF BULLYING AND VIOLENCE IN SCHOOLS The prevalence rates for bullying vary greatly across studies. Approximately 20–25% of youth are directly involved in bullying as perpetrators, victims, or both (Juvonen & Graham, 2014). A recent meta-analysis showed a mean prevalence of 35% for traditional bullying (both perpetration and victimization roles) and 15% for cyberbullying involvement (Modecki, Minchin, Harbaugh, Guerra, & Runions, 2014). Other studies report 10–33% of students reporting victimization by peers and 5–13% admitting bullying others (Kessel Schneider, O’Donnell, Stueve, & Coulter, 2012). These variations are attributable to varying assessment approaches and differences across individuals (sex, age), contexts, and cultures (Hymel & Swearer, 2015). Typically, boys report more bullying than girls, but girls report more victimization (Hymel & Swearer, 2015). International research suggests that bullying is common at schools and occurs beyond elementary school. Bullying occurs at all grade levels, beginning as early as preschool, but most frequently peaking during elementary school. It occurs slightly less often in middle schools and declines somewhat by the end of high school, with high school freshmen particularly vulnerable (Currie et al., 2012). However, youth reports of physical bullying in the United States have declined from 22% in 2003 to 15% in 2008 (Finkelhor, Turner, Ormrod, & Hamby, 2010), but online harassment has increased from 6% in 2000 to 11% in 2010 (Jones, Mitchell, & Finkelhor, 2013). So, although traditional forms of bullying may be declining, cyberbullying appears to be on the rise as technology becomes more accessible and usable. One study of school violence victimization in grades 5–12 showed that students victimized multiple times were likely to be male, to perceive the school campus as being unsafe, to have poorer social support networks with peers and teachers, and to have pervasive worries about school violence (Furlong, Chung, & Morrison, 1995). Males experience nearly three times more physical attacks than females in junior and senior high school, with perpetrators and victims generally belonging to the same racial/ethnic group—Black students victimized by other Black students, and White students by other White students. A meta-analysis focused on ethnic group differences in peer victimization found that ethnic minority status alone was not strongly associated with higher levels of peer victimization (Vitoroulis & Vaillancourt, 2015). Vulnerable children, such as children with disabilities, LGBTQ youth, refugees, or children affected by migration; children who are excluded; children who belong to a minority ethnic or gender group; or simply children who differ from their peer group are at special risk (Menesini &

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Salmivalli, 2017). However, the risk for bullying and victimization is not equal across student groups, with a number of studies indicating that students with disabilities, or suffering from obesity, or belonging to ethnic or sexual minorities being at a greater risk for being victimized (Juvonen & Graham, 2014).

BULLYING AND ITS IMPACT ON THE LGBTQ STUDENT Research has consistently shown that gender-related discrimination is a problem in schools, with a study of 23,000 children in grades 6–12 showing that 42.1% of trans children and gender-nonconforming children had been prevented from using their preferred pronouns and nearly half of those (46.5%) forced to use the wrong bathrooms. Trans kids are two to three times more likely than their peers to be bullied (McKay, Misra, & Lindquist, 2017). Transgender children face alarming rates of bullying and abuse with 83.7% of trans and 69.9% of gender nonconforming students experiencing bullying at school (Kosciw, Greytak, Zongrone, et al., 2018). A recent survey (Nauert, 2020) found that 91% of LGBTQ adolescents reported at least one experience of bias-based bullying. This is more than double the estimates from previous studies of predominantly heterosexual youth. Other studies have found that 61% of students have heard peers make negative remarks about gender expression and 27% of students face physical abuse because of their gender expression (Kosciw, Greytak, Zongrone, et al., 2018). Many studies on the incidence of homophobic bullying are limited to single-item measures of sexual minority status and do not measure dimensions of sexual orientation (i.e., identity as well as behavior). In addition, even in large population-based samples, the prevalence of sexual minorities is quite low, and often different types of sexual identities and preferences are combined into a single category for statistical analyses (Menesini & Salmivalli, 2017). Despite these limitations, studies showed that there are higher rates of school bullying among sexual minorities living in higherstigma counties when they are open about their identity at school (van der Star, 2021). Also, sexual minority bullying and mental health issues begin in early childhood through adolescence (Mittleman, 2019). In addition, homophobic teasing or name-calling is a commonly reported experience, particularly by students who identify themselves as gay, lesbian, bisexual, or transgender, with 50–80% having experienced bullying (Espelage, Hong, Rao, & Thornberg, 2015). Bullying erodes one’s self-esteem, increases isolation, and makes it more difficult for children to assert their gender identity. Consequently, bullied children often become depressed and suicidal, with any involvement with bullying (as victim, bully, or both) raising a child’s risk of suicidal behavior (Centers for Disease Control and Prevention, 2014). By the



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time an LGBTQ youth reaches middle school, sexual and gender minority (SGM) adolescents are at heightened risk of suicide, depression, sleep troubles, and eating disorders (Nauert, 2020). The presence of a gay–straight alliance (GSA) at school, however, was associated with less bullying of students because of their weight, gender, religion, disability, or sexuality (Nauert, 2020). The harmful effects and wide range of bias-based bullying experienced by SGM youth underscore the importance of inclusion and acceptance in schools. Having GSAs in schools reduces stigma and rates of target victimization and helps lower the risk of unhealthy behaviors toward SGM but also those experiencing other types of bias-based bullying (Nauert, 2020). Smartphone and social media usage has increased during the COVID-19 pandemic, and thus the possibility for biasbased cyberbullying as well. Educators can utilize virtual GSA meetings and online learning platforms to foster social inclusion for adolescents at risk for victimization in the absence of in-person meetings (Nauert, 2020). Instructional programs should consist of multiple lessons by the teacher or other adult staff focusing on precursors or antecedents of violent behavior with the expectation that by targeting behaviors that predict violence (e.g., bullying, impulsive behavior), more serious aggression will be prevented (Juvonen & Graham, 2014). Trans-inclusive and anti-bias, anti-racism curricula need to be created. Schools can participate in LGBTQ History Month, highlight notable transgender historic figures, and discuss transgender history and civil rights with students (Villines, 2018). Students at inclusive schools with curricula that feature LGBTQ-affirming content are less likely to experience bullying, hear transphobic remarks, or feel unsafe at school (Kosciw et al., 2018).

IMPACT OF COMMUNITY VIOLENCE ON SCHOOLS Community violence often spills into the school (Lunenberg, 2010). Studies show that conditions in schools are strongly influenced by the conditions of the neighborhoods (Benbenishty & Astor, 2005). Violence in the schools is endangering the health, welfare, and safety of students and teachers. Students cannot learn when they are in fear of their classmates, and teachers cannot teach in an atmosphere where fear and anxiety prevail, and where there is fear for their own safety, as well as that of their students (Kupchik, 2011). Whether one is a witness or a victim, exposure to school violence can lead to a number of emotional and behavioral problems, such as posttraumatic stress disorder (PTSD), anxiety, depression, dissociation, self-destructive and aggressive behavior, and suicide, as well as severe psychological, academic, or physical harm to the victim, irreparable harm to the perpetrator, and rejection of responsibility by the bystander, especially if aggressive or violent behavior is allowed to persist over time (Flannery, Wester, & Singer, 2004). Boys and girls who were bullied at least once

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a week experienced poorer health, more frequently contemplated suicide, and suffered from depression, social dysfunction, anxiety, and insomnia (Wolke & Lereya, 2015). Consequently, creating a safe and disciplined learning environment is a necessary yet challenging task for all schools (Benbenishty & Astor, 2005; Lunenburg, 2010). School violence is not confined to urban schools. It is also prevalent in suburban schools and is most common in large schools, with middle school students the most likely targets of violent behavior (Benbenishty & Astor, 2005). Violent aggression can be school shootings, ganging up on a child, humiliation, intimidation, or the physical aggression of pushing and shoving. Students are fearful and intimidated by peer hostility that includes not only physical aggression (shoving, pushing, fights), but also face-toface verbal harassment (hostile or threatening remarks), public humiliation, cyberbullying, and rumor spreading. In fact, youth ages 8–15 rank bullying as more of a problem in their lives than discrimination, racism, or violence. And children who view themselves as targets of bullying show high levels of anxiety and depression that interfere with and depress their school performance (Juvonen & Graham, 2014). Bullying and violence are powerfully intertwined. Violent media provide a social structure and/or model for the bully to follow and also allow the bully to justify his or her actions by offering scenarios that affirm bullying behaviors as legitimate modes of problem solving and as a societal norm (Bushman & Anderson, 2002).

PROGRAMS TO COUNTER BULLYING AND VIOLENCE There are a number of program interventions that can be utilized within school settings to address and counter bullying. The following are a sample of effective interventions that are to be used within the school setting. The first three interventions can be led by teachers or designated leaders (such as school counselors) or embedded within existing school curricula. The last one focuses primarily on training parents and staff members for a school-wide approach. • Anger Coping Program. This program comprises 18 hours of weekly cognitive-behavioral training in small groups, ages 8–14, led by two program leaders. It includes modeling, role play, problem solving, and positive reinforcement. • Second Step—Middle School Version.  This program is embedded within the existing school curricula and consists of skills-based lessons that teach an understanding of violence, empathy, problem solving, and anger management skills to middle school students.



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• Think First. This program, which teaches anger and aggression management skills to secondary students using role plays, modeling, and rewards, comprises two 50-minute sessions a week for 6–8 weeks. • The Bullying Prevention Project.  This is a comprehensive model for bullying prevention in elementary and middle schools that includes training for parents and staff and utilizes classroom activities and schoolwide procedures for preventing and responding to bullying (Furlong et al., 2005; Sochet, 2000). The following interventions have been found to have limited value in managing school violence (Juvonen & Graham, 2014): • Training students in conflict resolution and peer mediation. Because bullying involves harassment by powerful children of children with less power (rather than a conflict between peers of relatively equal status), common conflict-resolution strategies or mediation may actually further victimize a child. The training often offers too little for those students who really need it, and too much for those who already have the skills. • Adopting a “zero-tolerance” policy. Fear of violent Black and Brown youth, along with high-profile school shootings primarily by White youth, led to the rise of zero-tolerance policies in schools in the 1990s. The Gun-Free Schools Act of 1994 made it mandatory to have a 1-year suspension for children caught bringing a weapon to school (National Summit on Zero Tolerance, 2000). Since then, schools have more broadly identified “weapons” as anything from actual guns and knives to forks and use of one’s finger as a “finger gun.” Some schools rush to adopt a zero-tolerance policy without an indepth analysis of their specific problem or the comprehensive involvement of administrators, teachers, other staff, student witnesses, parents, bullies, and victims at the school, class, and individual level. This approach often results in a high level of suspensions, often racially based, without full comprehension of how behavior needs to and can be changed. It does not solve the problem of the bully, who typically spends more unsupervised time in the home or community if suspended or expelled. And it does not deal with the fact that a year-long suspension can be devastating to a child’s educational outlook, result in the loss of joy in learning, and ultimately lead to becoming a school dropout, with future joblessness and repeat incarceration (Oluo, 2019). • Providing group therapy for bullies. Self-esteem training for bullies may be misdirected as research suggests most bullies do not lack self-esteem. Encouraging victims to simply “stand up” to bullies without

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adequate support or adult involvement may be harmful and physically dangerous for a victim of bullying.

THERAPY AND PLAY THERAPY FOR BULLYING Bullying can have long-lasting social, psychological, and health effects on victims. Children who experience bullying continuously or even once are at greater risk lasting into adulthood for depression and suicidal thoughts; anxiety disorders including panic disorders and agoraphobia; problems with physical activities; poorer physical health, including problems with eating and drug use; dropping out of school, impacting their education and careers; lower wages later in life; and future unemployment (Yan, Chen, & Huang, 2019). Consequently, treatment interventions should begin sooner rather than later to help enhance psychological well-being and encourage trauma recovery. Treatment can address managing anger, guilt, anxiety, sadness, or shame; enhance self-esteem or emotion regulation; instill healthy coping mechanisms; practice effective limit-setting skills; break the cycle of learned helplessness; address co-occurring conditions (mood, sleep, or eating; PTSD; self-harm; suicidal ideation or impulsive behaviors); and connect a client with innovative therapeutic modalities for self-regulation and relaxation (mindfulness, meditation, yoga, equine therapy, expressive arts) (Yan et al., 2019). Play therapy is an ideal modality to address these components. However, to date, there has been minimal play therapy research or literature on working with bullies or intervening in the culture of violence within the school setting. A few studies have focused on the use of art therapy in reducing bullying victimization (Yan et al., 2019) and anxiety (Triantoro & Yunita, 2014). These studies were conducted outside of the United States, in China and Indonesia. But there are abundant play therapy research studies that have demonstrated the efficacy of play therapy with children and teens, in both trans and non-trans populations, for the components of bullying. Play therapy studies have shown success with elementary school students suffering from conduct disorders (Cochran & Cochran, 1999), autism, obsessive–compulsive disorder, attention deficit/hyperactivity disorder, cerebral palsy (Johnson, McLeod, & Fall, 1997), PTSD (Shen & Sink, 2002), attention and hyperactivity issues (Ray, Schottelkorb, & Tsai, 2007), and aggressive behavior (Ray, Blanco, Sullivan, & Holliman, 2009), as well as children at risk (Post, 1999). All these issues can strongly impact the development of prosocial skills. One study (Sansone & Sansone, 2008) found that negative consequences for bullying victims included a variety of psychological problems such as somatic symptoms, difficulties in socialization, anxiety, depression, increase of suicidal ideation, and eating disorders (bulimia and anorexia nervosa). Somatic



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symptoms included reduced appetite, neck pain, shoulder pain, back pain, difficulty sleeping, stomach pain, and fatigue. Cognitive-behavioral play therapy techniques can also be utilized in school-based counseling sessions, as one of the negative effects experienced among bullying victims is anxiety. Shri (2010) suggested that cognitivebehavioral therapy, behavior therapy, and psychodynamic therapy can be used to treat anxiety disorders, giving the child an opportunity to explore traumatic feelings and unconscious conflicts. Recommendations were for use of spontaneous expression through art or free association using art, drawing, or writing in the therapy. The therapeutic powers of modeling, behavioral rehearsal, and direct and indirect teaching help the child stand up to bullies through use of role playing. Additionally, expression of positive emotions, stress management, social competency, positive peer relationships, stress inoculation, empathy, self-regulation, and empathy can help address the negative impact of being bullied that results in depression or suicidal thoughts (Schaefer & Drewes, 2014). Play therapy can offer immense support to transgender children and bullied children in general as well as their families. Family counseling can help a family identify strategies for supporting a child’s gender identity and fighting back against bullying. Individual therapy can help transgender children who struggle with depression, low self-esteem, and anxiety due to bullying. In therapy, a child can learn that being trans is not a mental health problem or a weakness, but an important component of a person’s identity that should be respected and celebrated. There are various play-based games that can help empower children and address bullying: • The Play Therapy Game—B-Aware: Bully Awareness Game (Shenika, 2021) addresses bullying in the school (for use with grades 2–5). Various bullying scenarios are offered, with ways to handle them both inside and outside of school. • The Ungame (Talicor, 2008) is designed to open communication and offer a fun way to express feelings, and is noncompetitive. • Coping Cat (Barrett & Ollendick, 2004) is a 16-session program to help a child deal with anxiety and begin to identify physical symptoms and address negative self-talk. • Social Skills Training (Fox & Boulton, 2003) was designed to help victims of bullying to improve their social skills. It uses verbal techniques to change negative thinking into positive thinking and to solve difficult situations.

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MEANS OF IMPROVING SCHOOL SAFETY The United States is a relative newcomer to implementing formal antibullying programs in its schools. Australia, Canada, England, Italy, Japan, and Norway have had national bully preventions programs long before the killings at Columbine High School in Colorado brought national attention to bullying in the United States (Piotrowski & Hoot, 2008). In fact, the Arizona Bullying Prevention Project and Colorado’s Anti-bullying Project are all adaptations of international models. Whole-school interventions, which include multiple disciplines and complementary components at different levels of school organization, reduce victimization and bullying more often than the interventions that include only classroom-level curricula or social skills groups. These approaches address bullying as a systemic problem meriting a systemic solution (Smith, Schneider, Smith, & Ananiadou, 2004). Components needed to create a culture of school safety include the following: • Physical surveillance, metal detectors, weapons deterrence, presence of security guards or officers on campus • School policies designed to prevent violence—legal consequences, addressing the school-to-prison pipeline and racial pathologizing of Black children • Instruction-based programs to address precursors of violence, offer measures to prevent violence and bullying, and address racial bias • Profiling of potentially violent individuals • Counseling at-risk students • Conflict mediation and resolution (Juvonen, 2001) A safe environment should be created in schools for both transgender and cisgender children. Students at inclusive schools with curricula that feature LGBTQ-affirming content are less likely to experience bullying, hear transphobic remarks, or feel unsafe at school (GLSEN, 2018). In addition, they are also less likely to be forced to use the wrong bathrooms or the wrong pronouns. Inclusive curricula can also raise self-esteem, reduce risk depression, and even improve grades (Villines, 2018). A variety of methods to effect change need to occur, starting with the teacher establishing clear rules on behavior and consequences. Teachers, school counselors, and others who work with transgender students need to be educated about transgender issues. These staff need to refuse to tolerate any bullying or transphobia, even from teachers or other adults (Villines, 2018). Infractions need to be addressed in private, thereby depriving bullies of the audience they often seek.



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The adult must confidently, unwaveringly, and consistently employ appropriate well-established consequences for the bullying behaviors. Bullies need to be provided with better behavior choices and instructed on how to improve their social interactions. Concrete words and actions need to be offered in place of the bullying behavior (Piotrowski & Hooter, 2008). Bullies need to be supported through a process of developing empathy for others and developing a commitment to help others. The target of bullying needs counseling in ways to cope with bullying and to avoid becoming a target again (Piotrowski & Hoot, 2008). Programs may focus on lessons in social skills aimed at making individuals more socially competent. Some programs target all students and the school system, while others may focus specifically on at-risk youth. Instructional material usually includes a series of exercises to help see problems from the perspective of the victim of bullying and raise consciousness about the role of bystanders in encouraging the bully, and offers role playing and other interactive teaching methods. These programs are curriculum-based and are often implemented like group counseling sessions (Juvonen & Graham, 2014). Activities need to be developed for less supervised areas of the school. In schoolyards and lunchrooms trained supervisors need to spot bullying and initiate activities that limit opportunities for it. Such activities must be of interest to bullies and curb their behavior (Juvonen & Graham, 2014). Vulnerability increases when children are less socially skilled, smaller than their peers or particularly sensitive. These children tend to play on the outskirts of their social group and therefore are easier prey for bullies. Thus, it is important to reduce the amount of time students can spend less supervised. Since much bullying occurs during less supervised time (e.g., recess, lunch breaks, class changes), reducing the amount of such time available to students can reduce the amount of bullying. Staggering recess, lunch, and/or class-release times minimizes the number of bullies and victims present at one time, so supervisors have less trouble spotting bullying. However, supervisors must be mindful that most bullies are in the same grade as their victims. Monitoring areas where bullying can be expected (e.g., bathrooms) can increase the risk that bullies will get caught, but may require increased staffing or trained volunteers (Juvonen & Graham, 2014). Schools should ensure that all their teachers have effective classroom management training. Since research suggests that classes containing students with behavioral, emotional, or learning problems have more bullies and victims, teachers in those classes may require additional tailored training in spotting and handling bullying (Juvonen & Graham, 2014). A multifaceted, comprehensive approach should therefore include establishing a schoolwide policy that addresses indirect bullying (e.g.,

