Dr. Eliana Gil on Children’s Mental Health

Christa Butler:

Welcome to The Voice of Counseling from the American Counseling Association. I'm Christa Butler, and joining me today is Dr. Eliana Gil, who is here to talk about children's mental health. Dr. Eliana Gil is a registered play therapist supervisor, registered art therapist, and licensed marriage and family therapist. She is best known for her groundbreaking clinical work and research with children, teens, and families impacted by trauma and abuse. As founder and clinical consultant of the Gil Institute for Trauma Recovery and Education in Fairfax, Virginia, she continues a lifelong commitment to therapy, training, consultation, and education in areas of play therapy, post-traumatic play, family therapy, and relational treatments.

Christa Butler:

Her work is widely published in areas of play, art, and family therapy. She's also a former president of the Association for Play Therapy and received APT's lifetime Achievement Award in 2011. Dr. Eliana Gil, thank you so much for joining us today to discuss children's mental health. Tell us more about yourself and the work that you do.

Dr. Eliana Gil:

Yes, I'm happy to do that and happy to be here. I am Eliana Gil, and I am a family therapist. I am bilingual bicultural. My parents are both from Ecuador, so we immigrated to this country when I was 14, and I say that because I do think it's really important to know that the background is there for appreciating cultural differences, and also as a child, having twice been language immersed, I became very conscious of how limiting language is. Verbal communication sometimes is very difficult. So I've been in situations where I've had to communicate in other ways, and I think that's influenced how I think about therapy as well.

Dr. Eliana Gil:

In addition to being a family therapist, I also incorporate a lot of the expressive therapies, and so I like to do play therapy, and sand therapy, and music therapy and just different kinds of things that allow people to express themselves in different ways. My life's work has been on trauma, childhood trauma, and I started in 1973, so it's been a very long and very rewarding career with those two passions in mind, one being childhood trauma and the other being finding ways to connect with people and to assist them during very difficult periods of crisis, so that's about me a little bit.

Christa Butler:

Thank you for sharing that. You bring up a really important point. I know a little bit later we're going to be talking more about play and expressive therapies, but as a play therapist myself, you mentioned language and communication, and how we communicate in other ways, and how play and creativity expression is one way that we do that, and I'm so excited for you to share with our audience today some of the tools and skills that you incorporate in your approach as a family therapist, a play therapist, as well as an art therapist.

Dr. Eliana Gil:

I learned a very long time ago that people who come to therapy come during periods of distress, frustration. They're not happy. A lot of the families I worked with for years and years were court-mandated, so they weren't voluntarily seeking help. And so I found it really critical to connect with people, to develop a personal relationship, to try to create opportunities for helping them in ways that were practical, immediate, useful, and I found verbal communication, I found talk therapy a little bit limiting in that regard. And I felt that especially people who came in and they were tense, and angry, or concerned, or sad, physically they were very constricted, and children, when they come in, they're very constricted.

Dr. Eliana Gil:

We sometimes call them resistant. I don't like that word, because I think really people come to therapy are hesitant. They're ambivalent about being there. They don't know what this is. Is it going to help me? And so I have had a mantra of integration and just making sure that I can assess this particular family, and what I think might be important to them, and then try to bring in ways of bringing up their interests, what's relevant to them in the therapy that I practice. And one of those things that I thought was really important was novelty and actually bringing joy into people's lives when they were in periods of high distress and feeling helpless and vulnerable, and not feeling personal control and mastery.

Dr. Eliana Gil:

And so I started incorporating just silly things, but they were unexpected things. And if I can help people suddenly relax a little bit, breathe, not feel so constricted, I would feel like, "Okay, we're going to start making a connection now." So I've often told people that I use balloons a lot, and sometimes people come in, and they folded their arms in front of them, and they have a face that's kind of challenging at times or provocative in some ways. And then I would say, "Look, I have some balloons. Let's just keep them up in the air for a few minutes," and, of course, that takes people aback.

