Play therapy

Author: Narelle Smith, 2009

Introduction

Play therapy has been practiced in one form or another since the early 1900’s. Whilst children are regarded as the experts of play, play therapy practice has been the domain of psychologists, psychiatrists, and social workers. However, children in early childhood settings, schools, and homes, spend much of their day playing supervised and facilitated by teachers and parents. Do play therapy techniques have any application in the places inhabited by children?

This paper reviews articles on non-directive or child-centered play therapy published in the past ten years, with a focus on children aged 3 to 8 years of age. The terms ‘non-directive play therapy’ and ‘child-centred play therapy’ are interchangeable, with both modalities sharing the same features (Ryan & Courtney, 2009), the former term frequently indicating that the programme was designed in the United Kingdom and the latter the United States. For an overview of child-centered play therapy, refer Guerney, 2001.

Searches of the key terms “non-directive play”, “child-centered play”, and “filial therapy” were conducted on the PsychINFO and Journals@Ovid PsychArticles databases.

Efficacy of non-directive play therapy

Seven studies on the efficacy of non-directive play therapy were located, and Associate Professor at the University of Texas, Dee Ray either conducted or co-authored each of the studies. The results of the studies indicated that non-directive play therapy was most effective in remediating children’s emotional difficulties and improving relationships, particularly when the child was engaged in more than ten play therapy sessions.

Child-centered play therapy has been found to lower child stress which led to improved parent-child relationship (Ray & Dougherty, 2007). The effect was higher for children in the concrete operational stage (aged 7 to 8 years of age) and this was attributed to the older children developing better relational skills in line with their stage of development, whereas the preoperational children (aged 3 to 6 years) were still engaging in pretend and symbolic play appropriate for their stage of development. The study measured the effects pretest, at midpoint, and posttest, and it is interesting to note that the effects were small to moderate at midpoint for all of the measures, and the most significant gains were made between midpoint and posttest. The authors of the study do not appear to have explicitly noted this effect in the article, however it seems that this is a significant result as it indicates that non-directive play therapy has the greatest effect over a period of 19 to 23 weeks. In a study in the United Kingdom (Ray, 2008), the number of sessions offered was found to have a significant effect on children’s behaviour and parent-child stress, with 7 sessions not being adequate to influence real change, and 19 or more sessions being most beneficial. Similar results were found in a study conducted by Muro, Schottelkorb, Ray, & Smith (2006).

The effects on teacher-student relationship of intensive short-term child-centered play therapy for 30 minutes twice per week for 8 weeks, was compared to the effects of 16 sessions of child-centered play therapy offered for 30 minutes once per week over 20 weeks (Ray, Henson, Schottelkorb, 2008). The children were chosen to participate in the groups due to exhibiting emotional and externalising behavioural difficulties in the classroom. The intensive short-term play therapy group had significantly better results than the longer term therapy group, with teachers reporting less stress and more positive student behaviours.

Teachers and parents reported moderate decreases in children’s aggression in a study (Ray, Blanco, Sullivan, Holliman, 2009) of children targeted for severe aggressive behaviours at school. The children participated in 14 sessions of child-centered play therapy, and the authors noted that effects over time indicated that up to 18 sessions would have been more beneficial.

Variable effects of play therapy on children’s symptoms of attention deficit hyperactivity disorder (ADHD) were found over time (Ray, Schottelkorb, & Hsai, 2007). Children diagnosed with ADHD, participated in 30-minute weekly sessions of child-centered play therapy for 16 weeks. The children’s symptoms of emotional lability and low adaptability (moderate effect), and anxiety and withdrawal (large effect) were reduced, however there small effects in the ADHD subscales of low ability/learning disability, and aggression/conduct disorder. Teachers reported experiencing less stress with the students at the end of the study primarily due to the students exhibiting less emotional distress and withdrawal, and more positive personal characteristics.

A meta-analytical review (Bratton, Ray, Rhine, Jones, 2005) of 93 studies in the period from 1953-2000, found that play therapy has a significant effect on children’s behaviour, personality, and social adjustment. The treatment effects of the humanistic approach of non-directive play therapy were compared to the directive play therapies and although there was a discrepancy in the number of studies reviewed (73 versus 12 respectively) there were indications that non-directive play therapy may be more effective than directive play therapies. However, the largest treatment effects were in programmes that offered up to 35 sessions of play therapy, and those that involved parents learning to play with their children (filial therapy). Filial therapy had a more significant effect over a shorter period than therapy provided by a play therapist.

