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A perceptive and intuitive approach is necessary to understand and facilitate the therapeutic process" Susan Garofolo
Play Therapy is the systematic use of a theoretical 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 the psychodynamic view, people (especially children) will engage in play behavior in order to work through their anxieties. 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 be an essential component of healthy child development. Play has been directly linked to cognitive 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 children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-
guided, self-healing process. As children’s 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' his feelings and problems just as, in certain types of adult therapy, an individual 'talks out' 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 Fröbel, in his book The 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 child’s 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 child’s freedom and strength to choose. Carl Rogers (1942) expanded the work of the relationship therapist and developed nondirective therapy, later called client-centered therapy (Rogers, 1951). Virginia Axline (1950) expanded on her mentor's concepts. In her article entitled ‘Entering the child’s 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
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 1960’s. 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 1960’s, 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-six countries (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 child’s 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 play with 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 behavior through a formal system of tests.
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 and child-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 have all 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 with their 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 create joyful 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 connection between the child and the parents, resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding.
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 is improved 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 normal development. 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
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.
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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
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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
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
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 of sessions 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 as possible 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. The clinician 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
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.
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 of therapy 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.
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
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 occur if 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 or Sandbox 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 or grief. 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 development of 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 child’s assortment of play 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 mother’s warmth & physical presence. Such tendency can also be carried over to toys such as teddy bears. The term transitional object implies that the child is gradually giving up the physical clinging to the parent but sustaining some concrete and palpable feature of that experience.
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. This consistent 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 therapeutic efforts with disturbed children. • ENHANCED LANGUAGE SKILLS One feature of imaginative play is that the children verbalizing aloud increasingly complex 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-believe play 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 objects or 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 study with 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). It may 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 makebelieve or metarepresentation.
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 disputes are 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 social skill. • TOLERATION OF DELAY Of extreme importance for the developing child is the ability to defer immediate gratification 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 few primitive 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-believe indicate 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 of tension, 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.
Discrimination between make-believe & reality: Some children get lost in the play; others may assure the nurse “it’s 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 the nurse 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 become so 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 the technique as an interpretative method with emotionally disturbed children. Therapeutic Play, on the other hand, is a very effective nondirective modality for helping 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 especially beneficial. 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 young children; 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, children’s 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 these images 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 be asked 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.
Although interpretation of children’s drawing requires special training, observing changes in a series of the child’s 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 child’s 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 events that 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 child’s environment (e.g. a physician, nurse, child, parent, therapist and member of the child’s own 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.
Bibliography: • www.apa.org • en.wikipedia.org • www.playtherapy.org • Webb, Nancy Boyd, ed. Play Therapy with Children in Crisis. 2nd edition. New York: The Guilford Press, 1999. • Lovinger, Sophie L. Child Psychotherapy: From Initial Therapeutic Contact to Termination. 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
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