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rumor spreading, isolation, social exclusion), which is less visible, as well as direct bullying (e.g., physical aggression). Guidelines need to be provided for teachers, other staff, and students (including witnesses) on specific actions to take if bullying occurs, and schools also need to educate and involve parents so they understand the problem, recognize its signs, and intervene appropriately. Specific strategies to deal with individual bullies and victims, including meeting with their parents, also need to be outlined. Students need to be encouraged to report known bullying by developing a comprehensive reporting system to track bullying and the interventions used with specific bullies and victims. Safe places, such as the counselor’s office, where students can safely discuss gender issues and bullying need to be identified (Villines, 2018). Students need to be encouraged to be helpful to bullied classmates, with tailored strategies to counter bullying in specific school hot spots, using environmental redesign, increased supervision (e.g., by teachers, other staff members, parents, volunteers), or technological monitoring equipment. Furthermore, postintervention surveys should be conducted to assess the strategies’ impact on school bullying so they can be modified and revised for effectiveness (Juvonen, 2001). The whole-school approach is somewhat easier to implement in elementary schools, due to their size and structure. Students in these schools generally interact with only one or two teachers a year, guaranteeing higher levels of consistent messages from teachers to students. However, significant gains can also be achieved in middle and high schools. Research tells us that one-time efforts are less effective, and that the whole-school approach requires renewed effort each year (Menesini & Salmivalli, 2017). The school principal’s commitment to and involvement is key. Research comparing schools with high and low bullying rates suggest that a principal’s investment in preventing and controlling bullying contributes to low rates of bullying (Evans, Fraser, & Cotter, 2014). Purposeful planning and organization start with a safety team that will create a comprehensive violence prevention plan. The team should be composed of administrators, faculty, and staff members, along with parents, students, and community members who can: implement systematic and recurrent assessment of the school’s needs through regular data collection and create a comprehensive plan based on a multilevel strategy that will seek to build and maintain a peaceful school campus. This plan should include strategies within the building and classroom, and at the individual student level (Furlong et al., 2005). School staff members need to be observant and respond to student needs before they escalate into unhealthy behaviors. Most students do not



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report bullying to adults. Surveys from a variety of countries confirm that many victims and witnesses fail to tell teachers or even parents (Menesini & Salmivalli, 2017). As a result, teachers may underestimate the extent of bullying in their school and may be able to identify only some of the actual bullies. Studies also suggest that children do not believe most teachers intervene when told about bullying (Menesini & Salmivalli, 2017). In a survey of American middle and high school students, 66% of victims of bullying believed school professionals responded poorly to the bullying problems they observed (Salmivalli, 2010). Some of the reasons victims gave for not telling include fearing retaliation, feeling shame at not being able to stand up for themselves, fearing they would not be believed, not wanting to worry their parents, having no confidence that anything would change as a result, thinking their parents’ or teachers’ advice would make the problem worse, fearing their teacher would tell the bully who told on him or her, and thinking it was worse to be thought of as a snitch than to be bullied (Salmivalli, 2010). To address the problem of students’ resistance to reporting bullying, some schools have set up a bully hot line. One in England received thousands of calls shortly after it was established. Some schools use a “bully box”: students drop a note in the box to alert teachers and administrators about problem bullies. Other approaches to increasing reporting are also used. In one Kentucky town, a police officer, keen to increase reporting, developed a short in-class segment titled “Hero vs. Snitch,” in which he discussed why reporting is heroic behavior, not tattling (Piotrowski & Hooter, 2008). A clearly articulated process is needed for threat assessment. In addition to bullying, which is a pervasive form of violence present in all schools, other forms of victimization that also need to be targeted and addressed include sexual harassment, relational aggression (i.e., harming another person’s relationships by spreading rumors or lies), and dating violence (Furlong et al., 2005). But there needs to be a balance with the school’s primary mission to educate and promote students’ well-being. It is essential that the gathering of school violence prevention information be done regularly and that it be shared with the school community so that everyone can understand and support the school’s safety efforts (Furlong et al., 2005). The first step is a problem-solving approach identifying the problem through a needs assessment, including current status and future goals. Bullying has been assessed via parent, teacher, and peer reports as well as direct observations, but most assessments rely on selfreport, despite concerns about biases related to social desirability, selfpresentation, and/or fear of retaliation (Pellegrini, 2001). Self-reports are economical and efficient and give youth a much-needed voice in the assessment process (Hymel & Swearer, 2015). Teacher and parent reports are

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more suspect, given that bullying primarily occurs in the peer group, in places with little adult supervision (Hymel & Swearer, 2015). However, these approaches should be viewed as complementary sources of information, helping to add to an understanding of bullying (Hymel & Swearer, 2015). Further assessment needs to identify strengths and risks of the school. It should include the various types of violence that occur, the experiences all have had with violence and discipline procedure and number of referrals, as well as impact of previous intervention efforts. Consideration also needs to be given to identifying the targets of the violence prevention program (Furlong et al., 2005). Next, problem analysis helps validate and prioritize problems and develops them into objective and measurable goals accomplished through specific, testable, actions (Furlong et al., 2005). Issues that need to be considered include who will take the lead provide training, who gets trained, for how long and how often, and how much time is required. Ideally all staff should receive training, including bus drivers, maintenance staff members, and cafeteria workers because bullying often happens in unsupervised locations such as hallways and the lunchroom. Next comes identification of programs and procedures that address the needs of students at all levels of exposure to school violence. Areas to consider include what type of training will be required, what will be expected of students after the intervention, and whether school rules will be changed (Furlong et al., 2005). Important considerations include how much funding is available along with allocation of funds. Designation of the people responsible, deciding what would indicate success and being sure there is ample staff member interest and motivation for the program have to be considered (Furlong et al., 2005). Programs and procedures need to be selected on the basis that they will address the identified problem, not because of the program’s popularity (Furlong et al., 2005). Then interventions should be implemented with communication with stakeholders as it is critical to gain involvement and avoid frustration and negative reactions to the efforts put forth. Gathering community and parent support in developing and maintaining an efficient and responsive violence protection program is necessary for the intervention to be successful. Alternative programs and services need to be considered for students who do not benefit from the intervention (Furlong et al., 2005). And, finally, an evaluation of the prevention strategy is necessary. This needs to include both an ongoing evaluation of whether and how well program implementation is working. Five years from now, the school needs to be able to know how and if the violence prevention program worked. The program and its activities can be tweaked to make it more effective on the basis of the evaluation (Furlong et al., 2005).



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Bullying intervention programs are an integral component to overall violence prevention efforts. They need to eliminate existing bullying problems, prevent development of new bullying problems, achieve better peer relations in the school, create a positive, safe school climate, and increase caring behaviors toward bullying victims by peers and adults (Furlong et al., 2005). There are over 200 institutional programs, whose specific goals and focus vary. Some focus on boosting physical safety by reducing extreme forms of violence, others promote a psychologically safe school climate, whereby students and staff feel protected. Others are proactive in trying to prevent the development of violent behaviors, whereas still others are reactive (Juvonen & Graham, 2014). Certain programs focus on skill building, and others rely on the deterrent of punishment, while some involve the entire school, including parents or the community at large, but others are student specific for those identified at risk. Finally, approaches can focus on resolving incidents rather than identifying problem students. Thus, schoolbased violence prevention efforts can differ drastically (Juvonen & Graham, 2014). Effective strategies should include a balance between security measures and discipline and positive supports, skill building, parent and community involvement, and improved school environment (Furlong, Felix, et al., 2005). These methods will not only reduce the culture of violence but also will improve academic and social outcomes for students (Furlong et al., 2005). Physical surveillance by campus security and police officers is most commonly used to keep weapons off the school campus. Federal and state funds have become available to place campus officers in schools. In many states, teachers who are licensed to carry a weapon have been permitted to bring them into the school as an additional deterrent toward student violence (Juvonen & Graham, 2014). Metal detectors and searches of student lockers and book bags are common. In addition, regularly scheduled “shutdown’ drills are practiced in schools to help students know what to do should there be an active shooter in the school. Sometimes real guns are shot, using blanks, so students know what gunfire would sound like (Juvonen & Graham, 2014). All these approaches can increase students’ fears and anxieties. While the presence of uniformed officers may provide peace of mind for administrators and parents, students may not see them as allies or defenders and they may create mistrust among students, unfairly target children of color, and adversely affect the school climate. So, while weapons deterrence may increase physical safety, it compromises the psychological safety of students (Schwartz, Proctor, & Chien, 2001; Oluo, 2019). School policies can also vary, from dress code enforcement to zerotolerance policies. A single violation can result in suspension or expulsion from school. These “get-tough” practices are presumed to send a message

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to potentially violent students and decrease school violence, but they may actually exacerbate it. In addition, repeated school transfers increase the risk for subsequent violence (Ellickson & McGuigan, 2000), and suspensions are relatively strong predictors of students dropping out of school and delinquency (Schwartz, Proctor, & Chien, 2001).

CASE EXAMPLE Carley, an 11-year-old cisgender girl who preferred male dress and hairstyle, was being seen for her anxiety and depression over being bullied in school through verbal taunts, exclusion, and cyberbullying. Carley had few friends, and they were also being bullied. Carley tended to socially isolate in the classroom and recess, which exacerbated her being a victim. While Carley did report incidents to the school counselor and principal, little was done to change the culture of transphobic bullying within her classroom and school. Carley’s family was generally supportive of her but was at a loss to help with her being bullied and wanting to avoid school. Carley’s symptoms included depression, social anxiety, and low self-esteem. Treatment was to address social skills development, empowerment, and coping skills via cognitive-behavioral play therapy. Initial sessions were spent helping Carley feel safe within the counseling setting and with her therapist. The Gingerbread Person Feelings Map (Drewes, 2001) was used as an ice breaker and to help assess Carley’s awareness of her feelings within her body. Her drawing was striking, as Carley immediately changed the smile on the drawing to a frown, and vertically split the face into two colors: red for anger and blue for sadness. Carley’s drawing was in marked contrast to her usual facial and physical demeanor. She would always come into the sessions with a smile on her face, which remained even when she was talking about things that upset her. During the fifth session, Carley came in and began to recount a particularly distressing incident in which a boy in her class was taunting her about her gender identification and ways she dressed. Carley’s voice was agitated, but her face displayed a smile in contrast to what one would expect. This contradictory appearance was brought to Carley’s attention, along with bringing out the drawing she initially made of the Gingerbread Person. Carley was helped to see how her smile might be encouraging the boy to continue his taunts, rather than stopping them. Sessions 5–8 were spent on helping Carley identify feelings, specifically what anger would look like on a person’s face. Carley spent sessions picking out pictures from magazines and making them into feeling cards, particularly angry faces. During the session a mirror was used to help Carley to make her face look like the cards and pictures when she spoke of events that made her



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unhappy, angry, and sad. The goal was to help Carley integrate her internal anger and feelings with her facial, verbal, and body expression. Carley then was helped by role-modeling how to express her anger and integrate facial expression with body language and verbal intonation. In Sessions 8–10 she worked on problem-solving skills, figuring out ways to respond to the taunts, and develop coping strategies. Puppets were utilized to play out scenarios and practice solutions. And deep breathing and mindfulness exercises helped to reduce anxiety and aided in anger management. Carley also chose the sand tray, where she could create safe environments and identify supports. Meanwhile, Carley’s therapist worked with her teacher on practical ways that her classroom could become a safer environment through establishing “no bullying” rules and setting up a buddy system with more popular students to enable Carley to have a protective support group. Sessions 10–14 were spent helping Carley build self-esteem by identifying areas of strength, limiting negative thinking, and increasing positive self-talk. As time progressed, Carley displayed a much more integrated expression of feelings, which in turn also helped in her feel less helpless and more empowered. Bullying incidents were dramatically reduced and her self-esteem increased.

CONCLUSION Growing violence, bullying, and chaos in classrooms have become a regular part of the school day for an increasing number of students, thereby creating a culture of violence and fear. Frequently, community violence spills into the schools as well. School safety, with the creation of a safe and disciplined learning environment, is clearly one of our national priorities, but yet a challenge (Lunenburg, 2010). Bullying should not be considered a “normal” stage of child development, but rather a precursor of more serious violent behaviors that necessitate immediate and appropriate intervention. Those who bully are four times more likely than nonbullies to be convicted of a serious crime by age 24. Schools need to provide leadership by instituting anti-bullying programs with a systemic approach that includes early intervention, adult training, and schoolwide anti-bullying interventions, anti-racism training, and discussion and exploration of the deeper societal causes of defiant and antisocial behavior in children of color in order to create a culture of safety. The inclusion of Gay Straight Alliance groups in schools can help reduce LGBTQ-related bullying as well as bias-based bullying, in addition to lowering the risk of unhealthy behaviors in vulnerable adolescents (Nauert, 2020). Creating safe supportive schools is essential to ensuring students’

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academic and social success. Critical components include creating environments in which youth feel safe, connected, valued, and responsible for their behavior and learning by preventing violence in all forms, including bullying, aggressive classroom behavior, gun use, and organized gang activity (Furlong et al., 2005; Oluo, 2019). School districts must take a systemic approach to be able to address systemic racism, which often results in a disproportionate number of children of color being expelled and transferred, while at the same time addressing ways to create safe school environments by offering training and skills development and be proactive as well as reactive in addressing violence, aggression, and bullying. In addition, play therapists need to conduct more research in order to offer effective means of treatment to children being bullied as well as the bullies themselves.

REFERENCES Amurao, C. (2013). Education under arrest. Retrieved from www.pbs.org/wnet/tavissmiley/tsr/education-under-arrest/school-to-prison-pipeline-fact-sheet. Barrett, P. M., & Ollendick, T. H. (2004). Handbook of interventions that work with children and adolescents: Prevention and treatment. Hoboken, NJ: Wiley. Benbenishty, R., & Astor, R. A. (2005). School violence in context: Culture, neighborhood, family, school and gender. New York: Oxford University Press. Bushman, B. J., & Anderson, C. A. (2002). Violent video games and hostile expectations: A test of the general aggression model. Personality and Social Psychology Bulletin, 28, 1679–1686. Centers for Disease Control and Prevention. (2014). The relationship between bullying and suicide: What we know and what it means for schools. Retrieved from www. cdc.gov/violenceprevention/pdf/bullying-suicide-translation-final-a.pd. Cochran, J., & Cochran, N. (1999). Using the counseling relationship to facilitate change in students with conduct disorders. Professional School Counseling, 2, 395–403. Cullen, D. (2009). Columbine. New York: Twelve/Hachette. Currie, C., Zanotti, C., Morgan, A., Currie, D., DeLooze, M., & Roberts, C. (2012). Social determinants of health and well-being among young people: Health behavior in school-age children (HBSC) study: International report from the 2009/2010 survey (Health Policy for Children and Adolescents, No. 6). Copenhagen, Denmark: WHO Regional Office for Europe. Drewes, A. A. (2001). Gingerbread Feelings Map. In H. G. Kaduson & C. E. Schaefer (Eds.), 101 more favorite play therapy techniques (pp. 92–97). Northvale, NJ: Jason Aronson. Ellickson, P. L., & McGuigan, K. (2000). Early predictors of violence. American Journal of Public Health, 90, 566–572. Espelage, D. L., Hong, J. S., Rao, M. A., & Thornberg, R. (2015). Understanding ecological factors associated with bullying across the elementary to middle school transition in the United States. Violence and Victims, 30, 470–487. Evans, C., Fraser, M., & Cotter, K. (2014). The effectiveness of school-based bullying prevention programs: A systemic review. Aggression and Violent Behavior, 19, 532–544.



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Farrell, A. D., Thompson, E. L., Curran, P. J., & Sullivan, T. N. (2020). Bidirectional relations between witnessing violence, victimization, life events, and physical aggression among adolescents in urban schools. Journal of Youth and Adolescence, 49, 1309–1329. Finkelhor, D., Turner, H., Ormrod, R., & Hamby, S. L. (2010). Trends in childhood violence and abuse exposure: Evidence from 2 national surveys. Archives of Pediatrics and Adolescent Medicine, 164, 238–242. Flannery, D. J., Wester, K. L., & Singer, M. I. (2004). Impact of exposure to violence in school on child and adolescent mental health and behavior. Journal of Community Psychology, 32, 559–573. Fox, C., & Boulton, M. (2003). Evaluating the effectiveness of a social skills training (SST) programme for victims of bullying. Educational Research, 45, 231–247. Furlong, M. J., Chung, A., Bates, M., & Morrison, R. L. (1995). Who are the victims of school violence? A comparison of student non-victims and multi-victims. Education and Treatment of Children, 18(3), 282–298. Furlong, M. J., Felix, E. D., Sharkey, J. D., & Larson, J. (2005, September). Preventing school violence: A plan for safe and engaging schools. Student Counseling, pp. 11–15. Hymel, S., & Swearer, S. (2015). Four decades of research on school bullying: An introduction. American Psychologist, 70(4), 293–299. Johnson, L., McLeod, E., & Fall, M. (1997). Play therapy with labeled children in schools. Professional School Counseling, 1, 31–34. Jones, L. M., Mitchell, K. J., & Finkelhor, D. (2013). Online harassment in context: Trends from three youth internet safety surveys (2000, 2005, 2010). Psychology of Violence, 3, 53–69. Juvonen, J. (2001). School violence: Prevalence, fears and prevention (Issue paper). Rand. Juvonen, J., & Graham, S. (2014). Bullying in schools: The power of bullies and the plight of victims. Annual Review of Psychology, 65, 159–185. Kessel Schneider, S., O’Donnell, L., Stueve, A., & Coulter, R. W. C. (2012). Cyberbullying, school bullying and psychological distress: A regional census of high school students. American Journal of Public Health, 102, 171–177. Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN. Kosciw, J. G., Greytak, E. A., Zongrone, A. D., Clark, C. M., & Truong, N. L. (2018). The 2017 National School Climate Survey: The experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. New York: GLSEN. Retrieved from www.glsen.org/research/2017-national-school-climate-survey. Kupchik, A. (2011). Homeroom security: School discipline in an age of fear. New York: Palgrave Macmillan. Leff, S. S., Power, T. J., Costigan, T. E., & Manz, P. H. (2003). Assessing the climate of the playground and lunchroom: Implications for bullying prevention programming. School Psychology Review, 32(3), 418–430. Lunenburg, F. C. (2010). School violence in America’s schools. (2010). Focus on Colleges, Universities and Schools, 4(1), 1–6. Mallet, C. A. (2016). The school-to-prison pipeline: A comprehensive assessment. New York: Springer. McKay, T., Misra, S., & Lindquist, C. (2017). Violence and LGBTQ+ communities: What do we know and what do we need to know? Retrieved from www.rti.org/ sites/default/files/rti_violence_and_lgbtq_communities.pdf.

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Menesini, E., & Salmivalli, C. (2017). Bullying in schools: The state of knowledge and effective interventions. Psychology, Health and Medicine, 22(51), 240–253. Mittleman, J. (2019). Sexual minority bullying and mental health from early childhood through adolescence. Journal of Adolescent Health, 64(2), 172–178. Modecki, K. L., Minchin, J., Harbaugh, A. G., Guerra, N. G., & Runions, K. C. (2014). Bullying prevalence across contexts: A meta-analysis measuring cyber and traditional bullying. Journal of Adolescent Health, 55, 602–611. National Summit on Zero Tolerance. (2000, June). Opportunities suspended: The devastating consequences of zero tolerance and school discipline. Retrieved from https://files.eric.ed.gov/fulltext/ED539008.pdf. Nauert, R. (2020). Study: LGBTQ youth bullied at twice the rate of hetero youth. Retrieved July 1, 2020, from https://psychcentral.com/news/2020/06/24/studylgbtq-youth-bullied-at-twice-the-rate-of-hetero-youth/157384.html. Nelson, L., & Lind, D. (2015). The school-to-prison pipeline, explained. Retrieved from www.vox.com/2015/2/24/8101289/school-discipline-race. Oluo, I. (2019). So you want to talk about race. New York: Seal Press/Hachette. Olweus, D. (2001). Peer harassment: A critical analysis and some important questions. In J. Juvonen & S. Graham (Eds.), Peer harassment in school: The plight of the vulnerable and victimized (pp. 3–20). New York: Guilford Press. Paolini, A. C. (2020). Reducing gun violence in schools: A school counselor’s role. Journal of School Counseling, 18(12). Pelligrini, A. D. (2001). Sampling instances of victimization in school: A methodological comparison. In J. Juvonen & S. Graham (Eds.), Peer harassment in school: The plight of the vulnerable and victimized (pp. 125–144). New York: Guilford Press. Piotrowski, D., & Hoot, J. (2008). Bullying and violence in schools: What teachers should know and do. Childhood Education, 84(6), 357–363. Post, P. (1999). Impact of child-centered play therapy on the self-esteem, locus of control, and anxiety of at-risk 4th, 5th, and 6th grade students. International Journal of Play Therapy, 8, 1–8. Ray, D. C., Blanco, P. J., Sullivan, J. M., & Holliman, R. (2009). An exploratory study of child-centered play therapy with aggressive children. International Journal of Play Therapy, 18, 162–175. Ray, D. C., Schottelkorb, A., & Tsai, M. (2007). Play therapy with children exhibiting symptoms of attention deficit hyperactivity disorder. International Journal of Play Therapy, 16, 95–111. Rodkin, P. C., & Hodges, E. V. (2003). Bullies and victims in the peer ecology: Four questions for psychologists and school professionals. School Psychology Review, 32(3), 384–400. Salmivalli, C. (2010). Bullying and the peer group: A review. Aggression and Violent Behavior, 15, 112–120. Sansone, R. A., & Sansone, L. A. (2008). Bully victims: Psychological and somatic aftermaths. Psychiatry, 5(6), 62–64. Schaefer, C. E., & Drewes, A. A. (2014). The therapeutic powers of play: 20 core agents of change. Hoboken, NJ: Wiley. Schwartz, D., Proctor, L. J., & Chien, D. H. (2001). The aggressive victim of bullying. In J. Juvonen & S. Graham (Eds.), Peer harassment in school: The plight of the vulnerable and victimized. (pp. 147–174). New York: Guilford Press. Shen, Y., & Sink, C. (2002). Helping elementary-age children cope with disasters. Professional School Counseling, 5, 322–330. Shenika. (2021). Play therapy game for bullying prevention. Retrieved from www.creativecounseling101.com/play-therapy-game-for-bullying-prevention.html.



