International Journal of Play Therapy, (4) 1, pp. 51-59 Copyright 1995, APT, Inc.

PLAY THERAPY WITH HOSPITALIZED

CHILDREN
Judy R. Webb
Sam Houston State University
ABSTRACT: This article provides a limited review of the literature pertaining
to the use of play therapy in the hospital setting. Specific attention is given to
situations involving the terminally ill child. Axline's original principles of
play therapy are examined and applied to the play therapist's role in
interactions with the hospitalized and/or terminally ill child.
INTRODUCTION
His head is bald. His legs are skinny and often bruised, but
more often covered with jeans and cowboy boots. His smile is full of
mischief. However, it is the eyes that catch one's attention - eyes that
reflect excitement, disappointment, curiosity, pain, questions, and
wisdom. Those eyes speak, and they speak loudly. They also take in so
much, including the reactions of the adults in his world. During play he
does not talk much, but he says volumes with his play and with his
eyes. He is just one child, but in many ways he is typical of so many
hospitalized children, some of whom experience hospitalization as a
brief interlude in an otherwise healthy life, others who come to see
weeks in the hospital as normal routine. A child in either category can
benefit from play therapy.
Hospitalized Children
A limited review of the literature reveals several approaches by
which play is used in the hospital setting. D'Antonio (1984) described
therapeutic play as it could be approached by nurses working with
young hospitalized children. It was proposed that, through
understanding play, nurses could both ascertain the effects that
hospitalization and illness had on the children and also enhance
Judy R. Webb, MA, 101 West Houston, Dayton, TX 77535
52 Webb
children's emotional growth. Cases were cited in which children's
perceptions of their hospital experiences were directly assessed through
play. Play opportunities were also seen as an opportunity for a child to
exert mastery and relieve stress, while in an environment where he or
she was likely to feel helpless and quite anxious. Through play,
especially with medical equipment, the child could establish a sense of
control. It was concluded that use of therapeutic play could make a
difference as to whether the hospitalization was a positive or negative
experience for the child.
D'Antonio (1984) noted that play in the hospital setting was
restricted both by the child's physical limitations and by the
environment. Webb (1991) also noted differences in play therapy
conducted with hospitalized children, but of a somewhat different
nature. She focused on differences such as greater informality, more
flexibility, lack of time boundaries, and interruptions such as treatment.
She emphasized the needs of hospitalized children for play, in that "play
is the reservoir and wellspring of a child's fundamental capacity to
assimilate and adapt creatively to life experiences" (p. 296). The
experience of being hospitalized, with its inherent anxiety, appears to
create a situation in which the child has a heightened need to
communicate through play. Webb even cited one case in which the
therapist played things out as per the instructions of a quadriplegic
child, thereby providing him with a passive play experience that
seemed to help him express himself.
Child Life programs have been developed as a specific
approach to using play with hospitalized children, with the intent of
both limiting anxiety and promoting growth (Froehlich, 1984). Such
programs generally emphasize medical play, providing common
medical supplies and equipment. "In an environment in which things
are threatening and nearly everything is out of the child's control,
helping children achieve and maintain a sense of comfort, safety, and
well-being is a major challenge to the child life specialist" (Webb, 1991,
p. 296). Sessions are generally somewhat structured and are most often
conducted in groups because this both encourages socialization and
allows children to benefit vicariously from the play of other patients
(Adams, 1976). Benefits of this play include helping the child separate
reality from fantasy, rectifying misconceptions, addressing personal
Hospitalized Children 53
concerns, and increasing cognitive learning about procedures (Doak &
Wallace, 1975).
While the benefits of play therapy for hospitalized children
seem apparent, and numerous reports exist of case studies, there appear
to be few outcome studies based on experimental designs used to assess
treatment effect. One of these was reported by Clatworthy (1981). In a
pretest-posttest design, 114 children admitted to general pediatric units
at two locations were assessed for level of anxiety upon admission and
again upon discharge or on the seventh day of their stay. Children in
the experimental group participated in play therapy sessions 30 minutes
per day. Significant differences were found between the experimental
group and the control group in that the level of anxiety did not increase
significantly in children who had received play therapy during their
hospital stay, but anxiety level did increase significantly in the control
group. It would appear that as little as 30 minutes per day in a
therapeutic play setting kept children's anxiety from escalating.
