June 18th, 2007 by Dr. Bromberg
This interview should be of great interest to clinicians specializing in, or curious about, work with children and adolescents who have experienced traumatic events. Craig Haen is a Registered Drama Therapist and Certified Group Psychotherapist. He is currently Clinical Director of Adolescent Services for Kids in Crisis, in Greenwich, CT, and has a private practice working with children, adolescents, adults and families in White Plains. He is co-editor, with Anna Marie Weber, of Clinical Applications of Drama Therapy in Child and Adolescent Treatment (2005, Brunner-Routledge), and serves on the Advisory Board for Creative Alternatives of New York. For five years, Craig was employed in the Child and Adolescent Psychiatry Division of New York Presbyterian Hospital—Cornell Medical Center in White Plains. He has worked with youth and families in shelters, community centers, hospitals, residential facilities, schools, and on Native American reservations. Craig was particularly active in the treatment of children, families, and service professionals in the New York area following the 9/11 terrorist attacks.
Contact information for Craig Haen is provided at the end of this interview.
Dr. Bromberg: Craig, how did you first become interested in working with traumatized children?
C. Haen: I always knew I wanted to work with children. When I was in graduate school I pursued an internship working on Long Island in a program that treats child witnesses to domestic violence, and I think that’s when my interest really crystallized. I saw the powerful impact that traumatic events had on those kids. Also, in my work with adults, so many of them were talking about wounds from childhood, and had become quite fixated on those wounds. So I became interested in the promise of early intervention—the idea that doing the right work at the right time can really alter someone’s course in life.
Dr. Bromberg: How long have you been working with this population?
C. Haen: It’s been about eight years postgraduate.
Dr. Bromberg: Your training is as a drama therapist?
C. Haen: Yes. I received my master’s degree from NYU. It’s a niche field, but I’m really glad I have the training I do. I grew up as an actor, and at a certain point, as an adolescent, I realized how powerful learning can be when you’re in a role. It allows you the distance to be a character and also to be yourself. In working with traumatized kids, much of the work I do is play therapy based, because with trauma, there are these dual-symptom patterns of hyper-arousal and avoidance. When you can work in terms of metaphor, play, and stories, it becomes much safer for children to take the risk, to do graduated exposure to trauma material and still feel grounded.
Dr. Bromberg: Can you help me get a sense of what, over a series of sessions, the graduated exposure to trauma material looks like?
C. Haen: Typically, in the first session, we usually begin by drawing, because I think it’s the least threatening way for children to engage with me. They don’t have to make eye contact, or they can make as much eye contact as they want. I give them a pretty simple drawing task, and we begin talking about the contract we have for working together, in terms of what will make it a safe space for each of us.
Dr. Bromberg: Is it often clear from the outset what has brought them in? Is that explicitly articulated, or is there an unspoken understanding that there has been a traumatic event?
C. Haen: Different practitioners have different ways of approaching this. It is my belief that you have to be really honest with the child from the outset about why you’re working together. I usually explain that we’re here to play about their worries, and, specifically, their worries connected to whatever single event or multiple events have taken place. I will also let the child know that some adults in their life are concerned because of x, y, or z. I want them to feel that there is honesty from the beginning. I also find that kids who have had horrific events happen to them are very mindful of protecting the people around them. So, unless they feel that it’s okay to talk about these things, that you can tolerate it and they have your permission, there’s a taboo that exists.
In terms of the play therapy work, I usually frame it in terms endemic to film—that we’re going to create a movie, using the toys. A lot of sexual abuse involves pornography or being filmed, so, obviously, if that’s the case I would not use that language, but I find a lot of kids today connect to terms like pause, rewind, and fast forward. I tell them that we’re going to create a movie or a story, and that the events may be similar to the things that happened to them, but it’s going to be pretend, we’re going to use pretend names, and the story can be about anything they want. If I feel that a child needs more direction, I may make some suggestions, like, “Maybe your story will be about dads, or about scary things that have happened, but you’re the director, you have control of it.”
In the first session I let them play out their story, and I observe. It’s part of an assessment period, and I learn a tremendous amount about where the kids need intervention from how they frame their story, how detailed their story is, where they get stuck, and where they tend to pull out of their play. From there, the course of therapy is really about going back and reworking some of the aspects where it’s clear they need intervention. A lot of kids, in the beginning, in order to do the work, need to contain the perpetrator. So, they may spend some time building a jail for the bad guy. Even that can be diagnostic. I had one boy who would build a jail for his perpetrator, and the perpetrator kept escaping. He’d have hundreds of police outside, to make sure the perpetrator wouldn’t escape. Other kids will build jails for their perpetrator, and they’ll put a bed in, and a mattress, and a television. They want to make sure that he’s comfortable in there. It speaks to the type of relationship that they had, and their concerns about that person.
