|Utilizing Recreation Therapy as Part of the Treatment Model|
|Christin Santiago-Calling, CTRS|
Director of Recreation Therapy, The Whitney Academy
When we look at
the effects of trauma, neglect and abuse on adolescents, we see lasting and
pervasive effects. One of the largest
impacts tends to be in socialization, and the ability to form positive and
reciprocal relationships. Often, they struggle to build trust, have low
self-esteem, question their competence and see the world as a dangerous place;
all of which impede ones’ ability to build relationships. Many prefer social isolation as a coping
mechanism, though what they often desire most is social integration.
Although I will
go into more specifics later, the overarching theme in the literature is that
these negative experiences impact on the brain and greatly impede the ability of the traumatized
individual to control their arousal and behavior, which also greatly impacts
their ability to form relationships (Cohen, Perel, DeBellis, Friedman, &
we are taught language-based methods to assist clients in dealing with the
effects of trauma, and ways to cope with stressors in an attempt to lead safer
and more productive lives. While these
methods may work for some individuals, research is finding that adolescents
especially, are responding more positively to body-based interventions, and
interventions utilizing Recreation Therapy (RT) techniques (Arai, Mock, & Gallant, 2012)
Therapy is a systematic process, which utilizes activity-based interventions
with the aim of improving the psychological and physical health of the
client. RT interventions are
goal-oriented, strengths-based and are whole-person centered, focusing on
improving the physical, emotional and psychological well-being of the
client. Interventions range from sports,
games, dance, music, drama, arts and work with animals. The main purpose of the activity is a
clinical goal, rather than pure enjoyment, which is what distinguishes RT interventions
from simple leisure activities.
interventions may address many of the same clinical goals as traditional trauma
talk therapy, such as shame, guilt, emotional regulation, problem solving,
impulse control, self-worth, risk taking behaviors, executive functioning,
effective communication, stress reactions, competence and sensory
integration. An important difference
being that RT interventions are on the surface “just for fun”. This allows the
client to participate fully without feeling “assessed”, giving the clinician
greater insight into the client.
Brain Development Impairments
We know that
traumatized and neglected children suffer from deficits in brain
development. Studies have shown reduced
volume in the hippocampus, corpus callosum and cerebellum, as well as a smaller
prefrontal cortex, an overactive amygdala and abnormal levels of cortisol in
the brain (Perry, 2009)
impairments lead to decreased learning abilities, decreased ability to self-regulate
and soothe, reduced hemispheric integration, reduced motor coordination,
reduced executive functioning, reduced emotional and behavioral control, an
overreaction to stimuli and an abnormal reaction to stress (Perry, 2009)
have been traumatized may lack impulse control, and are often easily flooded,
vigilant and guarded, dysregulated behaviorally and emotionally, and struggle
with language-based instruction. They
tend to endorse low self-esteem and self-worth, hopeless and powerless, and may
exist in “survival mode” whereby they attempt to manage what they perceive to
be a very dangerous and threatening world (see van der Kolk, 2003).
brain deficits occur, given the brain’s plasticity, changes may occur with
intervention. Although there is no
evidence to date, this writer’s hypothesis is that RT interventions may work (in)directly
to repair and restore brain connections to overcome the effects of trauma.
Using RT Interventions to Address Brain
interventions are multi-sensory and body-based, they can be used effectively to
overcome deficits in brain development as a tool to manage responses to the
effects of trauma. RT interventions can
be designed to address the following objectives: hemispheric integration, sensory integration,
executive functioning, emotional and behavioral regulation, motor coordination
and situational responses to perceived stressors. This article will look at four RT activities,
which have been developed by the author, to illustrate the specifics of how such
interventions may impact and augment recovery from trauma.
activity of adolescent clients is “Gotcha”.
The setup of “Gotcha” is as follows:
the group stands in a circle. The
facilitator prompts the group to place their right thumb (thumbs down) into the
open left palm of the person standing next to them, just touching the
palm. When the facilitator calls the
“magic number”, 3, all must pull their thumb away while grabbing the thumb that
is touching their own palm. The result
is the ultimate in multi-tasking, pulling your thumb while remembering to grab
the other thumb.
addresses multiple areas of deficit. The
most predominate is hemispheric integration.
Since the left and right hands of the clients are tasked with doing
different things, the activity increases connections between the left and right
hemispheres. Any activity that crosses
the midline of the body, works to enhance hemispheric integration, and
therefore increases the volume of the corpus callosum. Beyond this, executive functioning is
developed, through the ability to focus on the “magic number” and reacting
appropriately to it. Sensory
integration, specific to touch, is also an important part of this activity. The activity calls for the clients to touch
each other in safe, but unfamiliar ways, therefore allowing the clinician to
assess comfort with touch and safety with touch within their clients. Furthermore, this activity allows the client
to address motor control, as well as controlling arousal.
