Table Of ContentHELPING ABUSED AND TRAUMATIZED CHILDREN
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Helping Abused and
Traumatized Children
Integrating Directive
and Nondirective Approaches
ELIANA GIL
Foreword by John Briere
THE GUILFORD PRESS
New York London
©2006TheGuilfordPress
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LibraryofCongressCataloging-in-PublicationData
Gil,Eliana.
Helpingabusedandtraumatizedchildren:integratingdirectiveandnondirective
approaches/ElianaGil.
p.;cm.
Includesbibliographicalreferencesandindex.
ISBN-10:1-59385-334-3 ISBN-13:978-1-59385-334-1(cloth)
1. Childabuse—Treatment. 2. Playtherapy. I. Title.
[DNLM:1. ChildAbuse—therapy. 2. Child. 3. FamilyTherapy—methods.
4. PlayTherapy—methods. WS350.2G463h2006]
RJ507.A29G5522006
618.92′891653—dc22
2006010324
Dr. William Friedrich, you were a man of great humility
and integrity. I learned so much from you.
Your quiet and powerful leadership has inspired
and guided me. I am proud to have known you
a little, exchanged ideas with you, and had a few laughs.
I feel your absence and revere your substantial legacy.
About the Author
ElianaGil,PhD,isDirectoroftheStarbrightTrainingInstituteforChild
and Family Play Therapy and dedicates some of her time to providing
intensive courses on assessment and treatment of child abuse. She also
worksattheMulticulturalClinicalCenterinSpringfield,Virginia,where
sheisdevelopingTheChildren’sCornertoprovidementalhealthservices
for young children with a range of problems, including child maltreat-
ment. Dr.Gilhasfocusedherworkonhelpingsexuallyabusedchildren
and families for the past 33 years in California, Maryland, and Virginia.
She teaches courses on child maltreatment, play therapy, and family
therapyatVirginiaTechandhasauthoredseveralbooks.Originallyfrom
Ecuador, she is bilingual and bicultural.
vi
FFoorreewwoorrdd
Foreword
T
helastseveraldecadeshavewitnessedadramaticincreaseinour
knowledge of the impacts of trauma on children and adolescents. We
have discovered that child abuse and neglect by parents and other
caretakers—as well as victimization by peers and adults in the commu-
nity—canleadtooutcomesrangingfromanxietyanddepression,insecure
parent–childattachments,andposttraumaticstress,toaggression,interper-
sonal problems, eating disorders, substance abuse, and self-endangering
behaviors.Infact,itmaynotbetoomuchofaleaptosuggestthatexpo-
sure to trauma and emotional neglect is one of the prime causes of
nonorganic psychological disturbance in North American children and
youth.
At the same time, however, we have increasingly discovered that
nothingisassimpleasacursoryreadingoftheliteraturemightsuggest.
Forexample,wenowknowthattheextenttowhichachildoradolescent
developstrauma-relatedsymptomsisacomplexfunctionofanumberof
potentiallyinteractingvariables.Theseminimallyinclude(1)predisposing
factors, such as the child’s initial neurobiology; the quality of his or her
parentalattachments;broadersocialvariables,includingthechild’srela-
tive experience of racial or ethnic discrimination, poverty, and dimin-
ished resources; and cultural or subcultural influences on his or her per-
ceptionsofself,others,andthenatureofadversity;(2)characteristicsofthe
trauma(s), including the type, number, duration, and age of onset of
trauma exposure—with multiple, early, and extended experiences of
intrafamilialabuseandneglectbeingamongthemostpathogenic;and(3)
posttrauma variables, such as overall level of familial and social support;
vii
viii Foreword
the child’s capacity for emotional expression and help seeking; relative
safety from further violence or maltreatment; and whether appropriate
psychological treatment is available.
Theimplicationsofthesevariousinteractingvariablesfortheyoung
traumasurvivor—andforthosewhowouldtreathimorher—areimpor-
tant.Becauseeverychildhas,tosomeextent,adifferentbiology,psychol-
ogy, perceived family environment, social context, trauma history, and
postvictimizationexperience,eachisalsolikelytohaveadifferentsymp-
tomaticpresentation.Onechild,withahistoryofpositiveattachmentre-
lationships in the context of caring and nonabusive child rearing, a be-
nign social environment, and a relatively circumscribed and limited
trauma by a nonparental figure, may experience only mild anxiety, tran-
sient posttraumatic stress, and/or a limited period of social withdrawal.
