Play therapy

Play therapy
ICD-9-CM	93.81, 94.36
MeSH	D010989

Play therapy is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others.

General

Play Therapy is a form of counseling or psychotherapy that uses play to communicate with and help people, especially children, to prevent or resolve psychosocial challenges. This is thought to help them towards better social integration, growth and development.

Play Therapy can also be used as a tool of diagnosis. A play therapist observes a client playing with toys (play-houses, pets, dolls, etc.) to determine the cause of the disturbed behavior. The objects and patterns of play, as well as the willingness to interact with the therapist, can be used to understand the underlying rationale for behavior both inside and outside the session..

According to the psychodynamic view, people (especially children) will engage in play behavior in order to work through their interior obfuscations and anxieties. In this way, play therapy can be used as a self-help mechanism, as long as children are allowed time for "free play" or "unstructured play." Normal play is an essential component of healthy child development.

One approach to treatment is for play therapists use a type of desensitization or relearning therapy to change disturbing behavior, either systematically or in less formal social settings. These processes are normally used with children, but are also applied with other pre-verbal, non-verbal, or verbally-impaired persons, such as slow-learners, or brain-injured or drug-affected persons.

History

Play has been recognized as important since the time of Plato (429-347 B.C.) who reportedly observed, “you can discover more about a person in an hour of play than in a year of conversation.” In the eighteenth century Rousseau (1762/1930), in his book ‘Emile’ wrote about the importance of observing play as a vehicle to learn about and understand children. Friedrich Fröbel, in his book The Education of Man (1903), emphasized the importance of symbolism in play. He observed, “play is the highest development in childhood, for it alone is the free expression of what is in the child’s soul…. children’s play is not mere sport. It is full of meaning and import.” (Fröbel, 1903, p. 22) The first documented case, describing the therapeutic use of play, was in 1909 when Sigmund Freud published his work with “Little Hans.” Little Hans was a five-year-old child who was suffering from a simple phobia. Freud saw him once briefly and recommended that his father take note of Hans’ play to provide insights that might assist the child. The case of “Little Hans” was the first case in which a child’s difficulty was related to emotional factors.

Hermine Hug-Hellmuth (1921) formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyze the child. In 1919, Melanie Klein (1955) began to implement the technique of using play as a means of analyzing children under the age of six. She believed that child’s play was essentially the same as free association used with adults, and that as such, it was provide access to the child’s unconscious. Anna Freud (1946, 1965) utilized play as a means to facilitate positive attachment to the therapist and gain access to the child’s inner life.

In the 1930s David Levy (1938) developed a technique he called release therapy. His technique emphasized a structured approach. A child, who had experienced a specific stressful situation, would be allowed to engage in free play. Subsequently, the therapist would introduce play materials related to the stress-evoking situation allowing the child to reenact the traumatic event and release the associated emotions.

In 1955, Gove Hambidge expanded on Levy’s work emphasizing a “Structured Play Therapy” model, which was more direct in introducing situations. The format of the approach was to establish rapport, recreate the stress-evoking situation, play out the situation and then free play to recover.

Jesse Taft (1933) and Frederick Allen (1934) developed an approach they entitled relationship therapy. The primary emphasis is placed on the emotional relationship between the therapist and the child. The focus is placed on the child’s freedom and strength to choose.

Carl Rogers (1942) expanded the work of the relationship therapist and developed non-directive therapy, later called client-centered therapy (Rogers, 1951). Virginia Axline (1950) expanded on her mentor's concepts. In her article entitled ‘Entering the child’s world via play experiences’ Axline summarized her concept of play therapy stating, “A play experience is therapeutic because it provides a secure relationship between the child and the adult, so that the child has the freedom and room to state himself in his own terms, exactly as he is at that moment in his own way and in his own time” (Progressive Education, 27, p. 68).

In 1953 Clark Moustakas wrote his first book Children in Play Therapy. In 1956 he compiled Publication of The Self, the result of the dialogues between Abraham Maslow, Carl Rogers, Clark Moustakas and others, forging the Humanistic Psychology movement.

Filial therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy during the 1960s. The filial approach emphasizes a structured training program for parents in which they learn how to employ child-centered play sessions in the home. In the 1960s, with the advent of school counselors, school-based play therapy began a major shift from the private sector. Counselor-educators such as Alexander (1964); Landreth (1969, 1972); Muro (1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute significantly, especially in terms of using play therapy as both an educational and preventive tool in dealing with children’s issues.

1973 Clark Moustakas continues his journey into play therapy and publishes is novel "The child's discovery of himself". Clark Moustakas' work as being concerned with the kind of relationship needed to make therapy a growth experience. His stages start with the child's feelings being generally negative and as they are expressed, they become less intense, the end results tend to be the emergence of more positive feelings and more balanced relationships. Today, his daughter Kerry Moustakas continues his legacy as an author and president of The Michigan School of Professional Psychology. 2004 Clark and Kerry Moustakas publish Loneliness, Creativity and Love: Awakening Meanings in Life.