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CHAP TER 8

Filial Therapy with Hearing-Impaired Children Cary M. Hamilton Sarah Moran

T

his chapter discusses the use of therapeutic play and relational dynamics with Deaf children and their families. Deafness affects around 3 million children in the United States; approximately 50% are under the age of 3 (Center for Hearing and Communication, n.d.). About two to three in every 1,000 children are diagnosed with congenital hearing loss, which is the most frequently recorded disability among children from the medical model (Tapia-Fuselier & Ray, 2019). The vast majority (90%) are born to hearing parents (Center for Hearing and Communication, n.d.; Flaherty, 2015; Ritter-Brinton & Stewart, 1992). Deafness affects children in the way that they develop attention, language, and communication patterns with their family and peers (Flaherty, 2015; Kelman, 2001; Loots, Devisé, & Jacquet, 2005; Mitchell & Karchmer, 2004; Morgan et al., 2013). The diagnosis of deafness in an infant or child can have profound effects on the family system, especially when parents have little to no prior experience with Deaf culture (Flaherty, 2015; Ritter-Brinton & Stewart, 1992). Understanding the needs and relationship challenges of Deaf children and their hearing parents as it relates to attention, language, mental health, behavioral implications, attachment, parental stressors, and available Deaf intervention services will be addressed to highlight the need for an intervention that serves the family as a whole. The core of filial 152



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therapy, also manualized as child–parent relationship therapy (CPRT), is attachment and healthy communication (Bratton, Landreth, Kellam, & Blackard, 2006). Although there are differences in these models, the core principles are the same. Research has demonstrated the efficacy of using filial therapy for a variety of presenting problems and populations; however, there has yet to be a study corroborating the value of this intervention with families with Deaf children. This chapter seeks to make a logical connection between the needs of this population and the value of strengthening the parent–child bond through filial therapy.

DEFINITION OF CULTURE The Deaf community is a cultural and linguistic minority with its own history, art, customs, language, and social and athletic organizations (Walker, 2013) that differs from the larger, more dominant, culture in which its members live (Gil & Drewes, 2005; Sacks, 1989). There is an important distinction between the terminology of “deaf” and “Deaf” with a capital “D.” Individuals within the Deaf community identify themselves with the use of a capital “D,” which designates a separation between the medical diagnosis of congenital hearing loss from the membership of the Deaf community, without the attached stigma of disability (Walker, 2013; TapiaFuselier & Ray, 2019). Walker (2013) states that “Deaf people do not have a disorder of communication but are disabled by society’s failure to provide communication access” (cited in Tapia-Fuselier & Ray, 2019). While several subcategories of families with Deaf or hard of hearing (D/HH) children exist, research typically focuses on comparing D/HH parents with D/HH children and hearing parents with D/HH children (Flaherty, 2015; Guarinello, Berberian, Santana, & Massi, 2007; Hintermair, 2006; Mitchell & Karchmer, 2004; Morgan et al., 2013; Peterson & Siegal, 1999; Ritter-Brinton & Stewart, 1992). In the category of hearing parents with D/HH children, there is a spectrum of awareness parents have of Deaf culture prior to their child’s diagnosis, but in the majority of cases the parents are inexperienced (Flaherty, 2015; Ritter-Brinton & Stewart, 1992). D/HH children grow up with different social, cultural, and linguistic development (Mitchell & Karchmer, 2004). Frequently, there are early signs of social and cognitive delay in D/HH infants and young children (Morgan et al., 2013). Early communication of all types, rather than any specific language, is imperative for social–cognitive development (Morgan et al., 2013; Ritter-Brinton & Stewart, 1992) and the development of self-esteem (Ekim & Ocakci, 2016; Walker, 2013; Weisel & Kamara, 2005). In every system that the D/HH child is part of, including their family, community, school, and wider society, there are underlying political and contextual issues that

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are frequently changing and under discussion (Walker, 2013). Thus, it is imperative that play therapists understand the value of play as a language and its use for strengthening relationships. Children raised in families where more than one culture is represented may struggle with their identity and ability to adjust to one culture or the other (Gil & Drewes, 2005). D/HH children with hearing caregivers face a unique challenge, in which they are unable to identify with the culture of either caregiver (Gil & Drewes, 2005; Sacks, 1989). D/HH children are at specific risk of developing an insecure attachment with their hearing caregivers, which can lead to outward expressions of aggressiveness and poor social skills (Guarinello et al., 2007; Landreth, 2012). Walker (2013) reported mental health difficulties in D/HH children to be approximately 1.5 times more common than their hearing peers. Neurodevelopmental disorders such as attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are more common diagnoses for D/HH children, though often diagnosed late. Other mental health diagnoses that are common in this population include anxiety and depression (Walker, 2013). It is highly common for children with presenting problems such as these to end up in child or play therapy offices, and unless therapists are knowledgeable about these specific challenges, the D/HH population will function from a deficit in the therapeutic relationship.

SYMBOLIC PLAY Play is the natural language of children, and it is universal across cultures. Play allows children to express their interpretation of the world, which enables them to develop mastery of their emotions and experiences (Gil & Drewes, 2005). Imaginative games and toys can provide children with symbolic meaning to their experiences that they may not be able to articulate verbally (Gil & Drewes, 2005; Landreth, 2012). Vygotsky and Piaget studied the play patterns of young children in comparison to their brain development (Ray, 2011). Piaget’s preoperational stage is when a child begins to attach meaningful symbols to objects of play (Gil & Drewes, 2005; Ray, 2011). Understanding the value of the various forms of play in all children is necessary for play therapists who see a child’s play in session. Remember that symbolic play is the ability of children to use objects, actions, or ideas to represent other objects, actions, or ideas in play. When children engage in symbolic play it informs them about the context of their situations and experiences. This information is then integrated into understanding and further development of language, expression, and cognitive understanding. Symbolic play is universal and part of a healthy childhood, therefore a D/HH child needs to be afforded the ability to experience symbolic play, which happens when a child is in



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a safe and secure environment and in relationship with another, particularly a primary relationship .

Preoperational and Nonverbal Play Often the preoperational stage includes the attachment of language to play, which can be seen in both hearing and nonhearing children (Kelman, 2001). Parents with preverbal infants were found to engage in symbolic play nonverbally, communicating with their child through the use of smiling, eye contact, gestures, pointing, manual movement of objects, and joint attention (Chen, Castellanos, Yu, & Houston, 2019; Quin & Kidd, 2019). The use of nonverbal communication allowed parent–child dyads to establish meaning and find context within the play (Quin & Kidd, 2019). Language and cognition both contribute to the way the brain processes information, which guides how children interact with and represent the world around them (Piaget, as cited in Musyoka, 2015). Early communication behaviors lay the foundation for prosocial behaviors and language development in symbolic play (Quin & Kidd, 2019). Just as hearing children often talk during their play, D/HH children might vocalize or express extralinguistic behaviors while they play that can include silent lip articulation, murmuring, oral-facial mimics, body expression, sign languages, and vocalization (Kelman, 2001). Research demonstrates no significant differences in play levels between hearing and D/HH toddlers (Quin & Kidd, 2019). When D/HH children communicate to D/HH parents through sign language, they exhibit similar behaviors and interactions to their hearing counterparts (Hintermair, 2006; Musyoka, 2015; Ritter-Brinton & Stewart, 1992). Musyoka (2015) found that when a D/HH child had access to a native user of sign language from an early age, play behaviors were developmentally consistent with hearing peers. This demonstrates the need for D/HH children to feel understood. Studies show that symbolic play is foundational to language development. When interventions occur at the earliest stages, child language development improves and the child–parent relationship is strengthened (Quittner, Cejas, Wang, Niparko, & Barker, 2016). Delays of a child’s play experience either by lack of access, time, or engagement with others limits his or her development at the foundational level and can impact the development of language and higher-order play, such as cooperative play and pretend play (Brown & Watson, 2017). Research has found that pretend play is delayed in D/HH toddlers when language delay is present, whereas children who engage in play with parents of the same hearing status are not affected in the same way due to greater ease of communication. Professionals understanding this correlation can use play to further all other aspects of a D/HH child’s experience (Quittner et al., 2016).

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Child-Centered Play Therapy as Foundational to Filial Therapy Research has been conducted to look at the ways child-centered play therapy (CCPT) can be adapted to serve D/HH children. These studies have looked at the need to make adaptations to materials and toys offered in the playroom, such as including assistive listening devices, amplifiers, telecommunication devices, digital hearing aids, vibrating instruments, and/or the use of a clock that vibrates or has flashing lights (Brown & Watson, 2017; Guarinello et al., 2007). Including these items in the playroom could help make D/HH children feel that all aspects of their world were well represented. Musyoka (2015) found that a D/HH child’s play behaviors differed when the type and arrangement of toys were inconsistent. A play therapy room needs to have these same indicators to have consistent play spaces, and consistent therapist behaviors to reach the most therapeutic benefits of the child. Play is intrinsic to children; it is the therapist and adults who must understand the need for this consistency. Communicating with a D/HH client in a culturally appropriate language, such as American Sign Language (ASL), allows a session to be less disjointed than it would be if there were a translator present (Gil & Drewes, 2005). Since D/HH individuals understand language through visual prompts, it would be difficult for a D/HH child to focus their attention on both the play therapist’s lips and the translator’s signs (Guarinello et al., 2007; Kelman, 2001). (You can explore further research that focuses on the specific communication methods and challenges as well as ethical considerations that are present for therapists working with this population in our references.) A therapist using play therapy is fostering the development of crucial neural networks for future communication skills. Child-centered play therapists know the mantra of “being with” to communicate “I’m here, I hear you, I understand, I care” with sensitivity, understanding, and acceptance of the child (Landreth, 2012). A working knowledge of the child’s sign language (such as ASL) needs to be present for this mantra to be accurately conveyed to the client (Tapia-Fuselier & Ray, 2019). A play therapist’s nonverbal skills are essential to the therapeutic relationship and serve to facilitate conditions for change (Ray, 2011). In working with children who are D/HH, a play therapist’s reliance on spoken language limits relationship-building capacity and may limit progress in therapy. The adaptations needed to meet the needs of a D/HH child in CCPT is noteworthy, with the focus being to transfer this same therapeutic value to parents through filial therapy. The research is consistent in its exploration of a therapist’s need to understand the Deaf community at a cultural level, which encompasses the views, perspectives, and working knowledge of how D/HH individuals



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view themselves within the context of the greater cultural community they are a part of. It is not enough to simply communicate with a D/HH individual through sign language (such as ASL).

ATTENTION AND LANGUAGE Joint Attention The most profound difference between hearing and D/HH children is the way they focus their attention. Sustained attention is a necessary predecessor to language learning and cognitive development (Chen et al., 2019). When young children learn early vocabulary and object names, they do so by attending to an object while their parents name it. Nonverbal communication strategies to establish and maintain attention can include facial expression, body language, and gesture (Brown & Watson, 2017). Parents of hearing children can vocally point out an object to the child, and the child will receive both the auditory and visual information (Chen et al., 2019; Guarinello et al., 2007; Loots et al., 2005). D/HH children require split attention, as all information is obtained visually, so they must shift visual attention between the communication they receive and their environment (Loots et al., 2005). When parent and child hearing status is the same, deaf-and-deaf or hearing-and-hearing, there are similar patterns of positive engagement and fluency in language (Peterson & Siegal, 1999), in comparison to parent–child dyads with differing hearing statuses. D/HH parent–child dyads communicate as fluently in sign language as hearing parents and children converse verbally because the parents are attuned to the need to gain the child’s attention before communicating (Guarinello et al., 2007). Similarly, there are subtle differences in the way that adults familiar with Deaf culture identify and gesture to objects in comparison with their inexperienced hearing peers. For example, positioning of one’s body sideby-side with or in front of a D/HH child and identifying objects by the use of sign over or next to the item provides a point of reference without the need for eye contact (Guarinello et al., 2007). D/HH parents attract their child’s attention through the use of exaggerated signs and facial animations (Chen et al., 2019). Conversely, hearing parents, especially ones with other hearing children, may begin to interact before the visual attention is gained or after eye contact is lost. Language development falls short when hearing parents use verbal communication tactics more often than visual ones (Guarinello et al., 2007; Loots et al., 2005). The child may miss out on part of the information, although the parent may be under the impression that he or she communicated well (Guarinello et al., 2007). This may be true in all areas of a D/HH child’s life, as visual cues are necessary for context orientation and comprehension. This reliance on the visual sense

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may keep one or more senses from functioning in a typical fashion and/or delayed that function. This also means referrals to services and additional assistance are required to ensure brain and body regulation is occurring on target developmentally.

Development of Language Regardless of hearing status, humans are innately social (Schick, de Villiers, de Villiers, & Hoffmeister, 2007). Infants and toddlers learn about the world primarily through social interactions, particularly with their parents (Chen et al., 2019). Prior to and alongside the development of language, D/HH children communicate with extra-linguistic behaviors, such as motor activity, silent lip articulation, oral–facial mimics, body expression, and vocalization or murmuring (Kelman, 2001). The development of language is a critical part of the human experience, as it is the basis for all interpersonal relationships and provides a common understanding for feelings, emotions, memories, thoughts, ideas, and social norms. Language comes naturally to children, and they become fluent in whatever language is used most frequently around them (Humphries et al., 2012). Research shows that D/HH children who are exposed to sign language from infancy, or at least prior to age 3, can effectively decrease the gaps in communication delays later on (Musyoka, 2015; Sacks, 1989). It is common for D/HH children to have challenges with language development when parents overfunction for their child, use simplified language, or otherwise decrease the opportunities for the child to hear more complex language and develop foundational social skills (Chen et al., 2019). This overfunctioning includes parents remaining in “educational” mode when interacting with the child, which limits the child’s capacity for fantasy/symbolic play and child-led play, necessary for healthy brain development. Ekim and Ocakci (2016) found that as hearing children age, their parents provide more autonomy. This increase in autonomy is not true with D/HH children, which may negatively impact the D/HH child by developing a sense of inadequacy (Chen et al., 2019). When parents are focused on educational scaffolding techniques in their parenting they lack joint attention in the relational dynamic of play between parent and child, resulting in less connection and attachment (Brown & Watson, 2017). Parental encouragement is necessary for D/HH children to develop autonomous behaviors for healthy functioning. Parents of D/HH children educated on raising D/HH children for acquisition of autonomy will improve their social and emotional development.

Cochlear Implants There is an ongoing discussion and debate in the Deaf community around the use of cochlear implants, which this chapter will not explore. There



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are a variety of perspectives in the research on cochlear implants (CIs) which highlight the complicated cultural and ethical considerations around the use of this technology as it relates to an individual’s experience of the Deaf community and the terminology of deafness as a medical disability, which many D/HH individuals would consider to be an ableist perspective. Medical interventions are often focused on the development of spoken language used at home, and hearing parents of D/HH children often choose to get their child a cochlear implant (Flaherty, 2015; Humphries et al., 2012; Quittner et al., 2016; Walker, 2013). A CI is a biomedical device that is surgically implanted to offer an individual with sensorineural hearing loss some degree of sound (Peterson, Pisono, & Miyamoto, 2010). About 80% of Deaf children in the developed world have CIs, which offer some children access to sound and assist in the development of speech when the devices work as intended (Humphries et al., 2012). The surgery for implantation is invasive; it causes permanent damage to the cochlea, and there are few predictors to indicate which individuals will have success (Humphries et al., 2012; Peterson et al., 2010). The development of language is difficult for D/HH children, with or without the use of CIs or hearing aids. There is some research that indicates a successful CI will contribute to the development of language, reducing parental stress, and improving attention in a D/HH child (Quittner et al., 2016). However, the research suggests that outcomes are also varied and unpredictable (Walker, 2013). Regardless of the choice to explore the use of a CI, it is crucial that children learn sign language as early as possible to prevent isolation from the Deaf community and increase later language development and emotional well-being (Flaherty, 2015; Humphries et al., 2012; Jean, Mazlan, Ahmed, & Maamor, 2018; Peterson et al., 2010; Walker, 2013). There is a critical period for the development of language in early childhood, which is known to take place around the age of 5, when brain plasticity starts to decrease (Flaherty, 2015; Humphries et al., 2012; Pallier, 2007). By the time many families recognize that a CI was not successful, that critical period has often passed already, and the D/HH child may never have a natural language (Humphries et al., 2012; Peterson et al., 2010). Compounded with the stress of initial diagnosis of deafness, an unsuccessful CI can increase the risk for parental depression; a child who might have had partial hearing at birth is now profoundly deaf, and unable to communicate fluently with either the hearing or D/HH communities (Humphries et al., 2012). Jean et al. (2018) found that parents associated CI devices with “hassle, stigma, and cost,” which caused “mixed feelings of hope and helplessness in making CI a reality for their children.” Therefore, the focus for parents and professionals should be on the relational development of the child through the parent–child dyad.

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Sign Language Unlike hearing children, who experience communication spontaneously in the company of others, D/HH children are only able to learn language through direct instruction (Sacks, 1989; Szarkowski & Brice, 2016). Just as there are several spoken languages, there is not just one sign language, and it is imperative that the D/HH child is first introduced to one that is appropriate for communicating with his or her local community (Flaherty, 2015). Learning sign language gives the child access to language that cannot be obtained orally. Children of all hearing statuses can benefit from the use of sign language, because gesture is a natural form of communication before verbal language is mastered (Quin & Kidd, 2019). There are numerous books and classes offered nationwide, which are directed at parents to teach their babies basic sign language. This introduction to sign language not only welcomes the child into the world of Deaf culture, but it allows for better communication and attachment between child and parent (Flaherty, 2015; Humphries et al., 2012; Ritter-Brinton & Stewart, 1992). The research demonstrates that D/HH children have the most success when there is language consistency in the home, which can be more difficult in families with hearing siblings (Antonopolou, Hadjikakou, Stampoltzis, & Nicolaou, 2012; Pallier, 2007; Ritter-Brinton & Stewart, 1992). When hearing siblings participate in learning and communicating with sign language, the D/HH child’s chances for academic and social success increase twofold (Ritter-Brinton & Stewart, 1992). There is consensus in the research that early introduction to a sign language such as ASL that has its own set of vocabulary and rules for conveying context is the best way for a D/HH individual to reach adulthood with functional language skills (Flaherty, 2015; Humphries et al., 2012; Morgan et al., 2013; Pallier, 2007; Ritter-Brinton & Stewart, 1992; Walker, 2013).

