PatPernicano, PsyD

(see author central)


Pernicano, P. Using Stories, Art and Play in Trauma-Informed Treatment: Case Examples and Applications Across the Lifespan

Routledge/Taylor Francis

This book is primarily a set of case studies across the lifespan in which stories, art and play contributed to the assessment and treatment of trauma-related problems. The author adheres to an integrative model of trauma-informed treatment and notes the influence of Milton Erickson and Jung in understanding symbols, metaphor and change. Each case provides history and conceptualization, and artwork in the book serves as evidence of both symptoms and qualitative change. The front matter provides an overview of the elements of trauma-informed treatment and the limitations of manual-based care when the therapist-client "fit" and therapeutic alliance are not considered. Dr. Pat offers several new therapeutic stories as well as guides for effective use of stories and interventions. This book serves as an excellent companion volume for Pernicano's 2014 Using Trauma-Focused Therapy Stories: Interventions for Therapists, Children and Their Caregivers

Reprint Article from Liana Lowenstein Newsletter

Contributing Author 2015

Using Therapy Stories and Metaphor in Child and Family Treatment

Pat Pernicano

Children and their families benefit from integrative therapies (play-based, experiential, interpersonal, and cognitive-behavioral) that teach coping skills, improve the capacity for attachment and interpersonal relationships and calm physiological arousal by altering neurological pathways (Pernicano, 2014).

Metaphor and stories may be used within any theoretical orientation, including client-centered, cognitive-behavioral, Adlerian, narrative, family, Gestalt, Jungian, psychoanalytic, object relations and psychodynamic; and the clinician’s theoretical underpinnings guide the manner in which the material is utilized. Depending on the therapist’s theoretical orientation, metaphor and stories are used to discover, change or create meaning, teach or model concepts, see change, alter schemas, change behavior, induce hypnotic trance, strengthen parent-child relationships, change or construct a personal narrative, trigger an aha moment, or reduce defensive and resistance (Pernicano, 2014).

Solution oriented treatments, hypnotherapy, filial therapy, narrative therapies, mindfulness approaches, cognitive-behavior therapy CBT, and a variety of play therapies all utilize stories or metaphors. Through metaphor, storytelling, and play therapy techniques, a therapist can access the inner world of a child, help the child make sense of that world, connect to others, and discover solutions to problems. (Pernicano, 2015). "Through metaphorical communication, children reveal their concerns, demonstrate their desires, express their emotions, gain a clearer understanding of their experiences, and create solutions to problems" (Snow, Ouzts, Martin, & Helm, 2005, p.63).

Metaphorical stories "springboard" children and families into discussing, with less avoidance, personal and family experiences and how they have been affected by them. Stories and subsequent interventions linked to the stories, help children and their parents make meaning of life events, reduce arousal, increase self-efficacy, and bolster trust & attachment (Pernicano, 2010, 2014, 2015).

There are many publications that describe the use of metaphor in therapy (Blenkiron, 2010; Burns, 2005, 2007; Cattanach, 2009; Drewes, 2009, 2010; Erickson, 2011a, 2011b; Gil, 1994, 2013; Greenwald, 2009, 2014; Kopp, 1995; Kottman, & Ashby, 2002; Markell & Markell, 2008; Oldford, 2011; and Pernicano, 2010, 2014, 2015). In 101 Healing Stories for Kids and Teens, Burns describes how stories inform, educate, teach values, build experience, facilitate problem-solving, and propel change or heal; and in Healing with Stories, he provides a fascinating set of case studies contributed by well-known therapists that illustrate use of metaphor in treatment.

The themes of play are coherent metaphors in and of themselves: triumph/conquering, fearlessness/courage, power/control, dependence/independence, abandonment/separation, safety/security/protection, chaos/instability, grief/loss/hopelessness, forgiveness/revenge, and mastery/competence (Drewes, 2010; Erickson, 2011b). Children, in their transparency, identify with story characters; reveal confusion, painful memories and feelings; and seek solutions to their problems. Stories set the stage for and move the client toward change.