Growth of Organizations

In 1982, the Association for Play Therapy (APT) was established marking not only the desire to promote the advancement of play therapy, but to acknowledge the extensive growth of play therapy. Currently, the APT has almost 5,000 members in twenty-six countries (2006). Play therapy training is provided, according to a survey conducted by the Center for Play Therapy at the University of North Texas (2000), by 102 universities and colleges throughout the United States.

In 1985, the work of two key Canadians in the field of child psychology and play therapy, Mark Barnes and Cynthia Taylor, resulted in the establishment of Certification Standards through the non-profit Canadian child psychotherapy and play therapy association. A fledgling group of practising Canadian child psychotherapists and play therapists worked on developing an organization to meet professional needs. It gradually expanded and eventually a Board of Directors was formed; objects and by-laws were designed, revised, re-revised and finally approved by the Government of Canada. The Canadian association was eventually recognized as a non-profit organization in 1986.

During 1995/1996, a whole new horizon opened up for the profession of play therapy as a result of the Canadian Play Therapy Institute's pioneering efforts on an International basis. Play Therapy International was founded from the Canadian Play Therapy Institute and there now existed a mutually supportive recognition between Play Therapy International/The International Board of Examiners of Certified Play Therapists, The Canadian Play Therapy Institute, as well as a number of other professional bodies throughout the world.

In the UK, The United Kingdom Society for Play and Creative Arts Therapies Limited (known in short as PTUK) was originally set up in October 2000 as Play Therapy UK with the encouragement of Play Therapy International. Meanwhile the British Association of Play Therapists was distinguished from its American counterpart in 1996 and was granted charity status within the UK in 2006 by the UK Charities Commission.

By 2010 Play Therapy International has partnered sister organisations in Ireland, Canada, Australasia, France, Spain, Wales, Malaysia, Romania, Russia, United Kingdom, Slovenia, Germany, New Zealand, Hong Kong, Korea and Ethiopia.

Efficacy of Play Therapy

An extensive body of literature has documented the effectiveness of play therapy, as a counseling model, in working with children and adolescents. Since the 1940s play therapy researchers have studied play therapy and documented its effectiveness. Research examining the effectiveness of play therapy related to conduct disorder, aggression and oppositional behavior have been undertaken.

Authors (Dogra and Veeraraghavan, 1994) found parents and their children (ages 8–12) who had been diagnosed with conduct disorder and were exhibiting significant aggression, after receiving sixteen sessions of nondirective play therapy and parental counseling, showed significantly less “extrapunitive” responses and significantly higher “impunitive” and “need-persistence” compared to the control group. Additionally, they exhibited significant positive change in adjustment while significantly decreasing aggressive behaviors. Authors studying school maladjustment (Wong et al., 1996), using the board game ‘Stacking the Deck’ to teach social skills to boys diagnosed with conduct disorder (ages 16–17) who were mildly retarded, found eight sessions or less showed “clear improvements after unit training.” Schmidtchen, Hennies and Acke (1993) compared a treatment group of children (ages 5–8), who exhibited behavioral disturbances and received thirty sessions of nondirective play therapy, with a control group receiving non-play therapy social education. Results showed a decrease in behavioral disturbances and an increase in “person-centered competencies.”

Authors Burroughs, Wagoner & Johnson (1997) studied twenty-one participants (ages 7–17) whose parents were either divorced or divorcing. They found that treatment group members who played ‘My Two Homes’ as well as group members who participated in conventional play therapy exhibited a decline in parents’ scores on the Internalizing Scale of Child Behavior Checklist as well as the parent form of the ‘Children’s Depression Inventory’. State and trait anxiety also decreased in both groups. A study on the effectiveness of play therapy on multiculturalism was undertaken. The author studied 168 children (ages 10–12; 82% were African-American) who were identified as “at-risk” and participated in a mean average of four nondirective play therapy sessions. Results indicated that children who participated in the play therapy sessions maintained the same level of self-esteem and internal locus of control, while children in the control group showed a statistically significant level as measured by the ‘Coopersmith Self-Esteem Inventory’ and the ‘Intellectual Achievement Responsibility Scaled-Revised’. Play therapy has also been studied with sexual abuse victims, and one study by Reams and Friedrich (1994), who placed victims or siblings of victims (ages 3–5) in a 15-week treatment group using directive play therapy, found that they engaged in “less isolated play” than the control group.