SYSTEMIC CHALLENGES Parenting Experience/Stress Parenting today is an overwhelming task with a myriad of voices and opinions pulling parents in all directions. The stress and challenges of raising a D/HH child are mostly associated with obtaining the diagnosis and in regard to the unknown; hearing adults who have had no prior experience with D/HH adults or Deaf culture may experience the diagnosis as traumatic, and it’s one that undoubtedly impacts the family system (Flaherty, 2015; Guarinello et al., 2007; Jean et al., 2018; Ritter-Brinton & Stewart, 1992; Schick et al., 2007). Denial, confusion, disbelief, guilt, grief,



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anger, anxiety, uncertainty, shame, and helplessness are common reactions parents have to diagnosis (Flaherty, 2015; Jean et al., 2018; Pallier, 2007; Ritter-Brinton & Stewart, 1992). Parents of a D/HH infant are faced with greater short- and long-term needs than most parents with hearing or otherwise able-bodied infants (Jean et al., 2018). These parents are faced with a multitude of demands, including making appropriate educational decisions, increased professional contacts, learning new communication methods, and a pressing need to learn all the information they can about their child’s diagnosis, all of which foster immense amounts of stress for parents entering this new realm (Antonopolou et al., 2012; Jean et al., 2018; Pallier, 2007). The information parents receive is typically vast and contradictory, making it difficult to come to a decision on how and when to introduce language to their D/HH child (Humphries et al., 2012; Pallier, 2007). There is inconsistent or inaccurate information about the efficacy of cochlear implants (Humphries et al., 2012), the need for early exposure to sign language (Humphries et al., 2012; Loots et al., 2005; Ritter-Brinton & Stewart, 1992), and the availability of D/HH intervention services (Flaherty, 2015; Ritter-Brinton & Stewart, 1992). First-time parents may overcome the diagnosis of deafness more rapidly than their experienced peers, as parents with hearing children might rely on what they have learned from peers with children or from their own experiences in childhood (Antonopolou et al., 2012) and may be inclined to have unrealistic expectations (RitterBrinton & Stewart, 1992) or an unintentional rejection toward their D/HH child (Flaherty, 2015). Extended family’s lack of understanding or unwillingness to accept the child’s diagnosis often places additional strain on the parental unit. This leads to overprotective parenting strategies with heightened defensiveness and pressure to get their child to meet societal expectations (Jean et al., 2018). Factors that determine the impact of a D/HH diagnosis on the family are ethnicity, severity of hearing loss, social supports, parents’ hearing status, parent exposure to Deaf community, parent confidence, and parent knowledge of/familiarity with using sign language and visual communication (Antonopolou et al., 2012; Jean et al., 2018; Szarkowski & Brice, 2016). Research shows that parental acceptance of deafness can be pivotal in the long-term academic and social successes of D/HH children (Flaherty, 2015; Lieberman, Volding, & Winnick, 2004; Pallier, 2007; Ritter-Brinton & Stewart, 1992). The grieving process can take many years, but it is important for the families to act in the best interest of their child as rapidly as possible (Flaherty, 2015). Encouraging and fostering increased attention to the parent–child relationship can help develop resilience in the family system. The focus of family dynamics and communication should be assessed, particularly as it pertains to implications for the parent–child relationship in terms of attachment and bonding.

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Attachment Building a relationship with one’s caregiver is a crucial part of childhood development. Infants interact with their caregivers through verbal and nonverbal communication, such as eye contact, touch, and facial expressions (Ainsworth, 2008). A secure infant–caregiver attachment bond will eventually lead to the development of language and autonomy in the child (Ainsworth, 2008). Communication is a key factor in any relationship, regardless of culture or disability. D/HH children often miss out on a secure attachment with their hearing caregiver because of the visual–linguistic language gap between them (Guarinello et al., 2007). This language gap widens when a hearing caregiver uses verbal communication tactics more often than visual ones, because for a D/HH child to understand verbal communication, they need to focus intently on the speaker’s lip movements and facial expressions (Sacks, 1989; Guarinello et al., 2007). There is varying research concerning the attachment style of D/HH children in regard to the incongruence in attention and communication patterns between them and their hearing parents (Guarinello et al., 2007; Ritter-Brinton, 1992; Weisel & Kamara, 2005). Parent–child dyads of the same hearing status have the same chances of secure attachment, hearing or not (Koester & MeadowOrlans, 2004), as they tend to engage in more positive interactive behaviors and identity is formed in a nonpathologizing environment (Tapia-Fuselier & Ray, 2019; Walker, 2013). Research suggests that hearing parents overcompensate for the incongruence of communication by being more directive (Barker et al., 2009; Chen et al., 2019; Koester & Meadow-Orlans, 2004) and controlling (Barker et al., 2009) in interactions with their D/HH children, which in turn makes these children less likely than their hearing peers to initiate interactions with their parents and may impact their developmental experiences (Tapia-Fuselier & Ray, 2019). It is noted that differences in communication create challenges to the child–parent relationship and attachment style (Smith & Landreth, 2004). Hearing parents with D/HH children spend less time communicating than parent–child dyads with the same hearing status (Barker et al., 2009), which may be partially due to the fact that D/HH children are unable to be comforted by their parents’ voice when the parent is out of sight, which is shown to reduce separation anxiety in hearing children (Weisel & Kamara, 2005). A D/HH child’s inability to understand their hearing mother’s natural communication style may explain the overrepresentation of insecure or ambivalent attachment (Koester & MeadowOrlans, 2004) or fear of attachment and individuation (Weisel & Kamara, 2005) in dyads of hearing parents and D/HH children. Thus the attunement of a therapist to the innate attachment struggles of D/HH children would encourage him or her to focus therapy on the parent–child relationship.



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Implications for the D/HH Child and the Parent–Child Dyad Lack of a foundational language threatens the development of motor and social skills (Lieberman et al., 2004), emotional maturity (Kelman, 2001), memory organization (Humphries et al., 2012), literacy and number manipulation (Humphries et al., 2012), and the ability to complete Theory of Mind tasks, which are used to demonstrate an individual’s ability to separate one’s own beliefs and experiences from that of others (Humphries et al., 2012; Morgan et al., 2013; Peterson & Siegal, 1999; Schick et al., 2007). Research indicates that D/HH parent–child dyads perform higher in academic, social, and language areas than D/HH children of hearing parents (Lieberman et al., 2004; Ritter-Brinton & Stewart, 1992; Walker, 2013). Children of all hearing statuses have an increased level of behavioral problems when their communication skills are lacking (Stevenson et al., 2010). This demonstrates that hearing status itself is not a risk factor for social, academic, and behavioral challenges, but rather how deafness is handled impacts the D/HH child’s experience (Walker, 2013). Research has determined a reciprocal relationship between language difficulties and behavioral problems (Barker et al., 2009; Stevenson, McCann, Watkin, Worsfold, & Kennedy, 2010). The emotional and behavioral problems among D/HH children of hearing parents are notably higher (41%) than children with parents of the same hearing status (van Eldik, Trefferes, Veerman, & Verhulst, 2004). Behavioral problems in D/HH children can present within the family system when the child has difficulty communicating their needs and desires effectively to parents and/or has trouble understanding parental rules and societal norms (Barker et al., 2009). Miscommunication with primary caregivers can lead to outward expressions of aggressiveness and poor social skills (Betman, 2004; Guarinello et al., 2007), lower self-concept (Tapia-Fuselier & Ray, 2019), and feelings of isolation and emotional distress in D/HH children (Betman, 2004). Additionally, D/HH children with limited communication opportunities may have a delay in developing positive coping skills (Tapia-Fuselier & Ray, 2019; Walker, 2013). Behavioral regulation in children of all hearing statuses relies heavily on maintaining attention and picking up on social and environmental cues (Barker et al., 2009). Just as with other sensory system deficits, the absence of auditory input may have a role in the development of behavioral problems in D/HH children since visual information takes more overt effort for them, and the split attention of D/HH children may be misconstrued by parents or teachers as a behavioral problem or learning deficit (Barker et al., 2009). This also explains the rate of anxiety and ADHD diagnoses found in D/HH children (Walker, 2013). Schoolage D/HH children often experience teasing or bullying from their peers

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because their deafness is misunderstood (Betman, 2004; Walker, 2013). Early childhood behavioral problems are a risk factor for future behavioral problems, poor academic performance, and peer rejection (Barker et al., 2009). D/HH children have the added biological, psychological, and social risk factors that contribute to the development of behavioral problems and mental health challenges (Barker et al., 2009; Walker, 2013). Therefore, by engaging the family system in an intervention such as filial therapy to strengthen the relationship, it is possible to prevent or resolve behavioral problems that may arise from the diagnosis of deafness. Educating parents to learn supportive, relationally connected parenting skills is essential and will improve outcomes for both hearing and D/HH children. Parents supporting and teaching effective communication strategies to promote healthy relationships between D/HH children and hearing siblings create a supportive family climate (Jean et al., 2018). Encouraging families to play together and develop “play” language skills as a unit can benefit the whole family system. It is suggested that interventions centered on the parent–child relationship will help to diminish the impact of these parenting dilemmas (Antonopolou et al., 2012; Ekim & Ocakci, 2016).

AVAILABLE SERVICES Deaf intervention services are primarily focused on the D/HH child, rather than the family as a whole (Flaherty, 2015; Ritter-Brinton & Stewart, 1992). Programs that include family members are usually based on learning sign language, such as classes and videos to accommodate varying levels of adult skills in sign language (Ritter-Brinton & Stewart, 1992). Although sign language is crucial in facilitating parent–child interaction (Vernon & Leigh, 2007), parental stress is impacted by the availability of support groups (Flaherty, 2015; Jean et al., 2018), opportunities to interact with D/HH adults or other native signers (Ritter-Brinton & Stewart, 1992), and resources that encourage positivity and empowerment within the family (Hintermair, 2006). It should be noted that mental health services for D/HH individuals are sparse, due to a lack of providers with experience in Deaf culture and communication in ASL (Vernon & Leigh, 2007). There is a need for ongoing services for families of D/HH children, ones that might be cost-effective and individualized to meet the needs of the family (Ritter-Brinton & Stewart, 1992), and offered by providers knowledgeable in Deaf culture (Vernon & Leigh, 2007). Parental belief and anxiety around their D/HH child’s possible delayed development due to lack of hearing will lead to parents engaging more often with educational instruction and less in relational skill building (Brown & Watson,



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2017). The use of filial therapy or CPRT will reverse this dynamic, focusing the parental efforts on attachment and relationship with the child, which has been noted to decrease stress and improve the parent–child relational dynamic.

FILIAL THERAPY Play is an important aspect of child development regardless of culture or disability because it acts as a child’s language (Association for Play Therapy, n.d.; Landreth, 2012; Landreth, Ray, & Bratton, 2009). Play provides children with the ability to express their experience in the world, relieve stress, and foster creative thinking, self-efficacy, and emotion regulation, and build positive connections to others (Association for Play Therapy, n.d.; Landreth, 2012; Landreth & Bratton, 2020). Similar to client-centered theory and therapy, child-centered play therapy (CCPT) focuses on the relationship between clinician and client, and it is based in the belief that children will innately move in the direction of growth when offered the safety needed to do so (Landreth, 2012). Filial therapy was developed with the intention of providing a childhood foundation of positive interpersonal relationships to prevent later mental health issues (VanFleet, 2014). Filial therapy highlights the importance of play in child development (Cornett & Bratton, 2015; VanFleet, 2014) and assists families with both their immediate needs and ongoing interaction patterns (Topham & VanFleet, 2011). The effectiveness of CCPT lies in the process of being with children rather than in applying specific theoretical techniques (Landreth, 2012), and the same premise applies to filial therapy, in which parents are trained to “serve as the therapeutic agents of change” (Landreth & Bratton, 2020, p. 10). Filial therapy and CPRT both work with families to transfer the knowledge of play, child development, and parenting skills from a play therapist to the parents to support parenting long-term (Cornett & Bratton, 2015; Landreth & Bratton, 2020; VanFleet, 2014). In filial therapy, parents are taught the skills of CCPT such as reflecting feelings, nonverbal attunement, setting developmentally appropriate boundaries and limitations, and encouraging the child’s effort (APT, n.d.; Landreth & Bratton, 2006; VanFleet, 2014). Filial therapy can be implemented with individual parents, couples, or with groups of six to eight primary caregivers (Landreth & Bratton, 2020; Van Fleet, 2014). CPRT is a manualized model of filial therapy that is structured into 10 two-hour sessions (Landreth & Bratton, 2020). This group therapy format functions as a support group: the therapist offers the parents a safe environment to work through difficult communication and attachment issues (VanFleet, 2014) and learn from

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one another’s experiences (Cornett & Bratton, 2015; Landreth & Bratton, 2020; VanFleet, 2014). Parents participate in one-on-one, judgment-free, child-led play sessions in order to gain an understanding of the child’s perspective (Landreth & Bratton, 2020; VanFleet, 2014); a powerful opportunity for hearing parents to get a glimpse into the Deaf world, feel less stress, and be in connection with their child. You can find research on the efficacy of filial therapy with a variety of cultural groups as well as specific populations and presenting problems, including but not limited to low-income families, military families, victims of domestic violence, children with learning disabilities, children with autism spectrum disorder, chronically ill children, and adopted children with attachment disruption. This research has recognized the value in filial therapy in helping families of these populations reduce parental stress, encourage positive patterns of communication, improve communication, increase attunement and responsiveness to their child, understand the importance of play in child development, gain confidence in parenting skills, increase flexibility and respect in a co-parenting relationship, and increase empathy and overall acceptance of the child for his or her individual needs and traits, which is important for improving parent–child attachment. Research has demonstrated a positive and lasting impact on children served as well, through increased academic and psychosocial functioning, boosted self-confidence and self-esteem, decrease of maladaptive behaviors, and reduced chance of developing anxiety or depression in childhood or adolescence. D/HH children need every opportunity to establish a healthy relationship in the parent dyad to gain future competency, mastery, and emotional expression when using ASL or CCPT. There is a gap in the research addressing the efficacy of doing filial therapy with the parents of D/HH children, who experience immense stress upon diagnosis and throughout the process of adapting to the needs of their child. One study looked at doing filial therapy with preschool teachers of D/HH children (Smith & Landreth, 2004), which indicated that preschool teachers could provide a supportive relationship and be a change agent for these children. D/HH children who had undergone the intervention had significantly fewer behavioral problems and increased their sociability (Smith & Landreth, 2004). Jean et al. (2018) found that stress-reducing factors for parents of D/HH children included parental optimism about the child’s abilities, social support of other parents, time spent playing, reading, or drawing together with their child, increased professional support surrounding access to accurate medical information and a counterbalance to negativity and stigma. Filial therapy or CPRT meets the needs of parents with D/HH children in that it is short-term and cost-effective (Landreth & Bratton, 2020; Ritter-Brinton & Stewart, 1992) and provides social



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support, community, and counseling (Flaherty, 2015; Jean et al., 2018). Filial therapy would be valuable to parents struggling with the grieving process of diagnosis as well as parents with older D/HH children, as the treatment can be modified to meet the needs of a specific population (VanFleet, 2014). It can address the developmental needs that can pose a threat to the relationship between hearing parents and their D/HH children, so that parents can make informed decisions about the physical and mental well-being of their child (Ritter-Brinton & Stewart, 1992). Filial therapy can benefit this population because of its efficacy in decreasing parental stress, encouraging parents to have realistic expectations, and increasing acceptance of the child as an individual because it focuses on looking at the whole child and not solely on behaviors (Cornett & Bratton, 2015; Topham & VanFleet, 2011; VanFleet, 2014). Filial therapy targets the needs of the family systemically by addressing attachment issues (Topham & VanFleet, 2014) and providing emotional support while promoting meaningful interactions between parent and child (VanFleet, 2014). Whether or not there is a correlation between D/HH development of attention, language, and externalized behaviors and an insecure attachment to hearing parents, filial therapy or the CPRT model can help heal the attachment breakage by training parents to provide healthy interactions with their child (Landreth & Bratton, 2020).

SUMMARY AND FUTURE STUDIES As previously discussed, research has demonstrated the cultural considerations for working with D/HH children in CCPT. Additionally, you can find research on working with D/HH individuals in similar expressive therapies such as art therapy, dance/movement therapy, and sand tray therapy. D/HH children are at higher risk for increased mental health difficulties than their hearing peers and may struggle to find professionals who are knowledgeable about Deaf culture and have the ability to appropriately communicate through sign language (Tapia-Fuselier & Ray, 2019; Walker, 2013). To adequately meet a D/HH child’s mental health needs, clinicians need to be mindful of the cultural complexities that underlie the medical diagnosis of deafness. It is crucial that D/HH children and their families be provided opportunities to engage in culturally appropriate models of early intervention that focus on strengthening primary relationships, developing consistency in communication methods, and otherwise building positive coping strategies (Walker, 2013). Encouraging the relational aspects of the parent–child relationship fosters the child’s growth and resilience by improving language, social and emotional development, particularly when play, our natural language, is being used. Deafness is more than a medical diagnosis; it encapsulates a distinct

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culture of attention and language development that operates in the larger hearing community (Koester & Meadow-Orlans, 2004). Parents of D/HH children benefit from access to social resources, such as the opportunity to learn from other parents’ experiences and perspectives of Deaf culture (Brown & Watson, 2017; Flaherty, 2015; Hintermair, 2006), and to socialize directly with D/HH adults (Walker, 2013), both of which can occur in the group format of CPRT. This cultural exposure can promote understanding of how to help address the needs of their D/HH child in a hearing-dominant world, teach strategies for focusing attention visually, and highlight the necessity of exploring multiple signing options to level the power struggle between Deaf and hearing worlds (Guarinello et al., 2007; Ritter-Brinton & Stewart, 1992). We know that the strengthening of parent–child communication is vital to a child’s development, language development, and socialization in the community (Barker et al., 2009); therefore, all D/HH children, with either hearing or D/HH parents, can benefit from services that promote familial bonds and strengthen communication patterns. Some research has focused on the positive aspects of parenting a D/HH child, in an effort to shift from a “problem-focused” lens (Szarkowski & Brice, 2016), showing that parents could focus on the “everyday wonders” they experienced through the bond they had with their child. Szarkowski and Brice (2016) noted that many of the parents expressed gratitude for the relationship they had built with their D/HH child, one stating, “I wonder how well hearing parents of hearing kids really know their kids?” This demonstrates the need for connection in relationships between parents and children, no matter their hearing status.

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relationship therapy (CPRT) treatment manual: A 10-session filial therapy model for training parents. New York: Routledge. Brown, P. M., & Watson, L. M. (2017). Language, play and early literacy for deaf children: The role of parent input. Deafness and Education International, 19(3–4). Center for Hearing and Communication. (n.d.). Statistics and facts about hearing loss. Retrieved from http://chchearing.org/facts-about-hearing-loss. Chen, C., Castellanos, I., Yu, C., & Houston, D. M. (2019). Parental linguistic input and its relation to toddlers’ visual attention in joint object play: A comparison between children with normal hearing and children with hearing loss. Infancy, 24(4), 589–612. Cornett, N., & Bratton S. C. (2015). A golden intervention: 50 years of research on filial therapy. International Journal of Play Therapy, 24(3), 119–133. Ekim, A., & Ocakci, A. F. (2016). A comparison of parenting dimensions between deaf and hearing children. Clinical Nursing Research, 25(3), 342–354. Flaherty, M. (2015). What we can learn from hearing parents of deaf children. Australasian Journal of Special Education, 38(1), 67–84. Gil, E., & Drewes, A. A. (Eds.). (2005). Cultural issues in play therapy. New York: Guilford Press. Guarinello, A. C., Berberian, A. P., Santana, A. P. O., & Massi, G. A. (2007). Deafness and attention in deaf children. American Annals of the Deaf, 151(5), 499–507. Hintermair, M. (2006). Parental resources, parental stress, and socioemotional development of deaf and hard of hearing children. Journal of Deaf Studies and Deaf Education, 11, 493–513. Humphries, T., Kushalnagar, P., Mathur, G., Napoli, D. J., Padden, C., Rathman, C., et al. (2012). Language acquisition for deaf children: Reducing the harms of zero tolerance to the use of alternative approaches. Harm Reduction Journal, 9(16). Jean, Y. Q., Mazlan, R., Ahmed, M., & Maamor, N. (2018). Parenting stress and maternal coherence: Mothers with deaf or hard-of-hearing children. American Journal of Audiology, 27, 260–271. Kelman, C. A. (2001). Egocentric language in deaf children. American Annals of the Deaf, 146(3), 276–279. Koester, L., & Meadow-Orlans, K. P. (2004). Attachment behaviors at 18 months. In K. P. Meadow-Orlans, P. Spencer, & L. Koester (Eds.), The world of deaf infants: A longitudinal study. Oxford, UK: Oxford University Press. Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York: Routledge. Landreth, G. L., & Bratton, S. C. (2020). Child parent relationship therapy (CPRT): A 10-session filial therapy model (2nd ed.). New York: Routledge. Landreth, G. L., Ray, D. C., & Bratton, S. C. (2009). Play therapy in elementary schools. Psychology in the Schools, 46(3), 281–289. Lieberman, L. J., Volding, L., & Winnick, J. P. (2004). Comparing motor development of deaf children of deaf parents and deaf children of hearing parents. American Annals of the Deaf, 149(3), 281–289. Loots, G., Devisé, I., & Jacquet, W. (2005). The impact of visual communication on the intersubjective development of early parent–child interaction with 18- to 24-month-old deaf toddlers. Journal of Deaf Studies and Deaf Education, 10(4), 357–375. Mitchell, R. E., & Karchmer, M. A. (2004). Chasing the mythical ten percent: Parental hearing status of deaf and hard of hearing students in the United States. Sign Language Studies, 4, 138–163.