Another study using a pretest-posttest design was conducted by
Rae, Worchel, Upchurch, Sanner, and Daniel (1989) at Scott and White
Memorial Hospital in Temple, Texas. Forty-six children were randomly
assigned to four experimental groups (verbal support, diversionary
play, therapeutic play, and control). While differences between groups
were not apparent in either parents' or nurses' reports of children's
anxiety, significant differences were found in children's self-reports.
Children in the therapeutic play group reported a significant reduction
in fear; this difference was not found in any of the other groups. It is
interesting to note that these children received only two 30-minute play
sessions.
Abused children. While there are numerous global
applications of play therapy in the hospital setting, there is also reason
to believe that children with specific needs, beyond the general anxiety
produced by hospitalization, will benefit from therapeutic play. One
population of interest is children who have been abused and/or
neglected. Chan and Leff (1988) addressed the contribution of play to
the acute pediatric care of the abused child. Children admitted for
acute care following abuse display characteristics which make play
therapy an ideal approach for meeting their needs. Many of these
young patients express themselves much better through actions than
through words, and provision of typical play therapy materials in a safe
54 Webb
environment with an empathic adult allows them to "learn how to use
play to express, explore, and work through their difficulties" (p. 170).
Children with cancer. Children with cancer present a special
need for play therapy because, in addition to the normal stress induced
by hospitalization, the young cancer patient and his or her family face a
possibly fatal disease, a potentially long course of treatment, and
numerous hospital stays (Adams, 1976). This, along with the side
effects of treatment and the possible disruption of family life, creates a
scenario in which play therapy can meet the very real need of the child
to express herself or himself and work through issues.
In interviewing numerous children in preparation for writing a
book on children surviving cancer, Bombeck (1989) noted the isolation
imposed on children by their disease and its treatment. She noted the
differences in the way adults in a child's world change their responses
to the child once a diagnosis of cancer has been made. It would seem,
then, that the play therapist, by providing an atmosphere of acceptance,
absent of pity or negative adult emotion, could fill a void that exists for
these children.
Webb (1991) recognized the growing "interest in the emotional
impact of cancer" (p. 310), due probably to the fact that the survival rate
for children with cancer has soared since the early 1970s. She stressed
the need of the child both to continue normal growth and to deal with
the concept of death. Play therapy can provide the climate in which
young patients can develop a sense of control, an opportunity to
"manage their own lives their own way" (p.329).
Citing several case studies involving the use of play therapy
with young cancer patients, Cooper and Blitz (1985) made a strong case
for programs such as the one at Sloan-Kettering Cancer Center, where
an interdisciplinary approach is stressed. Group play therapy sessions
take place twice per week and are led by a team consisting of a nurse
and a social worker. An active network of communication exists,
allowing the entire pediatric staff to better treat the child.
Terminally 111 Children. While the survival rate for childhood
cancer is overwhelmingly higher than it was just 20 years age, the
terminally ill child in the pediatric oncology unit is still a reality. While
the value of play therapy for these children is obvious, a special
challenge exists for those therapists who work with this population.
Hospitalized Children 55
Most authors writing about the dying child agr.ee that often the
child develops an awareness of his or her impending death, even
though the adults in the child's world refuse to speak of it (Adams,
1976; Buckingham, 1989; Knapp, 1986; Price, 1989; Webb, 1991). In
many cases, this awareness creates a unique type of isolation for the
child. Children and parents often live under a condition that
Buckingham (1989) calls "mutual pretense" (p. 60). Both know the child
is dying, but neither acknowledges it. It is not uncommon for the child
to develop a need to protect parents and others from what he or she is
experiencing.