Dr. Eliana Gil:

They're going, "What is this?" But if you can get them moving their bodies, and breathing differently, and having a little bit of fun, unexpected fun, then suddenly they're available for human contact, and suddenly we can all sit down tired and go, "So what was that like?" And then start talking a little bit about why they're there, what brings them, but it changes the context. And so that's why I've always felt like inviting people to do... An adolescent, as an example, comes in, and she's had a tough week at school, and she got expelled. So I know that because the parents told me she got expelled.

Dr. Eliana Gil:

So she comes in, and she does not want to be there. She doesn't want to talk to me. She says, "I don't want to talk about it." And I go, "That's fine. You know we don't have to talk. Go find something that best shows your thoughts and feelings about your week." And there's a whole bunch of miniatures available, and they just go and find maybe a fire hydrant, or maybe a brick wall, or maybe a fire, and they bring it back, and now they have something inside... Outside of themselves, I should say, that represents their inside worries and preoccupations. So now we're talking about the fire. So how big did that fire get? So how did that fire start?

Dr. Eliana Gil:

And now we're talking about the problem, but we're talking about it in metaphor language, and that's a way I think that is easier for people. I think Milton Erickson used to say this, that you want to sometimes sidestep the defensive mechanism, and one of the best ways to do that is to start talking in metaphor. And so if I can do that, I've made a different kind of connection with a child who expects that I'm going to be there to ask a lot of questions, and kids don't really like that too much.

Christa Butler:

Yeah. Yeah. And so I think also incorporating the use of symbols, and you talked about the metaphor of the fire hydrant, and what that may represent for that child, and using the sand tray miniatures, and using art in different mediums, whichever that client is attracted to as a way for them to express themselves with or without words if they so choose to. You talked about some of the stressors as well that clients are experiencing and some of the clients that you've worked with as far as having court-mandated clients and the challenges that some of those clients were going through as well, and so I'm thinking about the current mental health crisis with children specifically. And so I'm curious if you could share with us what are some of those present-day challenges impacting children's mental health that counselors should be aware of.

Dr. Eliana Gil:

I think there are so many stressors right now. I think this is a very difficult time that we've gone through in the last few years. I think social media is one of those double-edged swords. It's incredibly useful to us all, and yet it has all kinds of dangers incorporated into it. I think for children who feel vulnerable or isolated, they reach out. They think of their friendships as being online with people they've never met. Social media presents a lot of threats and dangers. I think children who are lonely can begin to see social media as their only outlet for social contact, so they're missing the human connection.

Dr. Eliana Gil:

I think this has become a problem that we just need to be aware of and so many dangers. We get so many children who basically start responding to these people who are talking to them, and it turns out they're in disguise, and they're adults who are actually looking to do harm to them. I think the social political climate is pretty intense. There are issues around racism. There are issues around political polarization. I think all of us have to be aware of that, that we sometimes tend to think that some people have racial issues and some don't. Well, that's not the case. We're all affected by everything, and so there's so much on television that kids are exposed to.

Dr. Eliana Gil:

When George Floyd was killed on television, that affected so many kids who just happened to be walking by, and what's that? And so there were hopefully some good discussions about it, but nevertheless, those scenes are in their minds now without a lot of ways for any of us to understand how things like that can happen. And the political issue is the same. The insurrection was fully televised, so children see that. And so unfortunately these children live in family settings where sometimes those political opinions are so intense that the kids take them on and carry them to school, and they end up getting into fights, and there's just so much confusion going on around all of that and the attention that we need to pay to it. I think there's also the health concerns around COVID and all these other variants. I think that for a lot of families, that was really a very intense time of having this anxiety, and this fear, and almost really rallying to protect your life.

Dr. Eliana Gil:

And that kind of anxiety got translated to children, so we have now these kids who are a little bit germophobic. We have kids who are shy to make any kind of connection with other human beings. They don't want to touch. They don't want to shake hands. So I think there's a lot of that that's just kind of lingering that we need to pay attention to. Social challenges, just the fact that there's so many bullies out in the world in schools. I mean, when I was a kid, every now and then there would be someone who would tease somebody else, and it would be very hurtful, but these days there's almost kids who organize themselves around harm they're going to do to others, and we get the child victims into our practice.

