Clin Soc Work J (2014) 42:336–345 DOI 10.1007/s10615-013-0439-0
ORIGINAL PAPER
Making Room for Play: An innovative Intervention for Toddlers and Families Under Rocket Fire Esther Cohen • Ruth Pat-Horenczyk Dafna Haar-Shamir
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Published online: 22 February 2013 Ó Springer Science+Business Media New York 2013
Abstract Evidence from both clinical reports and empirical research suggests that symbolic play may help heal children’s traumas. Playfulness, an enduring individual characteristic, also contributes to resilience. However, trauma often sabotages children’s ability to engage in imaginary play and parents’ ability to be involved in playful interactions with their young children. This paper describes an innovative preventive group-intervention program by the name of NAMAL (Hebrew acronym for Let’s Make Room for Play), designed for mothers and their toddlers who live under the chronic stress of recurrent missile attacks in Israel. The major objective of the program is to bolster children’s resilience by enhancing their playful interactions with their mothers. The theme and activities of each session are organized around a saying with a relational or developmental message. Reports collected from 70 mothers after their participation in the program highlighted the success of the intervention and the changes in the children and parents, as well as in their interactions with each other. Follow-up interviews conducted a year after the intervention provided further information on the long-term positive effects of the program. Keywords Preventive intervention Play and playfulness Resilience Traumatic stress Toddlers Mother–child interaction Dyadic group program E. Cohen (&) R. Pat-Horenczyk School of Social-Work, The Hebrew University of Jerusalem, 91905 Mt. Scopus, Jerusalem, Israel e-mail:
[email protected] R. Pat-Horenczyk D. Haar-Shamir Herzog, Israel Center for the Treatment of Psychotrauma, Jerusalem, Israel
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Introduction The considerable lag in studying the effects of traumatic events on young children, in comparison to adults and adolescents, has been repeatedly criticized in the trauma literature (Almqvist and Brandell-Forsberg 1997; Cohen 2006; Joshi and O’Donnell 2003; Salmon and Bryant 2002). This shortcoming is particularly striking because recent research has revealed that children under five are subject to more potentially traumatic events than older children (Chu and Lieberman 2010). Furthermore, evidence suggests that ‘‘children’s mental health in the first 5 years of life can be profoundly and lastingly affected by the impact of traumatic stressors, such as domestic violence, child abuse, community violence, and war’’ (Lieberman 2011, p. 640). Young children’s experience of traumatic events appears not only to be associated with posttraumatic symptoms, but also to affect their biological, emotional, social, and cognitive functioning and development (Cohen and Scheeringa 2009; Graham-Bermann et al. 2008). Therefore, a focus on prevention seems especially relevant for this age group. Despite its clear importance, the predominant focus in the field has largely ignored prevention and instead has concentrated on alleviating the effects of traumatic exposure involving a single episode. Consequently, evidencebased therapy models developed to treat traumatized children, such as Trauma Focused CBT (Cohen et al. 2000), are limited in their focus to helping children process a single traumatic event. This limitation is particularly worrisome because young children are routinely exposed to multiple sources of familial and community violence, or to prolonged situations of war and recurrent terrorism (Chu and Lieberman 2010; Feldman and Vengrober 2011; Finkelhor et al. 2007). The developmental and mental-health risks for
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these children are manifold, due to the accumulated damage of recurrent stress over time, the possible occurrence of adversities during sensitive developmental periods and the frequently deleterious effects of traumatic events on the children’s caregivers and communities (Dyregrov and Regel 2012; Shonkoff et al. 2009). Nevertheless the importance of early interventions for children affected by traumatic events is still not widely recognized. We concur with Dyregrov and Regel (2012), who argued that the ‘‘watchful waiting’’ stance espoused in many clinical guidelines for the assessment and treatment of posttraumatic stress disorder is not feasible and may even be harmful. Considering the needs of children and parents, especially when coping with stressful and recurrent traumatic conditions, a proactive preventive approach tailored to the needs of this particular group is needed, rather than the more common focus on providing conventional individual therapy for severely affected individuals. This article describes an attempt to introduce a preventive intervention focusing on the needs of young children and their families who have experienced recurrent and prolonged periods