Jennifer Baggerly on Disaster Response Play Therapy: Shelter from the Storm

Jennifer Baggerly: Thank you. It’s wonderful to be here with you, Larry.

JB: Typically, when I’m working with children in private practice in the United States who have experienced trauma, I use a child centered play therapy approach in which I’m allowing the child to direct the play. In this non-directive approach to play therapy, I’m trusting their self-actualizing potential. I’m providing a protocol of therapeutic responses during their play and trusting that through the therapy, the therapeutic relationship, and their play, I can facilitate self-understanding that promotes their emotional understanding and eventually their healing.

Along with this child-centered, or in a broader sense, this person-centered play therapy approach, I will sometimes add some psychoeducation in the form of children’s books that may be relevant to their particular presenting problem or to something else that they may need. So that’s typical in my private practice in the United States.

Disasters, and natural disasters in particular; however, require a different therapeutic approach. There, I work from a disaster response therapy perspective, which is a trauma-informed disaster response/play therapy perspective. There’s a whole protocol for this that is reflected in some of my earlier work around preparing play therapists for disaster response and cultural adaptations for play therapy after Hurricane Maria in Puerto Rico. Just recently, the Association for Play Therapy has developed disaster response guidelines for play therapists.

That’s very helpful because it takes into account the particular setting and scene of a disaster. There are many different types of protocols you must follow. For example, the number one protocol is you do not go to disaster to provide disaster response for children unless you have been invited by a particular organization. When you get that invitation, you’re going to be following the incident command structure, depending on whether it’s been a very recent event such as a hurricane that just happened.

Many families will be staying in shelters. You also need to be able quickly oriented to the particular culture that you’re working with which means that you need to work closely with the contact person on the ground who is helping you to understand the social and political issues that are occurring. And from there, it is important to be able to adapt your clinical approach.

That’s the preparation stage of the work. And then when you get there, the primary goal is to do no harm. We’re not going to do a big assessment looking into their past traumas and such. We’re just focused right there, at that time, and that’s where child-centered play therapy really fits well.

We’re just looking at that child in the moment and giving them a safe place to play. We also have to be aware that every child comes with a family who may need some help and guidance while the child is in their play session. Sometimes they need a little bit more structure, or perhaps they need some psychoeducation about typical responses after a disaster. Sometimes they need coping strategies to calm themselves down and get themselves back into the window of tolerance of being able to emotionally self-regulate. We provide that as well as opportunities to play. It’s a much bigger picture in disaster response that you have to navigate compared to the work you do in an office.  

JB: We’re using the child-centered play therapy within the trauma informed disaster response. So we provide a lot more structure leading up to the actual play sessions. But when we do provide the sessions, we often take a mobile play therapy kit in a suitcase which we’ll have available for a local response.

For example, I did some responding after the tornadoes in Oklahoma and Texas. If the events are local, I can bring more equipment. Like I might bring the bop bag, often known as Bobo. What you bring depends on the setting you’re going into, and I prefer to be in a setting that is a little bit more contained like a school or a place of worship where they have rooms and there’s not a lot of people going back and forth. That way you can set up a play area, particularly for the child and provide privacy.

However, sometimes you have to be very, very flexible. For example, I’ve done disaster work in shelters where I’ve just had the corner of a room, where we set up chairs to make a boundary for the therapy space from the people walking by. In those spaces, our typical play kit will have the aggressive release toys and nurturing toys, as well as toys and materials for creative expression.

One time, we were using dart guns which upset some of the parents and disaster shelter folks, so we had to put them away. It was the same with the bop bag, or Bobo doll. While we knew therapeutically that these kids were releasing some aggression and gaining a sense of power and control, we had to respect the others around. After Hurricane Katrina, I was working with some children in Louisiana who were playing in a classroom with the dart gun. In that instance, people were not walking by, so we had a bit more freedom. A boy grabbed the dart gun and jumped up on the table, “okay, we’re going to shoot the monster that’s coming toward us.” He was referring, of course, to the hurricane. They played out what we would call a trauma reenactment.

They were, in a sense, shooting this monster hurricane that had impacted their community. That particular child had been at the Superdome where he had witnessed actual shootings. Had that play occurred in the corner of busy shelter rather than a private room, that group would not have been able to play out that particular scene out of concern for re-traumatizing others in the immediate vicinity. That’s why understanding and working within context is critical.  

JB: Sometimes, yes but it a lot of it depends on the exposure they had to the particular incident and their history. Important factors include whether they were impacted by the death of somebody that they knew, being close to that person as they were dying, their own resilience, and their own history of trauma.

Many times, you will see more direct reenactment of the incident through what we call traumatic play. For example, I was working with a group of children in Florida after a major hurricane. There, because of the setting, it was not possible to have individual sessions. On their own, this particular group of children decided to make a circle and then have one kid in the middle pretend to be the hurricane. The kid would spin around while going around the group which worked together to push the hurricane back. Those kids loved that game that they created and eagerly took turns being the hurricane. That pretend play gave them a sense of power and control; a sense of mastery over this terrible thing that they had experienced.   

JB: For example, if the monster is coming at them and they’re shooting or something like that, I’m looking to see if they have a sense of resolution. Can they overcome this? Many times, kids will play good versus bad, kind of a cops-and-robbers type of idea. But then maybe, they will play the bad guy or the bad thing, in this case the hurricane and will get to the point where they are the superhero that comes in to rescue everyone. And so, I often look for the rescue to happen as a sign that they are working through the trauma in a healthier way. 