Parents and Teachers providing play therapy

Play therapy conducted by a therapist has been shown to change children’s behaviour over time which has had a positive effect on the child’s relationship with parents and teachers (Ray, 2008), however there is concern that the parent’s characteristics do not change placing responsibility for change directly on the child and not empowering families to solve their own difficulties (Hutton, 2004). There are several types of therapy used by practitioners working intensively with families which facilitate a change in family dynamics by supporting parents to play with their children in child-directed play.

Parent-Child Interaction Therapy (PCIT) (Eyberg, 1999) works individually with a family to instruct parents in child-directed interaction in an effort to remediate the child’s insecure attachment to his/her parent. Parents are requested to structure 5 minute play sessions, which are called “special time”, into the daily routine. During this time, parents are to avoid making commands, asking questions, and criticising the child. Parents are instructed to ignore inappropriate behaviour and stop the play only for aggressive behaviours from the child. Parents are taught non-directive play therapy skills such as reflecting what the child says, describing the child’s behaviour, and providing praise based on process.

Filial Therapy is a 10 week group programme for families, where parents are instructed in child-centered play with their children (Landreth & Bratton, 2006). The principles taught to parents include: reflective listening; acknowledging and responding to children’s stated feelings; and setting appropriate limits. The parents are requested to establish weekly 30 minute play sessions with their child, where the child leads the play, and provided the limits are adhered to, the parent is to accept the child’s decisions on what and how to play. When setting limits, parents are asked to provide the child with the opportunity to develop an internal locus of control rather than an external one.

In a pilot study (Ray, Muro, & Schumann, 2004) conducted in a primary school in the United States, the programme consisted of three components – direct play therapy services with individual children, filial therapy training for parents and teachers, and teacher education for all of the teachers at the school. Teachers found it difficult to provide a regular and consistent time for conducting play sessions with individual children, due to other demands on their programming time and classroom schedules. Despite these difficulties, most of the teachers found that the 20 minute play sessions with individual children were beneficial to the teacher-student relationship, and that they changed their teaching style to a less directive role and incorporated play into their daily lesson plans. In an unpublished doctoral thesis, Bahl (1998, cited by Herschell, Calzada, Eyberg, & O’Neill, 2002) applied the principles of PCIT to the preschool environment and supported teachers to engage in 5 minutes of daily play with children whom they were having difficulties with.

Early childhood teachers are taught how to conduct non-directive play therapy with individual children through either Kinder Training (Post, McAllister, Sheely, Hess, & Flowers, 2004) or Child-Teacher Relationship Training (Pretz Helker & Ray, 2009). Both programmes are based on filial therapy training, and teach and support teachers to run child-centered play therapy with individual children for 30 minutes once per week. Results from studies (Post et al, 2004; Pretz Helker et al, 2009), report that teachers working with at-risk children found the skills they learnt in the programme helped them to become more responsive to the children, and have more empathy and understanding of the children they were working with, and they used their new skills in the classroom.

In a qualitative study (Robinson, Landreth, & Packman, 2007), fifth grade students were taught filial therapy in a peer mentoring scheme for kindergarten children experiencing difficulties adjusting to school and exhibiting shyness, withdrawal, anxiety, depression, problems arising from unsettled family life, or inattentive behaviours. As a result of the programme, the fifth grade students perceived themselves to be more mature and responsible, and the kindergarten children felt more connected to someone at school.

Therapeutic relationship

Therapeutic relationship is the glue that binds non-directive play therapy practice. Play therapists advocate that sensitivity and responsiveness to the child, and a structured approach to therapy are the most important skills and qualities that a therapist possesses (Nalavany, Gomory, Ryan, & Lacasse, 2005). These are closely followed by therapists’ core skills of empathy, warmth, genuineness, self-awareness, and self-growth. All of the aforementioned skills were regarded as the most difficult to develop, particularly the subset of skills under the responsiveness category such as respecting a child’s autonomy, reflecting the child’s verbal and non-verbal behaviours, and setting limits. Technical knowledge of theory and interventions were rated by play therapists as the least important, but were regarded as the easiest skills to acquire. The process of developing and establishing a therapeutic relationship (Guerney, 2001; Riedel Bowers, 2009) may explain the reason that the treatment effects of play therapy do not become statistically significant until at least the eleventh session (Ray, 2008).

