Play Therapy is the Systematic Use of A

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"Each child is unique. A perceptive and intuitive approach is necessary tounderstand and facilitate the therapeutic process"

Susan Garofolo

Introduction

Play Therapy is the systematic use of atheoretical 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 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 thepsychodynamic view, people (especially children) will engage in play

behavior in order to work through theiranxieties. 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 bean essential component of healthy child development. Play has been directly linked

tocognitive 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.

Definition:

Play therapy is generally employed with childrenaged 3 through 11 and provides

a way for them to express their experiences and feelings through a natural, self-
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guided, self-healing process. As childrens experiences and knowledge are often

communicated through play, it becomes an important vehicle for them to know

and accept themselves and others.

"Play Therapy is based upon the fact that play is the child's natural medium of

self-expression. It is an opportunity which is given to the child to 'play out' hisfeelings and problems just as, in certain types of adult therapy, an individual 'talksout' his difficulties."

Virginia Axline

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 Frbel, in his bookThe Education of Man(1903),

emphasized the importance of symbolism in play. 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.

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. Anna Freud(1946, 1965) utilized play as a means to facilitate positive

attachment to the therapist and gain access to the childs inner life.

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 childs 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

childs 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
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himself in his own terms, exactly as he is at that moment in his own way and in his own

time.

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.

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-sixcountries (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.

Systematic Model of Success

The therapists 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 childs 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 playwith 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 people will interact with others, in order to work through internal

anxieties. In this idea, children should be encouraged to play, in order to develop 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 behaviorthrough a formal system of tests.


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complete history of the child is attained followed by a clinical assessment and

consultation with the care giver. Based on this information an appropriate treatment

modality is chosen. For instance, a directive or non-directive approach may be used,

depending on what the situation calls for. In all cases, the treatment is play-based andchild-centred, focusing on the individual needs of the child. For example:

Children dealing with loss

Children caught in the middle of divorce and children who have been abused haveall experienced various forms of loss. Through the healing medium of play, they

are given the opportunity to express their feelings and understand the events that

have taken place. This process offers children new skills to help them deal withtheir circumstances, move forward and enjoy their childhood.

Play Therapy for children with attachment related problems

Play therapy is play therapy for children and their parents. It is designed to

enhance attachment, raise self-esteem, improve trust in others and createjoyful engagement. Play therapy is based on the natural patterns of

healthy interaction between parent and child, and is personal, physical

and fun! Play therapy sessions create an active and empathic connectionbetween the child and the parents, resulting in a changed view of the self

as worthy and lovable and of relationships as positive and rewarding.

Purpose

The aim of play therapy is to decrease those behavioral and emotional difficulties

that interfere significantly with a child's normal functioning. Inherent in this aim isimproved communication and understanding between the child and his parents. Less

obvious goals include improved verbal expression, ability for self-observation, improved

impulse control, more adaptive ways of coping with anxiety and frustration, and

improved capacity to trust and to relate to others. In this type of treatment, the therapist

uses an understanding of cognitive development and of the different stages of emotional

development as well as the conflicts common to these stages when treating the child.

Play therapy is used to treat problems that are interfering with the child's normaldevelopment. Such difficulties would be extreme in degree and have been occurring for

many months without resolution. Reasons for treatment include, but are not limited to,

temper tantrums, aggressive behavior, non-medical problems with bowel or bladder

control, difficulties with sleeping or having nightmares, and experiencing worries or


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fears. This type of treatment is also used with children who have experienced sexual

or physical abuse,neglect, the loss of a family

At times, children in play therapy will also receive other types of treatment. For instance,

youngsters who are unable to control their attention, impulses, tendency to react with

violence, or who experience severe anxiety may take medication for these symptoms

while participating in play therapy. The play therapy would address the child's

psychological symptoms. Other situations of dual treatment include children

with learning disorders. These youngsters may receive play therapy to alleviate feelings

of low self-esteem, excessive worry, helplessness, and incompetency that are related to

their learning problems and academic struggles. In addition, they should receive a special

type of tutoring called cognitive remediation, which addresses the specific learning

issues.