of war. The name of the program, Namal, is an acronym in Hebrew for ‘‘Let’s Make Room for Play’’ (Naase Makom Lemishak). The word namal also means port and has the connotation of a safe haven. The Namal program was created and designed by the first author and was further adapted and implemented by a team at the Israel Center for the Treatment of Psychotrauma1. This article is devoted to a description of the goals of the intervention and the evidence base that informed the creation of the program. The format, themes and techniques of the Namal program are also described. Theoretical Considerations and Evidence Base for the Program The program was based on two main theoretical premises and associated empirical research dealing with resilience and coping with traumatic events: (a) Attachment processes and the parent child-relationship play a central role in young children’s resilience and their ability to cope with traumatic events; (b) Play and playfulness are instrumental in helping children cope with trauma and in developing resilience. Each of these notions is described more fully below. 1
Our appreciation to Dafna Ba-Gad, M.A., Michal Achituv, M.A., Atoosa Khodabakhsh, M.A., and Lisa Asulin-Peretz, M.A., from the Israel Center for the Treatment of Psychotrauma for their valuable contributions; to Anat Lerner, M.A. and Frida Golan, M.A., from the Early Childhood Center in Sderot for their collaboration. Rinat Yalin, M.A. and Liz Young, B.A. successfully co-facilitated the play groups. The Jewish Family and Children’s Services and Parents Place in San Francisco generously supported this work. Special thanks to all the participating families
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Attachment Theory and the Role of the Parent–Child Relationship We decided that the intervention, although carried out in a group setting, would focus on in vivo experiences of the dyadic interaction between parent and child. This decision was based on the recognition that parents are powerful mediators of the effects of traumatic events on their children. The literature shows that mothers influence the development of their children’s capacities prior to traumatic events, model behavior during the event, and shape the healing environment following a traumatic event (Cohen 2009). Recent investigations of resilience have placed particular emphasis on the quality of the attachment relationship and its role in the development of affect regulation in children. It has been shown that children who have experienced sensitive caregiving develop neurological systems and reflective capacities which function effectively in regulating emotional arousal (BraungartRieker et al. 2001; Fonagy and Target 2003). Child-parent psychotherapy, a relationship-based intervention for traumatized children, has been shown to improve the quality of the child’s attachment and contribute to a decrease in children’s behavioral and emotional problems. The use of joint child–mother sessions allows the treatment to focus simultaneously on the child’s and the mother’s affect and behavior. The assumption is that the support the mother and child receive while processing their traumatic memories and creating a shared trauma narrative enables the mother to understand and respond to the child’s fears and attachment needs in developmentally appropriate ways (Lieberman 2011). However, as successful as this model has been found to be, it only serves the needs of individual children or families and its usefulness for large numbers of families in need is quite limited. Very little is reported in the literature on interventions which address the needs of groups of families living under chronic traumatic stress. One exception is Dybdahl (2001), who used a theoretical perspective similar to ours and reported the results of an intervention based on weekly group meetings conducted for 5 months with refugee mothers and their preschool children. The meetings focused on coping with problems and promoting good mother–child interactions. The participants’ children showed better weight gain, and both the mothers and the children showed a reduction in distress symptoms, compared with a control group receiving only a medical follow-up. Focus on Play and Playfulness Play, especially ‘‘pretend play’’, has long been considered of central importance to children’s cognitive, social and emotional development (Ginsburg 2007). Research shows