Cultural competence

Australia has a diverse multicultural population, and more recently there has been an increase in immigrants from strife-torn areas such as the Sudan, Afghanistan, Burma, and Iraq (Department of Immigration and Citizenship, 2009). Cultural competence in play therapy is an important issue as misunderstandings have the potential to affect the therapeutic relationship. The principles and practices of non-directive play therapy affirm the child’s rights, needs, and wants (Landreth, Ray, Bratton, 2009), however there are challenges for play therapists in working with children of different cultures particularly when working with parents who are more committed to maintaining cultural practices than the child is (O’Connor, 2005).

Some of the differences in working cross-culturally include (O’Connor, 2005): play behaviours and the value placed on play; restrictions on expressed emotion; verbal and non-verbal communication styles including eye contact; conflict resolution; achievement and goal orientation; forms of address and adult-child relationship structures; self-disclosure; family honour; cultural views of mental illness; and holistic or spiritual approaches to illness. In addition, the play therapist may make generalisations that a child has had certain experiences (for example, racism, trauma) because s/he is of a particular race. There are also subgroups within cultures and these can represent diversity in values, language, structures, social class, beliefs, and experience.

Providing the opportunity for open communication and understanding from the initial contact with the child and his/her family is essential and will require informing the family and child about the purpose and process of non-directive play therapy (O’Connor, 2005). The therapist needs to: be aware of all of the issues of working cross-culturally; be aware of one’s own assumptions and stereotypes, and gain further knowledge of the culture (a good place to start is to ask the family and child); and develop skills in accommodating cultural difference (O’Connor, 2005). The materials and toys used in the play therapy room should reflect a diversity of cultures, ages, genders, abilities, as well as offering some gender-neutral items (O’Connor, 2005).

Play Materials

The type and range of play materials offered to children in play therapy is an issue which elicits a wide range of responses. For the purposes of non-directive play therapy, the materials and toys offered to children should emphasise the social and emotional aspects of play. Cognitive materials such as blocks, puzzles, mechanical toys, and construction sets do not facilitate creative expression and release of emotion (Landreth et al, 2009).

Some play therapists offer children realistic aggressive release toys such as rubber knives, plastic guns, handcuffs, and bop bags. This approach has been criticised by some in the play therapy field as inciting and condoning aggression and having the undesirable effect of increasing children’s aggression (Drewes, 2008). Children who wish to express their aggression during play therapy sessions will find symbolic and metaphoric ways of doing so with clay or craft materials without the need for realistic toys (Drewes, 2008).

Life is messy for some children, and they need to be able to express those messy aspects of their lives (Jennings, 2005). Some play therapists seek to contain their client’s expression through limiting access to certain materials (Jennings, 2005). Paint and clay is considered too loose for those children who have difficulty with control (for example, attention deficit hyperactivity disorder). Children who are withdrawn or anxious prefer materials that are neat and easy to control such as pencils. Thus, offering an anxious child only messy materials would create more tension within the child. Children can be redirected to safe alternatives if the play is becoming unsafe or destructive (Jennings, 2005).

For some children the world is not a safe place. The room should have an area where a child can go to feel safe and nurtured, and the freedom to regress to earlier stages of development if s/he needs to (Jennings, 2005). A child’s earliest experience of play is sensory and physical. Some of the items may include cushions, a cardboard box for the child to sit in, blankets, a feeding bottle, and cuddly toys. Children who have not had the opportunity to explore texture may benefit from having access to textiles, musical instruments, colourful and patterned items, baby toys which they can mouth and suck, and natural objects (such as seeds, cones, feathers, stones, cork, wood, shells, fleece) (Jennings, 2005). The physical aspect of a child’s play could be catered for by providing a gym ball, instrumental music, and colourful scarves for dancing.

Implications for practice

In their work, teachers see a lot of children who experience psychosocial problems at home, early childhood settings, school, and in the community, particularly if they are working in disadvantaged communities. Although psychosocial problems affect children’s current health and wellbeing and pose a risk for further problems in the future, few receive mental health or counselling interventions. Non-directive play therapy techniques are available to parents and teachers based on filial therapy programmes (Landreth & Bratton, 2006; Post et al, 2004) and have been shown to be the most effective methods of improving parent-child and teacher-student relationships. Teachers working with children aged 0 to 8 years may be interested in seeking training in non-directive play therapy techniques for themselves, the service they are working in, and the parents they are working with, to offer children greater opportunities to express their emotions through play.

