Puppets for Trauma Psychotherapy
Puppets for Trauma Psychotherapy
Pitipies were born from an idea of Alessia Tomba (Doctor in Psychotherapy) as a solution for a clinical need: how to explain to traumatized children how structural dissociation works, in terms of split personalities.
The Puppets for Trauma Psychotherapy (PiTiPies) are great tools to support the process of psychotherapy. But above all, they can be used as part of a bigger and more structured process, and can be adapted to various psychological approaches, terminologies, and clinical strategies, with the aim of helping adults and children elaborate difficult psychological and traumatic experiences.
Here is a brief therapeutic description of the process (that we cannot
describe in full, due to its complexity), that can help understand the
utility and functions of the PiTiPies.
Psycho-education is an important part of the therapeutic process.
Traumatized adults and children need to understand how structural dissociation works.
Why is this important?
Explaining to children and adults what happens in the mind in terms of defensive mechanisms and functioning makes it easier for them to understand their symptoms and the significance of the therapeutic interventions that the clinical work may offer to them during the process.
(For the following, Dr. Tomba refers to the theory of Structural Dissociation presented by Van der Hart et al., 2006, “The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization”, Norton Series on Interpersonal Neurobiology).
Traumatic experiences can be defined as experiences that represent a threat to life and/or to the psycho-physiological wellbeing of a person, or of someone very close to them, (i.e. car accident, aggression, abuse, catastrophes, etc) and that activates the instinctive defensive mechanisms.
These mechanisms sometimes fail or cannot be activated or, even if initiated, are unsuccessful at preserving the person or their beloveds from harm and from the psychophysical threat (i.e. anyone who gets hit, attacked, abused, wounded, and cannot avoid or interrupt the event). At this point the person becomes overwhelmed on all levels: emotional, cognitive, sensory, and psychophysiological, and the mind activates in the only way possible: by dissociating.
The above authors have highlighted that, following traumatic events, it is possible for individuals to develop parts of their personality defined “Apparently Normal Personality” (ANP), focalized on one or more daily tasks, and the “Emotional Part” (EP) that contains elements of the activated defense system, and is rooted in the traumatic experience.
The ANP is the part that is apparently “normal” in most realms, except in the awareness of everything or almost everything regarding the trauma; the EPs are rooted to the traumatic memories, and to the experiences connected to the trauma.
This theory originates also from the idea that adaptive mental and behavioural tendencies developed based on the pre-existing psychobiological systems in many animal species (thus also in “ours”, although we are more evolved).
Some of these action tendencies regard functions of daily life: energy regulation, attachment and nurturing, the social engagement system, exploration, play, and reproduction. These all imply coming near an attractive stimuli (Lang 1995). The ANP is based on these action systems.
Another main action system is focused on survival in the face of danger, and includes various subsystems of defense, such as cry for help, attack, escape, freez, submission, or feigned death.
The emotional parts of the personality (EP) are connected to these active defensive systems.
According to the degree of fragmentation in the mind of a patient, Van Der Hart et al (2006) classified structural dissociation as primary, secondary, and tertiary.
In the case of primary dissociation there is only one EP that is completely concentrated on the moment of the trauma, and an ANP that carries on daily life (this is the equivalent of simple PTSD).
In secondary structural dissociation there is one ANP and several EPs, that belong to different defense systems, and get activated in traumatizing environments (in this category you can find DDNAS, and BPD, borderline personality disorder).
In tertiary structural dissociation there is more than one EP, but also more than one ANP. The split of ANPs happens when certain aspects of daily life (the psychobiological systems mentioned above) are associated to traumatizing events, and may activate memories of this kind. In these cases, the patient’s personality splits more and more in the attempt of continuing to “live daily life” without bumping into any traumatic memories (only DDI).
Trauma work is subdivided almost universally into three phases:
- Elaborating traumatic memories,
- Integration into normal life.
In the first phase, psycho-education is fundamental to support stabilization. It is important to explain to parents and children where certain behaviour and symptoms come from; that they derive from traumatic experiences, and that these can often seem “weird”. It is useful for them to understand that these are simply expressions of EPs becoming active.
