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What’s Under the Anger?

What's under the anger?This is a nifty exercise to do with kids and I’ve had occasion to think about it lately so I thought I’d also write it up here.

Many of the kids I see are struggling with angry behaviors and getting to what lies under the anger is part of our process together. Depending on the child’s age and understanding, we do a modified version of this exercise.

First we talk about how angry is made up of lots of different emotions but figuring out which ones is tricky. So I tell them that we’re going to play detective and look at some different scenarios to figure out what’s going on under the anger.

I use index cards or slips of paper with the following emotions listed on them (these are taken from this Managing Your Anger poster).

  • Anxiety
  • Disappointment
  • Embarrassment
  • Fear
  • Frustration
  • Guilt
  • Hurt
  • Jealousy
  • Sadness
  • Shame
  • Worry

We go through the list and I make sure they have a basic understanding of what each one means. I also have blank cards available for children to add an emotion if they feel like there’s something missing. Sometimes they’ll want to add something that seems redundant to me, like Unhappiness. I’ll check in, does Sadness cover that or do they want to add it? Sometimes they won’t realize sadness is there or sometimes they’ll explain to me why Unhappiness is different and I get to learn something new about their experiences. Likewise if they say that Anxiety and Worry seem the same to them I tell them to just use whichever one they feel is the best fit.

To keep kids interested, we usually use figures or puppets to set the scenarios up. This might be acting out the scenario or it might just be placing the figures as a kind of panorama of what’s happening. This can be a lot of fun for them. I’ll say, “Ok, for this one we’ll need a sister or brother and a mom” and they giggle to pick out the people or animals who fit.

I try to choose stories that the children can relate to and I try to choose ones that come from real life. Something like:

–Amy wakes up super excited about going to the park but when she comes down for breakfast her mom tells her that it’s going to rain so they have to cancel the park date. What do you think is under Amy’s anger?

or

–Sebastian is supposed to play four square with his friend at recess but when he comes out after lunch is friend is already playing with someone else. What do you think is under Sebastian’s anger?

For older kids I might use more complicated scenarios:

–Cleo has been thinking about the slumber party for weeks and can’t wait to go. When she gets there she finds out that the other girls have been texting each other plans for the night but Cleo doesn’t have a phone yet so she wasn’t included. Now all the girls are giggling about something and they won’t tell Cleo what. What do you think is under Cleo’s anger?

–Dane studied super hard for the math test and thinks he did well. The next day the teacher calls him over and tells him that his answers were exactly the same as the student sitting next to him. Dane realizes that his friend must have copied the answers. What do you think is under Dane’s anger?

We do several of these with the child picking out the emotion cards that fit the situation. After they’ve done this we take a minute to contemplate what they’ve chosen. I always praise the child’s insight and we discuss those underlying emotions.

I don’t ask why they made their choices as in “Tell me why you chose Worried” because that can put some kids on the defensive. First I agree with them and then I might ask for more: “Yeah, frustration, I bet Sebastian was really frustrated! I’m curious about Fear, can you tell me more about that?”

I do not ask them what they’re missing or if they can think of one more because this exercise is to help them start feeling more confident about their ability to identify emotions (and sometimes it’s also a good assessment tool for me if I’m not sure where they are). If I do think there’s a glaring omission I might say, “This is really excellent. You’ve caught the Sadness and Frustration that might be under Amy’s anger. I wonder if she might feel Disappointed, too. What do you think?”

And we talk about it.

I usually do five or six of these generic scenes (with one specifically picked because the child will probably relate to it — for example, using a sibling scenario if the child struggles with anger towards a sibling). Using a generic but familiar scenario opens up the idea that we can come up with a scene from their own lives. Most of the time they’re willing to do this but if not, that’s fine.

Sometimes we invite a parent to come in and play the game to see if they can guess what feelings are under their child’s anger during a particular incident that’s come up in therapy and then the child gets to tell their parent what they got right and what they got wrong.

