Play Therapy

Play therapy can be defined as a cluster of theory-driven treatment modalities used to establish an interpersonal process wherein trained play therapists help clients prevent or resolve psychosocial difficulties, facilitate optimal development, and reestablish the ability to engage in adaptive play behavior. For more than half a century, it has been the most prevalent child mental health therapy in the United States. While play therapy is traditionally implemented with children ages 3 to 12, many play therapy techniques (e.g., tray construction with miniature objects) are also used as therapeutic interventions with teenagers and adults. There is no single play therapy approach; instead, there are several prominent theoretical schools of thought and numerous play therapy techniques. Though play therapy is most often used as an individual therapy, it is also implemented via group play therapy and family play therapy. Often, professional therapists conduct the play therapy, but parents and other care providers can also be taught to perform play therapy. The following play therapy overview includes discussion of the definition of play, the therapeutic use of play, play therapy history, play therapy outcomes, and play therapists’ qualifications.

Definition of Play

Although there are multiple definitions of play, it is generally considered to be an activity that is intrinsically motivated, freely chosen, nonliteral, actively engaged in, and pleasurable. In contrast, children with psychological disturbances often exhibit play that is compulsive, impulsive, irrational, and devoid of pleasure. Play has been called the singular central activity of childhood. It occurs in virtually all cultures and circumstances.

Given the prevalence of children’s play, it is often seen as integral in human development. Jean Piaget described play as “a process that allows children to mentally digest experiences and situations.” Play is fundamental in children’s development of expressive language, communication skills, emotional development, social skills, decision-making skills, and cognitive development. The functions of play have been classified into four categories: biological (learn basic skills, relax and release excess energy, kinesthetic stimulation and exercise), intrapersonal (mastery of situations, mastery of conflicts), interpersonal (develop social skills, separation-individuation), and sociocultural (imitate desired roles).

Therapeutic Use of Play

Play has been described as a form of self-therapy for children. Through play, children have the opportunity to work through conflicts, relieve anxieties, and make sense of their worlds. Consequently, play functions well as a facilitative force in children’s therapy. A goal of play therapy is to help disturbed children work through their issues, so they can experience pleasurable play again.

Researchers have identified specific qualities of play behavior that facilitate the therapeutic process (i.e., communication, relationship enhancement, creative thinking, overcoming resistance, catharsis, abreaction, role-play, fantasy/visualization, metaphoric teaching, attachment formation, positive emotion, mastering developmental fears, game play) and the accompanying beneficial outcomes (working alliance, understanding, self-esteem, innovative solutions to problems, emotional release, adjustment to trauma, practice/acquiring new behaviors, empathy, fantasy comprehension, insight, attachment, self-actualization, self-esteem, growth and development, socialization).

Play Therapy History

Documentation of psychotherapy with children reaches to the early 1900s. Early records describe Sigmund Freud’s work with Little Hans’s father in the attempt to alleviate Hans’s phobic reaction. Play was first directly applied to children’s therapy in 1919 through Hermine Hug-Hellmuth’s utilization of play for child assessment and treatment and analysis. Anna Freud began using play in 1928 as a way of building therapeutic alliances and enticing children into the process of analysis, and in 1932 Melanie Klein proposed using play as a substitute for children’s verbalizations. These early forms of psychoanalytic play therapy were focused on the attainment of insight through interpretation of the child’s play.

A variety of play therapy theories and techniques were developed and refined between the 1930s and 1950s, including psychoanalytic and goal-oriented structured therapy in the late 1930s; David Levy’s 1938 release therapy for trauma treatment; Joseph Solomon’s 1938 active play therapy for impulsive acting-out children; Gove Hambridge’s 1955 directed abreaction reenactment procedures; and the relationship therapies of Jessie Taft (1933), Frederick Allen (1942), and Clark Moustakas (1959). Carl Rogers’s client-centered approach, developed in the 1940s, was modified into child-centered play therapy by Virginia Axline in 1947. This nondirective form of play therapy has come to be referred to as traditional play therapy.

In the late 1960s, Ann Jernberg developed an approach focused on recreating and fostering healthy parent-child attachments called theraplay. Bernard Guerney’s 1964filial therapy was designed to involve parents in the play therapy process. Constance Hanf developed a two-stage model in the early 1970s that became more well known in the 1990s as parent-child interaction therapy (PCIT). Viola Brody’s 1978 developmental play therapy emphasizes the use of physical contact and semistructured sessions. Kevin O’Conner developed an approach that integrates a cognitive developmental framework and an ecosystemic perspective into ecosystemic play therapy.

The significant contributors throughout the history of play therapy have produced an abundance of approaches, including psychoanalytic, client-centered/humanistic/nondirective/traditional, behavioral, cognitive-behavioral, family, developmental, Adlerian, gestalt, reality, time-limited, theraplay, fair play, ecosytemic, and dynamic.

Play Therapy Outcomes

It is important to demonstrate the effectiveness of play therapy to justify practice, provide court testimony, and receive third-party insurance payments. The widespread use of play therapy dictates that its effectiveness ought to be clearly established. However, there is ongoing controversy among researchers regarding how well play therapy works. Play therapy critics have asserted that there is not an adequate research base to demonstrate the efficacy of play therapy, largely due to small sample sizes, case studies, and anecdotal reports. In particular, critics cite too few well-defined and well-executed empirical studies evaluating the efficacy of play therapy.

