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Section 6
Recall in Depression and Posttraumatic Stress Disorder

Question 6 | Answer Booklet | Table of Contents

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In the last section, we discussed issues of trauma flashbacks and bodily reactions to supposed repressed memories of a trauma.

In this section we will discuss recognizing abuse internalizations and a Trauma Recall Technique to use once abuse has been established related to play therapy. We will discuss two case studies regarding the child's feeling that "I am damaged" and the ethical use of play therapy.

♦ #1 The Internalization Model
As you are aware, the Internalization Model alerts the therapist not only to what may be expressed in the play therapy but also to what needs to be addressed if the child is to work through the abuse and reclaim a sense of self and world unaffected by the trauma of the abuse. In this section, the Internalization Model will be used as a framework for recognizing what the "I am a damaged child" is expressing through play.

The following is an example of how Cindy, age 10, was interviewed by the therapist. Cindy had been admitted to the emergency room for vaginal bleeding. Following her sexual abuse by her step-father, she would not talk about the incident. See what you think about this therapist's ability to facilitate Cindy's recall. Is the therapist bordering on ethical misconduct by misleading the client? Or does the therapist use neutral feedback allowing the client to focus the session?

--Cindy starts scratching herself and says that she is dirty and is trying to get the dirt out.
--Therapist: (Notices that there is no dirt on the child, and therefore, she is talking about internal dirt. She also notes the word "out," clearly indicating that Cindy is talking about something internal.)
--The therapist stated, "Listening to you talk about dirt inside, I'm wondering if you are feeling that there is dirt inside from the abuse." (Cindy nods yes.) The therapist continues, "How big is that feeling of dirt?"
--Cindy shows a small size with her hands and then a larger size.
-- The therapist stated, "That dirt doesn't belong there. The dirt belongs to the abuse, not you. And the abuse is out, over, so let's get that feeling of dirt out, over. You could draw it, model it out of clay, what do you want to do with it?"
--Cindy picks up a pencil.
--Therapist tapes together two pieces of paper to accommodate the size Cindy had indicated.
--Cindy scribbles all over the paper.
--The therapist stated, "What now? You could tear it, cut it, squish it, or something else. What do you want to do?"
--Cindy tears it up, stamps on the pieces, and then with a big smile, puts them in the trash can.

Do you see how this therapist separated Cindy's internalization of the abuse by saying, "The dirt belongs to the abuse, not you"? Personally, I feel an ethical boundary was not crossed because the abuse had been established, medically, prior to the session and memories were not being implanted in Cindy's mind. To maintain this ethical boundary, the therapist asked neutral questions such as: "What do you want to do with it?" and "What now?" keeping the client in control.

♦ "I am Damaged."
Here is another example of the feeling, "I am Damaged." See if you can spot how the therapist remains neutral and does not violate an ethical boundary. Terry was an 8-year-old, sexually abused by her father between ages 5 to 7. Terry came into her therapist, Sandra's office and took out a paper.

On the piece of paper she wrote, "From Terry to Sandra" and drew a heart. She then wrote "I love Sandra" but then erased her name and wrote "Love Mommy" as a signature. So her note read, "To Sandra" with a heart and at the bottom, she wrote "Love Mommy" as a signature.

--Sandra: (Notices that the very common 8-year-old activity of writing "to" notes and "love" notes had been altered in a way that eliminated Terry's name. if you recall Terry erased her name). According to Sandra, Terry's erasing her name seemed to indicate Terry was possibly unable to link herself with love.
--Sandra stated, "It seems as if it is really important for you to love me and love Mommy. But I'm also noticing that you erased your name. Do you love yourself?"
--Terry shakes her head to indicate no.
--Sandra stated, "Close your eyes for just a moment and imagine yourself. Now give yourself a hug. (I feel this was an error by the therapist because it did not first address the internalization expressed in the play.)
--Terry stated emphatically, "Yucky, yucky!"
--Sandra asks, "Where's the yuck?"
--Terry answered, "In the heart."
--Sandra goes over to the chalkboard and draws a heart and then draws some scribble lines inside the heart. This is the yuck in Terry's heart. I am going to take the yuck out because it doesn't belong to Terry. (Sandra gesturing took the yuck in her hands, she turns to Terry.) Where shall I put the yuck?
--Terry stated, "In da trash. No, to the devil."
--Sandra: Goes over to an empty chair in the room and states, "Hi, Daddy," as if Terry's father were sitting in the chair, then stated, "Terry got all this yucky feeling from your touching her. She wants you to know how it felt."
--Sandra holds out her hands as if putting the yuck in the chair, then after a moment, with a hand movement, scoops the yuck back up. Sandra stated, "OK, do you know now how Terry felt?"
--Terry, in her comment, had made it clear that it would have been too threatening to her and her love for her father at that point for the "yuck" to be left in the chair that represented her father.
--Sandra moved back to Terry, and asked, "What shall we do with it now?"
--Terry stated, "Throw it away." Then smiled slightly.

♦ #2 Internalized Feelings
In this therapy session, the internalized feelings regarding the memory of the abuse was made into a role play of giving the feelings of the abuse trauma to Terry's father then taking it back and throwing it away. Sandra asked the neutral question, "Where is the yuck?" rather than "Is your father the yuck?" in my opinion no ethical boundaries were crossed in this role play regarding internalization of the abuse trauma. You may disagree.

In this section we discussed recognizing abuse internalizations. Two examples were given of ways in which a therapist can remain neutral and not violate an ethical boundary regarding recall of a trauma via the use of play therapy and role playing.
Reviewed 2023

Peer-Reviewed Journal Article References:
Frewen, P. A., & Lanius, R. A. (2010). Non-idiographic emotional script-driven imagery in posttraumatic stress disorder: Impact of priming of episodic recall and self-referential processing. Zeitschrift für Psychologie/Journal of Psychology, 218(2), 89–95.

Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496–507.

Himmerich, S. J., Ellis, R. A., & Orcutt, H. K. (2020). Application of PTSD alcohol expectancy symptom clusters to the four-dimensional model of PTSD: Support from moderations of the association between symptoms of posttraumatic stress and alcohol use. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 347–355.

Hyland, P., Karatzias, T., Shevlin, M., McElroy, E., Ben-Ezra, M., Cloitre, M., & Brewin, C. R. (2021). Does requiring trauma exposure affect rates of ICD-11 PTSD and complex PTSD? Implications for DSM–5. Psychological Trauma: Theory, Research, Practice, and Policy, 13(2), 133–141.

Mott, J. M., Galovski, T. E., Walsh, R. M., & Elwood, L. S. (2015). Change in trauma narratives and perceived recall ability over a course of cognitive processing therapy for PTSD. Traumatology, 21(1), 47–54. 

O'Kearney, R., & Parry, L. (2014). Comparative physiological reactivity during script-driven recall in depression and posttraumatic stress disorder. Journal of Abnormal Psychology, 123(3), 523–532.

Olson-Morrison, D. (2017). Integrative play therapy with adults with complex trauma: A developmentally-informed approach. International Journal of Play Therapy, 26(3), 172–183.

QUESTION 6
What is one example of a neutral non-leading type of statement you might make in a therapy session with a trauma client? To select and enter your answer go to Test.

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