I don’t think you can effectively do this work without also teaching coping skills and providing psychoeducation. So, I fold that into the process, especially when we’re de-roling or debriefing from their play at the end of session.
Dr. Bromberg: What are common themes that you’ve seen come up in therapy for children who’ve dealt with trauma? What is it that you see across the spectrum of people who’ve dealt with trauma?
C. Haen: Let’s separate it out. What’s great about play and metaphor is that there are a lot of themes that come up that perhaps children aren’t able to articulate. In their play, you see clashes between good and evil, monsters, invasion, bodily damage, and a lot of reworking of the same event over and over in a dull, monotonous way.
In terms of the treatment themes, different populations of traumatized kids have different things that tend to resonate. What keeps drawing me to this work is that each individual processes his or her trauma so differently. So, for some kids who have been sexually abused, it is the betrayal of trust that they thought they had with that person, and how that forms a map for them in terms of future relationships and how they relate to people. For other kids, it’s a specific aspect of the abuse; a physical pain associated with it or the bodily arousal they felt, that leads to a lot of confusion about what it means about them. For other kids, it may be the series of questions that they were asked by whoever came in to investigate the abuse, and that might have been the most traumatizing aspect. Nightmares are very common as well and provide an opportunity to work in vivo in the room and to practice skills for dealing with nightmares. How the parents process and understand the trauma events tends to influence what comes up for the child. Kids are very savvy; I’m always amazed at how bright they are, and how they are keyed in to what’s going on in their family. They know, for example, if mom can’t tolerate talking about whatever happened to them. Maybe they feel they need to be functional, because somebody else in their family isn’t functional.
Dr. Bromberg: Do you ever do family work as part of the treatment?
C. Haen: I do. When I was working at New York-Presbyterian Hospital, we developed an interesting model for trauma treatment. I would do individual, trauma-specific work in a play room that only the child and I entered. The parents never went into that space. It was a very consistent space; the rest of the staff didn’t use it for any other purpose. The social worker would work with the family. I didn’t meet with the family. After we had done the individual work, we spent the last five minutes of our session sitting down together—the child, the social worker, and me. We would discuss what information the child wanted to transfer from the session to the social worker. So, the child and I would have an active dialogue about what to tell their social worker about what he or she worked on, and it did not become a secret that the child and I held. Then, from there, the child would share that material with the social worker, and they would meet together with the family. I think that split really helped children with a lot of their conflicts over loyalty, because they were doing that work with a different person than the person who met with their family.
Obviously, when you’re doing outpatient or private practice work, you don’t always have the luxury of working with multiple clinicians. I think it’s important, from the beginning, to establish trust and understanding with the parents about the work I am going to be doing with their child, what I will and will not be sharing with them. The child is very tuned in to all this, and I do not share things without the child’s permission. I’ve adapted this model so that at the end of each session, the child decides what information he or she wants to transfer to mom and dad, and then we sit down and talk about that.
At a certain point, for any traumatized child, there is a need to talk about follow-through. How do we transition skills they’re building in session to the home? When you’re working with kids where domestic violence is involved, you really can’t do trauma work until they’re in a safe environment. So, if the domestic violence is still happening, it becomes tremendously difficult. You’re really just talking about how to stay safe, how to manage themselves when frightening events happen. If the home can become a safer place, then there’s a lot of great work to be done with the parents around: understanding their child’s symptoms, understanding the triggers that exist in the environment, and helping to empower the family to make it a safer place for the child.
The other key thing is that traumatized people can look very crazy to the rest of us, because their bodies have been wired to protect them in dangerous situations, and it continues to utilize what it’s wired to do in situations that the rest of us know are safe. It’s important to help parents understand that, even though the situation may be safe, children are just doing what their bodies are wired to do, because they have been exposed to things that aren’t safe. That’s really critical, because traumatized kids can look like they have ADHD or Oppositional Defiant Disorder, or they can look like they’re psychotic, at times. That doesn’t mean that those other things aren’t comorbid, but I think these children often get misunderstood, because they’re at school and having intrusive thoughts, or something in the environment triggers them, and they respond in a way that looks, to the rest of us, very inappropriate. But for children who are trying to protect themselves, while receiving cues that they are in danger, it’s an appropriate response.