Dr. Eliana Gil:

And it's just very distressing that all of that... School stopped being a safe place for kids to go, not only with the bullying, but there's been an increase in school shootings in the last couple of years, and I think for children, they, I mean, I think understandably feel that this is a place where they have to be on guard and hypervigilant. So everything is hard. There's no place you can go these days that feels easy and relaxed, and I think all the unmet needs show up in schools. So I'm sort of making a segue into there are all these things happening within a family dynamic, and the isolation brought about by COVID, and the fact that a lot of people who were used to spending time away from the house are suddenly together.

Dr. Eliana Gil:

And for some people, that was wonderful, and for other people, it was very frustrating, and there was an increase in family violence during that time. So I mean, all of these things then are things kids are incorporating, and then they go to school, and the teachers, and the guidance counselors, and everyone has to be really attentive to the unmet needs that are expressed through behavioral problems, because kids don't knock on your door and go, "Listen, I'm having these real worries, and fears, and concerns." They go and punch somebody, or they have a temper tantrum and a meltdown. So this is what we all have to begin to take into account that there's kind of a global stressor and individualized forms of that, depending on community needs, and socioeconomic issues, and all of that, but that all of us in positions of having contact with families have to offer more than, "Traditional psychotherapy," sit down and talk to me for 50 minutes, but things that might include going beyond that into advocacy roles and taking more action, maybe doing home visits.

Dr. Eliana Gil:

I mean, I've worked across many cultures, and for some people, including my own culture, going to a therapist is a weird thing. I mean, it's just not something that we believe in or we think about when we think about I need help. And so we have to be attentive to that and make the help more relevant, more immediately useful to someone, so that could include meeting the kids at school with their families, or going to their homes, or becoming more accessible as it were. So those are, I think, a lot of the important things that are going on. I'm sure I'm missing many of them, but these are the ones that we tend to see a lot.

Christa Butler:

Yeah, you touched on so many things there, and as an adult, I can recall experiencing these things as well, and it can feel like you're being flooded with so much violence and so much negativity, and so I think about children, and how that feeling might be magnified in their bodies, and in their minds, and their spirit by also witnessing these things that are really, really tough to continue to take in. You've mentioned how children express their unmet needs through behavioral problems, and so I'm curious if you could share a little bit more on that, because as we know as child therapists is that sometimes when children are experiencing emotional or mental distress, that how it shows up in the school setting, how it shows up in the community settings, the home settings might look different sometimes.

Christa Butler:

And so I'm curious if you could share what are some things that clinician should or providers should look for, maybe even parents should look for so that they could know like, "Okay, maybe this is a good time for me to see if I can find help from my child considering that they have so many unmet needs that are again being expressed through these behavioral problems,"?

Dr. Eliana Gil:

I think the first thing is for people to look at those behaviors in a broader way. So sometimes the child who's aggressive, and provocative, and difficult in a classroom, for example, gets a lot of negative attention. And it's human nature I think also for teachers to feel like, "Oh, if that kid just wasn't in the class, it would be so much easier." And so these kids get identified, but they also provoke in us, the caretakers, a little bit of frustration, and anger, and resentment as well, and I think that those are the kids that are the squeaky wheels that get the attention, the kids who are very aggressive and acting out. They tend to be referred for therapy, but sometimes even before that happens, people already think of them differently. They think of them as bad kids, or they want to isolate them, or punish them, or whatever it may be.

Dr. Eliana Gil:

And that's a misconception, because honestly, these kids are trying to get something that they need, and it's the only way they know how to do it. They're dysregulated, and they come by that naturally. It could be a result of not having a good attachment figure who regulates them. It could be a result of so many stressors in buildup, no outlets, no support systems, and then they appear in the classroom. So we get a lot of those referrals for kids who are angry, aggressive, however, there's also the other side of the coin, and those are the children who are kind of invisible, and they're compliant, and they're doing their work, and yet they're sad, and they're depressed, and they're anxious, and they'll sit in a classroom, and they're biting the inside of their mouth, or they're worried that someone' is going to come in and shoot them, and they're picking at their skin.