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that pretend play contributes to the development of narrative abilities, which in turn may be associated with the ability to construct a coherent trauma narrative and therefore enables children to cope better with traumatic events (Cohen et al. 2010; Hafstad et al. 2010). Pretend play between parent and child also has been linked theoretically to the development of reflective abilities, self-regulation and resilience (Fonagy and Target 2003). Greater resilience in children who have been exposed to terrorism has been associated with the following characteristics of playful behavior: a greater tendency to engage in play; a better ability to plan and play out a coherent, progressive, creative and satisfying narrative while showing ‘‘awareness of self as player’’ (awareness of being the director as well as the actor in one’s play); a better capacity for self-soothing; and a greater tendency to engage in a relationship with an adult during the play (Cohen et al. 2010). These characteristics all can be grouped under the concept of ‘‘playfulness.’’ Playfulness refers to spontaneous physical, cognitive and social behavior that expresses joy, humor, curiosity, imagination and creativity. From a developmental point of view it may be regarded as a stable individual characteristic evident in play as well as in other interpersonal interactions (Lieberman 1977). Bundy (1997) defined playfulness as contingent on a combination of four elements: intrinsic motivation, internal control, the freedom to suspend reality, and framing. Intrinsic motivation refers to the self-rewarding aspect of play, the experience of interest and the enjoyment, rather than an interest in an external reward. Internal control suggests that the child is largely in control of his/her actions and some aspects of the activity’s outcome. Freedom to suspend reality means that the child decides how close the action will be to objective reality. Framing means that the player organizes a frame and inner rules for the play that are coherent and can be shared with another, thus showing the ability to provide and interpret play cues. The relationship between playfulness and resilience may be based on the fact that playfulness involves two major mechanisms which play a central role in coping with stress and trauma: positive affect and self regulation. Schore (2003) has underscored the often overlooked regulatory mechanism of positive affect regulation evident in parentinfant playfulness. According to Schore, ‘‘affect regulation is not just the reduction of affective intensity, the dampening of negative emotion. It also involves amplification, an intensification of positive emotion, a condition necessary for more complex self-organization’’(p. 78). Studies with both adults and young children show that positive affect can occur even during periods of distress and has important adaptational significance because it is an important facilitator of adaptive coping with acute and chronic stress and post-traumatic distress (Bonanno et al.
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2011; Fredrickson 2000; Folkman and Moskowitz 2000; Jung 2010). Playfulness develops early in the context of caregiverchild interactions. Based on animal studies, Panksepp (2009) has argued that early playful interactions strengthen interpersonal regulatory circuits in the brain and form the basis for social learning. Similarly, Trevarthen and Aittken (2001) maintain that a baby has a basic need for a joyful dialogic companionship that includes vitality, contingency, rythmicity, and positive affect. They describe how prosodic vocalizations, coordinated visual eye-to-eye messages, and tactile and body gestures serve as channels of communicative signals in the earliest forms of dialogue between infant and mother. It appears that the gradual working out of collaborative strategies for the elaboration of shared meanings is a principal function of joint pretend play in early childhood. This playful collaboration helps the child regulate affect and process aspects of traumatic experience (Lyons-Ruth 1999; Lyons-Ruth 2006). The sad paradox in the interplay between trauma and playfulness is that while play and playfulness may be helpful in processing traumatic events, exposure to traumatic events may lead to a defensive reduction in children’s symbolic play (Drewes 2001; Feldman et al. 2007). Furthermore, the play may lose its joyful quality and become repetitious, rigid, serious or morbid (Cohen et al. 2010; Nader and Pynoos 1991; Varkas 1998). Concomitantly, a similar paradox operates with parental support of children’s playfulness. Playfulness develops with caregivers who engage with the child playfully, support and enrich his or her play and use play for affective processing of stressful events (Bronson and Bundy 2001; Fonagy et al. 2002). However, the quality of the parents’ caregiving is often diminished during stressful periods, when their children need them most, due to the parents’ depression, anxiety or posttraumatic distress (Cohen 2009). A major focus in our intervention was to promote mothers’ playfulness with their young children and raise their awareness about the importance of imaginative play for the child’s development and resilience. The Main Goals of the Namal Program In addition to these theoretical considerations, we also had to consider both the children’s developmental stage and the needs of parents and children which might be relevant to their trauma experience. We set the following main goals for the Namal program: 1.
Provide opportunities for exclusive mother–child interactions, using a variety of sensory and expressive modalities, to strengthen the attachment bond and improve the mother–child relationship.