Attention-Deficit Hyperactivity Disorder (ADHD) has been a significant diagnosis for well over a decade. Kaduson and Finnerty (1995) conducted a study with sixty-three children between the ages of eight and twelve. The authors compared three groups of children diagnosed with ADHD using a game (Self-control Game) for one group, biofeedback for another and a control strategic game only in the final group. Results indicated biofeedback was the most effective in improving the child’s self-perception of self-control. All three groups indicated a significant improvement in sociability and attention. Peer play therapy groups combined with art therapy groups, and family play therapy groups combined with art therapy groups, have been shown (Springer, et al., 1992) to improve depression and hyperactivity scores, in both boys and girls, according to the Child Behavior Checklist in children who have at least one parent who is suffering from alcohol or drug dependency. Additionally, aggression and delinquent behaviors significantly decreased in boys. The study included 132 subjects between the ages of seven and seventeen. Over the past two decades there has been a concerted effort to develop and implement well-designed controlled play intervention studies. Two meta-analytic studies have examined the effectiveness of play therapy with children (e.g., LeBlanc & Ritchie 1999; Ray, Bratton, Rhine, & Jones, 2001). LeBlanc and Ritchie’s meta-analysis included 42 experimental studies, dated from 1947 to 1997. The studies used came from multiple sources, including journals, dissertations, and unpublished studies.

Models of Play Therapy

An individual engaging in sandplay therapy.

Equipment used for sandplay therapy.

Play therapy can be divided into two basic types: nondirective and directive. Nondirective play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy. Both modes of play therapy have received at least some empirical support. On average, a child suffering with an emotional or behavioral difficulty that is treated with play therapy will improve functioning at 0.80 standard deviations than children who are not treated with play therapy.

Nondirective Play Therapy

Nondirective play therapy, also called client-centered and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. Thus, nondirective play therapy is regarded as non-intrusive. The hallmark of nondirective play therapy is that it has few boundary conditions and thus can be used at any age. The principles under which this therapy operates originated in Carl Rogers's non-directive psychotherapy and in his characterization of the optimal therapeutic conditions. Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is widely considered the founder of this therapy. Different techniques have since been established that fall under the realm of nondirective play therapy, including traditional sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms is covered briefly below.

Traditional sandplay therapy and its development are attributed to Margaret Lowenfeld, who established this technique in 1929. As in traditional nondirective play therapy, the notion is that allowing an individual to freely play with the sand and accompanying objects inside the sandtray will facilitate the healing process and be therapeutic to the unconscious. When constructing the sandtray, little instruction is provided and little to no "talk" therapy on the part of the therapist is give. This protocol emphasizes the importance of the non-verbal free play in this therapy. Upon its completion, the patient may talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may provide guidance. After a number of sessions, the therapist may provide interpretations. This is also often used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also observance by the therapist of a family working together on a sandtray may show evidence of unhealthy alliances, depending on who works with who, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships. Parents may sometimes conduct this nondirective play therapy with their children while a therapist observes. It has been shown that therapy conducted by a parent produces a larger treatment effect than play therapy conducted by a therapist.

Using toys in nondirective play therapy with children is another common method therapists employ, a method which was derived from the creative toys used in Freud's theoretical orientations. The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalization of their feelings. Through these actions, then, children may be able to experience catharsis, gain more or better insight into their consciousness, thoughts, and emotions, and test their own reality. Popular toys used during therapy are animals, dolls, hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to encourage dramatic play or creative associations, both of which are important in expression.

Efficacy of Nondirective Play Therapy

Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years. Critics of play therapy have worked to undermine the effectiveness of the technique for use with children and to provide support for different interventions, such as cognitive behavioral therapy. They also argue that therapists focus more on the institution of play rather than the research of play and outcome of studies when conducting therapy Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research - many studies included small sample sizes which limits the generalizeability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment. Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.

To date, research is lacking on the overall effectiveness of using toys in nondirective play therapy. A study done by Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during nondirective play therapy were not more likely to verbally express themselves to the therapist. There is also ongoing controversy in choosing toys for use in nondirective play therapy, with choices being largely made through intuition rather than through research. It has been shown, though, that following specific criteria when choosing toys in nondirective play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and lead to play that can be easily interpreted by a therapist.

Directive Play Therapy

Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist, then, plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself. Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities. This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy.

Directed sandtray therapy is more commonly used with trauma victims and involves the "talk" therapy to a much greater extent. Because trauma is often debilitating, directed sandplay therapy works to create change in the present, without the lengthy healing process often required in traditional sandplay therapy. This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives.

Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate. Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of Beck's cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy. In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children's verbalizations in these interactions but rather on their actions and their play. Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists in order to change children's maladaptive thinking.

See also

• Charles E. Schaefer
• Child life specialist
• Therapy
• Theraplay
• The P.L.A.Y. Project

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Further reading

• Play Therapy by Virginia Axline (original print 1947). ISBN 0-345-30335-0. Houfton Mifflin Company.
• Play Therapy: The Art of the Relationship by Garry Landreth (Second Edition 2002). ISBN 1-58391-327-0. Brunner-Routledge.
• Play Therapy Theory and Practice: A Comparative Presentation by Kevin O'Connor & Lisa Braverman (1996). ISBN 0-471-10638-0. Wiley.books

External links

• Canadian Association of Play Therapy
• Association of Play Therapy
• Play Therapy International
• The Play Therapy Institute
• Play Therapy. ERIC Digest.
• Sandtray Therapy
• Play Therapy Australia
• Arquetipo Ludi (Spanish)
• British Association of Clinical Play Therapists
• British Association of Play Therapists