Reduces anxiety about traumatic events in the child's life

Facilitates a child's expression of feelings

Promotes self-confidence and a sense of competence

Develops a sense of trust in self and others

Defines healthy boundaries

Creates or enhances healthy bonding in relationships Enhances creativity and playfulness

Promotes appropriate behavior

Excessive anger, worry, sadness or fear

Aggressive behavior (hurting others or self)

Separation anxiety

Excessive shyness Behavioral regression Low self esteem

Learning or other school problems

Sleep, eating or elimination problems

Preoccupation with sexual behavior

Difficulty adjusting to family changes
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Physical symptoms such as headaches or stomach aches that have no medical

cause

Parents

Physicians

Nurses

Family Lawyers

Marriage and Family Therapists

Teachers Social Workers

Psychotherapists

Child Care Workers

Children who are dealing with parental conflict, separation or divorce

Children who have been traumatized (sexual, physical or emotional abuse) Children who have been adopted or are in foster care

Children who are dealing with issues of loss, such as illness or death of a loved

one

Children who have been hospitalized

Children who have witnessed domestic violence

Children diagnosed with Attention Deficit Disorder (ADD/ADHD)

Children who have experienced serious accidents or disasters

Precautions

Play therapy addresses psychological issues and would not be used to alleviate medical or

biological problems. Children who are experiencing physical problems should see a

physician for a medical evaluation to clarify the nature of the problem and, if necessary,

receive the appropriate medical treatment. Likewise, children who experience academic

difficulties need to receive a neuropsychological or in-depth psychological evaluation in

order to clarify the presence of a biologically based learning disability. In both of these

cases, psychological problems may be present in addition to medical ailments and

learning disabilities, but they may not be the primary problem and it would not be


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sufficient to treat only the psychological issues. Alternatively, evaluations may show that

medical or biological causes are not evident, and this would be important information for

the parents and therapist to know.

Description

In play therapy, the clinician meets with the child alone for the majority of the sessions

and arranges times to meet with parents separately or with the child, depending on the

situation. The structure of the sessions is maintained in a consistent manner in order to

provide a feeling of safety and stability for the child and parents. Sessions are scheduled

for the same day and time each week and occur for the same duration. The frequency ofsessions is typically one or two times per week, and meetings with parents occur about

two times per month, with some variation. The session length will vary depending on the

environment. For example, in private settings, sessions usually last 45 to 50 minutes

while in hospitals and mental health clinics the duration is typically 30 minutes. The

number of sessions and duration of treatment varies according to treatment objectives of

the child.

During the initial meeting with parents, the therapist will want to learn as much aspossible about the nature of the child's problems. Parents will be asked for information

about the child's developmental, medical, social and school history, whether or not

previous evaluations and interventions were attempted and the nature of the results.

Background information about parents is also important since it provides the therapist

with a larger context from which to understand the child. This process of gathering

information may take one to three sessions, depending on the style of the therapist. Some

clinicians gather the important aspects of the child's history during the first meeting with

parents and will continue to ask relevant questions during subsequent meetings. Theclinician also learns important information during the initial sessions with the child.

Sessions with parents are important opportunities to keep the therapist informed about the

child's current functioning at home and at school and for the therapist to offer some

insight and guidance to parents. At times, the clinician will provide suggestions about


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parenting techniques, about alternative ways to communicate with their child, and will

also serve as a resource for information about child development. Details of child

sessions are not routinely discussed with parents. If the child's privacy is maintained, it

promotes free expression in the therapist's office and engenders a sense of trust in the

therapist. Therapists will, instead, communicate to the parents their understanding of the

child's psychological needs or conflicts.