Part of the efficacy controversy seems to stem from epistemological differences between positivist, empirical traditions and naturalistic, qualitative paradigms. Empirically based clinical studies have a well-established reputation in the field as hard research, but qualitative traditions are still suspect by some researchers’ values.

Others state that case studies can lend credibility to the effectiveness of play therapy. Sue Bratton and Dee Ray reviewed over 100 case studies that document effective results with play therapy treating children with a wide variety of therapeutic concerns. They also reviewed 82 experimental studies of play therapy and concluded that play therapy demonstrated effective results in treating self-concept, behavioral change, cognitive ability, social skills, and anxiety.

A meta-analysis of 94 play therapy efficacy studies by Ray and her colleagues found that play therapy is a helpful intervention in child psychotherapy. The authors summarized that play therapy worked in a variety of settings across modalities, age, and gender with clinical and nonclinical populations, and across various theoretical schools of thought. Not only did this research report the positive effect of play therapy, the overall effect size was in the large effect range.

This meta-analysis confirmed two findings previously reported by Michael LeBlanc and Martin Ritchie: Parental involvement significantly improves the effectiveness of play therapy, and the effectives of play therapy increases for up to 35 to 45 sessions. (At 45 sessions, effectiveness levels started to decline.) A 2005 meta-analysis of 93 controlled play therapy outcome studies also supported LeBlanc and Ritchie’s research that maximum effect size was reached between 35 and 40 sessions and that involving the parents and using humanistic treatments resulted in more positive effects. Through a meta-analysis of 42 play therapy outcome studies, LeBlanc and Ritchie found maximum effect sizes between 30 and 35 sessions. While most research indicates greater gains from a larger number of sessions, significant positive results have been reported for as few as 12 to 15 child-centered play therapy sessions.

Finally, Ray and her colleagues concluded that through the use of further experimental studies with specific measures and clear definitions, play therapy research has adequately addressed the critics’ concerns regarding the efficacy of play therapy, small sample sizes, case studies, and anecdotal reports. They recommended that play therapy researchers (a) produce more research on the immediate and long-term effects of play therapy, (b) compare play therapy to other child psychotherapies, (c) explore the optimal number of sessions, (d) examine the most appropriate issues addressed by play therapy, (e) determine the most accurate outcome measures, and (f) utilize specific play therapy protocols so replication is more easily achieved.

Play Therapy Training and Qualifications

Before providing play therapy, it is important to be qualified to do so. Ethical guidelines require that professional counselors provide competent services and not advertise or practice beyond their levels of training. Certainly there are qualified professionals who provide play therapy services who are not registered play therapists. At the same time, especially if play therapy is a major part of one’s practice, it is wise to seek the highest level of training possible. The Association for Play Therapy (APT) is the primary organization that provides professional standards for play therapists. The APT is also referred to as the International Association for Play Therapy (IAPT) and is responsible for publishing the International Journal of Play Therapy. In 1982, Charles Schaefer and Kevin O’Connor cofounded APT to provide a forum for professionals interested in helping children through play therapy. Professionals interested in learning more about becoming registered play therapists (RPTs) or a registered play therapist supervisor (RPT-S) can find the necessary information at APT’s Web site.

Summary

The play therapy field includes a group of interventions with a rich history and a continually developing vision of how to best treat children’s mental health needs. From the helping field’s first pioneers to today’s professionals, play has been employed as a natural tool to assist children in working through a wide range of issues. Because play is an activity with which most adults are familiar from their own childhood, some helping professionals without play therapy training erroneously assume that they can use play to effectively help children. Though playing with a child may be enjoyable, it may not be therapeutic. Thus, the more training and supervision play therapy professionals receive, the greater the likelihood of treatment success. As with all psychological interventions, play therapy can benefit from more rigorous research. This not withstanding, there are certainly a number of noteworthy studies that point to the helpfulness of play therapy.

With its long history and promising outcomes, play therapy will likely continue to evolve and be used as a primary intervention with children for decades to come.

References:

Axline, V. M. (1969). Play therapy. New York: Ballantine Books.
Boik, B. L., & Goodwin, E. A. (2000). Sandplay therapy: A step-by-step manual for psychotherapists of diverse orientations. New York: Norton.
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36, 376-390.
Carmichael, K. D. (2006). Play therapy: An introduction. Glenview, IL: Prentice Hall.
Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent-child interaction therapy. New York: Plenum Press.
Hughes, F. P. (1999). Children, play, and development (3rd ed.). Boston: Allyn & Bacon.
Landreth, G. L. (2002). Play therapy: The art of the relationship. New York: Brunner-Routledge.
Leblanc, M., & Ritchie, M. (2001). A meta-analysis of play therapy outcomes. Counseling Psychology Quarterly, 14, 149-163.
Muro, J., Ray, D., Schottelkorb, A., Smith, M. R., & Blanco, P. J. (2007). Quantitative analysis of long-term child-centered play therapy. International Journal of Play Therapy, 15, 35-58.
Pedro-Carroll, J., & Reddy, L. (2005). A preventive play intervention to foster children’s resilience in the aftermath of divorce. In L. Reddy, T. Files-Hall, & C. Schaefer (Eds.), Empirically based play interventions for children (pp. 51-75). Washington, DC: American Psychological Association.
Ray, D., Bratton, S., Rhine, T., & Jones, L. (2001). The effectiveness of play therapy: Responding to the critics. International Journal of Play Therapy, 10, 85-108.
Schaefer, C. E. (2003). Play therapy with adults. Hoboken, NJ: Wiley.