Pediatric social worker Monica Handlos, MSW, LICSW, spends most of her days in a toy-filled playroom. Her clients, a range of kids between the ages of 3 and 10 facing significant medical complexities, usually spend 45 minutes each week in one-on-one sessions, playing with Handlos’ extensive collection of toys. But it’s not all fun and games.
“When they spend time with me, the kids play hard but they also work hard,” Handlos said. “Sure, there are a lot of toys here. We have fun together. But we are also working through some pretty traumatic things, some tough issues. These kids have been through a lot in their lives. There might be toys involved, but there is also serious work happening here.”
Handlos’ employer, Roseville-based Pediatric Home Service (PHS), has been offering play therapy for its patients for three years. The for-profit agency, which offers medical home-care services for children, including infusion therapy, respiratory therapy and feeding support, began offering play therapy as a way to support the mental health needs of their young clients, many of whom have been undergoing daily invasive medical care since the day they were born. At the moment Handlos’ caseload is small — just 12 patients — but she hopes to increase that number up to 20.
“We have a population of kids who are trached and vented,” Handlos said. “Some kids might need all the services we offer. Some might need one or the other. Some might need to see us for only a few sessions. Others have ongoing treatment. We work with kids who are premature or who need different liver or kidney transplants. We deal with all different sorts of disorders and syndromes — and all the different kinds of emotional reactions they create.”
Life-saving but scarring
For kids, medical trauma can sometimes create emotional trauma.
“Often kids with medical complexities are dealing with the mental health piece,” Handlos said. “Many have fears around medical appointments and procedures. It makes sense: They’ve been traumatized by medical procedures their whole lives.”
Clearly, the medical professionals who inspire those traumas aren’t trying to hurt their young patients, Handlos said. They are working to save their lives. But many of the procedures that kids with medical complexities must endure, including blood draws and injections, medical infusions, tracheotomies and ventilators, are invasive — and sometimes painful.
“They’ve been poked and prodded,” Handlos said. “And for many of these kids, it happens every day.”
For these young patients, it can feel like their lives have been taken over by unwanted medical procedures. They strongly resist treatment, making life hard for themselves — and for their parents and caregivers.
“Kids get referred to me from many sources,” Handlos said. “It can be a clinician, a homecare provider, a home-care nurse, an infusion nurse, a respiratory therapist.”
Sometimes it’s a parent. “A kid may be presenting problems around coping with medical appointments. They may be anxious or sleepless. They may be crying and kicking and can’t breathe. That’s typically how young kids will exhibit anxiety and stress. In those cases, each treatment can be really traumatic for everyone involved.”
A safe space
Taking a “non-directive” therapeutic approach, Handlos begins each session by sitting back and letting the child lead through his or her choice of toys and style of play. There is no clear talk of medical procedures, no rules, no medicine: Just a roomful of toys and a calm, quiet therapist.
“I’m not telling kids what to do or how to do it,” Handlos said. “Some therapists might be more directive, but I believe that a non-directive approach allows the child to voice their perspective and their ideas. Play therapy is a form of therapy. For children, play is an avenue for them to be able to express their perspective and experiences through the use of toys.”
When PHS first began offering play therapy, Handlos brought her toys to her patients’ homes — the agency is a home-care provider, after all — but she soon learned that the sessions worked better away from her patients’ homes, in PHS’ offices.
“What I’ve found is that the kids that I am working with are receiving a lot of their medical treatments at home,” Handlos said. “Because of that, certain areas of their home become places of trauma. In the PHS playroom, they are able to leave their ‘stuff’ in the playroom and their other stuff at home. It is an easier place for them to transition. It is a safe environment.”
Handlos explained that the PHS playroom offers five categories of toys designed to help children process emotional issues:
- Realistic toys, including a real stethoscope, Band-Aids and lab-draw kits.
- Nurturing toys, including play food, a kitchen set, baby dolls and bottles.
- Aggressive toys, including swords, chain saws, guns, aggressive animals like lions and tigers and an angry puppet.
- Expressive toys, including a sand table, coloring books, musical instruments.
- Pretend and fantasy toys, including dress-up clothes and masks.
After some free-choice time, Handlos usually steps in with some gentle direction in the play. Ahead of the sessions, she has consulted ahead with the children’s parents and caregivers, and she knows what mental health issues they have highlighted. But she also knows to back off and observe and to let the children lead her to the issues that concern them the most.
“Kids will often work through their first trauma first,” Handlos explained. “They may be working on their earliest traumas through an infancy-type play. It’s not super concrete. Each session has a story. Or you might be getting little bits and pieces each time. It lays itself out after two or three sessions. I’ll eventually see the whole story that the child is trying to convey.”
The play-therapy process takes time. (“I have to be invited into the play, Handlos said. “It’s really relational. If the child doesn’t trust me, the first couple of sessions are really about them trying to figure me out.”) And it doesn’t always follow a clear and direct line.
“Sometimes parents will say, ‘This is what our kid needs to work on,’” Handlos said. “But what I see is that the kids are playing out something totally different. In their own way, they’re telling me, ‘This is what I need to work on.’ Sometimes kids can’t move from one story. They want to play that out, and I need to let them do that.”
In those cases, Handlos meets with parents and explains the direction her therapy sessions are taking. Life with serious pediatric medical issues can impact every member of a family, and Handlos also provides therapy sessions for parents and physically healthy siblings.
“Some of the kids I work with have mental health concerns that are only focused on their medical issues and treatments,” Handlos said, “but often there might be other issues intertwined. I might be working with the kid, and the parents say they want to just take care of just the medical piece. But, like any other kid, they might also be struggling with family issues at home. We need to work through that, too.”
When families agree to broaden the focus of their therapy, clear progress can be made, Handlos said. With processing, therapy and family support, they can learn to build emotional resilience around the events that cause them the most trauma.
“It can take a long time, but there are these little milestones,” Handlos said.
She recalled one patient, a young girl who had experienced medical trauma and was anxious about medical interactions.
Even though Handlos makes a point of not dressing like a medical professional (no white coat or name badge), she recalled, “This girl couldn’t even sit in the same room with me without her mom being there. Even with her mom nearby, at first we were sitting across the room from each other. I’d communicate with the mom and she’d communicate with her daughter.”
It took two years of weekly therapy, but now the girl feels comfortable enough to be in the playroom alone with Handlos. This progress has made the girl’s ongoing medical treatment easier for everyone.
“It can take a long time, but it works,” Handlos said. “Some of my greatest success stories, where the client is no longer in therapy, happen when we write down clear goals and the patient is able to meet them.”
And that’s what Handlos sees as the ultimate goal of her work with children. “I want them to be able to live happy lives without being interrupted by anxiety and fear.”