Citing work by Bluebond-Langer, Buckingham (1989) proposed
that the child should be allowed to "maintain open awareness with
those who can handle it and, at the same time, mutual pretense with
those who cannot" (p. 62). It is essential, then, that the play therapist
working with the terminally ill child falls into the category of those who
are capable of open awareness. In providing the atmosphere of
acceptance so essential to play therapy, the therapist must accept the
ultimate result of the child's illness. Since the child is so alert to
unspoken cues, and more astute at interpreting these cues than most of
the adults in his or her world realize, it is essential that the therapist
work through his or her own feelings about working with a dying child.
As Landreth (1991) so touchingly points out in reporting his experiences
with Ryan, a dying child, there was a point before each session where he
had to acknowledge to himself that the feelings he was experiencing
were "my problem, not Ryan's" (p. 295).
According to Grace Zambelli, clinical psychologist and art
therapist, "You have to be very clued into the symbolic messages of
their art, play, body language" (McCullough, 1993). All the skills
needed by the play therapist in other settings are also needed in
working with the terminally ill child. Play therapy appears to provide
these children, especially, with brief interludes when they can feel in
control (Landreth, 1991; Webb, 1991). Externalizing frustrations and
fears and enhancing self-concept are seen as important needs to be met
by those working with these children (Price, 1989). Dying children are
experiencing much for which they have no words, but, through play,
children can express to themselves and to an alert therapist much about
their emotional conditions.
56 Webb
At the same time that the child is dealing with facing death, and
often attempting to protect parents from his or her knowledge, it is
likely that other adults in the hospital environment are withdrawing
from the child as well. It would appear that medical personnel give less
attention to the dying child than to those expected to survive (Price,
1989). Few pediatricians have training in "dealing with the death of a
patient" (Buckingham, 1989, p. 75). The attention of hospital personnel
is often directed at "helping the parents cope with the psychological
upheaval of tending to a terminally ill child" (Buckingham, 1989, p. 66).
It would seem, then, that the relationship offered by the play therapist
would be especially valuable to the child during this time.
While most research regarding working with terminally ill
children is focused on children with cancer, another rapidly growing
group is that of children infected with the AIDS virus. Because the
condition is relatively new, little research is available, but this would
appear to be another population for whom play therapy during
hospitalization would be highly beneficial. As Webb (1991) stated,
"There exists a population of intellectually intact school-age children
who have AIDS. The risk for psychological suffering among these
children is self-evident" (p. 336). Not only are these children faced with
a terminal illness with an uncertain course of treatment, but, unlike the
cancer patient, they also experience a high possibility of social rejection.
Additionally, it is likely that the family from which the child comes has
already undergone the illness and possible death of another family
member.
Principles of Play Therapy Applied
As in play therapy with any other child, when working with the
hospitalized child, "the play therapist holds the key to the success or
failure of the play therapy process" (Hyde, 1971, p. 1366). Although the
environment may present special challenges, the same principles
outlined by Axline (1969) that serve as a guide to the therapist in other
nondirective play therapy sessions can be applied to sessions with
hospitalized children.
1. "The therapist must develop a warm, friendly relationship
with the child, in which good rapport is established as soon as possible"
(p. 73). Many of the adults in the hospital, of necessity, must in the
course of treatment produce physical pain for the child. In this
Hospitalized Children 57
situation, the child needs someone who has a different type relationship
with him or her, a therapist who clearly tries to see the world from the
child's point of view.
2. "The therapist accepts the child exactly as he is" (p. 73). In
the case of the hospitalized child, acceptance includes accepting the
physical condition. Furthermore, in the case of the terminally ill child, a
necessary part of acceptance by the therapist is the acceptance that the
child is indeed dying.
3. "The therapist establishes a feeling of permissiveness in the
relationship so that the child feels free to express his feelings
completely" (p. 73). The hospitalized child may have many feelings
related to his illness and treatment that are not expressed openly. The
play therapy session should be such that these feelings can be expressed
in a confidential setting. The dying child, with need to protect parents,
particularly needs this safe outlet.
4. "The therapist is alert to recognize the feelings the child is
expressing and reflects those feelings back to him in such a manner that
he gains insight into his behavior" (p. 73). As in any other play therapy
setting, the child may or may not know the words for the feelings he or
she is experiencing. By accurate reflection, the therapist not only gives
the child additional vocabulary for feelings, but communicates an
understanding of the child's emotions.