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2.
3.
4.
5.
Raise the parents’ awareness of their central role in building the child’s sense of uniqueness, trust and selfreliance through positive encouragement and support. Educate mothers about the importance of supporting the expression and regulation of emotions and teach skills for attuning and reflecting feelings as well as soothing skills. Sensitize mothers to their role in supporting their child’s curiosity, creativity and imagination through play and playfulness. Help mothers identify signs of stress in children, understand the children’s feelings about traumatic events, help them create a coherent and empowering narrative and increase their sense of competence in coping with the stressful events.
Method Target Population The program targeted families of young children (initially toddlers, and following adaptation, also preschoolers) residing in the area of Sderot, a southern Israeli town near the Gaza Strip, which has suffered recurrent rocket and mortar attacks from 2001 to the present. Although the frequency and intensity of these attacks has varied over the years, they have never stopped for any extended period of time. At the end of 2008, for example, approximately 4,000 rockets and mortars were fired into the area during a period of a few weeks, representing an average of eleven incidents every day, resulting in a total of three deaths and close to 200 injured. Each such incident is preceded by an early warning radar system which detects a rocket launch and activates a public broadcast alarm, termed ‘‘Color Red’’ in Hebrew, which allows all residents (including children) 15 s to take cover in a protected area. However, many homes and some schools lack protected areas. The experience of living under continual exposure to missile attacks and raising children in a reality of ongoing fear and uncertainty impacts both children and parents. A recent study found that, according to maternal reports, 45 % of the young children in Sderot (aged 2–6) suffer from PTSD, and 41 % of the mothers reported posttraumatic symptoms (reflecting probable PTSD). A similar rate of mothers reported moderate to severe symptoms of depression (Pat-Horenczyk et al. 2012a, b). The mothers who participated in Namal groups were recruited on a voluntary basis through child-care settings, with the approval of the local Resilience Center and directors of daycare facilities. Two facilitators were responsible for leading ten group meetings. A light supper was served at the end of each meeting, during which the facilitators made themselves available for individual discussions with the mothers.
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The learning process in the group was interactive and experiential. It involved engaging the participants in various expressive and artistic modalities, including music, rhyming, movement, and art. A child puppet was introduced to the children in the first session and conversed with the children during following meetings. Each meeting began with a welcome song and ended with some relaxation activities. Description of the Program: Themes, Messages and Activities Each meeting was organized around a theme that is introduced via a saying with a developmental or a relational message. This was an important feature of the program and was designed to counteract the negative potential of traumatic events and to increase the level of reflection and symbolization of caregivers. The sayings typically had a double meaning, one concrete and one abstract, which makes their use playful. The saying was introduced and explained briefly at the beginning of each session and all the activities were connected with this message. At the end of each session, the facilitators summarized the meeting by pointing out how the activities were connected with the day’s message. The mothers then took home a printed page with more detailed information about the session’s theme as well as a decorative refrigerator magnet with an imprint of the saying. Although the program used a group format, and the group sense of support and cohesion was considered an important benefit, the activities were nevertheless aimed mostly at modifying the dyadic interaction between the mother and child. Large colorful sheer scarves were used in various ways to delineate the intimate dyadic space in which child and mother interact. Session 1—Theme: The importance of secure attachment for positive personality development. Saying: If we look at something with love, it becomes beautiful. Messages: The mother–child relationship is the basis for the child’s perceptions of him/herself and ways of relating to others; it is important for parents to spend exclusive time together with the child, to delight in the child, to be emotionally available, to soothe, regulate and to mediate experiences. Examples of Group Activities: The mothers follow in song and movement the lyrics of a taped song involving her search for her child and delighting in finding her/him just behind her back. The mother invites the child to a ‘‘special meeting’’ under the sheer scarf, which covers them both, and observes and comments on the child’s loveable features. The mother watches the child rocking while lying on a big ball. She encourages the child’s independent movement in a