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Morgan, G., Meristo, M., Mann, W., Hjelmquist, E., Surian, L., & Siegal, M. (2013). Mental state language and quality of conversational experience in deaf and hearing children. Cognitive Development, 29, 41–49. Musyoka, M. M. (2015). Understanding indoor play in deaf children: An analysis of play behaviors. Psychology, 6, 10–19. Pallier, C. (2007). Critical periods in language acquisition and language attrition. In B. KÖpke, M. S. Schmid, M. Keijzer, & S. Dostert (Eds.), Language attrition: Theoretical perspectives (pp. 155–168). Philadelphia: Benjamins. Peterson, C. C., & Siegal, M. (1999). Representing inner worlds: Theory of mind in autistic, deaf, and normal hearing children. Psychological Science, 10(2), 126– 129. Peterson, N. R., Pisono, D. B., & Miyamoto, R. T. (2010). Cochlear implants and spoken language processing abilities: Review and assessment of the literature. Restorative Neurology and Neuroscience, 28(2), 237–250. Quin, S., & Kidd, E. (2019). Symbolic play promotes nonverbal communicative exchange in infant-caregiver dyads. British Journal of Developmental Psychology, 37, 33–50. Quittner, A. L., Cejas, I., Wang, N-Y., Niparko, J. K., & Barker, D. H. (2016). Symbolic play and novel noun learning in deaf and hearing children: Longitudinal effects of access to sound on early precursors of language. PLOS ONE, 11(5). Ray, D. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York: Routledge. Ritter-Brinton, K., & Stewart, D. (1992). Hearing parents and deaf children: Some perspectives on sign communication and service delivery. American Annals of the Deaf, 137(2), 85–91. Sacks, O. (1989). Seeing voices: A journey into the world of the deaf. Berkeley: University of California Press. Schick, B., de Villiers, J., de Villiers, P., & Hoffmeister, R. (2007). Language and theory of mind: A study of deaf children. Child Development, 78(2), 376–396. Smith, D. M., & Landreth, G. L. (2004). Filial therapy with teachers of deaf and hard of hearing preschool children. International Journal of Play Therapy, 13(1), 13–33. Stevenson, J., McCann, D., Watkin, P., Worsfold, S., & Kennedy, C. (2010). The relationship between language development and behavior problems in children with hearing loss. Journal of Child Psychology and Psychiatry, 51(1), 77–83. Szarkowski, A., & Brice, P. J. (2016). Hearing parents’ appraisals of parenting a deaf or hard-of-hearing child: Application of a positive psychology framework. Journal of Deaf Studies and Deaf Education, 21(3), 249–258. Tapia-Fuselier, J. L., & Ray, D. C. (2019). Culturally and linguistically responsive play therapy: Adapting child-centered play therapy for deaf children. International Journal of Play Therapy, 28(2), 79–87. Topham, G. L., & VanFleet, R. (2011). Filial therapy: A structured and straightforward approach to including young children in family therapy. Australian and New Zealand Journal of Family Therapy, 32(2), 144–158. van Eldik, T., Trefferes, P. D., Veerman, J. W., & Verhulst, F. C. (2004). Mental health problems of deaf Dutch children as indicated by parents’ responses to the Child Behavior Checklist. American Annals of the Deaf, 148(5), 390–395. VanFleet, R. (2014). Filial therapy: Strengthening parent–child relationships through play(3rd ed.). Sarasota, FL: Professional Resource Press. Vernon, M., & Leigh, I. W. (2007). Mental health services for people who are deaf. American Annals of the Deaf, 154(4), 374–381.



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Walker, R. (2013). Child mental health and deafness. Paediatrics and Child Health, 23(10), 438–442. Weisel, A., & Kamara, A. (2005). Attachment and individuation of deaf/hard-of-hearing and hearing young adults. Journal of Deaf Studies and Deaf Education, 10(1), 51–62.

CHAP TER 9

The Culture of Technology and Play Therapy Rachel A. Altvater

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echnology is a central focus of modern society, increasingly integrated into countless aspects of our daily lives. The newest advancements in technology become a trendy topic, and many people cannot wait to access the “next big thing.” The excitement quickly wears off, until the next technological advancement is revealed. This pattern causes anxious excitement surrounding technology. As a result of these continuous developments, technology is expanding with extreme rapidity, and many people remain eager to be the first to obtain the newest technological device. Modern children are growing up surrounded by technology, and they do not know or understand a world without these technological advancements. Infants and toddlers gaze at caregivers who remain absorbed by their handheld devices. In some instances, children are babysat by a pocket-sized computer and fully occupied by its possibilities. Children and adolescents become some of the predominant marketing targets and consumers of advertisements for new technologies. The curiosity leads to an increased desire to interact with these devices. As a result, children often demand smartphones, tablets, and/or video game consoles from young ages. Children’s and adolescents’ play is presently centered primarily on technology. Children do not play outside in the same manner as they did several decades ago. Instead, they immerse themselves in a virtual world from the comfort of their own home. They stare at screens for hours on 172



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end while they converse with peers, play live video games with others, and gather a wide range of information from across the globe. Their lives are implanted in a digital world. Methods of connection and communication between generations are disparate, which habitually leads to conflict and misunderstanding. The older adults did not grow up with today’s technology; young to middleaged adults were on the cusp of the rapid technological evolution we have seen in the past decades. Children and adolescents can speedily establish expertise, as technology is available in many homes and a staple item in most classrooms. Children have learned to interact, connect, learn, and play through technological means. Some adults believe that modern children and adolescents must shift their culture to fit that of older generations. Some fear unhealthy habits or addictive behavior, so they withhold children’s or adolescents’ abilities to connect with the virtual world. Caregivers are unsure of how to set healthy limits, so technological devices are suspended for extended periods of time to break unhealthy habits. When this happens, children and adolescents feel that their world is being ripped from them, so they respond with desperation and at times aggression. Caregivers do not fully understand the rationale behind the despair and are at a loss for how to effectively manage their children’s behavior. Play therapists must remain mindful of this technological evolution and how it intersects with play therapy treatment. Since technology is the facilitator of modern children’s playing and communication, it is imperative to determine how it could be welcomed into treatment. By withholding technological interventions in play therapy practice, play therapists are doing a disservice to their clients and may not be able to sustain a child’s interest in mental health services. Play therapy is built upon the understanding that play therapists are meeting the child where they are and speaking their language (Landreth, 2012), especially during the assessment phase, as they get to know the child. Without technology as an aspect of communication, some children and adolescents’ voices could be lost. This chapter provides an overview of the technological culture that children and adolescents are immersed in and explores methods for embracing change and welcoming technology into play therapy, considering and implementing its use in play therapy, and understanding and addressing technological concerns and dangers. We discuss the ways technology can enhance communication, connections with others, and the therapeutic relationship. The chapter also offers guidance on increasing comfort with technology and technological interventions in the office and via teletherapy, addressing one’s own ambivalence toward technology, implementing technological interventions, setting limits surrounding technology sessions, and educating parents to help them understand their children and set proper limits.

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INTEGRATING TECHNOLOGY INTO PLAY THERAPY TREATMENT Understanding Contemporary Children’s Play and Interactions in a Technological Culture Children’s play has been transformed in recent times, largely by a sociocultural evolution that prioritizes the technology of our age. Some children continue to engage in traditional play methods; however, these interactions are becoming sparser, as technological toys and games replace them. Methods for technological play have rapidly evolved and provide a broad depth of opportunity in the palm of the hand. Technology has not only altered children’s play, it has also modified the manner in which children communicate, obtain support and resources, and form and maintain relationships. Children are interacting with technology preverbally, so they do not know or understand a world without this type of interaction. Technology has the potential to expand children’s ability to engage in communication and form meaningful relationships. It provides a platform for individuals from across the world to connect in ways that would not have been possible before. Children and adolescents interact with a variety of technological platforms, from scrolling through social media feeds to engaging in online gaming to viewing and posting content on video-sharing websites. Anderson and Jiang (2018a) conducted a survey of 743 adolescents, ages 13 to 17, from March to April 2018. They discovered that 95% of adolescents own or can access a smartphone. They report, “ownership is nearly universal among teens of different genders, races and ethnicities and socioeconomic backgrounds” (p. 7). Since access to the digital world has become easier and more inescapable, daily interactions have been boosted. From 2014 to 2015, 24% of teens reported utilizing the Internet almost constantly, 56% several times a day, and 20% less often. In 2018, the numbers increased to 45% almost constantly, 44% several times a day, and 11% less often. Several gender, race, and ethnicity differences were also highlighted in this survey. Fifty percent of adolescent girls and 39% of adolescent boys represented the almost constant users. Hispanic adolescents were more likely than White adolescents to report almost constant use (54 vs. 41%). Anderson and Jiang (2018a) also explored access to and interest in gaming. They found that 84% of adolescents have access to a gaming console at home and 90% report playing video games. Of note, due to the expansion of capabilities on a variety of digital platforms, gaming is available on computers, game consoles, and smartphones. So, while some adolescents do not own a console, they are able to engage in gaming on other digital platforms. They found that 83% of girls and 97% of boys play video games. Anderson and Jiang (2018a) noted an increase between 2014/2015 and 2018 in Hispanic adolescents and adolescents from lower-income



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families owning a game console. Within these few years, access to a game console by Hispanic families increased by 10%, and families with a household income of less than $30,000 a year increased from 67 to 85% ownership. This growth for lower-income families is noteworthy, as it suggests how essential it has become for all to remain connected and engage in leisure digital play, regardless of financial ability to obtain the expensive digital equipment. Technology is universally enticing, as it largely enhances communication, connection, and relationships. Anderson and Jiang (2018b) report: While notable shares [of adolescents] say they at times feel overwhelmed by the drama on social media and pressure to construct only positive images of themselves, they simultaneously credit these online platforms with several positive outcomes—including strengthening friendships, exposing them to different viewpoints and helping people their age support causes they care about. (p. 2)

The researchers found that 81% of adolescents feel more connected to their friends through social media use, 69% believe that social media allows for interaction with a diverse group of people, and 68% experience a sense of support from others when experiencing challenges. They also discovered “by relatively substantial margins” that adolescents often associate social media use with positive over negative emotions (p. 2). Seventy-one percent of adolescents report feeling included, and 69% express confidence, in comparison to 25% who feel excluded and 26% who experience insecurities. While it is important to consider the issues that arise through technology use and determine methods to address these concerns, the strengths of digital interactions are vital to consider when identifying effective methods of play therapy treatment. A fundamental aspect of play therapy is to provide a developmentally appropriate approach to communication and expression that allows play therapists to speak children’s language (Landreth, 2012). Since technology facilitates contemporary language, clinicians would benefit from an increased understanding of the relevance of this method in play therapy practice. Understanding the continual, steady increase in desire and perceived need for access to the digital world for play, interaction, and connection is critical for professionals who work with children and adolescents. To simply ignore this major aspect of their lives when attempting to understand and support them through their struggles is ill advised. The research shows how modern children and adolescents have advanced to utilizing technology and how this has altered the way they interact in the contemporary world. It is our responsibility to meet child and adolescent clients where they are to best assess, understand, and aid them in their growth and healing processes.

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Embracing Ambivalence and Change: Welcoming Technology into Play Therapy Treatment Understanding the evolution of play to incorporate technology is crucial for clinicians so that they also understand how play therapy needs to be reconceptualized to reflect this shift. Many current child therapists have minimal to no training in technological play therapy interventions. It does not appear to be incorporated in many basic training programs, although it is suggested that more individuals are inquiring about its usability in the modern play therapy room. Play therapists have expressed the belief that their comfort would increase with additional training and understanding (Altvater, Singer, & Gil, 2018). Professional development is obligatory for play therapists in order to increase their comfort and understanding of technology interventions in play therapy treatment. If clients sense discomfort or apprehension, it could be detrimental to the therapeutic relationship or process, as they might interpret this discomfort as the play therapist rejecting an aspect of them. Methods to increase play therapy digital intervention comfort and competence include personally exploring technology, continuously researching the use of technology in practice, staying abreast of new advancements, defining and establishing rules, limits, and boundaries regarding technology in sessions, gradually introducing technology in sessions, and participating in ongoing self-reflection about feelings regarding technology in general and in practice. 1.  Explore technology on your own. Prior to adapting technological interventions in the playroom, it is important to develop a sense of comfort with manipulating technology. Take the time to explore technology; investigate tablet and smartphone applications (“apps”), the Internet (you can type “list of popular websites” into a search engine to discover which sites are most active among children and adolescents), video and computer games, popular music, and any area of technology that sparks curiosity. Become familiar with what technology is available to and commonly used among your clients. 2.  Research the use of technology in play therapy. Search for recent research about the use of technology in play therapy. Information regarding ethical practices, technological interventions, and efficacy of these interventions within psychotherapy is essential for establishing a sound theoretical basis for your work. Be sure to review differing opinions and focuses of research, as alluring headlines become a central source for confirmation bias. Was the study a true experiment? What was the sample size and diverse makeup of the subjects? What are the limitations and implications of the study? It is our responsibility to remain good consumers of the research and to provide clinically competent and ethically sound treatment.

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3.  Establish ground rules, limits, and boundaries regarding technology in sessions. Set clear boundaries regarding technology in play therapy sessions. Will you allow your clients to bring in their own technology, or will you solely provide the technology? Will you deliver the particular technological interventions, or will you encourage your clients to bring in their own intervention ideas? What technology is acceptable and unacceptable to use in your sessions? How long will you spend on technological interventions? How will you monitor the safety of technology use within the session? How will you deliver these rules, limits, and boundaries to your clients? Consider all of your options. 4.  Gradually expose yourself and your clients to technology. Steadily introduce technology in your sessions. It is suggested to start with a simple technological intervention. Only incorporate what you are familiar and comfortable with using in session. For example, instead of playing a tangible, traditional board game, play a virtual version of the board game on a tablet. Or prepare a therapeutic YouTube video for the session and then discuss the video with your client. The more comfortable you become with technology in session, the more you might be willing to make it available for your clients. 5.  Continue to self-reflect on your feelings surrounding technology. Just because you feel open to, exhilarated about, or uncertain about using technology in sessions for a period of time does not mean that you will always experience these thoughts and feelings. After gradually incorporating technological interventions into sessions, continue to reflect on your thoughts, feelings, and experiences. Additionally, notice benefits and detriments to incorporating these interventions in your sessions. Make note of all these insights and adjust your technological interventions accordingly.

Introducing and Implementing Technological Interventions Assessment Begin your initial evaluation from a place of clinical curiosity. Here is a list of questions to consider asking clients and their caregivers during an initial evaluation or at the start of treatment: Children/Adolescents   1. “What is your earliest memory of screen time?”   2. “How much time a day/week do you spend on the Internet, social media, and gaming?”   3. “What do you spend most of your time doing during your screen time? What do you think makes you spend the most time here?”

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  4. “What are your favorite games/apps to play? How come?”   5. “Tell me all about [insert game/app the client enjoys].”   6. “What is your favorite character?” and/or “What character would you say you identify most closely with in [insert game/app the client enjoys]?” “What are their strengths and weaknesses?”   7. “What social media sites do you [and your friends, if applicable] use? Tell me as much or as little as you would like to share about [insert social media account name(s)].”   8. “What are some positive experiences you have encountered during screen time? Negative experiences?”  9. “What are your caregiver’s rules and limits surrounding your screen time?” 10. “What do you know about Internet safety?” Caregivers 1. “How much time a day/week do you and your child spend collaboratively and independently on the Internet, social media, and gaming?” 2. “How familiar are you with what your child is playing/doing online? Share any information that you know about how they spend their screen time.” 3. “Is your child presently encountering any difficulties related to screen time? If so, explain in as much detail as possible what is occurring.” 4. “What are your rules and limits surrounding screen time?” 5. “What does your child know about Internet safety?”

Introducing Technological Interventions to Caregivers During the initial evaluation, play therapists explain to caregivers that technological interventions might be implemented in play therapy treatment as an assessment and intervention tool. Landreth (2012) provides psychoeducation to caregivers about play being a child’s natural mode of communication. Clinicians can introduce technology as the modern facilitator of this communication. Technological interventions are described as therapeutic in nature and are not meant for reinforcement or pure leisurely purposes. Clearly differentiate between technology use at home and in play therapy sessions in the event limits or consequences are set at home about no screen time. A sample script for this introduction is as follows: “I implement play and other expressive therapy interventions to assist children in processing, understanding, and expressing what is occurring

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in their lives. Developmentally, children often lack the verbal ability to articulate and understand the reason they are having a hard time. Play is a beneficial method that allows children to communicate, gain a sense of permission to be themselves, and obtain a sense of control to ultimately master their struggles. I utilize a variety of toys that are carefully selected to encourage therapeutic expression. Oftentimes in play therapy, children inform their caregivers that they are ‘just playing.’ I can assure you that during their structured or unstructured play in sessions, they are doing a lot of beneficial therapeutic work. Their play is equivalent to our verbal interactions. With technology being a modern facilitator of communication, I will also provide a tablet or computer as an additional therapeutic toy option to gain insight and further assist your child with their difficulties. Screen time is a common interest and issue I see with many children I work with. I add the option of digital play as a way to further understand and assist children in navigating their struggles. While limits might be set on screens at home, I ask that you continue to allow the presence of the technological devices I provide in sessions to be used for therapeutic purposes. I do not implement screens as a reward or allow children to play games for pure leisurely purposes. I will carefully monitor all interactions on screens during sessions and will set and continue to reinforce appropriate limits when necessary.” Information about incorporation of technology in play therapy treatment must be included in informed consent documentation. The Association for Play Therapy (2019) indicates that play therapists must “provide all parties with a written informed consent, including the benefits and or limitations of the technology being utilized” (p. 19). Play therapists must also consult their state and national boards and include any additional information about technology use in the informed consent documents when applicable.

Treatment There is a broad spectrum of technological interventions, ranging from engaging in playful expression or verbal exchanges about technology that children are using at home to providing a tablet as an additional tool in the playroom, complete with various therapeutic games and apps. Engaging in technological discussions and/or direct interventions in sessions will strengthen play therapists’ connection, understanding, and progress with child and adolescent clients. This section will serve as a guide for navigating the ever-growing and changing library of technological games and apps to find clinically appropriate technological play therapy interventions.

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When implementing technological interventions, the play therapist can choose to take a more direct and interactive approach by engaging in collaborative play with the client in the digital world or take a more nondirective approach by being an observer (Ceranoglu, 2010) and tracking and reflecting on the process. Clinician therapeutic orientation, client age, presenting concerns, and the intervention of choice should all be considered when choosing the level of direct engagement in the play with the client. Of note, in regard to the intervention of choice, some apps and games are single player, and YouTube and other Internet interventions might already be purely observational in nature. For clients who engage in verbal exchanges in sessions, it is advantageous to ask open-ended questions about the premise of the game/app, what is occurring in the game/ app during the session, and the various characters (if applicable). Projections onto a screen are synonymous with projections onto traditional play therapy toys and provide insightful information about what is occurring in the client’s world. GAMING

A video game is defined as “a game that employs electronics to create an interactive system that includes a user interface to generate a visual feedback on a video device” (Ceranoglu, 2010, p. 142). When incorporating video gaming in session, play therapists have the option to choose electronic games for psychotherapy (EGP) or electronic games for entertainment (EGE). Both methods are shown to improve psychosocial functioning and result in positive clinical outcomes, including an increase in motivation, attention, and engagement, and they provide a space for therapeutic imagery and emotional expression (Horne-Moyer, Moyer, Messer, & Messer, 2014). EGPs are designed for use in psychotherapy and “allow for tailoring game design and interfaces to specific needs of patients” (HorneMoyer et al., 2014, p. 2). EGEs are defined as “off-the-shelf-games” that are designed for leisure purposes but could be applied as a therapeutic tool (Horne-Moyer et al., 2014, p. 1). EGPs and EGEs are analogous to traditional play therapy board and card games, as some are specifically designed for psychotherapy treatment (e.g., The Talking, Feeling, & Doing Game and Mad Dragon), and others are conventional, leisure games that can be adapted to the playroom in a therapeutic manner (e.g., Candy Land and Uno). In deciding what gamebased digital intervention to use, the play therapist first decides whether to use an EGP or EGE. EGPs that are tailored to treat specific presenting concerns can be found through Internet search engines and published scholarly research. EGEs can be chosen through researching trending games that are available or asking clients to show the play therapist video games they are presently playing.

