Play Therapy is the Systematic Use of A
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Transcript of 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/