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face-down position and offers greater help and protection when the child lies with his/her back on the ball. Session 2—Theme: The importance of autonomy and support. Saying: All a child needs is one adult who believes in him/her. Message: Promote the child’s strivings for autonomy and self-reliance by focusing on the child’s interests and motivations, encouraging and patiently facilitating independent coping, appreciating the process and not only the outcome. Examples of Activities: The dyad is invited to make leaves out of newspapers that will fly in the pretend wind to the sound of a relevant song. The mother supports and encourages the child’s independent coping. They then clean up the room together. The mother facilitates problemsolving by encouraging the child to reach the wastebasket, which is deliberately placed at too high a level for the child to reach easily. The puppet talks to the children about what she can do ‘‘all by herself’’ and what she still finds difficult. Session 3—Theme: The importance of play and playfulness. Saying: All you need for play are a good imagination and a pile of junk. Message: Playful interactions can be achieved through a variety of play objects (no need for fancy toys), movement, gestures, music, words and ideas. Promote playfulness, creativity, imagination and humor when interacting with your child. These are important for enjoyment, strengthening relationships, diffusing stress and developing cognitive and social flexibility. Examples of Activities: Using bodily movement and finger-play to represent animals and objects (to music); completing sentences with funny rhymes; decorating the mother’s face with colorful stickers. Session 4—Theme: The advantage of a focus on the positive and appreciating the child’s uniqueness. Saying: Always focus on the bagel and not on the hole; otherwise you may remain hungry. Message: Use observation and reflection to acknowledge and validate the child’s plans, choices, efforts, achievements and wishes; this will help the child experience and develop self-esteem and self-acceptance. Examples of Activities: The mother imitates the child’s movements, postures and facial expressions, guided by an appropriate song. The dyads engage in building a structure made of scraps, and the caregiver describes the child’s actions, intentions or choices and feelings reflectively. Session 5—Theme: The importance of helping children expresses a wide range of feelings. Saying: The heart has a mind of its own, which the mind cannot always comprehend.
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Messages: Be attentive to your child’s various emotions. Label, accept and validate all emotions, even if they appear unjustified or inappropriate. Encourage their expression in acceptable ways. Talking with children about unpleasant feelings reduces the child’s loneliness and helps the child understands, accept and regulate her/his own feelings; it also allows the mother to correct misconceptions and solve problems. Ignoring fears or criticizing negative emotions does not make them go away. Example of Activities: Songs about various emotions accompanied by movements and facial expressions; the puppet shares her fears at bedtime. Session 6—Theme: Helping the helpers. This session is conducted with the group of mothers only. Saying: God created parents because He is too busy to do everything Himself. Message: Processing your own stress and posttraumatic feelings and discussing ways of regulating them is a precondition for you to help your child regulate her/his feelings and behavior. Transitional objects, rituals and play are particularly important for the child’s self-regulation when she/he is stressed. Example of Activities: Group-sharing of personal coping resources; preparation of a ‘‘surprise box’’ with soothing objects for the child. Session 7—Theme: Play and playfulness are helpful in coping with life in the shadow of uncontrollable traumatic events. Saying: Imagination is one of the best weapons in the struggle against reality. Messages: Playing with your child offers an enjoyable diversion in stressful times; the mind can transport us to imagined situations and enhance pleasure and relaxation. It is important to cultivate the ability to imagine a good future. Play advances the child’s ability to process intense experiences symbolically, which in turn contributes to better coping and resilience. Examples of Activities: Hiding in imaginary and symbolic protective spaces; inviting pleasant memories; relaxation using guided imagery. Session 8—Theme: It is difficult at times to understand and respond to a child’s inner experiences and needs based on his/her behavior. Saying: Things that you keep to yourself inside your belly may give you a tummy ache. Messages: The child needs the help of a parent who emphasizes resources and protection for the purpose of understanding unusual, confusing and anxiety-arousing experiences, and creating narratives about them. Help your child express emotions and encourage questions. Engage in
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creative or make-believe play with the child and in playful, soothing interactions; help children introduce coherence and protection themes into chaotic play. Examples of Activities: The puppet shares her experience of a recent ‘‘Color Red’’ incident, and the facilitator, roleplaying the puppet’s mother, answers her questions and tells her the story of the incident. Dyads dance to a song using umbrellas to protect them from rain and hail. Sessions 9—Theme: The importance of adhering to and valuing long-term parenting goals in a supportive human network. Significant others are invited to this meeting by each of the participants. Saying: There are two gifts we can bestow to our children: One is roots, the other is wings. Message: Parents can achieve seemingly conflicting yet complementary parenting goals through the use of intimate play interactions with their children; these include a sense of human connectedness, endurance and stability together with a sense of agency, striving and hope for change. Example of Activities: Additional family members are invited to this session. Various previous group activities are shared with the guest family members. Session 10 Concluding, reviewing, and saying good-bye. Reflecting on the process of change and achievements gained through the group participation.