The discussion of the therapeutic relationship in non-directive play therapy supports principles already in place in early childhood training and services as detailed in the Early Years Learning Framework (Commonwealth of Australia, 2009). However, there is an increasing emphasis in early childhood services on children learning concepts of literacy and numeracy as part of their transition to school. However, children who experience challenges in their social and emotional development need to have those needs met before they are fully able to attend to formal learning. The methods used by play therapists to establish a therapeutic relationship with a child can be utilised by teachers to establish themselves as a secure base for children which then allows children to test new ways of being and relating through play. It must be recognised that it can take some time for children to process their past and/or continuing experiences of neglect, abuse, or dysfunction.

Possibly the most difficult concept for adults to grasp and put into practice is to allow the child to lead the play. One of the most prevalent concepts in early childhood undergraduate programmes is the scaffolding of children’s play and learning. However, non-directive play therapy is grounded in psychotherapeutic practice which allows the child to set the agenda and the adult reflects and supports the child’s activities within stated limits. The moment that the adult makes a suggestion or redirects the child’s intentions and motivations, the activity becomes directed and no longer is a reflection of the child’s issues as determined by the child.

Cultural issues are also covered in the Early Years Learning Framework and early childhood settings endeavour to respect and honour the cultures of the children attending the service. This is also reflected in the range of materials available for play. The play materials offered in non-directive play therapy encourage emotional, social, and symbolic play and allow the child to play out scenarios, and to regress or advance as necessary. Early childhood settings already have resources suitable for non-directive play and areas for home play, quiet-time, sand play, music, sensory play, etc. The challenge for teachers would be the practicalities of scheduling (how, where, when) non-directive play time in the playroom or classroom, particularly regarding issues of confidentiality.

Conclusion

The articles selected for review covered: the efficacy of non-directive play therapy; the therapeutic benefits for children when parents and teachers learn non-directive play therapy techniques; aspects of the therapeutic relationship in non-directive play therapy; cultural competence; and play materials used in non-directive play therapy. The articles selected provide further understanding of non-directive play therapy. The implications for practice with children aged 0 to 8 years were discussed with a focus on integrating some play therapy techniques into teachers’ work with children and families. There was no discussion of group play therapy in this paper, and this would be another topic to research for further implications of practice in early childhood settings.

REFERENCES

Bratton, S. C.; Ray, D.; Rhine, T.; & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytical review of treatment outcomes. Professional Psychology: Research and Practice, 36/4, pp376-390.

Commonwealth of Australia. (2009). Belonging, being and becoming: The early years learning framework for Australia. Australian Government Department of Education, Employment and Workplace Relations for the Council of Australian Governments.

Department of Immigration and Citizenship. (2009). Settler Arrival Data: Selected Countries of Birth by Migration Stream for the Financial Year 2007-08. Australian Government website: http://www.immi.gov.au/media/statistics/statistical-info/oad/settlers/setdatb.htm Accessed 10/9/09.

Dougherty, J. & Ray, D. (2007). Differential impact of play therapy on developmental levels of children. International Journal of Play Therapy, 16/1, pp2-19.

Drewes, A. (2008). Bobo revisited: What the research says. International Journal of Play Therapy, 17/1, pp52-65.

Eyberg, S. (1999). Parent-child interaction therapy: Treatment manual. University of Florida.

Guerney, L. (2001). Child-centered play therapy. International Journal of Play Therapy, 10/2, pp13-31.

Herschell, A. D.; Calzada, E. J.; Eyberg, S. M.; & McNeil, C. B. (2002). Parent-child interaction therapy: New directions in research. Cognitive and Behavioral Practice, 9, pp9-16.

Hutton, D. (2004). Filial therapy: Shifting the balance. Clinical Child Psychology & Psychiatry, 9/2, pp261-270.

Jennings, S. (2005). Creative play with children at risk. Brackley, UK: Speechmark Publishing Ltd. Landreth & Bratton (2006). Child parent relationship therapy (CPRT): A 10-session filial therapy model. NY: Taylor & Francis

Landreth, G. L.; Ray, D. C.; & Bratton, S. C. (2009). Play therapy in elementary schools. Psychology in the Schools, 46/3, pp281- 289.

