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Play Therapy

Cindy Dell Clark, PhD

Rutgers University, USA

June 2013

Introduction

Play therapy draws on the proven therapeutic power of play, using professional therapists as catalysts and support to help children with their troubles through play activity. Play therapy may also be of value beyond the clinical setting, conducted through parents as well as in preschools.

Subject 

How is play therapeutic?

Lay adults often view play as a medium of happy fun unrelated to troubles. The professionals who carry out play therapy have shown that play also extends to troublesome aspects of existence, including the stresses, trauma, family dysfunction, illness and other dilemmas that abound in the real experience of children. Play therapy, in which children are encouraged to act out their feelings and dilemmas through play and fantasy, draws on the power of play to give palpable expression to children’s concerns. Play therapy is consistent with children’s tendencies to “play out” problems outside of clinical intervention, reenacting troubling experience as a way to come to terms with conflicted feelings. Child inmates during the Holocaust pretended to be guards and prisoners, dramatizing in play concentration camp routines and killings.Following Hurricane Katrina, children who saw the hurricane on television improvised play at preschool, imagining how wind and flood waters threatened pretend characters.2 In play therapy the propensity for children to express dilemmas through play is channeled as a clinical intervention, supported by an adult therapist who catalyzes, but does not explicitly direct, a child’s therapeutic play. 

Research Context

As a mode of clinical intervention with children, play therapy established its credibility through praxis. The clinical case study has been a prevailing means of communicating the workings of play therapy. Two pioneers of clinical play therapy were Anna Freud and Melanie Klein, who argued that play was a means to adapt psychoanalysis, used with adults, to suit children. Play, Klein argued, could substitute for the verbal free association used in adult therapy. Freud asserted that play could reveal unconscious processes, even as it accommodated mutual relating between a child and a therapist.3 Virginia Axline authored case-based explications of play therapy still in use today.4 Axline influenced the idea that play should provide a secure therapist-child relationship, thereby allowing the child “freedom and room to state himself in his own terms” using play. 

Psychoanalyst Donald Winnicott produced case studies exemplifying the practice of play therapy as well as influential theoretical contributions about play and imagination. Winnicott’s book The Piggle described the treatment of a girl troubled by the birth of her younger brother, who visited Winnicott for treatment 16 times over ages two through five. A portion of Winnicott’s account of the girl known as Piggle was written by her parents, who reported that after play therapy she functioned well; Piggle’s parents speculated that play therapy had allowed her to be “understood on a deep level” and may have instilled in her a notable degree of inner judgment and insights into others. A theory of Winnicott, deriving from his clinical work, concerned the transitional object, an object (e.g., a toy, a blanket) regarded with a special status used for soothing purposes by children. Winnicott theorized that the significance of the transitional object derived from the mother-child relationship, with broad implications for children’s capacity to suspend disbelief when engaged with cultural or religious symbolism.6

The plentiful case records published about play therapy established its applicability to a wide range of conditions and circumstances. Among preschool-age children, play therapy has an established track record in treating separation problems, attention deficit/hyperactivity, disruptive behaviour, mood and anxiety disorders, trauma from natural disasters or violence, the stress of terminal and chronic illness, as well as countless other conditions. Play therapists work in varied settings including social services, schools and medical settings.

Play therapists are considered central to treatment. Conveying deep empathy, genuineness, and unconditional positive regard for the child contributes to a therapeutic relationship, thereby maintaining a supportive atmosphere for the child’s self-directed play. Play therapists use toys and a plethora of playful activities, but the child is empowered to choose what to play with and how to play.7 Play therapists actively observe and listen. They follow the child’s lead as the play proceeds, reflecting back to the child in attunement with the child’s play. Therapists respond to the child’s requests to enact pretend roles or to assist play in other ways. Play therapists are not judgmental, although they do set limits when a play action poses possible harm. 

The child-directed nature of play therapy is central to its healing dynamics. Children undergoing play therapy often choose to repeat play sequences across multiple sessions of therapy.8 In metaphorically representing events that were originally threatening, children are able to take an active stance to control events in the reenactment, contributing a sense of empowerment or mastery over what was once unresolved and unsettling.9 New associations can be made to negatively charged objects or incidents through make-believe transactions that symbolize conflicts, fears or wishes, in forms that children are able to cognitively and affectively assimilate.

Meta-analyses have assessed the effectiveness of play therapy in bringing about desirable change in children.10,11,12 Empirical assessment studies consistently have validated play therapy as effective.13 A child with emotional problems treated through play therapy, as it has been shown, does better than 75-82% of untreated children.14 Of course, play therapy does not have a monopoly on mental health interventions with children, since other methods including behavioural or cognitive interventions also play a part in current treatment.

Key Research Issues

Empirical studies support the effectiveness of parental involvement in play therapy. Filial play therapy (play therapy conducted by clinically-trained parents) has been associated with an even more pronounced effect on outcomes than play therapy using professional therapists.15 This opens the possibility for play therapy to be affordable on a large scale, by training parents to use empathic understanding and responsive involvement in therapeutic play. Historical precedents for filial therapy date to Sigmund Freud16 as well as to Carl Rogers, who guided his adult daughter’s use of filial therapy with a grandchild suffering from encopresis.17 In filial therapy, a set of playthings are put aside to be brought out strictly for use in therapeutic play, conducted on a regular and predictable schedule.

The use of trained lay therapists has also increased the accessibility of play therapy for preschool programs.18 There is promising evidence from recent empirical research that child-centered play therapy (guided by Master’s degreed counselors) can dramatically reduce disruptive behaviour and aggression among impoverished children of diverse ethnicities in Head Start programs.19

Research Gaps

While play therapy’s effectiveness has been established, it is still not fully clear how play therapy compares in effectiveness to other therapies, including behavioural or cognitive approaches.  Comprehensive research tracing the relative impact of various therapies on a full range of conditions is still to be completed.