JB: That’s why disaster response play therapy often includes a group session where we teach some coping strategies like deep breathing, some self-soothing, or distraction through a song of resilience like, “I am safe, I am strong.” We teach those coping strategies so that the child feels a sense of empowerment which is a more directive approach as opposed to typical non-directive, child-centered play therapy. That . We have to give the kids actual coping strategies along with psychoeducation about what they can expect, it’s part of the trauma informed disaster response play therapy protocol. And we want them to know that they will be OK.

We also want to extend that to the families, many of whom need a more direct psychological first aid approach to help them de-escalate, to become more emotionally regulated. Some parents are just not able at that particular time to provide the care and nurturing for their children. After Hurricane Katrina, there were displaced families I saw at a shelter––people who didn’t know where they were going or how they were going to survive. I respected the fact that the parents were in survival mode; fight, flight, or freeze! They simply couldn’t attend to their children in that state.

That’s when disaster mental health responders can be helpful to their children by providing them support the parents can’t. After Hurricane Maria in Puerto Rico, in spite of the fact that some time had passed since the storm, many people were still struggling. We went to a place of worship where families came together. There was a sense of community. The church leader gathered the parents around in a circle where they held hands and prayed. I thought that was a great example of using the community structure and its own built-in sense of resilience and support.

After we worked with children whose parents were most severely impacted, we went back to those parents or caregivers to give them a debrief about the progress their child(ren) made. We were giving a warm handoff back to the parents and providing them with some support. Sometimes those parents just need to talk and get that comfort from the play therapist. But we were also carefully watching those children for signs of serious trauma so we could refer them to local counselors and mental health professionals in that area. For example, I worked with one mom whose daughter was in a community that had been hit by a tornado. It seemed that the child was okay as there were signs of resilience. But the mom was really struggling because she had been on the phone with her older daughter when the phone went dead. She was terrified that her daughter had died. While it turned out that she was okay, they were out of contact for about 24 hours. That mom needed some extra help which we were able to provide. We were also saying to that mom that she would benefit from having someone else in her community to work through this trauma. In that instance, the child was more stable than the mom.   

JB: Yes. Many of the portable play therapy kits that we bring have a sandtray the size of a laptop computer, maybe a bit bigger, that can accommodate the miniatures kids like to place in there. That’s where a lot of kids will play out death scenes. I’ve had kids create scenes in the sand that are knocked down by a hurricane. In those scenarios there may be a burial. Some of the kids do it quite quickly, while others are almost in a trance type state while they are doing it. That’s where the play therapist comes in, so that they can process that scene with the child by reflecting their feelings and helping them to understand their beliefs through reflective feedback. 

JB: I’ll back up a bit to the preparation phase of deployment because we anticipate there will be challenges for the clinician. And because we know that each person will feel overwhelmed at some point, each play therapist has to do an inventory of how they will cope and what their self-care plan is; emotionally, physically, relationally, and spiritually. That is an essential part of the protocol. Before my team took off to Puerto Rico after Hurricane Maria, we talked about what each person needs to do when they become dysregulated.

If, for example, somebody says, “well, my back’s been acting up,” or that, “I’ve got a problem with my diabetes,” or “I have difficulty with some other ailment,” then that’s also not the time to go. Someone may have had a recent death in the family or be experiencing family issues, so those are also reasons for not going. And we also have to think financially, because deployment is not remunerated, and some people can’t afford to take the time away from work. And that reminds me of another disaster response protocol which is that you never go alone; you always go with the team.

At the scene, some people may get a little snappy, some people just may withdraw. Some people may just cry. So, we identify what dysregulation means for each member of the team and then the team will intervene and help the person develop what we call a “NAP” or non-anxious presence. That’s just basically getting yourself into your window of tolerance, de-escalating, getting yourself back, emotional regulation, and/or implementing your strategies. One person may say, “Look, I just was really overwhelmed by this one kid’s story of death,” so the team debriefing cuts down that sense of isolation and despair that often comes in the presence of death and dying.   

JB: That’s a great point and very helpful. To the extent possible, many play therapists will do a sandtray or an expressive arts activity. One such activity is drawing a circle with words expressing feeling overwhelmed on one side of a piece of paper. On the other side of the paper, the therapist draws a circle with words through it suggesting hope or resilience. The circle provides a sense of containment for the feelings evoked by the words within it. It can even be a group play activity, where the therapists stand in a circle and hit a ball back and forth. Or it can be as simple as enjoying a meal together.  

JB: Well, there there’s a real sense of Puerto Rican pride which was a beautiful thing to witness. There’s that deep sense of shared identity—we are Puerto Rican; we are a strong people. We would often see signs like that in peoples’ yards or common areas. Another thing that we did with a group of children was to sing songs about being safe and strong, which was similar to one of their own songs about a chicken. All across the island, there was singing, dancing, and the sharing of food.  

JB: Absolutely. As I mentioned, the Association for Play Therapy just came out with their practice briefs on disaster response for play therapists. I think that’s a very important document to see. They make it very clear that APT is not in the business of deploying people. So, for that part, therapists who are interested in disaster mental health and disaster response play therapy would need to link themselves with other entities. 

he American Red Cross would be another resource, as well as many other non-governmental organization. I also did a couple videos, one of which is called Disaster Response Play Therapy. So, there are opportunities, but the play therapist needs to be intentional in making those network connections prior to the incident. 

JB: Thanks Larry. I enjoyed this time with you.