5. "The therapist maintains a deep respect for the child's ability
to solve his own problems if given an opportunity to do so. The
responsibility to make choices and to institute change is the child's" (p.
73). In the case of an ill child, it is even more tempting than normal for
the adult to attempt to solve the child's problems for him. Even in the
case of very serious illness, though, the child knows the issues with
which he or she needs to deal.
6. "The therapist does not attempt to direct the child's actions
or conversation in any manner. The child leads the way; the therapist
follows" (p. 73). Particularly in the case of the dying child, this can be a
real challenge. Many adults in the child's world are shying away from
dealing with the issues of death and dying; the therapist must be willing
to follow the child into these issues if that is where the child chooses to
go-
7. "The therapist does not attempt to hurry the therapy along.
It is a gradual process and is recognized as such by the therapist" (pp.
58 Webb
73-74). Even though play therapy done in the hospital is naturally
limited by the length of the child's stay and may stop and start with
repeated admissions for treatment, it is still necessary to let the child
determine the pace. With the dying child, the temptation for the
therapist is to try to accomplish as much as possible in the remaining
time, but only the child knows the proper speed.
8. "The therapist establishes only those limitations that are
necessary to anchor the therapy to the world of reality and to make the
child aware of his responsibility in the relationship" (p. 74). Limit
setting is as important in a therapy session with a hospitalized and/or
dying child as it is with any other child. Limits communicate safety and
establish a sense of normalcy for the child.
CONCLUSION
Hospitalized children have a need to express what they are
feeling and to work through the challenges they are facing. Play
therapy provides a situation in which this is possible. The youngster
with the bald head and the big eyes has much to communicate. Though
those eyes express the "wise innocence" (Buckingham, 1989, p. 124) so
often seen in even the very young terminally ill child, he or she is still a
child, and play is still his or her largest vocabulary.
REFERENCES
Adams, M. (1976). A hospital play program: Helping children with
serious illness. American Journal of Orthopsychiatry, 46, 416-424.
Axline, V. (1969). Play therapy. New York: Ballantine.
Bombeck, E. (1989). / want to grow hair, I want to grow up, and I want to
go to Boise: Children surviving cancer. New York: Harper Collins.
Buckingham, R. (1989). Care of the dying child. New York: Continuum.
Chan, J., & Leff, P. (1988). Play and the abused child: Implications for
acute pediatric care. Child Health Care, 16(3), 169-176.
Clatworthy, S. (1981). Therapeutic play: Effects on hospitalized
children. Journal of the Association for the Care of Children in
Hospitals, 9(4), 108-113.
Hospitalized Children 59
Cooper, S., & Blitz, J. (1985). A therapeutic play group for hospitalized
children with cancer. Journal of Psychosocial Oncology, 3(2), 23-
37.
D'Antonio, I. (1984). Therapeutic use of play in hospitals. Nursing
Clinics of North America, 19, 351-359.
Doak, S., & Wallace, N. (1975). The doctors wear pajamas. Journal of
the Association for the Care of Children in Hospitals, 3(3), 47-53.
Froehlich, M. (1984). A comparison of the effect of music therapy and
medical play therapy on the verbalization behavior of pediatric
patients. Journal of Music Therapy, 21(1), 15.
Hyde, N. (1971). Play therapy: The troubled child's self-encounter.
American Journal of Nursing, 71,1366-1370.
Knapp, R. (1986). Beyond endurance: When a child dies. New York:
Schocken Books.
Landreth, G. (1991). Play therapy: The art of the relationship. Muncie, IN:
Accelerated Development.
McCullough, L. (1993, April). Counseling the dying. Guidepost, pp. 1,
10-11.
Price, K. (1989). Quality of life for terminally ill children. Social Work,
34(1), 53-54.
Rae, W., Worchel, F., Upchurch, }., Sanner, }., & Daniel, C. (1989).
Journal of Pediatric Psychology, 14(4), 617-627.
Webb, N. (1991). Play therapy with children in crisis: A casebook for
practitioners. New York: Guilford Press.