We can also talk about how Worried Anger might need a different response than Embarrassed Anger and we can come up with a game plan that the child can share with loved ones to help them deal with the next meltdown. If they’re not willing or able to talk about an incident from their own life or relate the exercise to their own experience we stay focused on other stories and I heap on the praise. If a child is having a hard time with emotional literacy than my goal is to build their confidence as we build their skills. Heck, if a child can identify one emotion — or can understand why I chose an emotion and help me talk about it — that’s a big accomplishment and sets the stage for more storytelling and emotional identification later on down the line.

Why Wonder Woman

wonder womanSome of you know that I have Wonder Woman all over my waiting room. Wait, scratch that. Some of you may know that I have Wonder Women all over my waiting room. I have artist renditions of different kinds of women — fat, thin, young, old, hip and matronly, different ethnicities — all as Wonder Woman. Some of them are very serious and dignified and some of them are silly. They are all awesome.

When I was first decorating my office I went back and forth about hanging them all up. If you’ve been to many therapist offices then you know that most of them are pretty neutral and I wondered if it would be too much of me there in the waiting room. I thought maybe I should go with a tasteful Pottery Barn neutrality or maybe just a touch of Ikea blank hipness. I thought about having, you know, a gentle beach landscape on my wall.

But then I decided that I am not really a neutral therapist. I mean, I crack jokes a lot. I’m not always all that dignified, much to my chagrin. So I figured that since the research says that our success depends on the relationship that we build together then we would all be better off if my clients knew what they were getting right up front and what they’re getting is someone who thinks it’s appropriate to have a comic book character all over her waiting room.

So why Wonder Woman? Why not Bat Girl? Or Buffy? Or some other out-sized heroine of justice and truth? Here is why.

When I was a kid my mom had a Wonder Woman picture hanging in our kitchen. (You can see it in my waiting room now — it’s the one on the wall you’re facing when you are heading into my play therapy room.) I wasn’t much for comic books and if I was reading a comic book it was much more likely to be Sabrina the Teenage Witch but I liked that Wonder Woman picture. I liked the TV show, too, and I liked the Saturday morning Super Friends episodes with her in them the most. I liked the idea of her. I used to run around my neighborhood pretending I was this character I made up, Shadow the Midnight Panther, leaping off my Huffy bike to fight the powers of evil. I’m not so sure that I would have invented Shadow if I hadn’t had Wonder Woman as an example. (The reason I was not actually Wonder Woman is that I really wanted a cape — Shadow had a cape — and I liked cats a lot and panthers are super cool.)

Later when I was a loud young feminist my mom mentioned that Wonder Woman was on the very first issue of Ms. Magazine. That’s when I realized that Wonder Woman meant something to a lot of women — not just to my mother and not just to me. I still liked her only now I liked that she was a touchstone. I liked that she reminded me of the terrible 70s fashion of my youth and of the specific feminism that I grew up with. (When I was little I would read Ms. and flip to the No Comment in back, then the “click” letters in the front and finally to Stories for Free Children.) That specific feminism taught me that it was OK to be angry, to be strong, to be outspoken and to have a sense of humor.

All of that is to say that Wonder Woman is hanging in my office as a way to share that I’m a feminist therapist. Now you don’t have to be a feminist to come see me — that’s the great thing about feminism, it very clearly says that we all get to be who and what we want and need to be — but I want people to know that they’re seeing a feminist therapist because, again, you should know what you’re getting right up front if you’re thinking about seeing me.

Very often clients will tell me that they saw a Wonder Woman thing — the book that just came out, a doll, a t-shirt — and they’ll say, “I thought of you!” But I’ll tell you the truth, I really hope that someday my clients will see Wonder Woman and think of themselves, of what they worked at and what they learned in our time together. I have all of these Wonder Women in my office because I want my clients to see their own strength and power and heroism. I want them to see themselves reflected in the Wonder Women on my walls.

I’ll add that while I do see men in my practice I mostly see women and kids — boys and girls. Someone — not a client — asked me why I don’t have male super heroes on my walls and my answer to that is that we get to see lots of male super heroes everyplace else. We get to see them at the movies and on television and on the shelves in our toy stores. I have nothing against male super heroes — I especially like Spider-Man — and you’ll find them in my sand tray toys. But I like to do my part to even out the representation in the world a little bit, which is why Wonder Woman gets the prime real estate in my office.

