Play is the child’s natural medium for self experience.” - Virginia Axline (1989), founder of child-centred play therapy
Play therapy is a powerful means of joining with the innate, creative, non-verbal capacities of children in order to engage and work therapeutically with them. It is a developmentally appropriate, evidence-based method of counselling younger clients. In play therapy, children can play out, literally and/or metaphorically, their inner and real life experiences in a way that builds insight and capacity. Play therapy allows children to express, regulate, communicate, practice and master new skills as well as their emotional responses.
Sensitivity to the culture of childhood
We are aware of the need to be sensitive and to adapt counselling methods and means of engagement with those who are culturally different from us. It can be argued that children are ‘culturally different’ from adults (Mullen, 2007). They have a different time orientation (reflected in the all too familiar travelling plea, “Are we there yet?”), speak language differently (“Birdy go bye bye”) and can hold different value sets due to their developmental stage (“Why do the adults just sit and talk at picnics when we can play chasings?”).
As adults we can often forget how different a child’s lived experience (and way of communicating) is from ours. This has profound implications for how therapists choose to engage, assess and work with young clients. To maximise sensitivity to and respect for children, we should allow them a means to express themselves in a language that is familiar to them. When children feel comfortable, relaxed and safe enough to express their concerns, abilities and interests, then we are allowed to see and hear some of their real experiences.
What is play therapy?
Play has long been recognised by developmental psychologists, such as Piaget and Vygotsky, as a critical pathway to healthy physical, cognitive and psychosocial development (Sigelman & Rider, 2012). Therapeutic play builds on the developmental appropriateness of play and offers a structured approach to intervention for children’s problems.
Landreth (2012) defines play therapy as:
… a dynamic interpersonal relationship between a child (or person of any age) and a therapist…who provides selected play materials and facilitates the development of a safe relationship for the child ... to fully express and explore self (feelings, thoughts, experiences, and behaviours) through play, the child's natural medium of communication, for optimal growth and development. (p. 11)
There are many approaches to using play in therapy. The psychoanalytic approach focuses on the child’s unconscious (e.g., Lanyado & Horne 2009; Blake, 2008; Poynton, 2012; Conolly & King, 2015), while gestalt and release methods focus on expression and integration (e.g., Oaklander, 1988; Pearson & Nolan, 1995; Pearson, 1998). CBT and solution focused methods of play therapy are more short-term, structured and goal directed (e.g., Schaefer & Drewes, 2009; Knell & Dasari, 2009; Lowenstein, 2013).
Child-centred or non-directive play therapy was originally developed by Virginia Axline in the mid-20th century. She was strongly influenced by the person-centred approach of Carl Rogers (1961). Axline’s principles of play therapy continue to be foundational for much contemporary play therapy practice and aim to maximise the child’s exploration of concerns through a trusted relationship and creative play. The eight basic principles that underline child-centred play therapy can be summarised as forming and maintaining a warm, caring, accepting and permissive relationship with the child that allows him or her to express any emotion (but not any behaviour) and gain insight. It respects children’s ability to solve problems and make decisions. The therapist does not lead, guide or shape the child’s expression or behaviour, hurry the therapeutic process or set limits until required (Axline, 1989).
The advantages of child-centred play therapy include children having choice about what, how, when and whether to express their worries and wishes. It is a respectful method optimally suited to 3-10 year olds.
Integrative approaches to play therapy
Contemporary integrative approaches recognise the need for different play therapy methods depending on presenting issue, child factors and stage of therapy. The Play Therapy Dimensions Model (Yasenik & Gardner, 2012) for instance, describes four discrete methods of utilising therapeutic play. These four methods emerge from intersecting two dimensions – consciousness of child and directedness of therapist. The non-intrusive responding method reflects the unconscious and non-directive play therapy approach suited to early stage work, traumatised and self-directed children. Conversely, the open discussion and exploration methods represent conscious and directed work and are argued to be suited to specific skill development and older children. The co-facilitation method, reflecting unconscious and directed work, is recommended for children with low play capacity and to interrupt repetitive play themes and deepen the play. Active utilisation methods represent conscious and non-directed play activity to support children with strong play capacities or coping abilities (Yasenik & Gardner, 2012).
The stage-based model proposed by Geldard and Geldard (2008) offers another integrative approach to play therapy involving a different therapeutic focus at different therapy stages. This model suggests initially using a client-centred approach to join with the child, followed by gestalt and narrative methods to gain awareness, experience and to release emotion and start to develop a new self-awareness. In the final stages, cognitive behaviour and behaviour therapies are suggested to challenge unhelpful thinking and practise new behaviours.