For the purposes of explanation, treatment can be described as occurring in a series of

initial, middle and final stages. The initial phase includes evaluation of the problem and

teaching both child and parents about the process of therapy. The middle phase is the

period in which the child has become familiar with the treatment process and comfortable

with the therapist. The therapist is continuing to evaluate and learn about the child, but

has a clearer sense of the youngster's issues and has developed, with the child, a means

for the two to communicate. The final phase includes the process of ending treatment and

saying goodbye to the therapist.

During the early sessions, the therapist talks with the child about the reason the youngster

was brought in for treatment and explains that the therapist helps make children's

problems go away. Youngsters often deny experiencing any problems. It is not necessary

for them to acknowledge having any since they may be unable to do so due to normal

cognitive and emotional factors or because they are simply not experiencing any

problems. The child is informed about the nature of the sessions. Specifically, the child is

informed that he or she can say or play or do anything desired while in the office as long

as no one gets hurt, and that what is said and done in the office will be kept private unless

the child is in danger of harming himself.

Children communicate their thoughts and feelings through play more naturally than they

do through verbal communication. As the child plays, the therapist begins to recognize

themes and patterns or ways of using the materials that are important to the child. Over

time, the clinician helps the child begin to make meaning out of the play. This is

important because the play reflects issues which are important to the child and typically

relevant to their difficulties.


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When the child's symptoms have subsided for a stable period of time and when

functioning is adequate with peers and adults at home, in school, and in extracurricular

activities, the focus of treatment will shift away from problems and onto the process of

saying goodbye. This last stage is known as the termination phase of treatment and it is

reflective of the ongoing change and loss that human beings experience throughout their

lives. Since this type of therapy relies heavily on the therapist's relationship with the child

and also with parents, ending therapy will signify a change and a loss for all involved, but

for the child in particular. In keeping with the therapeutic process of communicating

thoughts and feelings, this stage is an opportunity for the child to work through how they

feel about ending therapy and about leaving the therapist. In addition to allowing for a

sense of closure, it also makes it less likely that the youngster will misconstrue the ending

of treatment as a rejection by the therapist, which would taint the larger experience oftherapy for the child. Parents also need a sense of closure and are usually encouraged to

process the treatment experience with the therapist. The therapist also appreciates the

opportunity to say goodbye to the parents and child after having become involved in their

lives in this important way, and it is often beneficial for parents and children to hear the

clinician's thoughts and feelings with regards to ending treatment.


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Preparation

It is recommended that parents explain to the child that they will be going to see a

therapist, that they discuss, if possible, the particular problem that is interfering with the

child's growth and that a therapist is going to teach both parents and child how to make

things better. As described earlier, the child may deny even obvious problems, but mainly

just needs to agree to meet the therapist and to see what therapy is like.

Aftercare

Children sometimes return to therapy for additional sessions when they experience a

setback that cannot be easily resolved.

Normal results

Normal results include the significant reduction or disappearance of the main problems

for which the child was initially seen. The child should also be functioning adequately at


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home, in school, with peers and should be able to participate in and enjoy extracurricular

activities.

Abnormal results

Sometimes play therapy does not alleviate the child's symptoms. This situation can occurif the child is extremely resistant and refuses to participate in treatment or if the child's

ways of coping are so rigidly held that it is not possible for them to learn more adaptive

ones.

Sandtray orSandbox 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 orgrief.

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

TRANSITIONAL OBJECTS & IMAGINARY PLAYMATES

A special form of imaginative play essentially reflecting the same tendency towards the

development of a metarepresentational symbol system can be found in the developmentof an imaginary playmate. Wincott (1953) identified an early stage in such a

development. From about 1 year of age many children show tendency to carry a soft cloth

about with them & often to make it to bed. Often the soft clothes may be a blanket from

the crib; it may also be a spare diaper or some other item among the childs assortment ofplay materials to which the child has become especially attached.