 

Note: I haven’t blogged the last two weeks because as some of you know I slipped on the ice and jammed my finger by sliding hand first into a curb. I think the technical term for what I did to my finger is “stoved.” It was my middle finger, which made wearing a splint super hilarious since just by wearing it I was inadvertently flipping the entire world off. The most annoying thing about it was not being able to type. Years from now when I’m filing away my client case notes I will notice that two weeks worth are all lower case, terse and filled with typos. I will see them and remember, “Oh yes, those were the splint weeks!” And I will once again be reminded to always be grateful for spring.

Toy Guns in Play Therapy

Toy Guns in Play TherapyI have a basket of miscellaneous toys on my shelf and the kids like to rummage through them. Most popular are the real cell phones even though they’re not smart phones. The kids really like the ones that slide out so they can “text”. There’s also a magic wand, some rubber balls and a toy gun. Toy guns in play therapy aren’t as controversial as, say, toy guns in preschool but they are still part of an ongoing discussion that play therapists have with each other.

We all agree that a fully stocked play therapy office needs to include some ways to be aggressive like rubber swords, dragon puppets, lion figurines or guns. Most of us are ok with guns and some of us are not. We have different ideas about what kinds of guns can be used (at the agency where I used to work we had Nerf-type guns that shot spongy “bullets”) and we have different rules about how they can be used (some therapists don’t allow kids to point a gun at the therapist and some do — my decision depends on context).

The gun I have looks an awful lot like the cowgirl cap gun my mom bought me from Sears to go with my red-with-white-fringes cowgirl Halloween costume. I think that was 1975 so this one is a little different — it has more plastic, less metal and it has the orange tip that they started adding to toys in 1992.

I chose this gun because it is so clearly a toy. It doesn’t look like a modern gun (it isn’t black, you have to cock it) and it doesn’t actually shoot anything. Lemme tell you, I got really tired of helping kids dig under chairs for those spongy yellow “bullets” so when I set up my own office I decided no Nerf-type guns.

Some kids are very excited when they find the toy gun. Other kids don’t care one way or the other. Very, very occasionally a child will tell me that he or she is not allowed to play with toy guns and ask me to remove it and of course I always respect this request and we talk about that.

My decision to allow toy guns in my play therapy office is indicative of my belief that kids should have a full vocabulary in the language of play. As a mother I struggled with gun play and it was something my friends and I discussed at length. We all fell on different sides of the decision — some of our kids had full arsenals and some weren’t even allowed to play with figurines that had guns attached to their tiny hands — but we all thought about it a lot. Other weapons like swords, knives, and bows and arrows didn’t cause us as much concern. I suppose there are vestiges of this struggle in my decision to use an anachronistic cowboy gun in my play therapy room. But I never considered not having a gun available to my clients.

Kids are smart. They get that the play therapy office is different then the rest of the world. They understand that the rules I have aren’t the same as the rules that  their parents or their teachers have. Children who aren’t allowed to use guns in the rest of their lives but who welcome the one in my basket are OK with leaving it there when they go. (Although they are usually super excited about showing it to their parents — sometimes they even run out to the waiting room with it when they find it!)

Some of the children I work with use the toy gun to work out feelings of helplessness or power by shooting my stuffed dragon or the picture of the guy doing a handstand on a horse that hangs above my couch. Some of them don’t use it at all but keep it near them while they work in the sand tray or color; having the gun nearby makes them feel safe.

Sometimes children shoot my Feelings poster (a grid of pictures featuring kids making faces to illustrate different emotions) often as an indicator of their own frustration at their inability to understand or name their own feelings.

Sometimes kids tell me who they would like to shoot or announce that they’re shooting someone while they aim into the middle distance. This can be upsetting for parents to witness but I liken it to an adult saying in my office, “I could kill my boss!” or “I wanted to throttle my brother-in-law!”

Often children just want to use the gun because they think it’s fun. This includes both the kids who can play with guns at home and those who aren’t allowed to. Some of them include it in their play because it’s part of a language that’s familiar to them. Others use it because it’s novel and they’re excited to explore. Many, many children glance at the gun, cock it and pull the trigger a couple of times and then put it back never to play with it again.