In Using Trauma-Focused Metaphor and Stories Pernicano (2014, p. 20) states, "The impact of therapy stories is both cognitive and emotional, some metaphors hypnotically going in the back door to tap into right-brain emotional and sensory processes. It is often during the reading of a story or in the weeks following this that a family, child, or caregiver experiences a breakthrough, gains and acts on new insight, or experiences emotional growth. Attachment (sensed safety, love, and felt security) develops in the right-brain limbic areas, particular in the amygdala, and therapy stories seem to have the power to emotionally trigger interpersonal awareness and relational change."

Milton Erickson was the first to advocate using stories and metaphors in child and adult therapy (Carlson, 2001). He, unlike Freud, believed that the unconscious was a positive energy source, malleable and affected by experience. He posited that a therapist could influence a client’s unconscious experience by providing new information, arousing feelings, and creating new experiences through stories. Stories move the listener to a vulnerable, receptive state of readiness; for children this is a readiness to play. Young children, with their propensity for magical thinking, suspend reality and respond to non-logical aspects of metaphorical stories as if they are real (Pernicano, 2015).

Ultimately, a child’s play reflects neurodevelopment, including the capacity for emotional regulation, cognitive functioning, and interpersonal competency (Pernicano, 2014). A shared narrative often emerges within the therapeutic relationship that helps the child with emotional regulation, self-awareness, attunement, reduced fear, and attachment development (Cozolino, 2014). Gabbard writes, in the preface of The Metaphor of Play (Meares, 2005), "Despite the hard wiring of neural networks, new networks can be formed" in therapy, and play therapy is a set of activities that facilitate brain integration. Pernicano discusses ways that stories can bypass conscious, logical thought processes and connect with less "verbal" parts of the brain.

As we continue to learn more about neurobiological pathways and right-brain contributions to trauma and attachment, we better understand the ways in which stories have the capacity to open up right-brain processes, activate sensory memories, trigger strong unresolved emotions, and stimulate the "aha" of insight that propels behavior change (Pernicano, 2014, p. 19).

In Family Play Therapy Gil (2013) points out that the right hemisphere uses symbols, metaphors, fantasy and play to process information. Early in treatment, it is helpful to stay in the right hemisphere activities as long as possible, as this amplifies the impact of metaphor and leads to reflection. Left brain cognitive evaluation is useful once the right brain work is done.

Therapists can use metaphor and stories in play therapy, using the following guide (Pernicano, 2014, pp. 26-7):

 1) Select or create a story that parallels or pulls for client’s problem, client characteristics (attitudes, beliefs, feelings, or behaviors), goal or purpose of the treatment session and/or phase of treatment.

    2) The story should allow the character to resolve the conflict and achieve a desired outcome (Gil, 2013).

 3) Match the story to the child’s developmental level, so that the material is within the child’s zone of proximal development i.e. contains skills that the child has not yet mastered which are attainable with the therapist’s help (Carlson, 2001).

 4) Tell or read the story with the child and/or caregiver. If the child is able to read, take turns reading. Shorten or paraphrase the story for younger child or child with short attention span.

 5) After reading, see what comes up spontaneously before offering observation or interpretation. If the opportunity arises, help the child link the story to his or her life experience, perceptions or feelings.

  6)  Show curiosity: accentuate the metaphor, theme, story process and outcome. Ask questions to clarify the child and/or caregiver’s perceptions: "Why do you think this happened?", "What advice do you have for the character?", or "What do you think led to this?"

 7) Move into planned or client directed play therapy activity that follows from the story or client’s response to the story; and addresses a theme, schema, or feeling state in the story.