At this point it is also important to introduce concepts such as “The Window of Tolerance”. According to Siegel (1999), inside this window “…experiences of various degrees of emotional and physiological arousal can be elaborated without upsetting the balance of the system…”
It can be considered the emotional, cognitive, affect and psycho-physical interval within which we are able to “tolerate” and face events without being overwhelmed, to be able to activate some strategies and resources that enable us to reach useful outcomes, and survive, without having to recur to dissociative strategies.
When experiences are too strong and overwhelming, and/or happen when there are not enough resources to face them, it is most probable that structural dissociation will happen, and with it the genesis of ANPs and EPs.
The latter may be created in states of disregulation and hyper and hypo-arousal.
In the category of symptoms of hyper-arousal, there are three possible EPs (three shared by the above authors, and one, the scream or cry for help, described by theories that stem from sensorymotor psychotherapy): CRY FOR HELP, FLIGHT, ATTACK, FREEZE.
In the category of hypo-arousal is FEIGNED DEATH, (or Giving Up).
EPS: CRY FOR HELP FLIGHT ATTACK FREEZE.
WINDOW OF TOLERANCE
EP: FEIGNED DEATH
Each on of these EPs can have different manifestations in the human being (i.e. the EP of flight may translate into dissociative behaviour such as addiction, or escape through substance abuse, compulsive sexual habits, alcohol, gambling); manifestations of EPs are mostly symptoms or dysfunctional behaviour.
As mentioned above, trauma work is divided into phases:
STABILIZATION: working on stabilizing and balancing the level of disregulated arousal that activates the EPs, to mitigate and reduced symptoms, or even make them disappear.
This can be done through cognitive, emotional, and somatic work that increases the width of the window of tolerance. This goal can be obtained by increasing and establishing greater resources, (that can be somatic, cognitive, emotional, of mastery, competence, or spiritual…) or by regulating the arousal directly through sensorymotor techniques and strategies.
Only then it is possible to have access to the second phase of the process: ELABORATION of traumatic memories. Only then because the patient is then not able to regulate in the process, and can thus access all parts of his or her brain involved, that includes the prefrontal cortex, (that “disconnects” in states of dissociation and activation of EPs).
To sum up: in order to activate this entire process, we have to start from psycho-education, then we need to be able to find and recognize the EPs, evaluate the width and resilience of the Window of Tolerance, in order to work on stabilization.
After this, (that is often the most complex and difficult part of the process), it is possible to access and elaborate the trauma that generated the EPs.
It is at this point that Dr. Alessia Tomba began to ask herself
how to translate all this for children? How much, what, and how to do it?
The answer she found is: As long as it is necessary for them to understand what is happening to them, and in this way increase their experience of control and competence of themselves.
This encourages greater motivation to face the therapeutic process, and reinforces their alliance with the specialist.
Toddlers and little children, as Piaget had theorized, have concrete cognitive functions until they are 8-10 years of age, so for these patients it is necessary to adapt communication styles to be certain they understand.
In truth, many adult patients are also not able to access adult functions and abstract cognitive processes, due to complex traumas and the development of highly specialized EPs. Thus also for them there is, in fact, the need to find a style of communication and interaction that is more “simple” and concrete, rather than abstract.
The first step is teaching parents about healthy and post-traumatic mechanisms and functions. They can be helped to understand and interpret the child’s EPs, and the events that can be triggering (reactivating) them.
Then everything learned can be explained to the child by the parents about his/her difficulties, and what the adults have understood or imagined is the reason all this is happening.
The child can be taught about the Window of Tolerance, helping with examples from their daily life, and that comes from experiences before and after the traumatic event.
Children need to be able to feel and touch with their own hands, the characteristics, and the similarities and differences between behaviour that comes from a level of activation inside the Window of Tolerance, and those outside.
At this point they can be helped to understand “what these behaviour is”, why do they show up like they do? Why they cannot control them, and where they come from.
It is at this point that the PiTiPies come into play. But, what are they exactly?
They are four large puppets that represent the ANPs, two adult ones and two children, male and female.
At first sight they seem like “nothing much”, nothing special, but under their shirt they have a pocket…
…that can contain the EPs that have formed after the traumatic experience.
Dr. Tomba has “Humanised” 5 EPs that reproduce the categories of animal defenses mentioned above: CRY FOR HELP, FLIGHT, ATTACK, FREEZE, GIVING UP.
