Vol. XXIX, No. 4
Fall 2017
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In This Issue
Regular Features
Editor's Note
President's Message
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Why is Juvenile Polygraph Not Recommended by ATSA?
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Responding to Problematic Technology Use:
Creating a Therapeutic Toolbox
Looking After Ourselves and Each Other
Utilizing Recreation Therapy as Part of the Treatment Model
Understanding and Preventing Adolescent Pedophilia TEDMED Talk
Step One of Cultural Competency Addressing Privilege & Power
Students' Voice
Assessment of Deviant Preferences Using Novel Behavioral Assessment Procedures
A Studentís Guide to the ATSA 2017 Conference
Book Review
RNR Principles in Practice In the Management and Treatment of Sexual Abusers
ATSA News
2017 ATSA Conference Events
Preventing Harmful Sexual Behaviors in Youth: An Infographic from the ATSA Prevention Committee
Welcome Incoming Board Members
2017 ATSA Awards
ATSA Professional Code of Ethics 2017 Revisions and Additions
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Contact the editor or submit articles to:

Heather M. Moulden, Ph.D.
Forensic Program
St. Joseph's Healthcare
Hamilton, Ontario, Canada
E: hmoulden@stjoes.ca
P: (905) 522-1155 ext. 35539
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, & Putnam, 2002).

As clinicians, 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)

Recreation Therapy

Recreation 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. 

RT 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)

These 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)

Individuals who 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). 

Though these 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 Deficits

Because RT 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. 

Gotcha

A favorite 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. 

“Gotcha” 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. 

Up Chuck

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. 

Within “Up 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

In “Human 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. 

In “Human 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 questions.

“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. 

Two adaptations 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 non-threatening.

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 sensitive questions. 

RT at Whitney Academy

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.

At Whitney 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 Academy. 

Important Factors for Successful RT Interventions

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:  helicopter facilitation. 

When 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. 

This writer 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?

References

Arai, S. A., Mock, S. E., & Gallant, K. A. (2011). Childhood traumas, mental health and physical health in adulthood: testing physically active leisure as a buffer. Leisure/Loisir 35(4), 407-422.

Butler, S., & Rohnke, K. (1995).  Quicksilver:  Adventure Games, Initiative Problems, Trust Activities and a Guide to Effective Leadership.  Sage Publications.

Cohen, J., 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

Kraus, R., & 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.

Rohnke, K. (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 North America, 12(2), 293-317.

About the Author

Christin 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 offerings. 

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 models. 

 

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