Therapeutic stories can be pre-selected; or developed and told spontaneously as metaphorical themes emerge. Pernicano (2014, p. 21) describes ways in which therapists may develop their own stories and use them in child and family treatment. With regard to character development, if the main character will be an animal, it must have characteristics that fit the presenting issue and create a helpful response set in the child. The character’s problem has to be significant so that there is a strong need for problem solving. For example, an eagle should not be afraid of flying, and an obsessive compulsive frog would soon starve if he could not eat flies without washing them. A peacock can easily be seen as a show-off, and there is a perceived aggressive energy to dragons, lions, and alligators. The child character can be a victim or the person in charge that offers wise advice. Either approach can be helpful when the client perceives him or herself as a victim and needs to develop self-efficacy. A perpetrator character has one or more of the characteristics of someone that hurt the child: dangerous behavior, untrustworthiness, selfishness, arrogance, self-centeredness, cruelty, or disregard for others. The action of the story will remind the child of something he or she experienced.

Stories are good tools within family play therapy, as parents hear and accept things from story characters that they would not accept from a therapist; and families disclose things in play that they would otherwise guard against. In Play in Family Therapy (1994), Gil spells out creative ways to involve families in storytelling, art, and puppet play.

Pernicano (2015) discusses the pragmatics of story development in Schaefer & O’Connor’s Handbook of Play Therapy, Second Edition. To use storytelling, a therapist needs to have basic understanding of child development and some training in play therapy. The therapist needs to be able to evaluate play skills, attention span, language ability, cognitive development, and emotional understanding; as story and play intervention must be matched to the child’s development. It is important that the story fit the age and functioning of the client. With younger children (pre-verbal, pre-school and those with limited language ability), it is best to tell a short and simple story. The therapist actively engages the child while telling the story, asking questions about the characters, the action of the story ("guess what happens next?") and the outcome ("I wonder why he is doing that?" or "What can we do to help him/her?") Older children and families will generally participate in the reading of the story.

Translating a metaphor or story into a play therapy technique requires flexibility, spontaneity, and creativity. The play activity may be non-directive (especially when the therapist is assessing the child’s process and issues) or individualized and therapist led. The therapist must observe the child’s play; and listen carefully to the client’s language in order to pick up on emotional or thematic material connected to the child’s background and history.

Stories are not "one size fits all" and therapists need to match the story and delivery to the client (Pernicano, 2015). Certainly it is contraindicated to use a story that arouses painful emotion too early in treatment, before there is a therapeutic alliance and the child has coping skills to manage arousal. This can re-traumatize a child and result in premature termination, increased symptom intensity, decompensation or even dissociation.


Metaphors and stories may be utilized with clients of all ages regardless of therapist orientation or preferred treatment modality. When carefully utilized during treatment, they drive change through non-cognitive, sensory, and emotional processing. These tools invite identification with characters and story themes; and springboard clients toward a better understanding of self and others, cognitive restructuring and behavioral change (Pernicano, 2015).


Blenkiron, P. (2010). Stories and analogies in cognitive behavior therapy. West Sussex, UK: Wiley-Blackwell.

Burns, G. (2005). 101 healing stories for kids and teens: Using metaphors in therapy. Hoboken, NJ: John Wiley & Sons.

Burns, G. (2007). Healing with stories: Your casebook collection for using therapeutic metaphors. Hoboken, NJ: John Wiley & Sons.

Carlson, R. (2001). Therapeutic use of story in therapy with children. Guidance and Counseling,

Cattanach, A. (2009). Narrative approaches: Helping children tell their stories. In A. Drewes (Ed.), Blending play therapy with      cognitive behavioral therapy: Evidence-based and other effective treatments and techniques. Hoboken, NJ: John Wiley & Sons.

Cozolino, L. (2014). The neuroscience of psychotherapy: Healing the social brain, 2nd Edition. New York: W. W. Norton.

Drewes, A. (2009). Blending play therapy with cognitive behavioral therapy: evidence based and other effective treatments and techniques. New York: John Wiley & Sons, Inc.