Evaluation The program was accompanied by qualitative evaluations and quantitative research that is still ongoing. The research was approved by the ethics procedure and committees at the Hebrew University of Jerusalem. We describe the qualitative responses to semi-structured questionnaires completed by the mothers at the end of the group interventions. In addition, we conducted phone interviews a year after the intervention to follow up on changes that were attributed to the program. Evaluation After Completion of the Group Intervention This evaluation is based on the responses of 70 participating mothers from 10 different groups which met over a period of 2 years. All the mothers completed a semistructured questionnaire during the last group session. The response rate was 84 % (due to missing participants in the last group session). The mothers responded to open-ended questions asking them to specify the most meaningful group activities in the program and describe specific behavioral changes (in both themselves and their children) which they attributed to the group intervention. The
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content of the responses was analyzed by two independent raters, using a two-stage process: (1) A bottom-up analysis from each individual response to a category of responses, and (2) A top-down analysis, organizing and combining relevant categories (Lieblich et al. 1998). The inter-rater reliability was .92. The meaningful effects of the program, as defined by the mothers, fell into the following three domains: (1) changes in the parent–child bond (pointed out by 72 % of the mothers); (2) perceived behavioral changes in both the mother and the child (referred to by 59 % of the mothers); and (3) understanding and internalizing the relational and child-centered messages delivered through the program (mentioned by 35.7 % of the mothers). Perceived Changes in the Parent–Child Bond The majority of the mothers noticed positive changes in their relationship with their child following the program. These changes involved a greater tendency to engage with the child and mutual enjoyment (92 % of mothers’ comments). Their interactions were more playful and incorporated more imagination, humor and creativity. Examples are: ‘‘Our bond has strengthened’’; ‘‘We do more activities that involve being creative’’; ‘‘I give my child the opportunity to play with scraps, it is okay if it causes a mess; I am more free and get less upset by the mess’’;’’We play more fun games together.’’ In some cases the mutual joyful engagement was also perceived to be manifested in closer physical contact and demonstrations of affection (8 % of the comments) : ‘‘She kisses and hugs me more, approaches me more’’; ‘‘After the program and spending time just with her, she feels freer to hug and kiss at home.’’ Perceived Behavioral Changes in the Mothers and the Children Perceived Changes in the Child’s Behavior The most frequent description of changes in the child’s behavior (68 %) provided by the mothers involved an improvement in positive mood and expressions of excitement. Many comments (36 %) referred to a reduction in temper tantrums and a feeling that the child has a greater capacity to listen and cooperate, which leads to a reduction in conflicts at home. Examples are: ‘‘He is more patient’’; ‘‘He is calmer, has less temper tantrums, and listens more.’’ Changes in the child’s sense of self-reliance and autonomy were addressed by 12 % of the mothers, who observed an increase in the child’s sense of competence and selfconfidence. Examples are: ‘‘She is more independent and confident with other grown-ups’’; ‘‘He started to show a new side of himself when he participated in songs and
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movement in a way that didn’t happen at day care’’; ‘‘He is more open with other children and strangers and tells members of the extended family what he does in the program.’’ Perceived Changes in the Mother’s Behavior Dedicating more time to being exclusively with the child was often mentioned by the mothers when they commented on the changes in their own behavior following the program. About a third of them (31 %) stated that they devoted more time to being exclusively with the child in ways that promoted a strong bond between them. In their own words: ‘‘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’’; ‘‘We create more time for just him and me or him and his dad.’’ Many comments (56.25 %) involved the participants’ sense of competence in their parental role and described an improvement in their ability to better understand their child and his/her needs and help regulate the child’s emotional state. Examples are: ‘‘I understand him more when he is stressed’’; ‘‘My approach changed, how to deal with him in times of stress’’; ‘‘I am more patient with him’’; ‘‘When she wouldn’t join in I learned to let go and let her experience it in her own way.’’ Additional remarks involved the ability 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.’’ Understanding and Internalizing the Messages and Themes of the Program The message about the importance of spending exclusive time together with the child was mentioned in 28 % of the mothers’ comments. Three different examples make this point: ‘‘The most important thing for me was the time I spent with my daughter without having to be preoccupied with something else. This was time devoted only to me and her’’; ‘‘The main goal was to dedicate personal time to my child and this happened in every group activity’’; ‘‘It was the quality time with my daughter during the activities that strengthened the bond between us.’’ The importance of joint play and the use of imagination and playfulness in the parent–child interaction were mentioned in 28 % of the comments. The meaning of the saying ‘‘All you need for play are a good imagination and a pile of junk’’ was mentioned in many of the mothers’ statements. The value of this idea was nicely described by a mother who wrote: ‘‘The imaginative play activities helped me learn about new aspects of my daughter that I never knew before.’’
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Additionally, 32 % of the comments addressed the importance of a variety of coping skills, including reflective phrases (16 %) and techniques of soothing and relaxation as means of enhancing emotional regulation. Some examples in the mother’s own words are: ‘‘It is important to reflect her feelings and her wants, as it reduces the tension and anxiety felt by both of us’’; ‘‘We were reminded of how important it is to reflect and cope with the child’s difficulties’’; or ‘‘The relaxation techniques slowly sank in.’’ The message of stressing the value of focusing on the positive aspects of the child and empowering him or her was mentioned by 8 % of the mothers—for example: ‘‘The bagel saying and accompanying activities were most influential for me’’; ‘‘You have to focus on what the child does and to praise them and say a kind word, because sometimes we focus on the unimportant things and miss out on the essence, and the bagel is the essence, you need to eat something in the end’’; or ‘‘The most important saying really is that all a child needs is one adult who believes in him/her.’’ One-Year Follow-Up A one-year follow-up was conducted to assess the longterm effects of the program. A year after taking part in the dyadic groups, 53 mothers who had participated in one of six NAMAL groups were contacted by phone and asked to respond to a short semi-structured questionnaire. Thirtyeight mothers (71.7 %) responded to the full questionnaire. The mothers were asked what the most memorable aspects of participating in the program were and whether they had noticed changes in themselves since participating. The responses were analyzed in the same way as described above. The results showed that the most significant aspects of the program were the mothers’ sense of competence in their role, the importance of identifying and talking about feelings and fears, and their ability to address the child’s needs. The most frequent comment made by the mothers involved the change they felt in their emphasis on the importance of identifying emotional states felt by both their child and themselves and addressing these states (41.6 %). The mothers also expressed a sense of having more tools for coping with negative feelings, specifically fear and anxiety, experienced by their child and themselves. Examples are: ‘‘The program gave me an opportunity to help her express herself and share’’; ‘‘Today I see that she really shares her emotions, especially about security threats. She asks questions; things are coming out and I think I am able to answer in a way that calms her’’; ‘‘It seems that thanks to the program I am able to try not to silence the fear but instead to open it up and to allow her to
