“How Do You Work With That?” A Breakdown of How I Work with Different Challenges in Child & Adolescent Therapy
One of the most common questions I get when talking with parents and caregivers is how I work with various challenges and symptom presentations. Listed below is a breakdown of common challenges and symptoms, and what our work will look like to address those things. Keep in mind, work is always individualized to fit each child’s needs, goals, strengths, and interests, but this is a preview of what work may look like. I am also neurodivergent-affirming in all of my work and keep in mind sensory supports that children may need in sessions and goals that are appropriate.
Anxiety
Anxiety can present in a variety of ways, including avoidance, frequent worrying, perfectionism, and/or panic attacks. I also find that manifestations of anger and aggression can have roots in anxiety and worry; this is because anxiety is a manifestation of a hyper-arousal response, commonly referred to as our fight-or-flight response, in our nervous system. My overarching goal when working with anxiety is to widen a child’s window of tolerance, or capacity, for big feelings and anxiety triggers. Anxiety and panic can feel extremely uncomfortable (and sometimes scary) in the body, and children’s first defense is often avoiding things that may elicit those feelings. Over time, this strengthens the fear and anxiety response because our brains get the message that whatever is causing us fear or worry really is unsafe. The thing that will decrease anxiety symptoms over time is learning how to sit with and manage those feelings and body sensations. In play therapy sessions, children will naturally explore big feelings and challenges, and this gives us a chance to practice experiencing those feelings and related body sensations, naming them to increase awareness of triggers and feelings, and try out various regulation strategies so children identify and practice new ways to respond to their anxiety, panic, and big feelings.
For a lot of children, it can be helpful to learn about the stress response and the nervous system so they have context for why they are feeling the way they do and understand that it’s a reaction that all humans are born with - some people just have more sensitive “alarm systems” than others. For younger children, bibliotherapy (or reading about these things) or using metaphors and art can be helpful. For older children, teaching can be more direct, and we can start to engage in nervous system mapping and really understanding triggers and coping strategies.
Whether through non-directive play or directive activities, we work together to identify the root causes of anxiety, widen a child’s capacity for those feelings and body sensations, and identify and practice strategies that work so children have new options for how they respond to their anxiety, panic, and big feelings. In caregiver meetings, we can discuss the root causes, potential changes to make at home and school, and ways to co-regulate. I’m a big fan of sending book recommendations and personalized visual aids home so children and families can practice skills outside of sessions.
Depression
Symptoms of depression are often a manifestation of hypo-arousal, or the nervous system’s shut-down response. Depression can present as extreme sadness, but it can also present as feeling incredibly numb and difficulty feeling any emotions, a lack of motivation, a loss of interest and pleasure in activities, feeling hopeless, and low self-esteem. Typically, step one when working with a hypo-aroused is creating a felt sense of safety in sessions and within the therapeutic relationship so children and adolescents can start feeling again. Emotions like sadness, hopelessness, worthlessness, pain, etc., can feel incredibly intense, so our nervous systems often go into numbing or shut-down mode to try to protect us, but this can lead to a “flattening” of emotional feeling and expression; we no longer feel those painful emotions, but we also can’t feel things like joy, excitement, contentment, etc. Similar to working with anxiety, it’s about widening a kid’s capacity for feeling emotions and body sensations again. No matter what challenges we’re working with, I always follow a kid’s lead so we’re experiencing a bit of the discomfort that’s necessary for growth, but not so much that it feels overwhelming for kids and they shut down even further.
Similar to anxiety, I often teach kids about nervous system responses and how depression is a manifestation of hypo-arousal, and is often our system trying to protect itself. We can explore the roots of depression, practice feeling safe feeling emotions and body sensations again, and identify and practice strategies to regulate either through non-directive play or with directive activities. Directive activities can include art, discussing specific questions and topics, using the sandtray, writing, etc.
Over time, we can identify in-the-moment strategies and daily strategies to use when kids (or their parents) notice depression symptoms and/or a hypo-aroused presentation. When children and adolescents are able to feel again, we can start to explore a kid’s interests, sources of joy, and the areas of life they feel most confident in to start fostering self-esteem.
Suicidality & Self-Harm
A lot of the interventions related to anxiety and depression could apply here, but I tend to take a more directive approach when working with suicidality and self-harm, especially in the beginning. Along with being a Certified Synergetic Play Therapist, I am trained in Collaborative Assessment and Management of Suicidality (CAMS), which helps monitor suicidality and discover the root causes of suicidality so we have a clearer picture of what to address throughout treatment. I often discuss with kids and adolescents that they likely feel hopeless and want something to change, but right now, it feels hard to imagine what to change or how to fix things outside of thoughts of suicide. With self-harm, I also assess the “benefit” that kids and adolescents get from it - this can sound counterintuitive, but people typically self-harm when they have no other strategies at their disposal and are getting something from it, whether that’s a distraction, feeling something when they’re numb, stopping their thoughts from spiraling, etc. When we understand what kids are gaining from self-harm, we can then identify alternate strategies that aren’t harmful to use instead, but deliver the same benefit. Whether we’re dealing with suicidality, self-harm, or both, we develop a safety plan together that really focuses on strategies and support people that kids can turn to in times of crisis.
Trauma & Major Life Changes
Trauma or children’s presentations when they’re going through stressors or major life changes, such as separation, divorce, or grief, can look many different ways. Some children exhibit more externalizing behaviors, such as power struggles at home and school or increased conflict with others. Some children exhibit more internalizing behaviors and start to have more negative thoughts about themselves and life in general. Children might start experiencing nightmares, increased anxiety and worry, start to experience somatic symptoms such as stomachaches, etc. My first step when working with trauma or supporting a child going through major life changes is to allow them to express in sessions how it’s impacting them, either verbally or through play. As adults, we can often make assumptions about how a child is feeling or how something is impacting them, but we might miss something if we come in with assumptions. Using Synergetic Play Therapy, we can meet children where they’re at and better understand their perspective, feelings, and what feels most challenging.
From there, sessions can look a variety of ways. Step one for children dealing with trauma and extreme stress is often creating a safe space in sessions and safety within the relationship so we have a strong foundation for the rest of our work. Other interventions may look like:
- Supporting children to widen their capacity for intense feelings so they can better manage traumatic stress reactions or big feelings. In non-directive play sessions, we have ample opportunity to name feelings and experiences that are emerging to build awareness and model regulation strategies so children learn new ways to respond to feelings and challenges.
- Safely increasing interoception (or the ability to feel and understand internal body cues). Trauma can impact a person’s ability to feel into their body, but if kids can’t feel body sensations associated with their different emotions, this often means they don’t feel anything until it’s incredibly intense - this can lead to that “0 to 100” presentation that parents often describe. When children can feel and understand their body sensations, that means they can identify and express their feelings and figure out what strategy they may need to regulate.
- Providing education about the stress response, nervous system states, and trauma so children have context for their feelings.
- Supporting parents and caregivers in how to discuss trauma and/or major life changes in a developmentally appropriate way so things can feel open but still safe.
- Processing trauma and major life changes through play, art, or narrative. Traumatic memories can often feel “stuck” until they’re processed and integrated into a larger narrative.
- For older kids and adolescents, exploring core beliefs, where they come from, and how to change them if they feel ready to.