Drewes, A. (2010). How to respond to the child’s play through metaphor. Rome, Italy: Italian Association for Play Therapy.

Erickson, B. (2011a). Constructing therapeutic metaphors and stories (workshop handout). Phoenix: Fundamentals of Hypnosis Workshop, 11th International Erickson Congress.

Erickson, B. (2011b). Telling stories where they belong (workshop handout). Phoenix: 11th International Erickson Congress.

Gil, E. (1994). Play in family therapy. New York: The Guilford Press.

Gil, E. (2013). Family play therapy: Assessment and treatment ideas. CTAMFT Annual Conference and Meeting. Groton, CT.

Greenwald, R. A fairytale. Northampton, MA: Trauma Institute & Child Trauma Institute (

Greenwald, R. (2009). Treating problem behaviors: A trauma-informed approach. New York: Routledge.

Greenwald, R. (in press, 2014). Slaying the dragon: Overcoming life’s challenges and getting to your goals. Northampton, MA: Trauma Institute & Child Trauma Institute (

Kopp, R. (1995). Metaphor therapy: using client generated metaphors in psychotherapy. Bristol, PA: Brunner – Mazel.

Kottman, T. & Ashby, A. (2002). Metaphorical stories. In Schaefer, C. & Cangelosi, D. (Eds.), Play Therapy Techniques. Northvale, NJ: Jason Aronson.

Markell, K. & Markell, M. (2008). The children who lived: Using harry potter and other fictional characters to help grieving children and adolescents. New York: Routledge.

Meares, R. (2005). The metaphor of play: Origin and breakdown of personal being. New York: Routledge.

Oldford, L. (2011). The use of harry potter and fairytales in narrative therapy. Journal of Integrated Studies, 1(2), 1-10

Pernicano, P. (2010a). Family-focused trauma intervention: Using metaphor and play with victim of abuse and neglect. Lanham, MD: Jason Aronson.

Pernicano (2014). Using trauma-focused therapy stories: Interventions for therapists, children and their caregivers. New York: Routledge.

Pernicano (2015). Metaphors and stories in play therapy. In Schaefer, C., O’Connor, K. & Braverman, L. (Eds). Handbook of Play Therapy, Second Edition. New York: Wiley.

Snow, M. S., Ouzts, R., Martin, E. E., & Helm, H. (2005). Creative metaphors of life experiences seen in play therapy. In G. R. Walz & R. K. Yep (Eds.), VISTAS: Compelling perspectives on counseling, 2005 (pp. 63-65). Alexandria, VA: American Counseling Association.


Reprint Article

Psychotherapy Networker May / June 2014

Case Study

Rush to Judgment: Beware of the ADHD Diagnosis

By Pat Pernicano

 About once a month,a teacher, school counselor, or pediatrician refers a child to me for evaluation and treatment of attention deficit hyperactivity disorder (ADHD). Often someone has administered a Conner’s teacher or parent rating scale that presumably justifies the diagnosis, or the child has already been diagnosed with ADHD and has taken ADHD medication without symptom improvement. Such children commonly exhibit troublesome symptoms, including agitation, moodiness, hyperactivity, and distractibility,so I understand why they were referred to me. But what I can’t understand---and have become increasingly emphatic about pursuing---is why professionals diagnose and treat ADHD symptoms without first trying to understand the causes of those symptoms.

In my view, there’s an epidemic of misdiagnosis of ADHD in young children. Yes, school personnel are overwhelmed by the number of children whose poor concentration make it difficult for them to learn, and a number of likely explanations have been offered for the apparent increase in hyperactivity and inattention in children. Class sizes are bigger than they once were. Music, art, recess, and physical education---activities that used to provide a break from routine---have nearly been eliminated in many school systems. Children spend too many hours on video games to the exclusion of creative, unstructured play, and they don’t get the amount of physical exercise that contributes to healthy brain development. Lack of adequate sleep also contributes to poor mood and focus, as do the challenges faced by children of substance-abusing or addicted parents.