Since play is a cross-culturally variable activity, it is important for research to explore culturally related issues that might pose barriers for “standard” play therapy. Materials used, procedures followed, and interpretations made may vary according to cultural context, a topic for further research.

Another germane issue for study involves the ongoing reduction of play time in the United States, including the reduction of recess in favour of increased academic instruction. Since unstructured play has proven value to exercise affective flexibility and emotional resilience, the restriction of free play for children bears close examination with regard to children’s emotional adaptation. 

The therapeutic value of play, in general, justifies giving play a more prominent place in psychological and cultural research. 

Conclusions

Play therapy is a form of therapeutic renewal, guided by a therapist or a trained lay person.  Therapeutic play has proven value across a wide range of childhood problems. As Brian Sutton-Smith has shown, play is a viable model of adaptive human functioning, in which adaptability is achieved by the limber use of symbols and narratives.20 By age three and sometimes earlier, children play out their troubles with impressive flexibility as they manipulate meanings symbolically.

Play therapy, by formalizing a context for children’s self-guided play, highlights the importance of play to adaptive healing generally. Children’s intense involvements in particular play themes can be telling indicators of underlying unresolved issues, including for physically ill children.21 Given time to engage in pretense freely, children playfully confront difficult meanings on their own terms.  Peggy Miller’s son Kurt, as early as age two, relistened and retold the story of Peter Rabbit repeatedly in a home setting, using intriguing authorial license in his retellings. His story renditions ran in parallel with his everyday emotional concerns about misbehaviour and its anxious implications.22 Play can poetically encode what is not resolved, in an approachable and confrontable framework. Play therapy in a clinical setting enables children to address even extreme disruptions, scaffolded by an empathic and supportive adult.

References

  1. Eisen, G. Children and play in the Holocaust. Amherst: University of Massachusetts Press; 1988.
  2. Paley, V. The Boy on the Beach: Building community through play. Chicago: University of Chicago Press; 2010.
  3. Webb, N. Social work practice with children. New York: Guilford Press; 2011.
  4. Axline, V. Play therapy. New York: Ballantine Books; 1947.
  5. Winnicott, D.W. The piggle: An account of the psychoanalytic treatment of a little girl. London: Penguin; 1977.
  6. Winnicott, D.W. Transitional objects and transitional phenomena. In: Winnicott, D.W. Collected Papers. London:Tavistock; 1958.
  7. Cochran, N.H., Nordling, W.J., Cochran, J.L. Child-centered play therapy:  A practical guide to developing therapeutic relationships with children. Hoboken NJ:  John Wiley and Sons; 2010.
  8. Campbell, M.M., Knoetze, J.J. Repetitive symbolic play as a therapeutic process in child-centered play therapy. International Journal of Play Therapy.  2010;19:222-234.
  9. Glazer, H.R. Filial therapy for grieving preschool children. In: Schaefer, C.E. Play therapy for preschool children. Washington DC: American Psychological Association; 2010:89-106.
  10. Bratton, S.C., Ray, D., Rhine, T., Jones, L. The efficacy of play therapy with children:  a meta-analytic review of treatment outcomes.Professional Psychology: Research and Practice. 2005;36:376-390.
  11. Ray, D., Bratton, S., Rhine T., Jones, L. The effectiveness of play therapy: responding to the critics. International Journal of Play Therapy. 2001;10:85-108.
  12. Bratton, S. Ray, D. What research shows about play therapy. International Journal of Play Therapy. 2000;9:47-88.
  13. LeBlanc, M., Ritchie, M. A meta-analysis of play therapy outcomes. Counseling Psychology Quarterly, 2001;14:149-163.
  14. Carr, A. What Works With Children, Adolescents And Adults?: A Review Of Research On The Effectiveness Of Psychotherapy. London: Routledge; 2009.
  15. Porter, M.L., Hernandez-Reif, M., Jessee, P. Play therapy: a review. Early Child Development and Care. 2009;179:1025-1040.
  16. Guerney, B. Filial therapy: description and rationale. Journal of Consulting Psychology. 1964;28:304-310.
  17. Fuchs, N.R. Play therapy at home. Merrill-Palmer Quarterly. 1957;3:89-95.
  18. Koplow, L. Unsmiling Faces: How Preschools Can Heal. New York: Teacher’s College Press; 2007.
  19. Bratton, S.C., Ceballos, P.L., Sheely-Moore, A.I., Meany-Walen, K., Pronchenko, Y., Jones, L.D. Head Start early mental health intervention: effects of child-centered play therapy on disruptive behaviors. International Journal of Play Therapy. 2012:Advance publication.
  20. Sutton-Smith, B. The Ambiguity of Play. Boston: Harvard University Press; 1997.
  21. Clark, C.D. In sickness and in play: Children coping with chronic illness. New Brunswick NJ: Rutgers University Press; 2003.
  22. Miller, P.J., Hoogstra, L., Mintz, J., Fung, H., Williams, K. Troubles in the garden and how they get resolved: a young child’s transformation of his favorite story. In: Nelson, C.A. ed. Minnesota Symposia on Child Psychology: Vol. 26. Memory and affect in development. Hillsdale NJ:  Erlbaum; 1993:87-114.

How to cite this article:

Clark CD. Play Therapy. In: Tremblay RE, Boivin M, Peters RDeV, eds. Smith PK, topic ed. Encyclopedia on Early Childhood Development [online]. http://www.child-encyclopedia.com/play/according-experts/play-therapy. Published June 2013. Accessed December 14, 2017.