Muro, J.; Schottelkorb, A.; Ray, D.; & Smith, M. R. (2006). Quantitative analysis of long-term child-centered play therapy. International Journal of Play Therapy, 15(2), pp. 35-58

Nalavany, B. A.; Gomory, T.; Ryan, S. D.; & Lacasse, J. R. (2005). Mapping the characteristics of a ‘good’ play therapist. International Journal of Play Therapy, 14/1, pp27-50.

O’Connor, K. (2005). Addressing diversity issues in play therapy. Professional Psychology: Research and Practice, 36/5, pp566-573.

Post, P.; McAllister, M.; Sheely, A.; Hess, B.; & Flowers, C. (2004). Child-centered kinder training for teachers of pre-school children deemed at-risk. International Journal of Play Therapy, 13/2, pp. 53-74.

Ray, D.; Muro, J.; & Schumann, B. (2004). Implementing play therapy in the schools: Lessons learned. International Journal of Play Therapy, 13/1, pp79-100.

Ray, D. C.; Schottelkorb, A.; Tsai, M. H. (2007). Play therapy with children exhibiting symptoms of attention deficit hyperactivity disorder. International Journal of Play Therapy, 16/2, pp79-100.

Ray, D. C. (2008). Impact of play therapy on parent_child relationship stress at a mental health training setting. British Journal of Guidance & Counselling, 36/2, pp165-187.

Ray, D. C.; Henson, R. K.; & Schottelkorb, A. A. (2008). Effect of short- and long-term play therapy services on teacher-child relationship stress. Psychology in the Schools, 45/10, pp994-1009.

Ray, D. C.; Blanco, P. J.; Sullivan, J. M.; & Holliman, R. (2009). An exploratory study of child-centered play therapy with aggressive children. International Journal of Play Therapy, 18/3, pp95-111.

Riedel Bowers, N. (2009). A naturalistic study of the early relationship development process of nondirective play therapy. International Journal of Play Therapy, 18/3, pp176–189.

Robinson, J.; Landreth, G.; & Packman, J. (2007). Fifth-grade students as emotional helpers with kindergartners: Using play therapy procedures and skills. International Journal of Play Therapy, 16/1, pp20-35.

Ryan, V. & Courtney, A. (2009). Therapists’ use of congruence in non-directive play therapy and filial therapy. International Journal of Play Therapy, 18/2, pp114–128.

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About Narelle Smith

Child & Family Worker

4 Responses to “Play therapy”

  1. It’s the child-led aspect of all play I think many well meaning and conscientious parents struggle with – the pressures to constantly teach are pretty strong in the middle-class western-world at the moment. I found it interesting that cognitive toys are NOT the most helpful…
    Great post, Narelle. 🙂

    • Thanks Karyn

      Cognitive toys are not helpful for play therapy as the child’s focus is not immediately linked into their emotional world, they can distance themselves by thinking instead of feeling. Of course, they can still do that with any toy if their defences are strong.

      I would recommend wooden blocks, cars, construction for every child’s home, because it’s their home and thinking should be part of their experience, especially for those mechanically minded children. However, some parents focus on cognitive toys thinking it will give their children an academic edge. Parents of boys may also deny their boys of emotional expression by not allowing them to play with dolls, prams, doll houses, dress-ups, etc.

      As you know, many cognitive toys on the market are not open-ended. Resources that support emotional and creative expression are open-ended and have unlimited play value.

      Thanks for your comment.

  2. It’s that emotional distancing and focus on the academic edge, which are of concern to me even for children who are generally well parented. I think people forget that marketers are there to sell products not acutally help us in any way!

    We have a couple of extended family members who can’t quite get their heads around the fact that our kids are able to play with, what they think of as junk, for hours. Their own house looks like a toy-store, yet their kids are constantly bored. Everything is close-ended.

    I can see that the kind of free-play activity you write about here would be hugely beneficial to children who were struggling emotionally in some way. Again I come back to Steiner – the shells, wooden blocks, expressionless dolls and pieces of fabric the children use each day are just great.

    • I tend towards natural materials, soft dolls, play scarves etc.

      I recently attended a five-day workshop on child centered play therapy. Each participant had to bring along some toys for the role play sessions. One participant brought along some cheap, plastic, and brightly coloured (iridescent) beaded necklaces and rings and bracelets. Not something that I would have bought at all. They had tremendous play value, and I would definitely include them in a play therapy environment if I were setting one up. Surprised me!

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