Schools and physicians are aware of some of the above, but they don’t seem to understand the ways in which trauma leads to symptoms that resemble ADHD. Thus, we all need to ask the right questions and dig a little deeper in creative ways to find out what may be troubling the child, so that our treatment is effective and not just a surface remedy for a misdiagnosis. In other words, it’s crucial to figure out why a child is tuning out, having trouble concentrating, and being moody and hyperactive. A child living in dangerous chaos, for example, has to find ways to cope and adapt, and the resulting stress-based behavior can sometimes mirror ADHD symptoms. To complicate matters, many children referred for suspected ADHD are in preschool, kindergarten, or early elementary school and are so young they don’t yet have the verbal and conceptual skills to tell us what’s going on in their lives. Thus, therapists need to get a thorough family history, engage the child in play activities (e.g., art, stories, puppets, sand play, and dollhouse), and observe the child’s play for clues about the cause of the symptoms. Only then can we form a plausible hypothesis, develop a plan of care, and match interventions to a child’s issues.


Getting to Know Ella

Five-year-old Ella, who’d just started kindergarten, was brought to my outpatient treatment office by her mother at the request of her first-grade teacher. At school, Ella would talk out of turn, get out of her seat without permission, and boss other children around.

“Her teacher thinks Ella has ADHD and should be on medication. He says she’s behind the other children and can’t pay attention,” her mother told me. “I don’t know what to think.”

To start, I began collecting a life-and-developmental history to help me rule out ADHD. In other words, if Ella actually had ADHD, there’d be no other factors to account for trouble sleeping, difficulty completing or following tasks in school or at home, impulsivity, and hyperactivity. I also wanted to rule out conditions that include ADHD symptoms, including autism spectrum, depressive disorder, post-traumatic stress, complex stress, anxiety, and adjustment disorders.

I started by inviting Ella to play with the toys and puppets in my office so she could stay occupied while I spoke with her mother. Our conversation revealed that she was tired of Ella’s “bad attitude,” yet concerned about her daughter’s nightmares, fear of sleeping in her own bed, waking during the night, and frequent tearful and angry outbursts. She found her daughter’s high-intensity behavior exhausting and gave up quickly when Ella didn’t listen or when she pretended not to hear. I wondered if her lack of energy might indicate depression, especially since children of depressed mothers have to work so hard to get their mothers’ attention that they can show symptoms of anxiety and ADHD. If that proved to be the case, I’d refer the mother for treatment of her own.

Meanwhile, Ella offered a constant commentary on her exploration of the office toys; however, when she felt excluded from my conversation with her mother, she became provocative, intrusive, and pouty. She answered questions I directed to her mother about her sleep behavior, her school performance, and her compliance with chores and rules. I suspected that this little girl wanted to be in charge, in control, and independent. I wondered what in her life might have led her to mistrust and ignore her mother’s directions. Ella’s behavior mimicked some symptoms of ADHD, but she seemed too attentive and intentional in her actions for the diagnosis to fit.

Ella was more watchful than most ADHD children, even though eye contact was intermittent. I began wondering about the source of her vigilance. I noticed times when she’d tune out briefly (stare off and make no comment) or quickly change the subject. Whenever she came to, she didn’t remember what had been said. As I watched for a pattern to these episodes, it became clear that the tuning out increased when we said anything about her biological father, who was divorced from her mother and in jail. The subject of her father seemed to increase Ella’s level of physiological and emotional arousal. I suspected that Ella’s inattention and high arousal might actually be dissociation or avoidance related to her father.

When I finished my interview with the mother, I turned to Ella to ask why she thought she was coming in.

Without hesitation, she said, “I’m bad at school and I don’t like my teacher. I won’t sleep in my own bed, and mommy says I have a bad attitude. My daddy is in jail for hurting mommy and me.” She paused and added, “Dr. Pat, my daddy lied to me. He took me away, and he wouldn’t let me go home to my mommy.”