Dr. Bromberg: It sounds like an important part of the family work is this expert consultation you provide, giving psychoeducation and helping everybody better understand what’s going on.
C. Haen: I think so. Trauma can be intergenerational. So, one thing I’ve frequently found that has surprised me, especially in working with boys that have been sexually abused, is that sometimes mom has experienced sexual trauma herself. It can become a very complex dynamic, because she now has this son who is perhaps acting out sexually, and cueing her trauma triggers of her own abuse, and that can be very difficult to sort out. For dads, there can be a lot of fear that their son is gay, and what does that mean, how do they respond to that? There’s a lot of understanding that must be achieved in the family for them to be supportive in the right kind of way.
Dr. Bromberg: I’d like to talk a little about your definition of trauma, and just how broad that is. Would you include children whose parents have recently divorced, or who are having significant difficulties after adjusting to a new environment?
C. Haen: This is a good question, because I think the word trauma has become ubiquitous in our culture. Lots of people say they are traumatized: “I was so traumatized yesterday because I was stuck in traffic.” I think this has done a tremendous disservice to people who are truly traumatized. Even in the mental health field, I think there is a misunderstanding about what trauma means. Now, I’m going to say something that sounds a little contradictory to what I’ve just said: I don’t think you can define trauma by the event itself. You can have an event happen that would seem significantly impactful and traumatizing, but one person doesn’t experience it as trauma. You can have another event happen that, to most of us, would just be a bump in the road in our lives, but for someone else, that becomes a trauma.
I like the distinction that people in the field make between big t Trauma and little t trauma. With kids, I tend to think of it developmentally; it’s an event that blows them off the developmental trajectory they were on. I often talk to kids about it in terms of, “We’ve gotten off the highway, off on an exit somewhere,” and our work is about getting them back on the highway and back on the developmental path they need to be on. Big t Traumas are the ones that can halt normal development and functioning. Events that happen that bring about a lot of strong feelings, but may not necessarily impact how we go about our lives, are little t traumas. Those can have a cumulative impact over time.
I also think there’s an important distinction between single-event trauma, or Type I Trauma, and chronic, or Type II Trauma. Much of the trauma research has been done with those people who have experienced single and often public events, like September 11. When you’re looking at somebody who’s traumatized because of 9/11 and a child who’s being chronically sexually abused, there are two major differences. One is that, in public trauma, there’s an opportunity to process the event afterwards, sometimes as a community. There’s a normalization that can occur, because a lot of people have experienced the same event. With children who are being chronically sexually abused, secrecy is common. So, they don’t have the opportunity to process it in safety with adults afterwards. Also, because it’s chronic trauma, the impact goes beyond challenging their notions about a safe world to continually reinforcing that the world isn’t safe. Those kids can look very different, and I think the work with them can be more complex. Of the children I saw during my inpatient work who were diagnosed with severe mental health issues, as many as three-fourths of them had significant Type II Trauma.
Dr. Bromberg: You described this difference between public and secret traumatic events. I would suspect that correlates highly with the degree of shame—the more secretive and non-public the trauma, the more shameful it is for the child, and perhaps the whole family.
C. Haen: Absolutely. I think it was William Pollack who said, “Girls are shame sensitive, but boys are shame phobic.” For boys, culture has already taught them that they have to be strong, and that the only emotion they’re entitled to is anger. To be victimized is tremendously difficult for them to cope with. I think shame can become the mitigating factor for a lot of acting out and sexual reactivity in sexually abused kids. I just presented a workshop on working through revenge fantasies with traumatized people. I believe that shame can really fuel that desire for revenge, that desire to identify yourself as more powerful, because you felt so minimized and so disempowered during the trauma.
Dr. Bromberg: There’s a dyad that the child has internalized, with a powerful aggressor and a very powerless victim, and the child would prefer to be in the aggressor role than the victim role. The child may act out based on this, but in doing so, remains trapped within that dyad.
C. Haen: I would add a third person: the bystander. Often, when a child is engaged in play about the aggressor and the victim, I find myself sitting with being the bystander, watching the play and looking for places to bring in safe intervention. It is common that these kids are reenacting this posttraumatic play of aggressor and victim in many different ways, in their drawings, in school, or out in the playground. Often, the people who care about them really aren’t sure how to respond, and they find themselves trapped in the bystander role.