Anotherchild,raisedbydisengaged,neglectful,and/orabusivecaretak-
ers in the context of poverty and social deprivation, who has been ex-
posed to repetitive traumatic experiences within and outside of the fam-
ily, may experience severe depression, posttraumatic stress disorder,
substance abuse, and episodes of suicidality or aggression.
Obviously, these two scenarios require different intervention strate-
gies, since treatment must address different symptoms, etiologies, social
issues,andpersonalitystylesineachcase.Inthefirstinstance,thefamily
system is stable, attuned, and supportive. The therapist may easily in-
volve the parents and other family members in assisting the child, and
the treatment plan may be relatively straightforward. Family therapy
may be used to augment play, art, or “talk” therapy (depending on the
ageofthechild),duringwhichthechildisencouragedtoprocessmemo-
ries of the traumatic event until they no longer evoke symptomatology.
Because the child is not overwhelmed by posttraumatic symptoms and
hasahistoryofbeingabletotrustandrelyonadults,heorsheislikelyto
engage in treatment without undue hypervigilance, avoidance, or func-
tionalimpairment.Allotherthingsbeingequal,theimmediateprognosis
for this child is likely to be good.
Sadly, most therapists who deal with traumatized youth are more
likely to see the second scenario: a highly symptomatic child or adoles-
cent in a relatively unsupportive (if not hostile) environment who has
learnedtodealwithtraumaeitherthroughavoidanceorvia“acting-out”
responses.Further,becauseheorshehaslearnedthatadultscanbedan-
gerous, and that emotional attachment is a recipe for potential abandon-
ment, this second child may not easily permit the development of a
meaningful therapeutic relationship, let alone fully participate in serial
experiences of vulnerability in the context of an authority figure. More
than for others, therapy for this child will have to take his or her rela-
tionalinjuryintoaccount;theclinicianmustprovidedemonstrablesafety,
Foreword ix
relationalconsistency,andempathicattunement,andmayhavetobees-
pecially patient with the client as his or her triggered trauma responses
impinge on the therapeutic process. Further, the multiple targets of treat-
mentinsuchcases(e.g.,yearsofchildhoodsexualabuseand/oremotional
neglect, and/or multiple peer victimization experiences in a continuously
dangerouscommunityenvironment)will,ofnecessity,complicate—andoften
extend—therapy.
Of course, as demonstrated in this book, it is not even that simple.
Thereisno“secondscenario,”perse.Whenmultiple,interactingpredis-
posing vulnerabilities and complex traumatic events converge in the
same child, there is often no single syndromal outcome to diagnose, nor
anydefinitiveone-size-fits-alltreatmentmanualtoconsult.Instead,treat-
ment has to be customized for each child, based on ongoing assessment
of his or her specific psychological injuries, capacities, and attachment
style. Although all effective treatment is likely to involve a good thera-
peutic relationship, emotional validation, exposure-based processing of
traumamemories,andthereworkingofdistortedcognitions,thewayin
which these and other goals are implemented (i.e., their timing, context,
intensity,andorderofattention)willnecessarilyvaryfromchildtochild.
In this regard, neither the “forest” nor “the trees” of therapy can be
overlooked: The goal is to both (1) provide rational, components-based
treatmentthatreflectscurrentempiricalresearchandclinicalexperience,
and(2)takeintoaccountthechild’sindividualsymptoms,needs,vulner-
abilities, and personality.
Itiswithinthisgrowingunderstandingofthecomplexitiesoftrauma
andtreatmentthatElianaGil’snewbookappears.Amindful,pragmatic
thinkerwithmanyyearsofexperienceinworkingwithabusedchildren,
Dr. Gil provides the reader with an integrative text on the treatment of
traumatized children and adolescents. As is necessary in any modern
clinical treatise, this book incorporates a wide range of therapeutic ap-
proaches and includes detailed and useful information on the potential
interface between empirically validated and expressive treatment tech-
niques. An equally important contribution is the author’s “real-world”
attentiontothelivedexperienceofthetraumatizedchild.Dr.Gilisadept
atdiscerningthemanyforcesandadaptationsthatinfluencethetrauma-
tizedchild’songoingexperienceandresponsetotherapy,aswellasartic-
ulating the need for creative, intelligent interventions that call on both
technology and, ultimately, humanity.
JOHN BRIERE, PHD
Associate Professor of Psychiatry and Psychology
Keck School of Medicine
University of Southern California