Aha! There it was---a clear clue as to why Ella felt so powerless and needed to take charge. Something traumatic must have happened to her and her mother at the hands of her father. I knew I needed to explore what had happened, see how it was affecting the relationship between Ella and her mother, and help them process the trauma. For this to happen, both Ella and her mother would need to be involved in treatment. Her mother’s anxiety was palpable and contagious for Ella. What Ella needed was a strong, take-charge, nurturing protector. Instead, Ella seemed to sense her mom’s victim stance and acted out to communicate her fear and vulnerability to her mother. When behaving provocatively and making demands, Ella was pushing and challenging her mother to take charge.

At this point, I realized that Ella was a brave little girl who was just as worried about her mother as her mother was about her. By volunteering information about her father’s mistreatment of her and her mother, she showed she was purposely recruiting me as a partner to fix her and her mother’s shared problems. She displayed many traits of insecurely attached children whose parents are fearful, anxious, or depressed. Such parents are inconsistent in caregiving, and their children have to take care of themselves or make increasingly high demands on parents to notice them.

It turned out that Ella had been abducted by her father, and when her mother had gone to retrieve her, they’d both been physically assaulted. Subsequently, when her father was put in jail, Ella’s symptoms emerged. Ella’s mother, too, began showing symptoms of post-traumatic stress: she was irritable and short with Ella, lacked patience, and found herself being critical and negative instead of comforting or nurturing. She didn’t understand that Ella was responding out of fear, not defiance. Since Ella’s mother could see that she was sometimes contributing to her daughter’s problems, she agreed to participate in treatment.

Like most traumatized children, Ella had trouble talking about her feelings and reactions to what had happened with her father. She said it was her fault that her mother had gotten hurt, and she feared her father would come back and hurt her again. At the same time, she wanted to be the one who’d magically change her father into a “nice daddy” and be worthy of his love.

Young children almost always have ambivalent feelings toward an abusive or neglectful parent. Early on, Ella’s play indicated that she experienced loss, love, sadness, anger, and fear toward her father. She used the sand tray to enact power and control scenes where frightened victims fought back against a “mean bad guy.” The dollhouse became an orphanage for babies and children whose “mean daddies” were in jail, and they cried for them at night. I wanted to help Ella express her feelings and understand that she wasn’t responsible for her father’s behavior. I planned therapy activities that would allow Ella to “feel felt” by her mother and allow her mother to show empathy and protectiveness. She also needed to trust that her mother could handle whatever might happen and keep her safe. As her mother became less anxious and worried, I believed that many of Ella’s symptoms would spontaneously dissipate.

I began relaxation and breathing practice early on to help Ella and her mother lower their anxious arousal. We ended most sessions with our eyes closed, listening to a Tibetan bell bowl and holding stones to warm them. With practice, Ella became able to remain still and quiet, letting her fear and anger move into the stones. Body-mind approaches are helpful in trauma work, since calming the body and its arousal is essential for self-regulation. Ella slept with her stone at night, and claimed it chased away her nightmares and allowed her to sleep in her own bed. She and her mother practiced breathing at bedtime, and together their anxiety subsided.

Within a few weeks, it seemed time for Ella and her mother to process the trauma more actively. Over a six-month period, I worked with them using stories as well as fear-reducing and symbolic play-based, expressive, and cognitive behavioral techniques. Generally, I pulled her mother in as a helper. For example, when Ella revealed she thought the assault was her fault, I read a story about self-blame, and then identified a puppet that blamed himself for getting hurt. In an aside, I asked Ella, “Is it his fault? Why not? Who should’ve been in charge? Why do you think he’s blaming himself? I wonder what you could tell him to give him the facts and show him he’s not at fault.” Then Ella and her mother came up with a list of reasons why it wasn’t his fault. Together, they talked to him and corrected his faulty beliefs.


