Ruth Pat-Horenczyk, Director, Dafna Ba-Gad, Workshop Coordinator, Liz Yung, Group Facilitator, Sarit Schramm-Yavin, Research Coordinator, and Danny Brom, General Director, Herzog: Israel Center for the Treatment of Psychotrauma, Jerusalem, Israel
Children growing up in the Sderot area, adjacent to the Gaza strip, are exposed to the constant uncertainty and danger of missile attacks. How their parents respond can help to minimise the lasting psychological trauma. This article explores how the Israel Center for the Treatment of Psychotrauma (ICTP) works with parents to help their children through an upbringing in an environment of pervasive violence.
In times of crisis, the human body responds with an array of behaviours defined as ‘survival mode’: the sympathetic nervous system is activated and the parasympathetic system is inhibited. As a temporary state this is normal and highly adaptive, as it helps humans to be alert, avoid risk, and focus their efforts on staying safe and responding efficiently to threat (Pat-Horenczyk et al., 2012).
However, when the threat is recurrent and prolonged, survival mode is persistently activated, and this causes damage to individuals’ mind and body (Seeman et al., 1997). A study in Sderot showed that mothers and children living in the face of ongoing traumatic stress reported more post-traumatic distress and higher ratings of behaviour problems in their children than a comparison group who had experienced just one short-lived incident of political violence (Pat-Horenczyk et al., 2013).
Due to a widespread belief that children under the age of 5 are impervious to traumatic events, research on children exposed to prolonged war situations and acts of terrorism has historically focused on older children or adolescents (Feldman and Vengrober, 2011). However, more recent research indicates that exposure of very young children to repeated wartime trauma can have profound and lasting effects on their mental health (Lieberman, 2011).
This is exacerbated by the way ongoing threat also has an effect on parents and their parenting capacity. Survival mode affects parental abilities: attunement, containment, the ability to play, over-worrying, and an inability to create safe space (Chemtob et al., 2010). In the aftermath of traumatic events, the mother–child relationship and the mother’s adaptation and coping ability are of vast importance for children’s adjustment (Cohen and Gadassi, 2009). In light of this finding, it is not surprising that the single most important factor affecting children’s symptoms is a traumatic event experienced by the primary caregiver.
Others have reported a significant correlation between functional impairment of the mother, as manifested in her parenting functions, and the child’s reaction to stress (Cohen, 2009). Scheeringa and Zeanah (2001) coined the term ‘relational post-traumatic stress disorder (PTSD)’ to describe the co-occurrence of post-traumatic distress in a mother and a young child, when the symptomatology of the mother exacerbates the symptomatology of her child. The aforementioned Sderot study reported a higher prevalence of relational trauma, measured by co-occurrence of post-traumatic distress in both mother and child, in the ongoing exposure sample compared with the past exposure sample (Pat-Horenczyk et al., 2013).
Parents, playfulness and resilience
There is widespread evidence regarding the importance of play and playfulness in the development of children under normal circumstances. It is widely accepted that play is of central importance to children’s cognitive, social and emotional development (Vygotsky, 1966; Singer and Singer, 2006; Ginsburg, 2007) and it seems that the process of play itself, even without any outside intervention, may lead to important psychological transformations (Winnicott, 1971). The ability to experience a sense of agency in play may help children counteract feelings of depression, anxiety and panic often reported by traumatised children (Schonfeld, 2011), as well as give them the opportunity to create meaning in various ways. Thus, children who are able to play may be more resilient in the face of stress.
Unfortunately, in times of trauma and loss, children’s ability to play is often impaired. Children might exhibit post-traumatic play (PTP), a play pattern which is distinctly different from normal play (Wershba-Gershon, 1996) and which is characterised as driven, serious, lacking in joy and frequently morbid. PTP tends to involve simple defences such as identification with the aggressor, identification with the victim, displacement, undoing and denial, and tends to be developmentally regressed (Terr, 1981; Cohen et al., 2010).
According to Cohen (2013) there is support for the idea that playfulness developed prior to exposure to traumatic events enhances resilience for such events. Therefore, support in regaining playfulness can help children regain the use of ‘playful play’ to successfully process their traumatic experiences.
Parents play a major role in the development of play and playfulness. In the aftermath of a traumatic event, parents are powerful mediators of the events. They model behaviour during the event and shape the healing environment following a traumatic event (Cohen, 2009). Parents who are willing and able to engage in and support their children’s play foster children who are able to engage in complex, rich play which they are able to use for affective processing (Bronson and Bundy, 2001; Fonagy et al., 2002).
