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 his 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.

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 types of play therapy have received at least some empirical support. On average, play therapy treatment groups when compared to control groups improve by .8 standard deviations.

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. In other words, 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. This therapy originates from 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.

Play therapy using a tray of sand and miniature figures is attributed to Margaret Lowenfeld (UK), who established her "World Technique" in 1929. Dora Kalff (Swiss.) studied with Lowenfeld on the recommendation of her mentor, C.G. Jung, when Kalff studied at the Jung Institute in Zurich. Kalff combined Lowenfeld's World Technique with Jung's idea of the collective unconscious and received Lowenfeld's permission to name her version of the work "sandplay" (Kalff, 1980). In the US, training and certification in the Jungian-Kalffian method is provided by Sandplay® Therapists of America™ (STA) which received US trademark protection for the term in March, 2012. Therapists working in sand who are not certified by STA may legally term their work "sand tray" therapy or play therapy with sand.

As in traditional nondirective play therapy, research has shown that allowing an individual to freely play with the sand and accompanying objects in the contained space of the sandtray (22.5" x 28.5") can facilitate a healing process as the unconscious expresses itself in the sand and influences the sand player. When a client creates in the sandtray, little instruction is provided and the therapist offers little or no talk during the process. This protocol emphasizes the importance of holding what Kalff (1980) referred to as the "free and protected space" to allow the unconscious to express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may not choose to talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may offer supportive response that does not include interpretation. The rationale is that the therapist trusts and respects the process by allowing the images in the tray to excerpt their influence without interference.

Sand tray therapy can be 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.

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 questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as cognitive behavioral therapy. They also argue that therapists focus more on the institution of play rather than the empirical literature 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.

Research is lacking on the overall effectiveness of using toys in nondirective play therapy. 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. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checker game. 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. However, other research shows 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.

Several meta analyses have shown promising results toward the efficacy of nondirective play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for nondirective play therapy. This finding is comparable to the effect size of 0.71 found for psychotherapy used with children, indicating that both nondirective play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups. These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71, 0.71, and 0.66. Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with nondirective play therapy. Results from all meta-analyses indicate that nondirective play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.

There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes. Although positive effects can be seen with the average 16 sessions, there is a peak effect when a child can complete 35-40 sessions. An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child. Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behavior problems. Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.

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 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.

Efficacy of directive play therapy

The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have. Similarly in 2005 meta analysis by authors Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while nondirective play therapy had an effect size of 0.92. Although the effect sizes of directive therapy are statistically significantly lower than those of nondirective play therapy, they are still comparable to the effect sizes for psychotherapy used with children, demonstrated by Casey, Weisz, and LeBlanc. A potential reason for the difference in the effect size may be due to the amount of studies that have been done on nondirective vs. directive play therapy. Approximately 73 studies in each meta analysis examined nondirective play therapy, while there were only 12 studies that looked at directive play therapy. Once more research is done on directive play therapy, there is potential that effect sizes between nondirective and directive play therapy will be more comparable.

Parent/child play therapy

Several approaches to play therapy have been developed for parents to use in the home with their own children.

Training in nondirective play for parents has been shown to significantly reduce mental health problems in at-risk preschool children. One of the first parent/child play therapy approaches developed was Filial Therapy (in the 1960’s - see History section above), in which parents are trained to facilitate nondirective play therapy sessions with their own children. Filial therapy has been shown to help children work through trauma and also resolve behavior problems.

Another approach to play therapy that involves parents is Theraplay, which was developed in the 1970’s. At first, trained therapists worked with children, but Theraplay later evolved into an approach in which parents are trained to play with their children in specific ways at home. Theraplay is based on the idea that parents can improve their children’s behavior and also help them overcome emotional problems by engaging their children in forms of play that replicate the playful, attuned, and empathic interactions of a parent with an infant. Studies have shown that Theraply is effective in changing children’s behavior, especially for children suffering from attachment disorders.

In the 1980’s, Stanley Greenspan developed Floortime, a comprehensive, play-based approach for parents and therapists to use with autistic children. There is evidence for the success of this program with children suffering from autistic spectrum disorders.

Lawrence Cohen has created an approach called Playful Parenting, in which he encourages parents to play with their children to help resolve emotional and behavioral issues. Parents are encouraged to connect playfully with their children through silliness, laughter, and roughhousing.

More recently, Aletha Solter has developed a comprehensive approach for parents called Attachment Play, which describes evidence-based forms of play therapy, including nondirective play, more directive symbolic play, contingency play, and several laughter-producing activities. Parents are encouraged to use these playful activities to strengthen their connection with their children, resolve discipline issues, and also help the children work through traumatic experiences such as hospitalization or parental divorce.

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