may 2019, Volume XXXIiI, No 2

Behavioral Health

Play therapy

Helping medically complex pediatric patients

ix-year-old Hannah has required around-the-clock care for spina bifida and other complex medical conditions her entire life. A trach tube, feeding tube, and wheelchair are indicators of her numerous days and nights spent in a hospital or clinic awaiting another test or surgery—experiences that have impacted how she manages her emotions and interprets the world around her today.

While Hannah’s entire childhood has been surrounded by medical professionals dedicated to improving her physical health, there wasn’t a care plan in place to focus on her mental health and how she can learn to effectively communicate feelings or cope with challenges.

In addition to Hannah living through her own traumatic experiences, her parents have felt the emotional, physical, and financial impact of being primary caregivers, coordinators, appointment schedulers, and more. Her 8-year-old sister Sophie has also been affected by the care Hannah requires as she internalizes feelings about the attention, time, and difficult procedures she’s seen her sister endure.

An underrepresented segment of care

At Pediatric Home Service (PHS), we often see medically complex patients and the caregivers who support them focusing the majority of their attention on physical health care needs while overlooking emotional health—understandable, given the physical hurdles and challenges these individuals consistently face. But when mental health counseling is included in the conversation, another piece of the puzzle helps us to assemble a more holistic care plan—one that could also provide tips for physicians and other health care providers.

With many methods of counseling available, the age and cognitive level of a client can be an effective indicator of which approach will work best. Three types in particular—play therapy, individual therapy, and sibling support programs—have been efficient in meeting the needs of clients as young as age 2 through adulthood. They may have a diverse range of interactions with physicians and health care interventions, depending on their medical history or personal experience.

Clients who benefit from receiving therapy may be personally or closely connected to someone facing a chronic or life-threatening disease like cancer or muscular dystrophy. Multiple factors can impact their mental health: dealing with the long-term effects of repeated surgeries, therapies, and procedures; processing an unexpected life event like a divorce or death of a family member; or any number of other experiences.

By helping individuals, regardless of age, address their fears surrounding medical procedures or confusion about a personal experience, they can begin to build tools that will enable them to more effectively understand and express their feelings in the future.

Parents carry their own risk of secondary trauma.

Expressing emotion through play

It’s natural and healthy for play to bring out emotions from a child’s past experiences, and this is no different for children like Hannah who have endured extensive medical care in their short lives. At just 6 years old, she may not completely understand the feelings she is experiencing or how to express them—but that doesn’t make them less important.

In our play therapy sessions, children ages 2 to 10 use toys as their tools and play as their words. This therapeutic method is based on metaphors and, while it may look unstructured to an untrained eye, counselors are educated in observing and recognizing behaviors that indicate points of tension and insight on stress or emotional trauma. Throughout a series of sessions, the client and facilitator will organically work through what is presented in child-led play—not with the goal of solving all their issues, but to provide them new tools to help cope with future situations in a healthy way.

Play rooms may look like a random assortment of toys, but fall into categories specifically designed to help children process emotions. Categories may include:

  • Realistic toys—a real stethoscope, Band-Aids, and medical kits.
  • Nurturing toys—play food, a kitchen set, baby dolls, and bottles.
  • Aggressive toys—plastic swords, chain saws and guns, aggressive animals like lions and tigers, and an angry puppet.
  • Expressive toys—a sand table, art and craft supplies, and musical instruments.
  • Pretend and fantasy toys—dress-up clothes and masks.

Mental health professionals conduct these play therapy sessions, but primary care physicians are in a position to watch for signs of trauma or stress in their pediatric patients and encourage parents to consider a treatment like play therapy, just as they would recommend a care plan for any physical ailment. For parents of a play therapy client like Hannah, mental health counseling is an opportunity to prepare for success as their child learns to manage emotions in a healthy way, while also navigating the challenges that may arise with their physical health.

While Hannah and Sophie are top priorities for their parents, primary caregivers like mothers, fathers, and other close relatives would be remiss to overlook the importance of focusing on their own mental health needs. Through individual therapy, one-on-one conversation facilitates an opportunity for adolescents and adults to work through challenging experiences.

