Play therapy

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 the systematic use of a theoretical model to establish an interpersonal process wherein play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial challenges and achieve optimal growth and development. A working definition might be a form of counseling or psychotherapy that therapeutically engages the power of play to communicate with and help people, especially children, to engender optimal integration and individuation.

Play Therapy is often 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." From a developmental point of view, play has been determined to be an essential component of healthy child development. Play has been directly linked to cognitive development.

One approach to treatment is for play therapists use a type of systematic 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. Mature adults usually need much "group permission" before indulging in the relaxed spontaneity of play therapy, so a very skilled group worker is needed to deal with such guarded individuals.

Many mature adults find that "child's play" is so difficult and taboo, that most experienced group workers need specially tailored "play" strategies to reach them. Competent adult-group workers will use these play strategies to enable more unguarded spontaneity to develop in the non-childish student.

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 1930’s 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).

Filial therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy during the 1960’s. 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 1960’s, 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.

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.

Systematic model

The therapist's office will schedule an appointment with several children. In one session there can be as many as 2-5 children interacting. This organic interaction allows the psychologist and psychiatrist to properly evaluate the child’s emotions and feelings. This form of therapy allows the child to unknowingly reveal his emotion, while playing with other children.

Along with children interacting with other children, the therapist will have the child play with certain toys in order to determine his concentration and source of any stress. Each toy and each style of enjoying them represents a different emotion and feeling.

It is believed that as people interact with others, they may work through their internal anxieties. In this idea, children should be encouraged to play, in order to develop as a healthy child.

The therapist will engage in desensitization exercises, in order to eliminate stress for children. These exercises include teaching the child how to relearn certain behavior through a formal system of tests.

Sandtray Therapy {{safesubst:#invoke:anchor|main}}

Sandtray, sandbox or sandplay therapy is a form of experiential workshop which allows greater exploration of deep emotional issues. Sandplay therapy is suitable for children and adults and allows them to reach a deeper insight into and resolution of a range of issues in their lives such as deep anger, depression, abuse or grief.

Through a safe and supportive process they are able to explore their world using a sandtray and a collection of miniatures. Accessing hidden or previously unexplored areas is often possible using this expressive and creative way of working which does not rely on “talk” therapy.

The technique was developed by the Swiss therapist Dora M. Kalff (1904-1990) and Margaret Lowenfeld.

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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 1583913270. Brunner-Routledge.
• Play Therapy Theory and Practice: A Comparative Presentation by Kevin O'Connor & Lisa Braverman (1996). ISBN 0471106380. Wiley.books