Taming the Alligator

Metaphorical stories and puppet play (modeling and enactment) were powerful change agents for this dramatic, engaging child. I provided a story or theme idea for most play sessions, and Ella’s creativity propelled the action, in which she revealed her feelings and concerns. As Ella opened up through stories and puppets, her mother showed increasing empathy and offered more verbal encouragement and affectionate touch.

During a particularly pivotal session, about three months into treatment, Ella asked to do a puppet show and took charge of it. She selected an alligator perpetrator, a kangaroo caregiver, a small multicolored frog victim, and a colorful rainbow dragon as a helper. The characters helped her tell and process her trauma story, and the parallels to her family were obvious. In her show, the alligator puppet promised to be nice, but then started biting the other puppets. Ella shook her finger at him: “You need to tell the truth and stop telling lies. You have an anger problem! You need to change and be nice.” She then wrapped his long snout in duct tape.

Ella turned to her mother and me and said, “He has an anger problem. He needs to calm down and control his temper! We should put him in jail for biting.”

Ella’s mother agreed, and together they put the alligator in jail. We agreed that we should not be mean to him; rather we could feed and talk to him from a safe distance.

When I asked Ella how the alligator would learn to control his anger, she replied, “Let’s teach him to calm down.” She handed her mother and I each one stone and said to the alligator, “You need FIVE stones. You have BIG ANGER!” Ella shoved five stones inside the taped snout, taught him how to breathe, and rang the Tibetan bell bowl. “Close your eyes and relax,” she instructed. When the ringing stopped, Ella announced, “The alligator can stay in jail until he decides to be nice.”

Later in the session, Ella looked up from drawing on the dry erase board and said, “I’m going to the jail to tell my dad to stop being mean. Then he’ll change and be nice.”

Ella clearly had ambivalence about her own anger at her dad since, even though she feared him, she still loved him. To help her make sense of this ambivalence and gently challenge her magical thinking about change, I commented, “Ella, I know you love your dad and want him to change. Sometimes people change, and sometimes they don’t. They have to be sorry for what they did and really want to change.”

Ella went over to the cage where the alligator was being held. She asked him, “Are you sorry for what you did? Do you want to change?”

I spoke for the alligator and said, “Please let me out. I’m sorry I bit you. I promise to be nice this time.”

Ella said to me, “He says he’s sorry, and he promised to be nice. Can we take off the duct tape and let him out of jail?”

I decided to pull in Ella’s mother at this point and asked what she thought. She took Ella’s hands and said, “It’s too soon to do that. I don’t think he’s sorry. He doesn’t think he did anything wrong. He promises to be nice, but he doesn’t change. I don’t think he really wants to change. I’m going to keep you safe, and I won’t let him hurt you.”

Ella thought for a minute and said, rather matter-of-factly, as she crawled into her mother’s lap, “He’s always been mean. He needs to stay in jail. And leave the duct tape on. He’s not ready to come out yet.”

So were we talking about her father or the alligator? Obviously both, but in conquering the alligator, Ella had come to grips with her father’s behavior.


It’s worth noting that over time, the family system had changed: Ella’s mother had benefited as much as her daughter from the relaxation and healthy coping skills I’d taught them. The treatment had helped her recognize her own struggle with anxiety and depression, and she’d come to see how this struggle had affected Ella’s functioning. Thus, she asked her doctor to prescribe an SSRI antidepressant, and was demonstrating more nurturing behavior toward Ella. She’d become a safety advocate for Ella and herself, and as a result, Ella trusted her to be in charge and protect her.

During our final session, I complimented Ella on her hard work and progress and said to her mother, “She’s doing well in school. She can sit still and pay attention. She has no more nightmares and is sleeping in her own bed.”

At this point, Ella interrupted quietly and said, “Dr. Pat, I’m not as afraid of thealligator anymore either. My dad got out of jail, but I can’t see him until he gets better with his anger.”