Parents carry their own risk of secondary trauma as they maintain a routine of complex cares, endure their child undergoing invasive procedures, and work to maintain a normal family dynamic that doesn’t always have to focus on the medical aspect of their life. Hannah’s parents have encountered a wide array of circumstances since having their second daughter. Through individual therapy, they have been able to process the feelings of grief, trauma, anger, and anxiety left behind as a result—empowering them to improve their own emotional health.

Clients who are 11 or older—and therefore not good candidates for play therapy—would still benefit immensely from counseling and an opportunity to have conversations surrounding their emotions. As Hannah gets older, she may use individual therapy as a way to process new challenges she encounters, such as social issues at school or loss of people she has met along her medical journey. While older patients may have a better understanding of the procedures and care they’re receiving, this is still not without an abundance of emotion. Individual therapy provides an outlet for this processing to take place in a more age-appropriate setting.

Through this simple act of self-care, adolescents and adults can work on making sense of the experiences that have led them to where they are, and create a plan moving forward—a resource that all individuals can benefit from. Physicians and other health care professionals can stress this point during their patient visits, encouraging patients to take care of their physical and behavioral health needs.

Support for siblings

It would be an oversight to focus on medically complex patients and parents and ignore the siblings who also observe medical care and deal with its impact on family dynamics. Hannah’s sister Sophie, along with countless siblings in this community, carry their own concerns and often feel isolated from their peers who don’t have a medically complex sibling in the home, or a sibling undergoing treatment for chronic illness or repeated medical procedures.

In a PHS support program created specifically for siblings, children ages 6 to 11 meet in a group setting where they have a space to process thoughts, work through feelings, and express themselves amongst other individuals who have encountered similar experiences. While the conversation may not always be around their brother’s or sister’s medical needs, just having the knowledge that they’re in a safe environment of peers brings a sense of comfort and belonging as they interact and find a community.

“Our older daughter requires a lot of our attention because of her medical treatments and appointments,” said one mom whose daughter participated in a sibling support program. “Our younger daughter notices it and we talk to her, but recognizing she is not the only one who has a sister with some medical issues was very eye-opening for her. Now, she is a lot more comfortable talking about feelings, and knows there are other kids out there dealing with these same feelings she has.”

Medical care generates a great deal of emotion for everyone.

Utilizing different formats

As clients get older or their circumstances change, it is sometimes appropriate or necessary to shift into another type of therapy. In one circumstance, the sister of a child with medical complexities started in a 12-week sibling support program and then moved into play therapy—allowing her one-on-one interaction that continues to address her emotions.

“We used mental health services to help our 5-year-old cope with the implications of having a medically complex child in our home,” said another mom. “We wanted to make sure our daughter had an outlet and a way to express those feelings and emotions regarding her sister’s medical needs later in her life and give her the tools to deal with those, not only now but into the future as well.”

Data supports approach

n post-session surveys distributed following the completion of a sibling support program, 67 percent of parents who had a child enrolled said that their child is more comfortable talking about his or her emotions since attending the group. Seventy percent reported that their child realized that kids share similar experiences if they have siblings with medical support needs, thanks to the support group.

An abundance of options to fit needs

Clients may shift from play therapy to individual therapy or from the sibling support program to play therapy or individual therapy, or find another type of therapy that better suits their needs. It’s important to remember that there are numerous styles available beyond these three types that will best suit different needs, ranging from diagnosis-specific groups, family psychotherapy, medical support groups, or a number of other theory-based types of therapy. It is worth investing the time to find the right option for each person, and to remember that those needs may change over time.

Medical care generates a great deal of emotion for everyone involved in a patient’s journey, and taking time to address these feelings and concerns leads to better mental health for the individuals involved while providing lifelong tools for children, adolescents, and adults.

While these examples target the medically complex children we serve and their families, all patients—at all ages—benefit by focusing on both physical and mental health. Watch for signs of trauma or stress factors, and encourage your patients to seek help.

Monica Oberg, MSW, LICSW, is a clinical social worker at Pediatric Home Service, where she provides individual therapy, play therapy, and sibling support programming for children, adolescents, and adults. She received her Bachelors of Science degree in social work from Bemidji State University and her Master’s degree in social work from Augsburg College. 

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Monica Oberg, MSW, LICSW, is a clinical social worker at Pediatric Home Service, where she provides individual therapy, play therapy, and sibling support programming for children, adolescents, and adults. She received her Bachelors of Science degree in social work from Bemidji State University and her Master’s degree in social work from Augsburg College.