Dr. Eliana Gil:

And so we just have to keep an open mind to all of the communication through behavior that kids do with their full bodies, and kids who are... It's a word I never remember, trichotillomania, where they start pulling their hair out. A lot of the children we work with pull their eyelashes out. A lot of them, again, begin to pick up their skin, some of them slash their skin with things, but these are alerts, red flags. Something is going on. Please look, please listen, please see me and hear me without the judgment that some of us can develop as a result of having a child that is difficult, that does make our work a little bit harder. So I think we need to be attentive to the whole continuum of both the externalizing child, who usually is the one who gets the attention, and then the internalizing child, and the one who is just trying to stay out of trouble, and not get hurt, and that kind of thing.

Christa Butler:

No, I think you're bringing up an excellent point that the behaviors may occur on a continuum. You may have a child that is highly internalizing, and while they may not be externalizing and communicating through say... I won't use the term acting out per se, there may be children who might be depressed and might be holding a lot of things in. And we have to, again like you said, pay attention to what those behaviors may look like on the continuum so that we're not perhaps not meeting some children's needs by giving the other children the attention that are acted out while also perhaps overlooking the needs of other kids. So what different types of treatments? You talked about not using just talk-based therapies, but what are some of those treatments, and evidence-based approaches, or promising approaches that you might recommend when working with children and families?

Dr. Eliana Gil:

Well, I think that one of the important things for me is to have a systemic contextual lens, that that's really important. It's not just that this child's acting out. It's that this child lives in a particular family with a particular group of people that may be having difficulties with each other, may have been traumatized themselves, may not know how to be supportive, may not have emotional language, et cetera, et cetera. And then within that, they're living in a community that may be safe or dangerous, that may have a lot of resources or no resources at all. And we have to really take that kind of ecosystemic look and make sure that that's constantly in place, because sometimes I think the temptation is to work with a child, but without the system in which these issues come up, there's limited amount of work that we can do.

Dr. Eliana Gil:

The other thing is just being comfortable approaching parents. A lot of the school personnel and the guidance counselors, they're happy to work with the kids, but when it goes to reaching out to parents, they feel a little uncomfortable, so making sure that you feel comfortable reaching out and saying, "Hey, I'm noticing this. Let's talk about it. Let's work as a team. How can we help you? What's going on at home?" Those kinds of things. The other thing is no one method works with everybody, so that's why I think we just have to sometimes put the agendas aside or the protocols, and go in, and meet the child, and meet the family, and then have an understanding of what they might respond to. What's of interest? What's on their priority list? How do they organize their thinking? What's at the top of the risk factor, for example?

Dr. Eliana Gil:

If you have a family living in an unsafe neighborhood, that's what's on their mind is how do I walk back and forth from home without getting hurt? If it's a school where they're being bullied, how do I get safely out of there every day? So we have to deal with that and just understanding we have to get to know people and what's going on. I always use these three lenses for assessment, individual issues that might be going on, then the attachment piece, who's the child connected to? Is that working for them? And the last is the social. What we know about development is that kids need to make friends and have friends, and they learn a lot from that experience. If we have kids who isolate, I think we need to invite them into situations where they can interact with peers.

Dr. Eliana Gil:

There's a plethora of approaches right now. I was reading a study, I think it was done in 19... I'm sorry, in 2000. They said there were over 500 treatment approaches at that point, and now we've moved ahead. And yes, there are the evidence-based programs, and there's quite a few of those, and I'll mention a few of them in just a second, but I also think that we have people who have a lot of clinical experience and maybe work in a setting where doing academic research is not possible, but I think we need to be able to use both. I know that we're really led by can we prove that it works, and that makes sense to me. And there are other things you can prove they work by doing the work with the families, and seeing how they improve, and just kind of paying attention to what the strategies are that seem to get the best positive outcomes.

Dr. Eliana Gil:

So it's a combination of those things. So I believe in integrated therapy and invitations to be ample, because we never know what people are going to respond to, and I also think that supervision, or consultation, I should say, is a lifelong endeavor, that it's always a good idea to just check in with people from time to time and kind of say, "Hey, I've been doing this or noticing this," but it's just really important. In terms of the evidence-based programs, I mean, in my mind, the ones that are the easiest to research are the ones that are most researched. So cognitive behavioral therapies, for example, have a ton of research behind them, and obviously they're very useful. Actually, I'm very influenced by Dr. Bruce Perry, who has the sequential model of therapy, and he talks and he says, "All of these things have merit and value. It's a question of when you deliver them."