Dr. Bromberg: By being present in the bystander role in therapy, with a goal of intervening in a positive way, you create an opportunity to develop a new, healthier relationship, which may be internalized as a different kind of dyadic template.
C. Haen: I worked with a kid who framed it beautifully. I asked him what he wanted his future to be, and he drew a road with a series of stop signs. He said to me, “I want to be able to drive down this road, my life, and periodically stop and remember that this thing happened to me, and then move on and keep driving. And then stop again later, and remember, so that it’s a part of me, but it doesn’t define me.” One of the things that drama therapy has taught me is that, in order for kids to reach that point, understanding of the other is really important. So, in the play, we do spend time role reversing—having them understand the bystander role, for example, because maybe someone in their life was a bystander at the time. Being able to gain different perspectives makes them feel less locked into this one role of victim, or less desperate to be a perpetrator in their life in order to feel more empowered. It gives them control of that story.
Dr. Bromberg: Going back to my question about how you define trauma, if an event happens at a time when a child is developmentally vulnerable, and other temperamental vulnerabilities are present, then it could be a big t Trauma.
C. Haen: Yes. We haven’t talked about loss and how it figures into trauma. In my full-time job, I work with a lot of kids who are part of the foster care system. For them, moving to a new environment can mean a lot of loss: loss of a community, a particular person in that foster home, a pet, or a bedroom that felt safe to them. As adults, I think we discount how big those losses are to children. We forget what it was like, and how much certain objects meant to kids. I’m not saying that constitutes trauma, but I think loss is a significant piece of trauma. So, a divorce could be traumatic to the extent that, now that a family has reconfigured, it may not feel safe enough for the child, they may not be able to function in the same way. The loss may create certain fears.
Dr. Bromberg: Are you drawing a distinction between losses and big t Trauma?
C. Haen: Well, there is a distinction. In cases of complicated grief and traumatic grief, where a child has been witness to domestic violence that led to homicide, for example, or with a child who lost a parent in the World Trade Center, what often happens is that the trauma symptoms mask the grief and provide a barrier, so the child can’t grieve, because he or she is getting so overwhelmed by the trauma material. In these instances, you often have to do trauma work first, until it’s safe enough for the child to really grieve. I think that applies to a lot of the work. Whether you’re talking about adjusting to a loss, or divorce, or having been sexually abused, there is a component of the treatment that is about grief work. Because the clients are grieving for that lost relationship or that lost period of time, the loss of the part of themselves that was innocent, or the part of the self that they feel was robbed from them. So I am making distinctions, but for each person who I see, I want to understand what’s going on without worrying too much about quantifying and defining what he or she is going through.
Dr. Bromberg: At the same time, it seems there’s a fairly consistent rhythm to this, where you deal first with the blockages created by trauma, and then, eventually, there is work around grief and loss.
C. Haen: That’s correct.
Dr. Bromberg: How has your training as a drama therapist helped you in working with this population?
C. Haen: In trauma research, there is current work pointing to the importance of including the body in treatment. Trauma happens to us as physical beings, and it impacts us verbally, iconically, and kinesthetically. So, to just do verbal psychotherapy with traumatized people seems inadequate these days. One of the things that drama therapy has taught me is the value of experience, whether it’s the play a child engages in around the trauma in therapy, or whether it’s graduated exposure to treat panic attacks related to trauma. I’ll run groups with kids who say, “I’m not angry,” but you look at their fists, and they’re balled up like they’re ready to hit somebody. It’s important to ask about what it is their fists are saying. I think our bodies hold a lot of things that we can’t put into words, and that’s particularly true for traumatized people. The ability to talk about what happened gets split off from what they’re feeling inside. So, you can gain insight into your trauma experience, develop a cohesive narrative, and alter your cognitions about the events, yet your brain stem is still firing in response to those same trauma cues. Until you find ways to address that, you can’t fully resume development. I find the arts are a powerful way in. It’s using the back door, in a sense, because they help to bypass a lot of the defenses. The kids can say, “I’m just playing, that’s not me.” They can disown certain aspects of their expression, and the distance gives them permission to safely deal with things that would otherwise be intolerable to put into words.
Craig Haen’s contact information is:
Craig Haen, MA, RDT, CGP, LCAT
510 North Broadway
White Plains, NY 10603