The setup of
“Up Chuck” is as follows: the group
stands in a circle. The facilitator
empties a large bag of soft throwable toys (stuffed animals, soft rag balls,
stress balls, etc.) onto the floor and instructs each member of the group to
grab at least two items. One person
begins in the middle of the circle. The
facilitator instructs the group that on the “toss” command, the entire group
should toss their items into the air with the intent that the person in the
center of the circle can catch the items.
The person in the center is asked how many items they think they will
catch, and then asked if they are ready.
Once ready, the facilitator says, “one, two, three, toss”, and then the
group tosses their items toward the person in the center. After a few rounds of one person, add more
people to the center to catch items.
Chuck” many brain areas are being activated.
The most salient function is the sensory aspect to this game. Many of our clients have never had the
sensation of having safe and soft items fall all over them, similar to the
feeling of jumping into a ball pit. Many
clients who participate in this activity report feeling safe and secure as the
soft toys rain down upon them. Beyond
the sensory aspect of this game, the client has the opportunity to experiment
with various strategies to increase their success, allowing for creativity,
choice and safe failure. “Up Chuck” also
provides the client with the chance to increase motor control and how they use
their bodies in space, both of which can be areas of deficit with relation to
trauma and brain development. This is
often a new sensory experience for them, and assessing how they react to it is
a valuable tool for the clinician. Also,
this activity addresses making realistic or unrealistic goals and problem
solving strategies to meet those goals; and seeing what happens when we do not
meet our goals is valuable to the assessor as well. Watching the strategies of others that have
gone before, and evaluating their effectiveness is an executive function that
many of our clients lack, but one that is highly beneficial. Lastly, this activity allows those doing the
throwing to have a helper role to those in the middle. As a clinician, that is valuable information,
and it provides clinical direction and a framework for further discussions in
both individual and group work.
Human Pyramid Challenge
Pyramid Challenge”, the group leaders instruct the group that they are tasked
with making as many human pyramids as possible within a given time frame (30
seconds). Give no time for questions or
strategies, and simply say, “ready, go” and watch your watch. With each human pyramid, the facilitator
should offer brief praise (yes!, nice!) and keep a count of each pyramid. Once they realize that any triangle they make
with their bodies count, the creativity ensues.
After the first 30 seconds, challenge them to beat their time and run
the activity again.
Pyramid Challenge”, validation, problem solving, creativity and hemispheric
integration are the main drivers of this activity. Since the activity prompt is vague, it allows
for the clients to create their own version of what is meant by a “Human Pyramid”. And once the first is attempted and accepted
by the facilitator, it allows for more creativity and greater risk taking
within the bounds of what constitutes a human pyramid. Many of our clients externalize their treatment
success onto their clinicians, and look to us for the answers.
When presented with an ambiguous task, it often causes frustration and
anxiety initially. Again, this is an
excellent way to assess how clients handle those feelings, and what they do to
cope with, and overcome them. By
validating their efforts, they feel increased competence and confidence, which builds
self-worth. There is a measurable
difference in the demeanor before and after completing this activity (Barry
& Meisiek, 2010).
Have you Ever?
In “Have you
Ever?” each person in the group stands in a circle and is given something to
stand on (poly spots, pieces of paper, etc.).
The facilitator does not have anything to stand on. The facilitator tells the group that the game
is similar to “Musical Chairs” in that each person has a spot, except for one
person. The person in the middle asks a
question to the group, “Have you ever…” and fills in the blank with something
that they have done. The answer to their
own question must be yes, which will allow them to move. A “yes” answer to the question allows you to
leave your spot and find a new spot, a “no” answer allows you to stay on your
current spot. If a group member chooses
not to answer the question, they can just stay on their current spot. For example:
the person in the center of the circle asks the group, “Have you ever
eaten pizza?”, for those that have eaten pizza, they move from their spot and
find a new spot, those that have not eaten pizza stay put. The person that has no spot, is the new
person in the middle and asks a new question.
After a few rounds, challenge the group to ask clinically driven
“Have you Ever”
offers an activity with the potential for the most overt clinical application
for the client. Initially, the questions
posed are often superficial in nature, allowing for a sense of belonging and
normalcy. Once those feelings are
established, moving on to more clinically driven questions is highly
beneficial. Allowing clients to ask the
questions is a powerful way to derive what they are thinking and feeling based
on their own comfort. They have the
choices of what to ask, and more importantly, what to answer, in a
non-judgmental and non-confrontational manner.
Since answering the questions involves moving rather than speaking,
clients often feel freer to answer questions they might otherwise avoid. When questions are hard to come by or there
seems to be something being held back, the facilitator can find a spot to ask
the question of the group, which tends to open up a new direction of
questions. Clients typically really
enjoy this activity, and will often request to play it again and again.
to this activity: take away one or more
spots to have multiple people in the center, and an “all answer”.