Recommended toys and materials
Play therapists use a range of toys that are carefully selected to allow children to express and explore their experiences. Sturdy, easy to clean toys that represent expressive play themes such as nurturing, real life, aggression and fantasy, and that are appropriate from a gender and cultural perspective, are recommended (Landreth, 2012).
Suggested toys for the play therapy room include dolls house with family and baby dolls, hand and finger puppets (animal and human), art supplies (pencils, paints, craft materials, modelling clay), transportation vehicles, plastic animals, toy soldiers and action figures, Lego or construction blocks, play cookware, play handcuffs, foam sword, rubber knife, play doctor’s kit, play money, toy construction tools, dress up clothes or fabrics, musical instruments and balls (Cochran, Nordling & Cochran, 2010; Ray, 2011). Order and consistency of set up of materials is recommended to promote safety and regularity for the child.
Evidence for the effectiveness of play therapy
Meta-analytic reviews of over 100 play therapy outcome studies (Bratton, Ray, Rhine & Jones, 2005; Leblanc & Ritchie, 2001) found that the overall treatment effect of play therapy ranges from moderate to high positive effects. The review by Bratton and colleagues was conducted on 93 research studies, finding a large treatment effect size of .8 and indicating that play therapy was effective across a variety of presenting issues. Non-directive approaches were found to yield better outcomes than therapist-directed play approaches. Additionally, positive treatment effects were found to be greatest when there was a parent actively involved in the child's treatment.
There is emerging neurobiological evidence that therapies that allow for non-verbal enjoyment, safety and attunement (such as play therapy) can offer traumatised children a more sensitive and appropriate therapy (Gaskill & Perry, 2014). These authors posit that children affected by trauma have underdeveloped cortical modulation networks affecting impulse control, higher order thinking and planning, as well as over sensitised regulatory neural networks, and are very resistant to traditional talk-based interventions.
Reviews of research have indicated positive effects of play therapy for children with a range of presenting issues including behavioural disorders, psychosocial issues, physical and learning disabilities, and speech and language problems. Additionally, children experiencing anxiety, abuse, domestic violence, depression, grief and loss, and posttraumatic stress have demonstrated benefits from play therapy (Baggerly, Ray & Bratton, 2010; Landreth et al., 2010).
Suitability for play therapy
While there is substantial and growing evidence for the efficacy of play therapy, play therapy may not be suitable or necessarily the best form of assessment and intervention for all children or presenting issues. A thorough parent or carer assessment prior to working with children is essential to determine how best to understand and work with a child, if at all. In some families where children are displaying challenging affect or behaviour, the optimal intervention can involve working primarily with parents. When children are deemed to be at risk of harm, safety planning and relevant child protection notification to the appropriate authority takes precedence. Where children are showing symptoms of obsessive compulsive disorder, the research literature suggests behavioural interventions should be used in the first instance.
Feedback from children
Feedback from children who have experienced play therapy sessions attests to its popularity and usefulness. In qualitative studies, children report valuing the counsellor’s empathy and acceptance, allowance of choice of play methods, having fun, developing self-awareness and the relationship to the therapist (Axline, 1950; Green, 2010).
Children report valuing having their own concerns and experiences responded to (as distinct from those of referring adults) as this child reflected, “She (the counsellor) understands us. She understands children... You feel happy because you are being understood and not ignored” (Green, 2010, p. 257).
One boy described how play therapy had helped him with his terrible sadness and loss following the death of his grandmother. “When my grandma died, I went over to the doll house and kind of did what I needed to do for my grandma” (Green, 2010, p. 260).
While the purpose of counselling work is serious, the counselling process in play therapy can be fun and light-hearted. While not all play experiences are necessarily fun for children, the capacity for them to be so at times lightens the weight of sharing challenging experiences. As one boy reported, “I like coming to counselling a lot ’cause it’s fun” (Green, 2010, p. 258).
Play therapy is a creative counselling method that optimises children’s abilities to express, explore and resolve troubling thoughts, feelings, experiences, worries and wishes in developmentally appropriate ways. It is a method that respects the culture of childhood and has a strong and diverse theory base that informs practice. There is a substantial body of evidence to show that it works. Play therapy is gaining international recognition as an effective psychological intervention. Indeed, in the UK, USA, Canada and South Africa, play therapy is a registered, accredited and protected discipline of health practice.
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