Frankly the cell phones are way more popular.

If you bring your child to see me and have concerns about the gun or any other toys I have in the playroom, I encourage you to bring it up.

Helping Kids with Anxiety

Helping Kids with Anxiety

This is Goldilocks. She’s having a tough time.

This is the final post in the 3-part series about helping kids with anxiety. I reserve the right to blog more about it in the future because it’s a big topic and this is so general. Onward! To the helping!

Cognitive Behavioral Therapy or CBT is the counseling modality of choice for kids (and adults) with anxiety. Research on effective anxiety therapies tend to focus on these three areas:

  • Understanding and addressing the physical response to anxiety
  • Recognizing and challenging the thinking errors that perpetuate anxiety
  • Using controlled exposure to the anxiety-provoking situation and practicing the tools

Again this is super simplified and super general. Kids (and adults) have diverse learning styles, challenges, expectations and histories so how this works will look very very different depending on the child. But to help you get the gist, I’ll use Goldilocks as an example. We all know her story, right? On the very off-chance you don’t, you can check out this short version so we’re all on the same page.

So let’s say Goldilocks’s mom brings her to me because she’s gotten very anxious since her disastrous meet up with the three bears. She’s having trouble sleeping, she’s having some bad dreams, she is having tantrums at the drop of a hat and she hates leaving her mom to get on the school bus because she’s afraid the bears will come break into her house. She also can’t bear the thought of eating porridge ever again and will fall apart if her mom serves it at breakfast.

The first thing we would do is talk about Goldilocks’s physical experience of being anxious. We would talk about how being chased by bears would rev anyone up but now we need to help her calm her body back down. We would talk about how since this happened every time her heart starts beating or she starts breathing fast that her body immediately thinks BEARS! even if she’s faced with something much less concerning like shoes that are hard to tie or being a little bit late for school in the morning. We would work hard on helping her identify where in her body she feels the anxiety — is it in her stomach? Does her chest feel tight? Does she make fists with her hands or does her mouth go dry? We would talk about relaxation techniques and figure out which ones work for her. She might start keeping a worry diary or we might make a list of everything that makes her anxious.

What I tell kids is that we’re going to be detectives and we’re going to work together to solve the problem of their worries. I am very strengths based (that means I encourage focus on what’s going right even as we are talking about what’s going wrong) so we would also discuss times they have managed their anxiety in the past so we can figure out what shores them up.

The next thing we would do is look at thinking errors (also sometimes called “negative cognitions”). Here are some super common thinking errors:

  • All or Nothing Thinking: If I make one mistake then I’m an idiot.
  • Catastrophising: If I don’t turn in this one homework, I will flunk out of school.
  • Overgeneralization: I fell down at the roller rink one; I will fall down forever.
  • Personalizing: It rained on my birthday because nothing ever goes right for me.
  • Discounting the Positive: Sure my best friend likes me but that doesn’t count because she’s my best friend.
  • Mind Reading: I know everyone on my soccer team hates me.
  • Labeling: I’m taking so long to learn to ride my bike because I’m uncoordinated.
  • Should Statements: I shouldn’t have such a hard time learning math. I should know how to wrap this present without help.
  • Emotional Reasoning: I am in pain therefore I am right and you are wrong. I feel guilty and that proves I’m a bad person.

There are more but you get the gist and probably these are familiar to you either because your child does them or because you do them yourself. (Some of these are so ingrained in our cultural way of thinking that to confront them can be like wandering around in the dark your whole life and then stumbling over a flashlight and realizing you can use it to find the light switch and actually turn on all the dang lights.)

This is where I think counseling can help. I know in my own family that I can tell my kids something over and over but when they hear it from somebody else they believe it. Part of this is that they get tired of the sound of our voices (I haven’t seen studies on this but anecdotally I can tell you that my children get tired of the sound of my voice) and part of it is because it’s easy to get defensive with our parents. At least it was for me when I was a kid and then a teenager. If my mom disagreed with me it was automatically an opportunity for me to argue with her but if another adult said the same thing, it was an opportunity for growth and better understanding.