Wincott perception was that these clothes serve the purpose of providing a concrete

reminder in the absence of the mothers warmth & physical presence. Such tendency canalso be carried over to toys such as teddy bears. The term transitionalobject implies that

the child is gradually giving up the physical clinging to the parent but sustaining some

concrete and palpable feature of that experience.
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The function of this soft toy is not only one of the reminiscence but also one of the

possessions. That is while the child cannot possess indefinitely the warmth and closeness

of the parent, it can possess the soft cloth or soft toy. The child clings to its teddy bear,fights to retain its possession and begins to delineate a sense of self through being able to

assert this is my time.

ADAPTIVE ROLE OF IMAGINATIVE PLAY

GENERAL POSITIVE EMOTIONALITY

A number of studies, some already cited, consistently point to the fact that the use of

make-believe in the nursery school or in a variety of other settings or in the form of

imaginary playmate is associated with more positive affective states in children. Thisconsistent finding as well as the tendency for there to be an inverse relationship

between imaginative play skills on the part of the child and overt manifestations of

anger and aggression suggests the value of the use of play in a variety of therapeuticefforts with disturbed children.

ENHANCED LANGUAGE SKILLS

One feature of imaginative play is that the children verbalizing aloud increasinglycomplex situations. While some of their statements may reflect misunderstanding of adult

remarks; such as verbalization provides feedback to the child & may also evoke

correcting responses from overhearing adults or peers. Inherent nature of make-believeplay involves the development of plot sequences.

PERSISTENCE

Imaginative play, because requires, in effect, a story line, tends to provide the child with

focus & direction and then sustains concentration for longer periods. Children who have

no tendency for imaginative play often are captives of the momentary changes of objectsor toys in their environment. They seize at new things & often are embroiled in struggles

for possession with other children or flit from group to group.

DISTINGUISHING REALITY FROM FANTASY

There is at least some research evidence to suggest that children who have

experience in make-believe games are better able to discriminate real from unreal

situations & have learned to identify within their own thoughts that

metarepresentational realm described by Leslie(1987). For example in one studywith somewhat older children those who had scored higher on indications of

imaginativeness were better able to recall details of a story and then could

discriminate real instances from those that were purely fantasy.(Tucker,1975). Itmay well be that, even in those real instances of multiple personality, the affected

adults may have grown up without a clear sense of the extent to which fantasized

alternative selves are natural occurrences as part of a general dimension of make-believe or metarepresentation.


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EMPATHY

One of the consequences of solitary & group make-believe play is that the

child often learns to take on different roles. Often in the make-believe play of

two or three children, one observes brief struggles over who will be the good

guy or the bad guy, the hero or the victim. In such instances these disputesare often resolved by reversing roles either later in the game or on other days.

COOPERATION

Observational studies of children at play demonstrate that children prone to

symbolic play are likely to prove cooperation both with adults & with peers.

Indeed, the very necessity of negotiating roles and plots with other children in

order to sustain make-believe provides useful practice in this important socialskill.

TOLERATION OF DELAY

Of extreme importance for the developing child is the ability to defer immediategratification in the interest of a longer-term goal or simply to tolerate naturally

occurring delays. Make-believe play, whether it is sustained by the use of just fewprimitive toys or as it gradually becomes internalized in the form of imagery.

TAKING TURNS

The careful observation of Catherine Garvey (1974) demonstrate that one of the

important features to pretend play in children is the manner in which it is

associated with turn taking & a form of social interaction that has long term

socialization potential. Observations of children in various kinds of make-believeindicate that exigencies of the plot in any initially agreed upon make-believe

activity impose forms of self-control on child.

IMPORTANT ASPECTS OF PLAY

Content: Themes such as aggression or nurturing may appear repeatedly,

or play may involve a wide range of thematic material.

Anxiety: Play may involve a manageable-even pleasurable-level oftension, or the child may be overwhelmed by anxiety and interrupt the

play.

Imagination: Imagination may range from simple manipulation of objects

to richly elaborated fantasy play.


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Discrimination between make-believe & reality: Some children get lostin the play; others may assure the nurse its just pretend.