Dr. Eliana Gil:

If you have a family that comes in angry, frustrated, scared, psychoeducation, may or may not be the best approach at that particular moment in time, might be best to wait to make that connection, help them feel safe, and then they're receptive to psychoeducation. But there's ABA... I'm sorry, ABA, yes, applied behavioral analysis, there's behavioral therapy, cognitive behavioral. In the world of trauma, we have trauma focused cognitive behavioral therapy, which I like, and usually it's delivered a little bit later in the treatment process than starting with that. The expressive therapies are gaining momentum in terms of having research. We now have child-centered play therapy that's evidenced based, child-parent relationship therapy is evidence-based, dialectical behavioral therapy, motivational interviewing. I mean, so there's been so many studies, and I just think we need to practice, and we need to be very attentive to the needs of the family and then try to make a match.

Dr. Eliana Gil:

My play therapy friend, Charlie Schaefer, used to talk about prescriptive play therapy. You meet the family. You get to know them, and then you try to match what you think they might be receptive to, and of course, you always look for is there an evidence-based model? There's some really good things on coping and anxiety. So I go to those and then try to offer invitations to people. And if one thing doesn't work, you move on to the next thing. And having said that, there's also a ton of training available, and so there are now these established organizations, just to name a few, PESI. Everyone knows about PESI, P-E-S-I. They do trainings year round. Leading Edge Seminars, R. Cassidy, there's tons of them, and then the professional associations like the APA, the ACA, the AFTA, the Association for Play Therapy. They promote individualized kind of training packages.

Dr. Eliana Gil:

So we can always go to our associations and just look and see what's available through them, but wow, it's at a point now where you open your social media, and there's just offering after offering, after offering of all these really interesting trainings. So one positive of COVID was learning how to use mechanisms like Zoom, not only for treatment, but for training. I've done trainings now on Zoom that I could never visualize ever occurring on Zoom, like sand therapy, and yet they're very meaningful experiences. So it's been kind of a discovery process. So I think we're in a great place right now. There's a lot of information available, and it's just a question of delivery.

Dr. Eliana Gil:

If information alone could solve all these problems, we would've solved them, because everything is online. Go read. But a lot of parents and a lot of kids don't do well with that kind of learning. I can't read something and get it. I have to do it and get it. So experiential learning I think is the best, and that's why things like movement therapy, and yoga, and things that look at the whole body, and expressive therapies like sand, and art, and play, they can be so valuable in an integrated fashion. You don't have to be a certified person in 19 different things, but if you know enough about the basic principles, and how they might promote what you're doing, the goals you've set, the theoretical approach you have, then you're doing things in a responsible way.

Christa Butler:

Yes, there's so many approaches. For me at least, I think it could be a bit overwhelming to know which one, like you said, do you invest in? But I will say this, that there's one thing that you touched on that I think you embody the best out of any professional that I've watched throughout my career, and that is the commitment to lifelong learning, and the commitment to working integrable, and to recognizing that there is no one size fits all approach when it comes to working with clients, and it really does need to be an individualized approach, and it needs to be personalized, and it needs to have a connection to what the client is, and the family is in front of you, and what their needs are. And so I think that of the professionals that I've watched throughout my career, I think that you embody each of those things so well.

Christa Butler:

There's been so many gems that you've shared during this podcast. Oh my gosh, I wish we had more time. But one thing that I would love for you to leave us with is sharing a little bit more about some of the benefits that play and creativity offers children in counseling.

Dr. Eliana Gil:

Yes. And thank you, because I think I might have skipped over that. I think that one of the most important things about any of the expressive therapies is that they give people that safe enough distance, because sometimes people defend because they need to, and they put up walls because they need to have that safety. Sometimes our techniques are to go try to put a keg of dynamite under that wall, so it blows up, and we see that person, but they're completely exposed and vulnerable when that happens. And so it's recognizing that we need to provide them with ways that they don't need to have their guard up so much. And part of that is what the expressive therapies do, and metaphor does that really well.