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APPLICATIONS

Applications (apps) are independent software available on smart devices (e.g., smartphones, tablets, and personal digital assistants) that provide a broad depth of options for information and leisure (Lui, Marcus, & Barry, 2017). Apps are of particular interest in play therapy sessions because they provide an abundance of intervention possibilities. Lui et al. (2017) highlights some of the primary benefits of utilizing apps in therapy: Apps used in a clinical context can aid symptom assessment, provide psychoeducation, track treatment progress, provide real-time intervention and communication, and can take advantage of game technologies . . . and connectivity to external devices such as biofeedback sensors. Such features likely help enhance engagement, motivation, and adherence, which may lead to better clinical outcomes. (p. 1)

Similar to gaming, there are certain apps that are developed for use in psychotherapy and others that are commercially available and can be applied as a therapeutic intervention. The same guidelines should be followed for choosing an appropriate app as for choosing a video game in session. There is a growing collection of apps that are used for physical and mental well-being (Herndon, 2014). It is advantageous to categorize apps on a technological device for use in the playroom, much like categorizing traditional play therapy toys. Suggested categories include nurturing, fantasy, expressive, aggressive, and scary (Snow, Winburn, Crumrine, Jackson, & Killian, 2012). VIRTUAL REALITY

Virtual reality (VR) is “a technological interface that allows users to experience computer-generated environments within a controlled setting” (Maples-Keller, Bunnell, Kim, & Rothbaum, 2017, p. 103). It allows a “sense of presence (the psychological sensation of ‘being there’)” in immersive environments (Valmaggia, Latif, Kempton, & Rus-Calafell, 2016, p. 189). Children and adolescents have the ability to enter into a digital arena that allows for simulation of real-world experiences. Research highlights VR as a particularly viable treatment option for anxiety disorders (Valmaggia et al., 2016). Play therapists who choose to implement VR in their practice will need to obtain a VR headset with appropriate connectors and systems. Each headset brand has differing requirements for usability; some headsets have all the necessary data present within the device and others require connections to smartphones, gaming consoles, or computers. Be sure to research the headset requirements and systems that you are interested in to assure you have all the necessary equipment for your chosen therapeutic interventions.

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YOUTUBE

YouTube is a video-sharing site that offers a vast array of content for entertainment and educational purposes. It is exceptionally popular among children and adolescents, as they are infatuated with the wide variety of videos available on the site. YouTube content ranges from music videos to clips from movies and television programs to news stories to informative, educational videos to do-it-yourself (DIY) instructional videos to vlogs (video blogs) and much more. Some children and adolescents maintain their own YouTube channels and post original content to share with others who access the site. YouTube can be utilized in play therapy sessions as a technological intervention. Developing an understanding of the content that clients are watching or publishing on their own channels provides an advantageous insight into their lives. Play therapists can either select a specific video to show a client or invite the client to show the clinician a video. If the child or adolescent chooses a YouTube video to share in session, open-ended questions about the content, similar to questions asked with video games and apps, are recommended. These questions allow play therapists to obtain additional information about the video to assist in further assessment, understanding, and intervention with the client’s present concerns. If a client chooses a video that is developmentally inappropriate, play therapists are encouraged to implement proper limits and boundaries. This might be the first instance where an adult is immersed in the digital world with them and can provide the necessary guidance to suitably manipulate the site.

Virtual Play Therapy The COVID-19 pandemic forced a substantial number of play therapists to rapidly adjust their practice overnight. Virtual play therapy became a universal therapeutic go-to as a way to maintain a supportive and healing therapeutic space during an unprecedented time. Since this method of service delivery is in its infancy stage, many play therapists are at a loss for how to competently and ethically navigate this new play therapy platform. While some play therapists implemented play therapy interventions via teletherapy with children and adolescents long before the pandemic, it was not common practice, and very few, if any, training, teaching, and published works discussed this innovative method of play therapy treatment.

Conducting Virtual Play Therapy Teletherapy is the provision of psychological services using telecommunication technologies (e.g., mobile devices, interactive videoconferencing, email, chat, text, and Internet) (Campbell, Millán, & Martin, 2017). Play



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therapists implement traditional and innovative interventions virtually via ethically sound virtual play therapy platforms. Play therapists either prepare toys or encourage the child and family to prepare a therapeutically sound play therapy space with carefully selected toys and materials. When beginning teletherapy treatment, it is important to assure that the play therapist and client have the necessary equipment. The following are needed for virtual play therapy: computer or smart device (phone or tablet), webcam, speakers, a plug for the device, and a tablet or phone stand. Depending on the virtual play therapy platform, it might be necessary to download an app on a smart device. It is advised that both the play therapist and client close out of all of the programs on their browsers, as having other websites and computer programs running simultaneously slows the connection and interrupts the session. Also, if the therapist’s search history prepopulates, it might reveal some of the therapeutic content from another session or a play therapist’s personal search history. If private browsing mode is accessed on an Internet platform, client confidentiality and play therapist privacy can be further protected. In addition, be sure to turn off any other virtual assistant devices (e.g., Alexa, Google) that are in close proximity to the therapy session, as this presents a potential privacy concern.

Collaborating with Caregivers on the Therapeutic Plan When introducing the virtual play therapy process, play therapists explain the teletherapy platform and establish a plan with caregivers about the structure of the session. Play therapists assess presenting concerns and the appropriateness of individual, caregiver, and/or family therapy sessions. Sometimes sessions need to be modified via teletherapy, as this therapeutic space presents unique experiences and challenges. At the start of the virtual play therapy session, the play therapist introduces or reiterates the limits to confidentiality and discusses how to assist the client in establishing as private a therapeutic space as possible, given the unique circumstances and home environments of each client. Recommended suggestions include having a noise canceler, requesting that family members and other individuals present near the client’s therapeutic space go to an area away from the session, and soundproofing spaces as much as possible. Once the client and family have a clear understanding of the layout of the therapeutic session, it is helpful to establish an idea of how to manage the therapeutic space from a distance. Assist the child and family in creating a space that allows for the child to move about freely or remain in an enclosed space, depending on need and therapeutic relevance, and for the play therapist to be able to adequately see the client on the screen during the session. Younger children who are experiencing dysregulated emotions or are hyperactive might encounter additional struggles with remaining in a

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space that is visible to the therapist. Establishing a plan to address potential interruptions, such as enlisting the support and assistance of a caregiver, can be helpful in navigating issues as they arise.

Establishing Digital Interventions Play therapy interventions are chosen based on presenting concern, therapeutic orientation, and treatment goals, regardless of the service delivery method. However, the implementation of the intervention might be altered or adjusted to fit the teletherapy platform. For example, a traditional card or board game might be altered from offering a tangible to a digital version. There are various websites, apps, and video games that afford the opportunity to have both play therapist and client engage in a virtual version of a game by entering a game space together. Screen-share options also afford the opportunity to interact in digital play in a space that allows both parties to access the therapeutic content at the same time. The therapist decides if the session will implement clinician- or client-prepared materials. A play therapist can prepare a prepackaged home play therapy toy kit with therapeutic tools that are relevant to the child’s therapeutic goals, choose selected toys from the playroom to manipulate on their end of the screen during session, or ask the child and family to obtain specific toys present in the child’s space so the child can manipulate them during the session. Alternatively, play therapists can enter a child’s space by allowing the child to choose which therapeutic tools he or she would like to bring into the session. Child selection can provide much information about present interests and can serve as an emotionally connecting and safe tool for the child.

TACKLING CLINICAL ISSUES SURROUNDING TECHNOLOGICAL CHALLENGES AND DANGERS Confronting the Perils of the Internet: Addressing Safety and Security Concerns Children and adolescents are increasingly presenting to play therapy with digital usage concerns. Two chief concerns with their technology use are safety and security. Minors have easy access to various dangerous technology features, including content that is not age appropriate (e.g., pornography), connecting with strangers with perilous intentions, sexting, human trafficking, cyberbullying, and the “dark web,” which is precarious encrypted and unregulated Internet content. Children are accessing apps and websites, sometimes accidentally or with peer encouragement, that parents are unaware of and uninformed about. To maintain a sense



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of secrecy and/or privacy children and adolescents typically move on to another platform once parents become aware of the platform they are utilizing. Children and adolescents often do not want caregivers and other adults to know what they are engaging in on their technological devices. Online protections are implemented to safeguard children when they engage in digital interactions. The Children’s Online Privacy Protection Rule (COPPA) is an Internet safety law that went into effect in 2000 and was most recently amended by Congress in 2013 to limit the amount of private information collected about children ages 13 and under. According to the Federal Trade Commission (2013): The Rule requires that operators provide notice to parents and obtain verifiable parental consent prior to collecting, using, or disclosing personal information from children under 13 years of age. The Rule also requires operators to keep secure the information they collect from children, and prohibits them from conditioning children’s participation in activities on the collection of more personal information than is reasonably necessary to participate in such activities. (p. 3972)

Despite best efforts to protect children and adolescents online, safety and security continue to be an issue, so play therapists and parents must provide additional education and guidance to assist children in navigating the virtual world. There are online safety education programs available, such as NetSmartz by the National Center for Missing and Exploited Children, that provide developmentally appropriate videos and activities to teach children, caregivers, and professionals how to be safer online. Conversations about healthy Internet use are recommended to help children and adolescents remain protected.

Addressing Unhealthy Technology Usage There is a need for attention and intervention to address the seriousness of some technological problem behaviors. Some children and adolescents engage with electronics for extensive periods of time and display tremendous resistance to limits of any kind. They may engage in dangerous, aggressive behaviors when they are separated from their technological devices. Parental controls and limits are often insufficient, and caregivers are at a loss for how to effectively manage their children’s intense reactions. The World Health Organization (2018) recently classified gaming addiction as a mental health disorder. While this was met with vastly differing opinions and mixed research findings (Aarseth et al., 2017), it demonstrates the seriousness of some technological concerns. Prolonged engagement with technology, a lack of appropriate limits and boundaries,

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and regularly utilizing technology to occupy or “babysit” children all contribute to chronic technology usage issues. It is of primary importance for play therapists to assess for the reason behind unhealthy technology usage and address these problems with clients and their caregivers. What is luring individuals to remain in this digital space for extensive periods of time? Does this game or interaction result in an increased sense of purpose? Connection? Accomplishment? Is it emotionally or physically safer to escape to this digital world? Is this giving them an experience they are unable to obtain in the real world? Use the clients’ presenting and ongoing concerns as a reference point when assessing for the rationale behind problem behaviors. By developing a deeper understanding about the enticing nature of the digital world for clients and their caregivers, play therapists will be able to get some idea of how to appropriately intervene and help these individuals meet their needs both inside and outside the digital world. If warranted, play therapists can assist clients and their caregivers in setting appropriate limits on screen time. The American Academy of Pediatrics (2016) offers the personalized Family Media Use Plan and Media Time Calculator to help families establish limits that work within their values, obligations, and expectations. The calculator provides an estimated time that children and adolescents are able to engage with screens after considering various individual factors, including age, time needed for sleep, meals, family and free time, and all academic, extracurricular, and household obligations.

CASE EXAMPLE Mateo is a middle-school-age Hispanic boy who was referred to treatment following persistent sexual abuse by a close extended family member. Presenting symptoms included flashbacks, difficulties sleeping, fears of being alone, the dark, and retribution, and academic struggles with focus, attention, and declining grades. With litigation on the horizon, he remained in a constant state of anxiety due to the ambiguity surrounding the pending proceeding. Mateo was slow to warm in play therapy and often preferred to converse about his favorite video game Five Nights at Freddy’s (FNAF). Despite his mother’s unremitting attempts at encouraging him to verbalize his trauma in sessions, he unceasingly elected to spend his earlier sessions discussing the intricacies of the game. I quickly recognized the significance of these verbal interactions and that which was left unsaid, so I encouraged continued exploration about the game and provided psychoeducation to his mother about the relevance of engaging in nonverbal and verbal dialogue about the game.



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Mateo spent a considerable amount of time discussing the premise of and characters within FNAF. He explained that the setting of the game is a Pastiche pizza restaurant with a variety of animatronic characters. These homicidal characters begin to move around the restaurant at night. The player assumes the role of the security guard working the overnight shift at the restaurant. The guard remains stationed in a small room overlooking the security system cameras. As the night progresses, he recognizes that the animatronics are no longer stationary. They do not move when the surveillance is directed at their area; however, it is apparent that they are moving when the focus of attention is on another camera, because once the camera flashes back to their original location, they are no longer there. The more frequently the cameras are checked, the more quickly the battery runs out. If the battery expires before the night is over, the security guard is no longer able to check the cameras. The object of the game is to survive five increasingly terrifying nights without experiencing a “jumpscare,” which occurs when an animatronic manages to reach and attack the security guard. A chilling animatronic face swiftly flashes across the screen to terrify the player directly before the game ends and the night must start over, forcing the player to reexperience the horrifying encounter all over again. After discussing the game in detail, he asked to show me a YouTube video of another person playing the game to give me a clearer picture of the full experience. It became readily apparent how frightening the entire encounter is for the player, so I reflected on content and feelings throughout the video. I could feel my heart race as the player shifted between the security cameras. A surge of adrenaline rushed through my body as the person playing the game began screaming, the battery power dwindled, the cameras fleetingly panned across the screen, and the animatronics disappeared and reappeared, inching closer to the security room. This video increased my understanding of Mateo: he was likely reexperiencing his trauma through this gaming experience. The parallels between Mateo’s sexual abuse and FNAF were striking. He was forced to stay in a small room, alone, at night, and endure a constant state of anxiety and hypervigilance due to the uncertainty over whether or when his perpetrator would enter his room at night. The game appeared to allow for externalization of his experiences so he could process them at a safe enough distance. In a subsequent session, Mateo asked to restructure the room to playfully re-create FNAF. He instructed me to fashion a fort out of the couch cushions, blankets, and other objects throughout the playroom, while he prepared a hiding spot for himself in a small closet. Mateo informed me that I was the frightened security guard and he was an animatronic who was coming after me. I positioned myself in the narrow, dark fort and anxiously waited for the animatronic to approach. Mateo made loud, scary sounds and gently tossed several items at the fort. I outwardly expressed fears of the dark, of being alone, and of being unable to see the animatronic

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that was slowly approaching, as I knew these were primary concerns that Mateo was working through. Ultimately, the animatronic left the room, and I was able to escape. Several weeks after this session, Mateo ceased all discussion about FNAF. Since this was an integral part of the play therapy process, I inquired about his current status with the game. He stated that he was no longer interested in the game because it was “too scary.” Of note, at this time his perpetrator was convicted, and his presenting concerns dissipated. It is postulated that processing his sexual abuse thorough this video game, in conjunction with the passing of his court involvement, led to a resolution of his trauma. Throughout the course of treatment, he transitioned from taking a passive to an active stance in his play. At the start of play therapy services, it appeared that Mateo was testing the waters to see how I responded to the information that he shared with me. He was adamant about my fully understanding the game. After showing him that I was interested and that discussion about FNAF was not dismissed, he increased his comfort level from telling me about the game to showing it to me. Validating the fearful nature of the experience and providing an emotionally safe and accepting therapeutic space for him to express, process, and re-create his anxieties appeared to greatly assist him in resolving some of his traumas. Mateo was able to regain a sense of control and mastery through his play.

CONCLUSION Our sociocultural climate has been transformed over the past several decades by heavy reliance on technology in most facets of daily life. Children and adolescents never knew a world without this growing technology, and it is their subculture, often concealed from the view of adults. Understanding this diverse perspective is crucial when identifying methods of psychological treatment for youth today. Apprehension about incorporating technology is clearly apparent across the play therapy field due to uncertainties, fears, and overall discomfort. All current play therapists either grew up prior to or on the cusp of the technological revolution, and their life experiences are vastly different from those of children who are growing up today. Learning to lean into and embrace the technological world is vital to the ability to continue applying the foundational play therapy principles of meeting children where they are and speaking their language (Landreth, 2012). This chapter has aimed to inspire change by showing how therapists can align play therapy methodologies and practice with an ever-changing world. There is room for growth and improvement within the current play therapy strategies and treatments. Suggestions for implementing timely



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interventions have been outlined in this chapter. The main focus and common goal among all play therapists is to help children. While traditional methods remain advantageous, we cannot merely rely on what is tried and true. For example, while Gumby is a staple of play therapy lexicon, a child today, if asked who Gumby was, would probably not know. This is a sign that the relevance of play therapy imagery needs to be reevaluated. We must step outside the familiar and comfortable to connect with our clients rather than expecting them to step into our own preconceived comfort zone.

REFERENCES Aarseth, E., Bean, A. M., Boonen, H., Colder Carras, M., Coulson, M., Das, D., et al. (2017). Scholars’ open debate paper on the World Health Organization ICD-11 gaming disorder proposal. Journal of Behavioral Addictions, 6(3), 267–270. Altvater, R. A., Singer, R. R., & Gil, E. (2018). Part 2: A qualitative examination of play therapy and technology training and ethics. International Journal of Play Therapy, 27(1), 46–55. American Academy of Pediatrics. (2016). Family media plan. Retrieved from www. healthychildren.org/mediauseplan. Anderson, M., & Jiang, J. (2018a). Teens, social media and technology 2018. Retrieved from www.pewinternet.org/2018/05/31/teens-social-media-technology-2018/# vast-majority-of-teens-have-access-to-a-home-computer-or-smartphone. Anderson, M., & Jiang, J. (2018b). Teens’ social media habits and experiences. Retrieved from www.pewinternet.org/2018/11/28/teens-social-media-habitsand-experiences. Association for Play Therapy. (2019). Play therapy best practices: Clinical, professional and ethical issues. Retrieved from https://cdn.ymaws.com/www.a4pt.org/ resource/resmgr/publications/Best_Practices_-_ Sept_ 2019.pdf. Campbell, L. F., Millán, F. A., & Martin, J. N. (2017). A telepsychology casebook: Using technology ethically and effectively in your professional practice. Washington, DC: American Psychological Association. Ceranoglu, T. A. (2010). Video games in psychotherapy. Review of General Psychology, 14(2), 141–146. Federal Trade Commission. (2013). Children’s online privacy protection rule, final amendments (Federal Register, vol. 78, no. 12). Retrieved from www.ftc.gov/system/files/2012-31341.pdf. Herndon, P. L. (2014). The new world of apps. Good Practice: Tools and Information for Professional Psychologists, pp. 8–11. Horne-Moyer, H. L., Moyer, B. H., Messer, D. C., & Messer, E. S. (2014). The use of electronic games in therapy: A review with clinical implications. Current Psychiatry Reports, 16(12), 520. Landreth, G. (2012). Play therapy: The art of the relationship (3rd ed.). New York: Routledge. Lui, J. H. L, Marcus, D. A., & Barry, C. T. (2017). Evidence-based apps?: A review of mental health mobile applications in a psychotherapy context. Professional Psychology: Research and Practice, 48(3), 199–210. Maples-Keller, J. L., Bunnell, B. E., Kim, S. J., & Rothbaum, B. O. (2017). The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard Review of Psychiatry, 25(3), 103–113.

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Snow, M. S., Winburn, A., Crumrine, L., Jackson, E., & Killian, T. (2012). The iPad playroom: A therapeutic technique. Play Therapy, 7(3), 16–19. Valmaggia, L. R., Latif, L., Kempton, M. J., & Rus-Calafell, M. (2016). Virtual reality in the psychological treatment for mental health problems: A systematic review of recent evidence. Psychiatry Research, 236, 189–195. World Health Organization. (2018). International classification of diseases (11th rev.). Geneva, Switzerland: Author. Retrieved from https://icd.who.int/en.

APPENDIX A

Resources on Multicultural Play Therapy

CHAPTERS AND ARTICLES Social Justice Issues in Play Therapy Brown, E. C., & Oliveira, E. (2019). Social justice and advocacy in university-based play therapy training clinics. In E. M. Dugan, K. Vaughn, & K. Camelford (Eds.), Developing and sustaining play therapy clinics (pp. 170–193). Hershey, PA: IGI Global. Parikh, S. B., Ceballos, P., & Post, P. (2013). Factors related to play therapists’ social justice advocacy attitudes. Journal of Multicultural Counseling and Development, 41(4), 240–253.