Narrative Lines: Actions may be repeated endlessly, may jump from one

to another, or may flow smoothly with a sense of a beginning and an

ending. Persistence: One child may be easily frustrated and another may stick to a

task such as building a tower until it is completed.

Reciprocity: Some children ignore onlooker completely; others invite thenurse to participate actively, seeking a shared experience.

Adherence to rules: Blatant cheating is seen young children & sometimes

in older children with poor self-esteem; obsessional children may becomeso preoccupied by the rules that the point of the game is obscured.

Play therapy is reserved for the use by trained & qualified therapists who use thetechnique as an interpretative method with emotionally disturbed children.

Therapeutic Play, on the other hand, is a very effective nondirective modality forhelping children deal with their own concerns & fears; at same time, it often helps the

nurse to gain insight into their needs & feelings.

Tension release can be facilitated through almost any activity. With younger ambulatory

children, large muscle activity such as the use of tricycles & wagons is especiallybeneficial. Much aggression can be safely directed into games & activities that involve

pounding & throwing. Beanbags are often thrown at target or open receptacle with

surprising vigor & hostility. A pounding board is employed with enthusiasm by youngchildren; clay & play dough are beneficial at any age.

Creative expression: Although all children derive physical, social, emotional, &cognitive benefits from engaging in art or other creative activities, childrens need for

such activities is intensified when they are hospitalized. Drawing and painting are

excellent media for expression. Children are at more ease expressing their thoughts &

feelings through art, because humans think first in images & later learn to translate theseimages into words. The child needs only to be supplied with the raw materials such as

crayons and paper. Children usually require little direction for self expression; however,

older children may be given some direction in what to paint or draw. E.g. they may beasked to draw the hospital room or draw what they like or do not like about the hospital.

Groups of children can enjoy this creative activity either working individually or with

older children, collaborating on a group project such as mural painted on a long piece of

paper.


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Although interpretation of childrens drawing requires special training, observing

changes in a series of the childs drawing over time can be helpful in assessing

psychosocial adjustment & coping. The nurse can use children drawings, stories, poetry& other products

of creative expression s a springboard for discussion of thoughts, fear and understanding

of concepts and events. A childs drawing before surgery or chemotherapy, for example,will often reveal unvoiced concerns about mutilation, body changes, & loss of self

control.

Nurses can incorporate opportunities for musical expression into routine nursing care.E.g. simple musical instruments such as bracelets with bells can be placed on infants leg

for them to shake to accompany mealtime music or dressing changes.

Dramatic play:

Dramatic play is well recognized technique for emotional release, allowing children to

reenact frightening or puzzling hospital experiences. Through use of puppets and replicas

or actual hospital equipments, children can act out the situation that is a part of their

hospital experience. Dramatic play enables children to learn about procedures and eventsthat are of concern to them or to assume the roles of the adults in the hospital

environment.Puppets are universally effective for communicating with children. Most children view

them as peers and readily communicate with them. Children will tell the puppet feelings

that they hesitate to express to adults. Puppets dresses to represent figures in the childs

environment (e.g. a physician, nurse, child, parent, therapist and member of the childsown family) are especially useful.

Play must consider medical needs, but at times a procedure can be postponed for a short

time to allow the child to complete a special activity.


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Bibliography:

www.apa.org

en.wikipedia.org

www.playtherapy.org

Webb, Nancy Boyd, ed.Play Therapy with Children in Crisis. 2nd edition. NewYork: The Guilford Press, 1999.

Lovinger, Sophie L. Child Psychotherapy: From Initial Therapeutic Contact toTermination.New Jersey: Jason Aronson, Inc., 1998

Carson Benner Verna, Mental Health Nursing- The Nurse patient journey, 2nd

edition, saunders publishers, Pp 274

Lewis Melvin, Child & Adolescent Psychiatry, 2nd edition, Pp 724-726
http://www.apa.org/http://www.playtherapy.org/http://www.apa.org/http://www.playtherapy.org/

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Play Therapy is the Systematic Use of A