Yeah, we parents get it coming and going.

BUT! Let’s not resort to Overgeneralization! Sometimes parents have a lot of success doing this work at home without a therapist and there are workbooks (note I haven’t reviewed these so I can’t recommend one in particular) to help parents help their kids. AND even when kids are in therapy, we really need the grown ups in their lives to help them do the work. (I see a child an hour a week. Their parents are the ones bearing witness to the other 167 hours.)

Anyway. That’s the cognitive part of CBT therapy and it can take awhile. We’re talking about challenging ingrained ideas that make perfect sense to the person thinking them. That’s HARD and it takes practice.

For lots of kids, this is when we’re really leaning on the play part of play therapy because every little step we take needs to be ensconced in trust, respect and acceptance, which means a lot of time just hanging out and enjoying each other. The play therapy space (and the talk therapy space) is a place to safety say anything and be anyone and sometimes anxious kids just need one place where they can come and PLAY away from their worries.

tumblr_lsne2yzAIw1qh59n0o1_250Particularly with anxious kids whose anxiety ends up all centralized in their need to Do Good and Be Good, too much CBT pushing just triggers their anxious need to perform well. So sometimes my office is all about creating an island where they can goof off a little and experience themselves in a new way.

I’m emphasizing the slow part of this time in therapy because sometimes parents get (understandably) frustrated. They want to see change. At the beginning they get some concrete tools (breathing, relaxation, etc.), which feels great and proactive but it’s not a cure all. And then at this point things slow down and they may not see the any progress. But progress really is happening. Not to mention that this is where grown ups start slowing down, too, because it’s one thing to hear about Personalizing but it’s another thing to really get it and see how that kind of thinking is actually impacting your life.

The other thing is that anxious kids (and adults) have had people trying to talk them out of being anxious for a long, long time and that can make people hold on to anxious feelings even more tightly. They don’t mean to do this but being anxious, which many of them see as being concerned or cautious or careful or responsible (“I study all of the time because I’m a good student and if I’m not anxious about it then I’m being irresponsible.”) and often they get a lot of praise for being “good” in other anxious ways. (Oh the perfectionist students I see in my office! The ones who are running themselves into the ground for the praise and academic rewards!) To ask them to give up this way of thinking, well, that’s scary. It takes time.

Goldilocks may say to me, “You know this is all well and good but the minute I let my guard down I’m pretty sure Papa Bear is going to come charging in here, paws waving, and I can’t risk it.”

And so we’d keep working on it.

The next step of CBT is taking it out into the world and confronting those anxieties. Remember we’re simplifying these steps and we’re making them look more clear cut than they are (although they’re presented pretty clear cut in the Coping Kids group because we have a curriculum but we will adjust it as needed).

Goldilocks and I would keep on playing detective, we’d see what’s working for her and where she gets stuck. Maybe her big issue is not being able to eat porridge. Maybe I would get an empty box of oatmeal to have in the play kitchen or maybe we’d pretend to feed breakfast to the dolls.  When she’s ready maybe we’d have ourselves some porridge together. We’d go slow and we would be mindful of how it feels. We would see any small move forward as a victory even if she never actually gets the spoon in her mouth for a long, long time.

Maybe I’d ask her mom and dad to take her for a walk in the forest and practice her relaxation techniques and see how that goes. She and I might might write a game plan beforehand that confronts the “what ifs” and has strategies in place for whatever scenarios she can imagine. Again, we’d go slow. She might only get herself out the door the first time and we’d applaud that step even as we think about how to get her off the stoop next time.

Or maybe she’d need to play out what happened, putting the bears in the sand tray and working to make sense of the event by playing out the scene over and over again, trying out new ways of experiencing it and new outcomes.

There are other more specific ways to deal with particular kinds of anxiety. Treatment for OCD, for example, is more complex. Which brings me to medication.

Medication for kids is a tricky thing. Although many family practice and pediatricians will prescribe medication, it’s best to seek out help from a child psychiatrist. But this is hard. Columbus — like lots of other areas — has a dearth of child psychiatrists and parents don’t always have time to go search one out. I encourage parents to have an ongoing conversation with their family physician and to be aware that having a psychiatrist becomes even more important as the child gets older because hormones can make getting the right meds in the right dose super challenging (and things can turn on a dime if someone hits a growth spurt).