This case had a good outcome, but I wonder what would have happened if the school’s diagnosisof ADHD had guided Ella’s treatment. We need to be mindful of the possibility of trauma when a child presents with symptoms of ADHD. Child abuse, neglect, and domestic violence occur in all types of families, and we have to do a better job asking the right questions and digging deeper---for the sake of children like Ella.

 Case Commentary

By Martha Straus

The differential diagnosis of young children can be challenging even for the most trained and attentive clinician. After all, a five year old has a fairly limited repertoire for communicating distress. And as Pat Pernicano wisely notes in her compelling case study, oppositional behavior, sleep issues, irritability, tantrums, bossiness, and hyperactivity could all be symptoms of single, or comorbid, diagnosis, including ADHD. These same behaviors, however, might also describe a five year old going through a tough patch---a normative, and perhaps transient, response to developmental or environmental stressors. Compounding the issue is the fact that traumatic experiences are more common in communities with fewer resources to treat it, so trauma is inevitably underdiagnosed.

            The gold standard for making an ADHD diagnosis includes collecting as many data points as possible considering, for example, a solid developmental history, interviews, assessment, play evaluation, observations, rating scales, and other reports. Such a comprehensive diagnostic assessment makes tremendous sense, and would assist in sifting out the underlying stressors for young children who are challenging and challenged in those sit-and-be-quiet kindergartens. But it’s hugely expensive. Few children have the benefit of the skilled, costly, and time-consuming protocol that Pernicano describes and so deftly pursues. I wonder what might be different if schools and physicians did understand the way that trauma can show up as inattention? Would these kids then get competent evaluations? Would classrooms accommodate their special needs for compassionate support and predictable activity? Would they get to go to play therapy?

            In terms of play therapy, I particularly admire the combination of directive and nondirective techniques in Pernicano’s intervention. She’s able to make a strong and useful alliance with the mother while engaging in thoughtful dyadic play therapy. This approach has the wonderful advantage of modeling and practicing supportive parenting techniques, relaxation strategies, and coregulation. Ella’s mother was then better able to guide her within the healing metaphors of play, and set safe limits for both of them.

2014 Bio: Pat Pernicano, PhD, is a licensed psychologist in Louisville, Kentucky. She teaches part-time at Spalding University and treats children and families in Clarksville, Indiana. Her most recent book was Using Trauma-Focused Therapy Stories: Interventions for Therapists, Children, and Their Caregivers. Contact:

 Martha Straus, PhD,a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents and Adolescent Girls in Crisis: Intervention and Hope. Contact: 802.254.9196

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Dr. Pernicano authored a chapter on use of metaphor and story telling in the collection directly below. 

This book is an excellent resource for anyone working with children (teacher, therapist, etc.) that experience problems such as fear of the dark, parental divorce, eating disorder, anxiety, depression, obsessive compulsive symptoms, and anger. The stories in the book help children talk about their problems through the story characters.

This nextbook was written for use in a mothers' group with mothers involved with child welfare. Each had experienced domestic violence, homelessness, drug addiction, and/or incarceration. The stories and discussion questions provided the means for women to view their situations in a new light. 

This is Dr. Pernicano's most comprehensive work to date. The workbook includes trauma treatment guides to be used with children and their caregivers as well as a therapist guide to trauma intervention. It is most of all a collection of Pernicano therapy stories organized by the TF-CBT model, and a number of story-related interventions are described. There are case descriptions to illustrate the use of stories, art and play in psychotherapy. 

This systemically oriented book (below) addresses treatment with families that have experienced separation, trauma, attachment difficulties, and other disruptive life events. It arose out of an innovative and integrative family residential treatment program developed by Dr. Pernicano in Georgetown, IN. There are a number of topical stories with family-focused interventions as well as psychoeducational material about trauma and attachment.