Dr. Eliana Gil:

So if you have a little child who comes in, and daddy is beating up mommy, it's one thing to say to the child, "Oh, I understand that daddy is hurting mommy," and you might have a child who says, "No, he's not. I love my daddy." And suddenly now that child is on guard because you're breaking into the secrecy, and they're going to get in trouble, and they have loyalty to that parent. So that child might come in and pick a daddy bear, and a mommy bear, and a baby bear, and then it's the daddy bear who's hitting that mommy bear, and then it gets to stay at that safe enough distance. And now that child can say, "And the baby feels scared, and the baby is sad," and she's talking about herself, but she can do it in a safe way.

Dr. Eliana Gil:

So that's one of the biggest pieces I think around expressive therapy. It's very familiar to children, it's less threatening, and it connects them to less conscious material, because sometimes it's a difference between the left hemisphere of the brain, and when we talk to kids, we're in left hemisphere of the brain. We're asking them questions. They're giving us answers. It's linear. It's literal, but the right hemisphere of the brain is where there's more of the symbol, and images, and art, and that's the less conscious part. So sometimes when you say to the child, "Is everything okay at home," The left hemisphere of the brain has a rehearsed answer, "Yes, everything is fine," because it's supposed to be, but if you say to them, "Draw me a picture of you and your family," that's the right hemisphere of the brain. Now they can express things without feeling like they can't.

Dr. Eliana Gil:

And so there's something really beautiful about that, and it's intrinsically pleasurable for people. So you're bringing in those little sprinklings of joy and laughter, and what a great goal to have with families when you're working with them. Let's get them to have a different experience of each other. How do we bond with people? We play with them. We laugh with them, whatever. So that's what I think, and obviously play and other expressive work allows for problem solving, and coping, and compensating for things. A kid whose parents are divorcing came into my office, took rubber bands, and just put the rubber bands around the two parent figures, and then just wanted to play ball with them, and play catch with them. So in a way, he compensated for his parents' separation by putting them together in a way that would never separate, and then also making it lighter, and that's what kids do, and that seems to benefit them to be able to do things like that.

Dr. Eliana Gil:

So expressive work I think is great. It just kind of steps aside that all the guardedness that people can have, and it's just a way that we can invite people in and to connect with us in a different way. So hopefully people are interested, and they can go and learn a little bit, and then you have to practice it, and I used to practice everything with my kids, and sometimes with staff at staff meetings, so we could all get comfortable with it and kind of explore it for ourselves first, and then go, "Wow, I wasn't expecting that." And then you feel confident, and confidence builds over time, and you learn to trust these methods.

Christa Butler:

Dr. Gil, I cannot thank you enough for sharing your wealth of wisdom and knowledge with us today. Before we wrap up, can you share with our listeners who want to get in touch, want to learn more about how they can maybe attend some of your trainings? Can you share where can folks find you?

Dr. Eliana Gil:

Well, thank you for asking, and it's actually just my name, ElianaGil@me.com, me.com. So it's very easy, and just remember, it's Gil with one L. People want to put two L's in, and then it never gets to me, but it's just Elianagil@me.com, and also, I'm happy to refer people to lots of training programs. I'm familiar with a lot of them. Yeah, happy to respond if people have quick questions for me.

Christa Butler:

Awesome. Thank you so much, and again, I can't thank you enough for being here with us and for sharing all that you've shared in just a brief 30 minute interview, this has been great.

Dr. Eliana Gil:

Thank you. And thank you for the great questions. I appreciate it.

Christa Butler:

Thank you for answering them with such wealth of knowledge, and thorough information, and so many gems for people to go and take notes and to research further. This has been great.

Dr. Eliana Gil:

Thank you so much.

Christa Butler:

Be sure to subscribe to The Voice of Counseling on Apple and Google Podcast, and you can follow ACA on social media. To join ACA and to get exclusive access to all member benefits, check out Counseling.org.

Speaker 1:

ACA provides these podcasts solely for informational and educational purposes. Opinions expressed in these podcasts do not necessarily reflect the view of ACA. ACA is not responsible for the consequences of any decisions or actions taken in reliance upon or as a result of the information and resources provided in this program. This program is copyright 2023 by the American Counseling Association. All rights reserved.