Here below is a case example to illustrate the process developed by Dr. Tomba.
CLINICAL CASE EXAMPLE
Imagine a young boy that has been in a serious car accident that occurred in spite his parents attempt to warn the oncoming driver in the other car by soundly honking the horn. The boy witnesses the car about to hit him, but is helpless and cannot move, as he is tied to his seat with his seat belt. The father is badly wounded, and has to spend time in hospital to cure various serious fractures, as does the boy. From then on the child has nightmares, wets his bed, has anxiety attacks and, if he has to go in the car, when he hears a horn blowing he still tries to jump out, even if the car is moving,
This behaviour indicates the activation of a flight response, a flight EP that is triggered by the sound of car horns, even when there is no imminent danger.
We choose to use the ANP puppet that is most similar to the patient (the child). We explain to the boy that before the accident the puppet was fine, and give some examples of “good functioning”, that are relative to one or more areas that tend to be reactivating dissociation after the accident (for example “going in the car” before the accident).
Then we explain that the accident has produced some effects that he is not aware of, and that inside of him, without him realizing it, an EP has developed. This part of him usually “rests” and is “quiet” (when the child is inside his Window of Tolerance). However, when he hears the sound of a horn honking (trigger), he relives the trauma and it gets activated. This part jumps out before he can realize it, and when it comes out IT TAKES CONTROL. It makes him do strange things like trying to jump out of moving car.
At this point it is possible to let the ANP meet the EP, taking care and having respect for the phobia that the ANP has towards the EPs. Phobia and anguish are intrinsic to the existence of the two parts: one exists with the agreement that it will have little or nothing to do with the ideas, emotions, and memories of the other… This is a point that therapists who work with structural dissociation usually handle quite well.
In this way it is easy to deepen into the functioning of the EP with the patients; what to do when it “pops out”, what agitates it, and when and how it “calms down”. We can also explore what the triggers are, and the width of his Window of Tolerance.
Using the above strategies, we can begin to stabilize the system, step by step.
“Calming down” the EP in order to bring the level of arousal back into the Window of Tolerance, is not so easy. The phobia of the EP can be seen also in the reluctance or total rejection that children can have towards looking at, touching, or picking up the puppet that represents them.
Every case is different and requires different strategies, and most of all the skill and creativity of the therapist.
Only when a good stabilization has been achieved is it possible to work on the traumatic memory that has activated the particular EP (of escape, in the above example).
How? With the therapeutic approach most suitable for the patient.
Dr. Tomba uses EMDR, sensorymotor psychotherapy, and a combination of the two. PiTiPies can also be used in these contexts. The ANP and EP communicate, and the ANP discovers the trauma that created the EP. During de-traumatization, often the humanized EP is “present” and the child can discover affects, anxiety, and activation that belong to these parts. The child may experience these as distant and unfamiliar at first, but he can become more empathic with in time, until they are completely integrated.
We can just imagine having to explain to a child how that part of him that is responsible for his aggressive behaviors towards others was formed – behaviors that suddenly start when he hears sudden and loud noises.
Giulio was 5, when he was part of an armed robbery in a supermarket with his mom. The two aggressors also took his mother as a hostage and all he wanted to do was knock them out but he was held by a gentleman who was also present and wanted to protect him thereby preventing him from activating a defense of survival mechanism – the attack. The two thieves yelled and even shot into the air in order to intimidate those who were present.
The aggressors finally let Giulio’s mother go and ran away, but from that moment on, every time there are screams or sudden loud noises, Giulio becomes irascible and physically attacks anyone who approaches him even if it is to help. Nothing calms him down or stops him. At some point he comes back and is confused, exhausted. Sometimes he does not remember well what happened but feels bad and guilty.
What is described above is, of course, just a short outline.
As one can imagine, there is much more in this therapeutic world, and it requires constant adaptation and adjustment to better adapt to such complex aspects of the mind of a child.
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VAN DER HART, O., NIJENHUIS, E.R.S., STEELE, K., (2006), Fantasmi nel Sé Trauma e trattamento della dissociazione strutturale, Tr. It. Raffaello Cortina, Milano 2011.
SIEGEL, D.J. (1999), La mente relazionale: neurobiologia dell’esperienza interpersonale. Tr. It. Raffaello Cortina, Milano 2011