Cultural Issues in Therapy Beitin, B. K., & Allen, K. R. (2005). A multilevel approach to integrating social justice and family therapy. Journal of Systemic Therapies, 24(1), 19–34. Combs, G., & Freedman, J. (2012). Narrative, poststructuralism, and social justice: Current practices in narrative therapy. Counseling Psychologist, 40(7), 1033– 1060. Crowder, R. (2016). Mindfulness based feminist therapy: The intermingling edges of self-compassion and social justice. Journal of Religion and Spirituality in Social Work: Social Thought, 35(1–2), 24–40. D’Arrigo-Patrick, J., Hoff, C., Knudson-Martin, C., & Tuttle, A. (2017). Navigating critical theory and postmodernism: Social justice and therapist power in family therapy. Family Process, 56(3), 574–588. Imber-Black, E. (2011). Toward a contemporary social justice agenda in family therapy research and practice. Family Process, 50(2), 129–131. Jordan, L. S., & Seponski, D. M. (2018). “Being a therapist doesn’t exclude you from real life”: Family therapists’ beliefs and barriers to political action. Journal of Marital and Family Therapy, 44(1), 19–31. Kam, P. K. (2014). Back to the “social” of social work: Reviving the social work profession’s contribution to the promotion of social justice. International Social Work, 57(6), 723–740.

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McDowell, T., Knudson-Martin, C., & Bermudez, J. M. (2019). Third-order thinking in family therapy: Addressing social justice across family therapy practice. Family Process, 58(1), 9–22. McGeorge, C. R., Carlson, T. S., Erickson, M. J., & Guttormson, H. E. (2006). Creating and evaluating a feminist-informed social justice couple and family therapy training model. Journal of Feminist Family Therapy, 18(3), 1–38. Paré, D. (2019). At the level of the word: Nurturing justice in therapeutic conversations. European Journal of Psychotherapy and Counselling, 21(2), 112–129. Watson, M. F. (2019). Social justice and race in the United States: Key issues and challenges for couple and family therapy. Family Process, 58(1), 23–33. Zimmerman, T. S., & Haddock, S. A. (2001). The weave of gender and culture in the tapestry of a family therapy training program: Promoting social justice in the practice of family therapy. Journal of Feminist Family Therapy, 12(2–3), 1–31.

BOOKS General Bonilla-Silva, E. (2010). Racism without racists: Color-blind racism and the persistence of racial inequality in the United States (3rd ed.). Lanham, MD: Rowman & Littlefield. Cottom, T. M. (2019). Thick: And other essays. New York: New Press. DiAngelo, R. J. (with Dyson, M. E.). (2018). White fragility: Why it’s so hard for white people to talk about racism. Boston: Beacon Press. Eddo-Lodge, R. (2017). Why I’m no longer talking to white people about race. London: Bloomsburg. Kendi, I. X. (2016). Stamped from the beginning: The definitive history of racist ideas in America. New York: PublicAffairs. Kendi, I. X. (2019). How to be antiracist. New York: One World. Oluo, I. (2019). So you want to talk about race. New York: Basic Books. Saad, L. F. (with DiAngelo, R. J.). (2020). Me and white supremacy: Combat racism, change the world, and become a good ancestor. Naperville, IL: Sourcebooks. Sue, D. W. (2015). Race talk and the conspiracy of silence: Understanding and facilitating difficult dialogues on race. Hoboken, NJ: Wiley. Tatum, B. D. (1997). Why are all the black kids sitting together in the cafeteria?: And other conversations about race. New York: Basic Books. Vitale, A. S. (2017). The end of policing. Brooklyn, NY: Verso Books.

For Mental Health Professionals Aldarondo, E. (Ed.). (2007). Advancing social justice through clinical practice. Mahwah, NJ: Erlbaum. Allan, R., & Poulsen, S. S. (Eds.). (2017). Creating cultural safety in couple and family therapy: Supervision and training. Cham, Switzerland: Springer International. Audet, C., & Pare, D. (Eds.). (2018). Social justice and counseling: Discourse in practice. New York: Routledge. Benet-Martínez, V., & Hong, Y. Y. (Eds.). (2014). The Oxford handbook of multicultural identity. New York: Oxford University Press.



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Boyd-Franklin, N. (2003). Black families in therapy: Understanding the African American experience (3rd ed.). New York: Guilford Press.* Charlés, L. L., & Samarasinghe, G. (Eds.). (2016). Family therapy in global humanitarian contexts: Voices and issues from the field. Cham, Switzerland: Springer International. Degruy, J. A. (with Robinson, R.). (2017). Post traumatic slave syndrome, revised edition: America’s legacy of enduring injury and healing. Portland, OR: Joy DeGruy Publications.* Evans, S. Y., Bell, K., & Burton, N. K. (with Blount, L. G.). (Eds.). (2017). Black women’s mental health: Balancing strength and vulnerability. Albany: State University of New York Press.* Francois-Madden, M. (2019). The state of black girls: A go-to guide for creating safe spaces for black girls. United States: Author.* George, S. S., & Wulff, D. (Eds.). (2016). Family therapy as socially transformative practice: Practical strategies. Cham, Switzerland: Springer International. Griffith, E. E. H., Jones, B. E., & Stewart, A. J. (Eds.). (2019). Black mental health: Patients, providers, and systems. Washington, DC: American Psychiatric Association Publishing. Guidotti, T. L. (2010). The Praeger handbook of occupational and environmental medicine. Santa Barbara, CA: Praeger. Helms, J. E., & Cook D. A. (1998). Using race and culture in counseling and psychotherapy: Theory and process. Boston: Allyn & Bacon. Jones, M. C., & Shorter-Gooden, K. (2003). Shifting: The double lives of black women in America. New York: HarperCollins.* Kapola, M., & Keitel, M. (2016). Handbook of counseling women (2nd ed.). Thousand Oaks, CA: SAGE. McGoldrick, M., & Hardy, K. V. (Eds.). (2008). Re-visioning family therapy: Race, culture, and gender in clinical practice. New York: Guilford Press. Menakem, R. (2017). My grandmother’s hands: Racialized trauma and the pathway to mending our hearts and bodies. Las Vegas, NV: Central Recovery Press.* Neal-Barnett, A. (2003). Soothe your nerves: The black woman’s guide to understanding and overcoming anxiety, panic, and fear. New York: Simon & Schuster.* O’Connor, K. J., Schaefer, C. E., & Braverman, L. D. (Eds.). (2015). Handbook of play therapy. Hoboken, NJ: Wiley. Rowe, S. W. (with Rah, S.). (2020). Healing racial trauma: The road to resilience. Downers Grove, IL: InterVarsity Press.* Singh, A. A. (2019). The racial healing handbook: Practical activities to help you challenge privilege, confront systemic racism, and engage in collective healing. Oakland, CA: New Harbinger. Snyder, A. (2020). Black mental health matters: The ultimate guide for mental health awareness in the black community. Toledo, OH: Majestic. Walker, R. (with Akbar, N.). (2020). The unapologetic guide to black mental health: Navigate an unequal system, learn tools for emotional wellness, and get the help you deserve. Oakland, CA: New Harbinger.*

For Parents and Educators Brown, T. G. (2020). Parenting for liberation: A guide for raising black children. New York: Feminist Press. * From www.self.com/story/books-by-black-therapists.

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hooks, b. (1994). Teaching to transgress: Education as the practice of freedom. New York: Routledge. Pollock, M. (Ed.). (2008). Everyday antiracism: Getting real about race in school. New York: New Press.

For Children (Bibliotherapy) Asim, J. (2006). Whose knees are these? (L. Pham, Illus.). New York: Little, Brown. Celano, M., Collins, M., & Hazzard, A. (2018). Something happened in our town: A child’s story about racial injustice. Washington, DC: American Psychological Association. Chambers, V. (with Booker, C.). (2018). Resist: 35 profiles of ordinary people who rose up against tyranny and injustice. New York: HarperCollins. Cherry, M. A. (2019). Hair love (V. Harrison, Illus.). New York: Penguin. Davol, M. W. (1993). Black, white, just right (I. Trivas, Illus.). Morton Grove, IL: Albert Whitman. Hamanaka, S. (1994). All the colors of the earth. New York: William Morrow. Higginbotham, A. (2018). Not my idea: A book about whiteness (A. Higginbotham, Illus.). New York: Dottir Press. Holman, S. L. (1998). Grandpa, is everything black bad? (L. Kometiani, Illus.). Davis, CA: Culture Co-op. Hong, J. (2017). Lovely. Steven Point, WI: Creston Books. Hughes, L. (2009). My people (C. R. Smith Jr., Illus.). New York: Atheneum. Intrater, R. G. (1995). Two eyes, a nose, and a mouth. New York: Scholastic. Kendi, I. X., & Reynolds, J. (2020). Stamped: Racism, antiracism, and you: A remix of the National Book Award–winning Stamped from the Beginning. New York: Little, Brown. Kissinger, K. (2016). All the colors we are [todos los colores de nuestra piel]: The story of how we get our skin color [la historia de por qué tenemos diferentes colores de pie] (C. Bohnhoff, Illus.). St. Paul, MN: Redleaf Press. Lester, J. (2005). Let’s talk about race (K. Barbour, Illus.). New York: HarperCollins. Levinson, C. (2017). The youngest marcher: The story of Audrey Faye Hendricks, a young civil rights activist (V. B. Newton, Illus.). New York: Atheneum. Mason, M. H. (2010). These hands (F. Cooper, Illus.). New York: Houghton Mifflin. Nikola-Lisa, W. (1994). Bein’ with you this way (M. Bryant, Illus.). New York: Lee & Low. Nyong’o, L. (2019). Sulwe (V. Harrison, Illus.). New York: Simon & Schuster. Pinkney, A. (2010). Sit-in: How four friends stood up by sitting down (B. Pinkney, Illus.). New York: Little, Brown. Pinkney, S. L. (2000). Shades of black: A celebration of our children (M. C. Pinkney, Illus.). New York: Scholastic. Ramsey, C. A., & Strauss, G. (2010). Ruth and the green book (F. Cooper, Illus.). Minneapolis, MN: Carolrhoda Books. Reynolds, J., & Kiely, B. (2015). All American boys. New York: Atheneum. Rotner, S., & Kelly, S. M. (2009). Shades of people. New York: Holiday House. Taylor, M. D. (1991). Roll of thunder, hear my cry. New York: Puffin Books. Tingle, T. (2010). Saltypie: A Choctaw journey from darkness into light (K. Clarkson, Illus.). El Paso, TX: Cinco Puntos Press. Tonatiuh, D. (2014). Separate is never equal: Sylvia Mendez and her family’s fight for desegregation. New York: Abrams. Woodson, J. (2012). Each kindness (E. B. Lewis, Illus.). New York: Nancy Paulsen Books.



Appendix A 195

Book Lists www.commonsensemedia.org/lists/coretta-scott-king-book-award-winners www.embracerace.org/resources/20-picture-books-for-2020 www.diversebooks.org/resources/where-to-find-diverse-books http://hereweeread.com/2019/11/the-2020-ultimate-list-of-diverse-childrens-books. html

ORGANIZATIONS AND WEB RESOURCES General https://blacklivesmatter.com www.naacp.org https://alp.org www.blackwomensblueprint.org https://colorofchange.org https://eji.org www.familiesbelongtogether.org https://civilrights.org www.mpowerchange.org www.domesticworkers.org www.showingupforracialjustice.org www.unitedwedream.org https://actionnetwork.org/groups/raices-refugee-and-immigrant-center-for-education-and-legal-services www.theconsciouskid.org

For Mental Health Professionals www.bmhconnect.com www.melaninandmentalhealth.com www.therapyforblackgirls.com www.mylemarks.com/store/c32/Diversity_and_Inclusion_Worksheets.html

Developmental Lens (for Parents and Child Educators) Austin, N. (2018, February 15). Teaching your child about black history. PBS. Retrieved from www.pbs.org/parents/thrive/teaching-your-child-about-black-history-month. Bertucci, M. Y. (2020, June 2). Talking to kids about #blacklivesmatter. Retrieved from https://medium.com/@marissayangbertucci/talking-to-kids-about-blacklivesmatter-f21550566ded. Martin, M. (2020, June 4). How white parents can talk to their kids about race. Washington, DC: NPR. Retrieved from www.npr.org/2020/06/03/869071246/howwhite-parents-can-talk-to-their-kids-about-race.

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PODCASTS General Biewen, John. (2017). Seeing white [Audio podcast]. Scene on Radio. Retrieved from www.sceneonradio.org/seeing-white. Brown, B. (2020, June 3). Unlocking us: Brené with Ibram X. Kendi on how to be an antiracist [Audio podcast]. Retrieved from https://brenebrown.com/podcast/ brene-with-ibram-x-kendi-on-how-to-be-an-antiracist. Codeswitch [Audio podcast]. Washington, DC: NPR. Retrieved from www.npr.org/ sections/codeswitch. Crenshaw, K. (n.d.) Intersectionality matters [Audio podcast]. Retrieved from: https:// podcasts.apple.com/us/podcast/intersectionality-matters/id1441348908. Holmes, A., Thurston, B., Cepeda, R., & Colby, T. (n.d.). Our national conversation about conversations about race [Audio podcast]. Retrieved from www.showaboutrace.com. Leadership Conference on Civil and Human Rights. (n.d.). Pod for the cause [Audio podcast]. Retrieved from https://civilrights.org/podforthecause. New York Times. (2019, August 22–October 11). 1619 [Audio podcast]. Retrieved from www.nytimes.com/column/1619-project. Shapiro, A. (2020, June 18). “Interrupt the systems”: Robin DiAngelo on “white fragility” and anti-racism [Audio podcast]. Retrieved from www.npr. org/2020/06/17/879136931/interrupt-the-systems-robin-diangelo-on-white-fragility-and-anti-racism. Talking race with young children. (2019, April 26). Parenting: Difficult conversations. Washington, DC: NPR. Retrieved from www.npr.org/2019/04/24/716700866/ talking-race-with-young-children?fbclid=IwAR262i36JkNreR2lYg0pPPHDPL 9u6iyHSVkMV2vrR3Ehdl-1oG-0ZlXKMrY. Tippett, K. (2020, June 11). Eula Biss talking about whiteness [Audio podcast]. On being with Krista Tippett. Retrieved from https://onbeing.org/programs/eulabiss-talking-about-whiteness.

For Mental Health Professionals American Association for Marriage and Family Therapy. (2020, June 5). Episode 31: Healing racial trauma [Audio podcast]. Retrieved from https://aamft.org/podcast. Hamilton, A. (2015, November). Understanding your racial biases [Audio podcast]. Speaking of psychology. Retrieved from www.apa.org/research/action/speakingof-psychology/understanding-biases.

APPENDIX B

Resources on Gender and Sexuality in Play Therapy

FOR PROFESSIONALS, AGENCIES, AND SCHOOLS • American Psychological Association (APA) Toolbox to Promote Healthy LGBT Youth: The Safe & Supportive Schools Project: www.apa.org/pi/ lgbt/programs/safe-supportive/training/toolbox • Human Rights Campaign Glossary of Terms: www.hrc.org/resources/ glossary-of-terms • Human Rights Campaign Welcoming Schools Project: www.welcomingschools.org • Human Rights Campaign “All Children, All Families”: www.hrc.org/ campaigns/all-children-all-families • American School Counselor Association—Best Practices for Professional School Counselors Working with LGBTQ Youth: www.schoolcounselor.org/Standards-Positions/Position-Statements/ASCA-PositionStatements/The-School-Counselor-and-LGBTQ-Youth • APA Guidelines for Psychological Practice with Transgender and Gender-Nonconforming People: www.apa.org/practice/guidelines/transgender.pdf • APA Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients: www.apa.org/pi/lgbt/resources/guidelines • Substance Abuse and Mental Health Services Administration (SAMHSA): Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth: https://store.samhsa.gov/product/Ending-Conversion-TherapySupporting-and-Affirming-LGBTQ-Youth/SMA15-4928 • National Child Traumatic Stress Network (NCTSN): LGBTQ Issues and Child Trauma: www.nctsn.org/resources/lgbtq-issues-and-child-trauma • Play and Art Therapy Interventions for Gender Nonconforming Children and Their Families: www.lianalowenstein.com/article_gender.pdf 197

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• World Professional Association for Transgender Health (WPATH): www.wpath.org • GLSEN (Gay, Lesbian and Straight Education Network): www.glsen.org • Gender and Family Project—The Ackerman Institute for the Family (New York City): www.ackerman.org/gfp • Rainbow Access Initiative: www.raialbany.com • Center for American Progress: www.americanprogress.org/issues/lgbtqrights/view • Teaching Tolerance (Southern Poverty Law Center): www.tolerance.org

BOOKS FOR CHILDREN • Sometimes the Spoon Runs Away with Another Spoon Jacinta Bunnell • My Princess Boy (Cheryl Kilodavis) • It’s Okay to Be Different (Todd Parr) • William’s Doll (Charlotte Zolotow) • The Princess Knight (Cornelia Funke) • Pirate Girl (Cornelia Funke) • I Am Jazz (Jazz Jennings) • Being Jazz (Jazz Jennings) • You’ve Got Dragons (Kathryn Cave) • Tale of Two Mommies (Vanita Oelschlager) • Tale of Two Daddies (Vanita Oelschlager) • Heather Has Two Mommies (Leslea Newman) • Tomorrow Will Be Different (Sarah McBride) • Raising Ryland (Hillary Whittington) • Gender Born, Gender Made: Raising Healthy Gender-Nonconforming Children (Dr. Diane Ehrensaft) • Imagining Transgender: An Ethnography of a Category (David Valentine)

SUPPORT FOR LGBTQ YOUTH AND FAMILIES • PFLAG (Parents, Families, and Friends of Lesbians and Gays): https:// pflag.org • GLBT National Help Center: www.glbthotline.org • Trevor Project: www.thetrevorproject.org • TransYouth Family Allies: www.imatyfa.org • TransKids Purple Rainbow Foundation: https://transkidspurplerainbow. org • Family Acceptance Project: https://familyproject.sfsu.edu • Gender Expansion Project: http://genderexpansionproject.org



Appendix B 199

• Gender Spectrum: www.genderspectrum.org/articles/gender-spectrumgroups • Pride Institute (Minnesota): https://pride-institute.com • LGBTQ+ Care and Support: https://childrensnational.org/about-us/ourmission-vision-and-values/lgbtq-care-and-support • Whitman-Walker Health (Washington, DC): www.whitman-walker. org/youth-services • Boston Children’s Hospital and Child and Adolescent Transgender Center for Health: www.childrenshospital.org/centers-and-services/ programs/f-_-n/gender-services#

CONFERENCES FOR LGBTQ YOUTH AND FAMILIES AND PROFESSIONALS • Human Rights Campaign—Time to Thrive Conference: https://timetothrive.org • Gender Odyssey (Seattle): www.genderodyssey.org

Index

Note. f or n following a page number indicates a figure or a note. Abuse normalized, 121 of power, in schools, 132 sexual, 119–126 Adolescents; see also LGBTQ youth Internet use by, 174–175 introducing technological interventions to, 178–179 Adverse childhood experiences (ACEs), 19–20; see also Sexual abuse Advertising, antiracist, 44 Advocacy for LGBTQ youth, 102, 106–107 for undocumented immigrants, 128 Affirmative environment, LGBTQ youth and, 98–99, 103–104 American Academy of Child and Adolescent Psychiatry, principles for working with LGBTQ youth, 97 American Academy of Pediatrics, Family Media Use Plan and Media Time Calculator of, 186 American Civil Liberties Union (ACLU), 115 American Counseling Association, Advocacy Competency Domain of, 22 American Psychiatric Association, conversion therapy and, 92 American School Counselor Association, guidelines for working with LGBTQ youth, 98 American Sign Language (ASL) early exposure to, 155 research on use of, 160 Ancestors, veneration of, 68 Angelou, Maya, 43

Anger Coping Program, 136 Anti-racism, 3 discussing with children, 39 Anti-racism action, 32–37 combining with personal work, 34–35 Anti-racist, becoming, 49–55 Anti-Racist Baby (Kendi), 39 Anti-racist plans, White therapists and, 43–46 Anxious child, Coping Cat program for, 139 Apps (applications), 181 Art therapy, culture and, 3 Asian people, in Ecuador, 39 Association for Play Therapy, diversity guidelines of, 92–93 Attachment bond, between parents and D/ HH child, 162 Attention, deafness as culture of, 167–168 Attention focus, in D/HH versus hearing children, 157–158 Axline, Virginia, 14, 16

B

Biases about gender and sexuality, 92–93, 103 cultural, 6–11, 46–47 increasing awareness of, 43–46 racial, 6–11 of school administrators/staff, 132 self-examination of, 98 of white children/clients, 43, 60 Biblio/poetry therapy, culturally aligned, 68 Biculturalism, immigrant children and, 65–66 Bilingual child, case example of, 22–27