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express herself’’; ‘‘I learned how to deal with the security situation and give her the feeling that I am always there for her and how to cope, even when I am most distressed. Today I understand that you have to answer honestly even if you are in a rough state. I was given tools and it did a lot for me’’. Many of the comments (31.25 %) addressed the use of activities and techniques included in the program and the variety of sensory and expressive modalities experienced and learned in the group. Mothers recalled the activities in which they were creative with their child, reciting playful rhymes under the sheer scarf, use of the ‘‘soothing box’’ and the like. In 20.8 % of the comments, mothers stated that they continued to use the techniques acquired through the program a year later. Interestingly, some of the mothers reported using the techniques in their work as day-care staffers. One aspect that showed continuity over the one-year period was the importance placed on dedicating more time for exclusive interaction with the child and strengthening the parent–child bond. Twenty-five percent of the mothers’ comments indicated the importance of having exclusive time with their child and its contribution to strengthening their relationship. ‘‘It wasn’t one specific activity I recall, rather doing things together, creating together’’; ‘‘The bond between him and me; he loved being together, that was the essence. Two weeks ago he remembered the program and said that he misses it.’’ A quarter of the mothers’ comments (25 %) indicated that, since participation in the program, they tended to spend more time exclusively with the child, felt closer to the child emotionally and physically and their bond with the child was stronger. Here are some examples: ‘‘The change was extreme, our relationship is more productive. In the program we learned through play, it was physical, I moved with her and it connected me to her.’’ ‘‘The most significant change was me being more aware of the importance of spending quality time with him.’’ The importance of the sayings used in the program was highlighted spontaneously in 14 % of the comments, in which mothers stated that they still have the messages posted on their refrigerator as daily reminders of the meaning behind each phrase. For example: ‘‘The punch was in the sayings. Each session was accompanied by a saying that made it unique. I remember this most of all and the magnets are still on our fridge.’’ Lastly, the mothers spoke about the pleasant atmosphere in the group during the activities and the joint meals, as well as the anticipation their child felt before the meetings and the joy that gave them (14 %). Here is one example: ‘‘I remember the sense of cooperation, the children’s love for what was going on. It brought us all closer.’’
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Conclusions The feedback provided by the mothers at the termination of the program and a year later shows a remarkable level of internalization of the main messages which were designed to be imparted through the program. Although the mothers do not use professional concepts such as ‘‘attachment’’, ‘‘playfulness’’, ‘‘trauma processing’’ or ‘‘emotional regulation’’ to conceptualize their new experiences, it is clear that they not only understand the meaning of such developmental and relational challenges and tasks, but they also reflect upon them, change their interaction with their children to ameliorate their children’s distress and see the ensuing benefits. It also appears, according to the mothers’ responses that the experiential means used in the program, especially those combining playfulness with symbolization, were helpful in internalizing the group messages. It seems that, for many of the mothers, prior avoidance tendencies have been replaced with their active involvement in helping their children process potentially traumatic experiences. Given their situation, we could ask for no more. We hope to be able to support this evaluation in the near future by additional evidence based on observational data and quantitative measurements of changes in the mothers and the children who participate in the group intervention and in comparison groups.
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Author Biographies Esther Cohen, Ph.D (Michigan State University, 1973) is a Professor at the Child-Clinical Psychology Program at the Hebrew University of Jerusalem. She is a clinical psychologist and family therapist with 30 years of experience in treating traumatized children. Her publications focus on the parent–child relationship and traumatic exposure. Ruth Pat-Horenczyk, Ph.D is a clinical psychologist, the Director of the Child and Adolescent Clinical Services at the Israel Center for the Treatment of Psychotrauma and an Adjunct Associated Professor at
Clin Soc Work J (2014) 42:336–345 Hebrew University. Her research topics focus on risk and protective factors for childhood PTSD, Relational Trauma, Flexibility and Resilience.
345 sponsored by the Israel Center for the Treatment of Psychotrauma. A developmental psychologist at the Tel-Aviv Child Development Center, providing developmental assessment and therapy to children affected by developmental delays and their families.
Dafna Haar-Shamir, MA Developmental Psychology. Former project co-coordinator of the ‘‘Parent’s Place Program’’ in Sderot
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