By taking away
one or more spots, it forces more than one person in the middle, and they must
find a question that they all can answer “yes” to. The adaptation builds commonalities, and
group development. Beyond that, it gets
them talking to each other about issues in a manner that is safe and
An “all answer”
can be used when a question is too sensitive for the group members to answer in
the activity. Rather than move from
their spots, the person in the center calls for an “all answer”. When this is called, all group members turn
and face out the circle and put both hands behind the back, facing the person
in the center of the circle. If they
choose to answer “yes” to the question, they open one hand and keep one hand
closed in a fist. If they choose to
answer “no” to a question, they keep both hands closed in fists. This allows a safe way to answer more
RT at Whitney Academy
is a 50-bed residential treatment center for adolescent boys aged 10-22. There is a self-contained school and four
residences in the local community.
Clients at Whitney Academy are all dually diagnosed, have histories of
trauma/abuse/neglect and have a sexualized behavior problem.
Academy, RT is seen as one of the most important interventions in the
program. The RT program is used
throughout the Academy, across all disciplines.
During the school day, RT interventions are used in the classrooms, as
well as form the basis of the Physical Education program. Medically, RT interventions are often used to
assist with behavior regulation, weight management, sensory issues, and
treatment of various diagnoses (for example:
ADHD, depression, anxiety, ASD).
In the residences, RT interventions are used as part of the daily
schedule and routine. RT groups are held
daily, with community trips and life skill focused programming occurring on
weekends. Also within the RT program,
traditional sports are offered as part of Special Olympics of Massachusetts,
where RT principles guide the athletic team development, and are coached by RT
clinicians. Within the clinical
department, RT interventions are used as part of the clinical treatment model,
and RT staff often co-lead group therapy sessions. RT plays an integral role in meeting the
clinical, residential and academic needs of the clients at Whitney
Important Factors for Successful RT
Planning is the
single most important factor in using RT interventions. Plan for every possible outcome, and have
backup plans for your backup plans. Even
if most of the plans do not get used, having them will increase the confidence
of the facilitator, which will translate to the group. The more confident you, the facilitator feel,
the more safe the group will feel.
Understand the limits to what you can do with time, setting, and
equipment, and plan activities that can be done within those limits. Having a plan will help to avoid the biggest
threat to successful RT interventions:
facilitators do not feel confident in their abilities, or when they do not
trust their group, they tend to overcompensate and become helicopter
facilitators, who attempt to fix every problem, and create every solution. Effective facilitation allows for the group
members to dictate the direction and find their own solutions to problems. As clinicians, we tend to want to be leaders,
in RT interventions, we have to facilitate the learning, rather then teach
it. Allowing clients the freedom to make
choices, to take on leadership roles and problem solve on their own allows for increased
feelings of competence, which leads to increased confidence and
self-esteem. Their learning is
internalized to their own abilities and skills, rather than externalized to our
instructions. Things will go wrong, but
that is often where the learning occurs.
Allowing clients to fail in a safe environment, will foster a sense of
trust and allow for more risk taking within their clinical work. Connections that are made will be their
connections, and therefore have greater meaning to the client. Giving them the sense that you trust that
they will be safe and that they can handle these activities will be met with
the clients being safe and rising to the expectation.
proposes that effective use of RT interventions will lead to more effective
trauma work for both the client and the clinician. Goals will be achieved faster, and the work
will be deeper and more meaningful.
Adding one activity per group will lead to better buy in from the
clients, and more enjoyment from all involved.
Clients will look forward to the interventions, and will develop in ways
not seen in traditional clinical work; and, it is fun, and isn’t having fun
while doing our professional and clinical work a wonderful thing?
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S. E., & Gallant, K. A. (2011). Childhood traumas, mental health and
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Adventure Games, Initiative Problems, Trust Activities and a Guide to
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Perel, J., DeBellis, M., Friedman, M., & Putnam, F. (2002). Treating
traumatized children: Clinical implications of the psychobiology of
posttraumatic stress disorder. Trauma,
Violence & Abuse, 3(2), 91-108. doi:10.1177/15248380020032001
& Shank, J. (2010). Therapeutic Recreation Service: Principles and Practices. Wm. C. Brown Publishers.
Perry, B. (November
4, 2009). Understanding the Effects of Maltreatment on Brain Development. Child Welfare Information Gateway.
(1984). Silver Bullets: A Guide to
Initiative Problems, Adventure Games and Trust Activities. Kendall/Hunt Publishing.
van der Kolk,
B. A. (2003). The neurobiology of childhood trauma and abuse. Child and adolescent psychiatric clinics of
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About the Author
Santiago-Calling is a board certified Recreation Therapist, and is the Director
of Recreation Therapy for the Whitney Academy.
She has worked at Whitney Academy for 11 years, 8 of which have been in
the role as Director. As the Director of
Recreation Therapy, she has taken the department from a once per week group,
into the full department that now exists.
The RT department offers seven traditional sports, daily RT groups,
weekly community integration trips, weekly life skill groups, daily PE,
co-leading group therapy and social skills groups, and various weekly club
Beyond her work
at Whitney Academy, Christin is also on the Board of Directors for the National
Adolescent Perpetration Network.
Christin has also presented her work at conferences throughout the US,
Canada, Sweden and England. She has done
consulting work to bring RT services to other organizations, as well as
utilizing RT interventions within various clinical and recreational