201

202

Index

BIPOC and access to services, 45 becoming allies to, 44 mental health system and, 42 oppression of, 33–34 support for, 36, 40 BIPOC therapists, and responding to racist beliefs, 49–50 Black, Indigenous, People of Color (BIPOC); see BIPOC Black children, school-to-prison pipeline and, 131–132 Black communities; see also BIPOC becoming allies to, 44 Black inferiority, myth of, 60 Black Lives Matter movement, 2, 34, 41 Black Parents Explain How to Deal with the Police, 36–37 Black people oppression of, 33–34 police violence and, 2 Brown children, school-to-prison pipeline and, 131–132 Brown communities; see BIPOC Brown v. Board of Education, 60 Bully hot lines, 143 Bullying; see also Culture of violence in schools; Violence defining, 132 of D/HH children, 163–164 group therapy and, 137–138 homophobic, 134–135 impacts on LGBTQ students, 134–135 indirect versus direct, 141–142 intervention programs for, 145 of LGBTQ youth, 91–92 in media, 131 prevalence of, 133–134 programs to counter, 136–138 student reporting of, 142 teacher and staff intolerance of, 140–141 therapy and play therapy and, 138–139 transphobic, 146 Bullying behavior, as prelude to crime, 147 Bullying Prevention Project, 137

C

Caregivers; see also Parent–child dyad; Parents virtual play therapy and, 183–184 Central America; see also Undocumented families of color unaccompanied youth from, 113 Child development, deafness and, 152 Child neglect, case example of, 7–11 Child sexuality, cultural attitudes toward, 121–122 Child-centered play therapy (CCPT) adaptation for D/HH children, 156–157, 165 client–therapist relationship in, 16–17

cultural considerations for, 17–21 ending sessions of, 26 introducing, 24–25 middle sessions of, 25–26 non-Western cultures and, 15 origins and characteristics of, 14–17 research on, 14–15, 17–18 Child–parent relationship therapy (CPRT), D/HH child and, 18–19, 153, 165–167; see also D/HH children; Filial therapy Children discussing racism/anti-racism with, 39 empowerment of, 59 immigrant, biculturalism and, 65–66 introducing technological interventions to, 178–180 meeting them where they are, 173, 188 play and interaction in technology culture, 174–175 racist beliefs of examples of, 47–49 possible responses to, 50–55 Children’s Online Privacy Protection Rule (COPPA), 185 Child–teacher relationship therapy (CTRT), 19–21 play therapy skills and, 27 research on, 20–21 Cisgender children bullying of, 146–147 safe school environment and, 140 Cisgender privilege, 98 Clark, Kenneth, 59–60 Clark, Mamie Phipps, 59–60 Clients, court-mandated, 46 Client–therapist relationship, CCPT and, 16–17 Clyburn, Jim, 34 Cochlear implants, controversy over, 158–159 Cognitive development, symbolic play and, 154–155 Colorism, 37 Communication with extra-linguistic behaviors, 158 implicit, 84–85 language issues and, 22–27 nonverbal, parent–child dyad and, 155 opening, with Ungame, 139 social media and, 175 in technology culture, 173–175 Community violence, school violence and, 135–136 Confidentiality, cultural differences and, 19 Conflict resolution, student training in, 137 Conscienciser, Fanon’s concept of, 62 Contemplative practices, 80 Conversion therapy, professional organizations opposing, 92 Coping Cat program, for anxious child, 139 Coping skills, of D/HH children, 163–164 Counseling, multiculturalism and, 13–14



Index 203

Court-mandated clients, 46 COVID-19 pandemic, virtual play therapy and, 182–184 Cultural anthropology, healing practices and, 79 Cultural background CCPT and, 17–21 drawing as expression of, 86–88 increasing therapist understanding of, 21–22 Cultural bias case example of, 6–11 child safety and care and, 46–47 Cultural encapsulation, breaking free of, 63 Cultural expressions, sharing, 68 Cultural identity, 4–5 active exploration of, 5–6 Cultural issues, in mental health services, 116–117 Culturally competent counseling, guidelines and standards for, 59–60 Culturally/racially attuned play therapy, 58–74 case example, 70–72 and culturally affirming play therapy interventions, 67–70 pathways toward, 61–67 adopting social justice agenda, 61–62 breaking free of cultural encapsulation, 63 decolonizing methods, 63–64 dismantling internalized oppression, 64–65 grounding in sociopolitical history, 61 processing race-based stress/trauma, 66–67 understanding immigrant biculturalism, 65–66 Culture art therapy impacts of, 3 collectivist versus independent cultures, 24 violating norms of, 63 of Deaf community, 153–154 Falicov’s definition of, 1 redefining, broadening definition of, 1–11 Trauma-Informed Expressive Arts Therapy and, 77–78 Culture of violence in schools, 131–151; see also Bullying case example, 146–147 child vulnerability and, 133–134 community violence and, 135–136 and data collection and analysis, 143–144 improving school safety and, 140–146 programs to counter, 136–138 victim characteristics, 133–134 and “zero-tolerance” policy, 137 Cyberbullying, 133 bias-based, 135

D

Daily Show with Trevor Noah, The, 34 Davis, Kiri, 60

Deaf community; see also D/HH children cultural issues and, 3, 153–154 and disability stigma, 153 Deaf intervention services, 152–153 and use of filial therapy or CPRT, 164–167 Deafness child development and, 152 child prevalence of, 152 as culture of attention and language development, 167–168 Depression, in LGBTQ youth, 92 D/HH children attachment and, 162 available services, 164–165 cochlear implants and, 158–159 contradictory information about, 161 filial therapy and, 152–153, 165–167 future studies of, 167–168 with hearing versus D/HH parents, 153–154 joint attention and, 157–158 language development and, 158 mental health challenges of, 154 parent–child relationship and, 163–164 parenting experience/stress and, 160–161 sign language and, 160 Diagnostic and Statistical Manual of Mental Disorders (DSM), social blunders of, 41–42 Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender and sexuality in, 93 DiAngelo, Robin, 38, 40–41 Discrimination, self-actualization and, 15–16 Doll play, racial/cultural identity exploration and, 69–70 Doll Test, 59–60 Drawings, culturally sensitive perspective on, 86–88

E

Earhart, Amelia, 94 Ecuador, racial bias and inequities in, 38–49 Electronic games for entertainment (EGE), 180 Electronic games for psychotherapy (EGP), 180 Emotions, cultural attitudes toward, 83 Empowerment developing sense of, 17 play-based games for promoting, 139 Ethnicity, as subculture, 2 Expressive arts therapy, 75–89 characteristics of, 75–76 as cultural lens for therapists, 82–86 culturally sensitive, 86–88 four-part model for, 78–82, 81f as implicit communications, 84–85 as nonverbal expression, 82–84 as sensory-based experience, 85–86 trauma-informed, 76–78

204 F

Family of D/HH child, 165–167 of LGBTQ youth, 99–101, 104, 106 conferences for, 199 resources for, 198–199 values and resources of, 6 Family Media Use Plan and Media Time Calculator, 186 Fanon, Frantz, 62 Feelings, expressing, with Ungame, 139 Feminist theory, gender concept in, 94 Filial therapy child-centered play therapy and, 156– 157 efficacy of, 152–153 with families of D/HH children, 165–167 research on, 166 Five Nights at Freddy’s (FNAF), 186–187 Floyd, George, 2, 66, 131 Foster care case example of, 7–11 children in, 46

G

Gaming, online, 174–175 Gaming addiction, WHO classification of, 185–186 Gay–straight alliance (GSA), impact on bullying, 136 Gender, nonconforming/fluid, 3 Gender and sexuality, 90–110 biases and, 92–93, 103 books for children, 198 case example, 102–107 identity development and, 93–96 introducing in playroom, 96–97 LGBTQ youth and, 91–92 neglect of, in children, 90–91 research and advocacy recommendations, 107–108 resources on, 197–199 support resources for LGBTQ youth and families, 198–199 Gender binary, 91, 91n1 Gender expansive, 94, 94n3 Gender fluidity, 94 Gender identity development of, 93–95 society’s expectations about, 96 Gender stereotypes, awareness of, 96–97 Gender Unicorn, 95f Genogram, for exploring cultural identity, 5 Gil, Eliana, personal and professional evaluation by, 37–41 Gingerbread Person Feelings Map, 146 Girl Like Me, A (Davis), 60 Gun-Free Schools Act of 1994, 137

Index H

Hammerstein, Oscar, 39 Healing-centered engagement, 76–78 Hearing impairment; see also D/HH children case example of, 7–11 congenital, 152 Heteronormative attitudes, 91, 91n1 Heteronormative privilege, 98 Hispanic immigrants; see also Undocumented families of color sociocultural factors affecting, 115–116 Homelessness, of LGBTQ youth, 92 Homophobic bullying, 134–135 How to Be an Anti-Racist (Kendi), 39 Human rights, multiculturalism and, 13 Human Rights Campaign, LGBTQ Youth Report of, 91

I

Immigrant children biculturalism and, 65–66 expressive arts and, 82–83 storytelling therapy and, 84–85 Immigrants attitudes and policies affecting, 111–112 life circumstances of, 3 undocumented, 22–24 (see also Undocumented families of color) Immigration enforcement, militarization and violence of, 112 Implicit communications, 84–85 Indigenous people, healing practices of, 79, 82 Institutional racism, 32–33 Internet adolescent use of, 174 advancements and abuses of, 2 confronting perils of, 184–185 gaming on, 174–175 Intersectionality, healing-centered engagement and, 78

J

Japanese Americans, oppression of, 34 Joan of Arc, 94 Juvenile detention, BIPOC overrepresentation in, 45

K

Kendi, Ibram books on racism, 39 on Light and Dark people, 37 King, Martin Luther, Jr., 34

L

Language barriers, visual expression and, 83 Language development behavioral problems and, 163 deafness as culture of, 167–168



Index 205

in D/HH children, 157–158, 159 symbolic play and, 154–155 Latin American culture, skin color in, 37–38 Latinx children case example of, 22–27 working with, 17–18 Lazarus, Emma, 111 Lewis, John, 34 LGBTQ children, best practices for, 97–102 LGBTQ clients, and trauma-informed therapists, 101, 106 LGBTQ+ community, resources on, 4 LGBTQ students, bullying of, 134–135 LGBTQ youth advocacy for, 102, 106–107 American Academy of Child and Adolescent Psychiatry guidelines and, 97 best therapist practices and, 98–102 case example, 102–107 conferences for, 199 family of, 99–101, 104, 106 leading by, 100, 105 psychoeducation about, 98, 103 safe space for, 99–100, 99n4 stresses of, 91–92 support resources for, 198–199 well-being of, 91–92 LGBTQ Youth Report, 91

M

Marginalized/oppressed groups, empowering children from, 59 Marketing, antiracist, 44 McIntosh, Peggy, 33 McWhorter, John, 40 Media racism in, 67 violence and bullying in, 131 Meditation, 80 Mehri, Momtaza, 32 Mental health, White privilege in, 41–42 Mental health profession, elitism of, 41–42 Mental health services BIPOC access to, 45 culturally sensitive, 116–117 financial barriers to, 45 for immigrant families, 116–118 negative experiences with, 18 and principles of trauma treatment, 117–118 Meritocracy, myth of, 35 Metaphor, in expressive art therapy, 84–85 Mindfulness, 80 Minority children and CCPT in schools, 19–21 working with, 17–18 Minority families CPRT and, 19 discrimination and, 18–19 Movement therapy, 79–80

Multicultural and Social Justice Counseling Competencies revision of, 14 therapist obligations and, 27 Multiculturalism definition and emphasis, 13–14 in play therapy office, 44 social justice and, 2–3 Multicultural/social justice framework, 13–31 Music, healing and, 80, 81f

N

National Center for Missing and Exploited Children, 185 National Center for Trauma-Informed Care, 77 National Child Traumatic Stress Network, 118 Native Americans, oppression of, 33–34 Navajo child, 83–84 NetSmartz, 185 Neuroscience, mental health applications of, 85 Neurosequential model of therapeutics, 117–118 Neutrality, guise of, 62 Nonverbal expression, expressive arts as, 82–84 Nonviolence, Black Lives Matter movement and, 34

O

Obama, Barack, 34 Obama administration, and support for ending conversion therapy, 92 Office of Refugee Resettlement (ORR), 114–115 Oppression internalized, 16 self-actualization and, 15–16

P

Parent–child dyad implications with D/HH child, 163–164 with same hearing status, 153–154, 162 Parent–child relationship, CPRT focus on, 18–19 Parenting style, culture and, 25 Parents and conversations about racism, 50 of D/HH child, 160–161, 166–167 D/HH versus hearing, 153–154 Peer mediation, student training in, 137 Pernet, Karen, 5 Perry, Bruce, 117–118 Person-centered theory, 14 Play; see also Play therapy; Symbolic play preoperational and nonverbal, 155 transformation in technology culture, 172–175 (see also Technology culture)

206

Index

Play therapist and acceptance of digital world, 175–177 and awareness of gender stereotypes, 96–97 best practices for, with LGBTQ youth, 98–102 and biases about LGBTQ clients, 93 and conferences on LGBTQ youth, 199 increasing self-awareness and, 55 and resources on gender and sexuality, 197–199 self-reflection on technology use, 177 Play therapy cognitive-behavioral techniques in, 139 decolonizing, 63–64 and freedom from social norms, 96–97 incorporating cultural values into, 68 introducing technology into, 177–182 with caregivers, 178–182 with children/adolescents, 177–178 research on technology in, 176 virtual, 182–184 welcoming technology into, 176–177 Play Therapy Game—B-Aware: Bully Awareness Game, 139 Play therapy interventions, culturally affirming, 67–70 Play therapy office, White privilege in, 42–49 Play therapy offices, environmental changes to, 43–44 Police violence, black victims of, 2 Popular culture, violence in, 131 Poverty, family impacts of, 19 Power, unearned, 33, 55; see also White privilege Power abuses, in schools, 132 Power differential, conditions of worth and, 15–16 Power relationship, in client–therapist relationship, 62 Principal, involvement in anti-bullying policy, 142–143 Prison, BIPOC overrepresentation in, 45 Privilege; see also White privilege cisgender, 98, 103 heteronormative, 98 therapist awareness of, 6 Professional development, technological interventions in, 176–177 Professional organizations and opposition to conversion therapy, 92 and working with LGBTQ clients, 97, 98, 107 Psychoeducation, about LGBTQ youth, 98, 103 PTSD, school violence and, 135 Puppet theater, racial/cultural identity exploration and, 69–70

Q

Queer theory, gender concept in, 94

R

Race bias, case example of, 6–11 Racial identity case example, 70–72 children’s awareness of, 59–60 receiving negative messages about, 64–65 Racial inequality, US history of, 33–34 Racial injustice, impacts on clients, 2 Racial oppression dismantling, 64–65 internalized, 64–65 Racial/cultural identity restorying, 69 through doll play/puppet theater, 69–70 Racism discussing with children, 39 impact on delivery of therapy, 45–46 institutional, 32–33 school discipline and, 3 self-actualization and, 15–16 systemic (see Systemic racism) Racist beliefs, children’s, examples of, 47–49 Rebecca’s Daughters, 94 Resources family, 6 professional, 3–4 Rogers, Carl, 14, 15

S

Saad, Layla F., 36, 56 Safety Internet use and, 184–185 in schools, 132, 140–146, 148 of transgender students, 140 Safety education programs, 185 Salvadoran immigrants case example of, 7–11, 118–127 Sand trays, for exploring cultural identity, 5 School environment, immigrant children and, 26–27 School safety, improving, 140–146 School shootings, 137 School staff, involvement in anti-bullying policy, 142–143 Schools CCPT interventions in, 19–21 creating safety and support in, 132, 148 creating systemic changes in, 22 and culture of violence, 3 (see also Culture of violence in schools) School-to-prison pipeline, 3, 131–132 Second Step—Middle School Version, 136 Self-actualization cultural context and, 15 optimal conditions for, 16–17 Self-reflection, moving beyond, 34–36 Sensory-based experiences, 85–86 Sex exploitation, cultural attitudes toward, 121–122



Index 207

Sexual abuse case example, 186–188 undocumented families of color and, 119–126 Sexual and gender minority (SGM) adolescents, and risk of suicide, emotional disorders, 134 Sexual identity D’Augelli’s model of, 95–96 development of, 94–96 Sexual orientation, biological influences on, 94 Sexuality, 3 Sign language; see also American Sign Language (ASL) appropriate choice of, 160 Silence, healing and, 80, 81f Simpson, O. J., 34 Skin color, White assumptions about, 37–38 Sliding scale fees, 45 Sloan, Dulcé, 34 Smartphones, adolescent ownership of, 174 Social injustice, therapist awareness of, 6 Social justice healing-centered engagement and, 78 mental health system and, 41–42 multiculturalism and, 2–3 Social justice advocacy, CCPT and, 19 Social justice agenda, adopting, 61–62 Social justice framework; see also Culturally/ racially attuned play therapy; Multicultural/social justice framework case example of, 22–27 conceptualization from, 21–25 Social media; see also Technology culture enhanced communication and, 175 Social messages, negative, 64–65 Social Skills Training, for bullying victims, 139 Sociopolitical history, grounding in, 61 Sound, healing and, 80, 81f South Pacific, 39 Speaking, cultural taboos and, 83–84 Spencer, Margaret Beale, 60 Stereotypes, responding to, 51–52 Storytelling, healing and, 80, 81f Stress race-based, 66–67 of undocumented immigrants, 113 Subculture, 11 defined, 2 emergence of, 2 types of, 4 Suicide risk, of LGBTQ youth, 92 Symbolic play, 154–157 child-centered, filial therapy and, 156–157 preoperational and nonverbal, 155 social functions of, 154–155 Systemic oppression, minority children and, 14 Systemic racism, 1–2

T

Tatum, Beverly Daniel, 32 Teachers, and intolerance of bullying, 140–141 Technology, inundation by, 3 Technology culture, 172–190 adult reactions to, 173 case example, 186–188 challenges and dangers of, 184–186 child and adolescent play and, 172–173 and intersection with play therapy, 173 introducing and implementing, 177–182 limit setting and, 173, 177 and perils of Internet, 184–185 therapist self-reflection on, 177 understanding child play and interactions in, 174–175 unhealthy technology use and, 185–186 virtual play therapy and, 182–184 welcoming into treatment, 176–177 Teletherapy, 182–183 Therapist–client relationship cultural influences on, 18 differing backgrounds in, 63–64 power relationships in, 62 Think First program, 137 Transgender children, 16 bullying of, 134–135 play therapy support for, 139 safe school environment and, 140 safety of, 140 Transphobia, 140, 146 Trauma expressive arts therapy and, 76–78 and immigrant countries of origin, 113 LGBTQ youth and, 101, 106 race-based, 66–67 Trauma-Informed Expressive Arts Therapy, 76–78 Trump administration, parent–child separation and, 112, 115

U

Unaccompanied Alien Children Program, 114–115 Undocumented families of color case example, 118–127 special considerations in, 120–122 treatment plan, 122–127 challenges for mental health services, 116–118 legal issues and, 126 and mental health needs of youth in custody, 114–115 mental health services and, 116–118 mother’s treatment and, 126–127 and needs of children and youth, 114–115 normalized abuse and, 121 parent–child separation and, 112, 115, 127 physical and sexual abuse in, 119–122

208

Index

Undocumented families of color (continued) play therapy and, 122–125 political context and, 112 risks and disappointments of, 127–128 sexual abuse and, 119–126 sociocultural factors, 115–116 therapist advocacy and, 128 therapist challenges and, 128–129 trauma treatment and, 117–118 Ungame, for opening communication/ expressing feelings, 139 U.S. Department of Health and Human Services (HHS), and mental health needs of youth in custody, 114

V

Victimization, of school children, 133–134 Victims, of bullying, 138–139 Video gaming adolescent use of, 174–175 in play therapy, 180 Vietnamese child, 82–83 Violence causes of, 131 community, school violence and, 135–136 school culture and, 3 Virtual play therapy, 182–184 Virtual reality (VR), therapeutic uses of, 181 Vygotsky, Lev, 65

W

Walker, Alice, 37 White bias, of children, 60 White clients, addressing biases of, 43 White Fragility (DiAngelo), 40–41 White play therapists anti-racism action and, 35–37 and doing better, 43–46 and responding to racist beliefs, 49– 50 White privilege, 3, 32–37 defined, 32–33 impact on delivery of therapy, 45–46 in mental health field, 41–42 moving beyond acknowledgment of, 34– 35 in play therapy office, 42–49 anti-racist plan and, 43–46 children’s racist beliefs and, 47–49 whiteness/white power and, 46–47 therapist awareness of, 6 World Health Organization, gaming addiction and, 185–186

Y

Youth of color, and race-based stress and trauma, 66–67 YouTube, as technological intervention, 182