However, as mentioned earlier, during stressful periods the quality of parents’ caregiving and their capacity for play and playfulness are impaired. This is most unfortunate, since these are the times when the children need their parents more than ever. Therefore there is great need for interventions that aim to foster play and playfulness among parents in families who have experienced trauma. One such intervention is child–parent psychotherapy (Van Horn and Lieberman, 2009), which focuses on the parent–child relationship among young children who have been exposed to traumatic events in an individual or family format. Although this programme and its counterparts have shown positive results, there is still a need for programmes in a group setting which have the potential to reach a larger population and may be more suitable for periods of ongoing and/or collective trauma. This is one of the main approaches that guided the development of the ‘Parent’s Place’ programme.
Parent’s Place and NAMAL
Parent’s Place in Sderot was built with the vision of strengthening the capacity of parents living under continuous threat of missile attacks to provide their young children with the best care. The programme was designed to address parents’ needs by providing them with knowledge and practical tools for coping with stressful and traumatic experiences as parents of young children. It included five elements:
The first of those elements, the parent–child playgroup programme, was developed by Dr Esther Cohen of the Hebrew University in collaboration with the ICTP team. The Hebrew name of the programme – NAMAL – reflected the acronym for ‘Let’s Make Room for Play’. NAMAL is based on ‘child–parent relationship therapy’, a filial play therapy programme conducted in a format of parent groups. It aims to bolster children’s resilience and development by providing a safe haven for playful interactions between parents and their children, while also specifically addressing themes such as post-traumatic play and attachment. These are the programme’s main principles:
The NAMAL programme consists of ten afternoon group meetings for parent–child dyads. The meetings involve playful and fun music, craft, drama and movement activities suited to children aged 2–4. The theme and activities of each session are organised around a ‘saying of the day’ with a relational or developmental message; at the end of each session, parents are given handouts which include a summary of activities, song lyrics, and a simple explanation of the content, along with a decorative magnet showing the saying of the day. The activities are followed by a small, free dinner.
Programme evaluation and results
The programme was accompanied by qualitative evaluations and quantitative research which is still ongoing. Over 2 years, 70 mothers from ten groups completed a semi-structured questionnaire at the end of the programme. Analysis of the questionnaire revealed that its meaningful effects could be classified into three domains (Cohen et al., 2013).
The thing that changed most at our home is my considering everything she does. I try to really look at what she does and not just ‘by the way’ while doing other things.
Another change involved the participants’ sense of competence in their parental role and better understanding of their child. As one parent stated:
I understand him more when he is stressed.
Parents felt more able to promote a sense of autonomy in the child: I tell him:
‘You’re a big boy, you can wash your hair yourself.’ or: I, as a mother, give her more space for independence.
In a one-year follow-up, 38 of the 53 mothers contacted by phone agreed to respond to a short, semi-structured questionnaire. Their responses indicated that the most lastingly significant aspects of the programme were their sense of competence in their role as parents, understanding the importance of identifying and talking about feelings and fears with their children, and their ability to address the child’s needs.
As one mother said:
Thanks to the programme I felt that as a new mother, I have more tools for coping with situations we don’t always know how to deal with, in terms of feelings and thoughts. It gave me an opportunity to encourage my child to express herself. I can see that today she shares her feelings and fears more, especially regarding the security situation – she has questions, and I feel that I can answer her in a way that relaxes her. It seems that following the programme I manage to not silence the fear but to open it.
Adaptation for other populations
Following the success of the NAMAL programme, the parent–child therapeutic playgroups were culturally adapted for the Ethiopian Jews who migrated to Israel in the last two decades – an often traumatic transition.
Qualitative evaluations with mothers who participated in the programme for Ethiopian Jews revealed three main themes. First, they mentioned the importance of a variety of coping skills. For example, one mother stated she learned that:
It is important to reflect her feelings as it reduces the tension and anxiety felt by both of us.
Another mother said:
I learned how to deal with the security situation and to give her the feeling that I am always there for her and how to cope, even when I am most distressed.
The second theme was the importance of spending exclusive time together with the child. For example, one mother stated:
The most important thing for me was the time I spent with my daughter without having to be preoccupied with something else. This was the time devoted to me and her only.
It was the quality time with my daughter during the activities that strengthened the bond between us.
The third theme was the importance of joint play and the use of imagination and playfulness in the parent–child interaction. For example, some mothers reported learning from the proverb that was used in the group: In order to play, all you need are a good imagination and a pile of junk.
One mother stated that:
The imaginative play activities helped me to learn about new sides in my daughter.
Recently, another cultural and linguistic adaptation of the programme was made for the Bedouin population of Rahat. This involved a need to find parallel sayings that reflect the Bedouin culture correctly. Some of the Hebrew songs were replaced by songs in Arabic with which the Bedouin population were familiar, while others were translated and adapted. The project is now in its pilot stage, with one group currently following the course in a children’s day care centre. Early anecdotal feedback is encouraging: the day care manager has observed an increase in symbolic play among children who have been participating in the programme, while many mothers have expressed eagerness to participate in future groups.
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