Not all anxiety disorders NEED medication but medication can certainly make sense if a child is completely hamstrung by his anxiety to the point that he isn’t going to be able to participate in his therapy. (Some kids are so anxious that relaxation techniques aren’t going to be enough to get them to a place where they can do the cognitive work.) Or if her behavior is so problematic (tantrums, rages, violence) that the rest of her life is at a standstill then medication can make sense.

Ultimately this is a parenting choice and I support parents in making their own informed choices for their kids. I do think, though, that medication alone isn’t enough. We all need to learn how to function as our best selves within the gifts and limits of our particular personality make-up. Medication can help us get functioning but we still need to understand ourselves and how we work. We need to know how to get help.

Eventually, too, our children will be adults and will make their own decisions about how to manage their anxiety (since for most anxious people it’s part of their lifetime experience since our personality can be molded but we are essentially who we are) and getting therapeutic support gives them options.

I like the idea of saying to kids, “Hey, counselors are there to help us when we need it. You need to know how to find the right one for you and how to do the work of therapy and I will help you do that when you’re young so you can help yourself when you’re older.” So we can teach them how to be good consumers of therapeutic support by helping them find someone they like and feel comfortable with (because it all comes down to the rapport in the relationship).

This is a positive way to talk about anxiety and anxious temperaments. After all, some of us more athletically gifted and some of us need more help. Some of us are terrific musicians out of the gate and some of us need more practice. Likewise some of us have more struggles with anxiety or depression and that’s why we have therapists and that’s why we learn about medication options and that’s why we learn to take good care of ourselves.

Have questions? Let me know. Want to sign your child up for Coping KidsLet me know. (I’m trying to plan summer offerings so if Coping Kids is something you’d like your child to attend then, please let me know so I can email you when I get scheduled and also find out if there are particular days or times that might work for your family.)

First in the series: Anxiety in Kids

Second in the series: Child Anxiety Symptoms

Play therapy looks like playing

play therapyUsually I let my kid-clients decide whether or not they want their parents to come into their play therapy sessions with them. (Some situations require parents be an active participant but most don’t.) The littlest children always want a parent to sit in the room, which is absolutely fine.  The kids and I play together and the parents watch or read a book or play on their smart phones.

I know that sometimes parents are sitting there watching us have a tea party or race cars or build with blocks and thinking, “I drove all this way for this? Took time out of the day, got the other kids childcare, took time off of work, took my kid out of school for this?” Because play therapy looks an awful lot like playing.

I try to head this off by explaining how play therapy works at the intake session but it doesn’t always sink in. And then we’re all in the office together and their child is playing and I’m watching (because I don’t play unless I get invited to play — my job is facilitation and observation) and … well, I’m not surprised when the question comes up, “What exactly are you doing anyway? And how is it helping?”

What I tell parents is that talk therapy is facilitated exploration through discussion and play therapy is facilitated exploration through play. Play is how kids communicate.

What makes the play therapy space special are the same things that make the talk therapy space special:

  • Unconditional positive regard (I accept you, I appreciate you, I see the good in you no matter what you do or say);
  • Safety (with rare exception what you share is private and stays in that room);
  • Concentrated focus (I am paying sharp attention to what you do/say and trying to both understand you better and help you understand yourself better);
  • A commitment to helping you move forward (I am actively looking for ways to help you grow through your experience);
  • A particular kind of loaded environment (comfy chairs, quiet, tissues at the ready and specific toys that encourage sharing).

Unlike most adults and bigger kids who can learn through give and take discussion, young children lack the insight and the vocabulary that allows them to discuss their experiences and feelings. Through play they are able to share what is causing them concern and work through it.

Many of the children who come see me play the same game over and over, trying to make sense of something so they can move forward. Just as talking something out can help, playing something out can help, too.

A common example is a child who heads straight to doctor’s kit every session because she’s working out her feelings about her last well-child visit. Having an understanding witness who gives voice (through her unbiased observation) to the story helps the child take control of her narrative.

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