“When is Play Therapy A Good Choice ?” : Criteria for Play Therapy
2015 Andrew Rose, LPC
Since play is the language of children, play therapy is an appropriate intervention for children with ineffective or inappropriate soothing strategies. Besides behaviors, life circumstances can also call for an intervention, particularly major non-relational trauma, parental death, friend/sibling death, or divorce transition.
Indications listed by Association For Play Therapy (a4pt.org) are:
Behavioral problems, such as anger management, grief and loss, divorce and abandonment, and crisis and trauma.
Behavioral disorders, such as anxiety, depression, attention deficit hyperactivity (ADHD), autism or pervasive developmental, academic and social developmental, physical and learning disabilities, and conduct disorders.
Additionally, consider these questions:
- Is the child’s chronological age older than the emotional age / play style? (solitary, observer, parallel play are young, co-operative play is relational and expected before age 4).
- Is the child resistant to directives or “re-direction”? Are parents reporting “frustration”, “confusion”, “fear” in response to child’s behavior. Are there significant differences between at-home behavior and at-school?
- Is the child under-reacting? (Not stating needs when seems like there are needs, spaciness, absent, in books/flat screens all the time, mute)
- Is the child over-reacting? (outbursts, meltdowns > 1/2 hour, intense anger)
- Is the child self-aggressive (negative self-talk, suicidal talk, loss of interest, hopeless)
- Does the child have supportive peer relations? (few/no friends, no best friend, not invited to events, only friends with adults)
- Is the child enduring major grief? (parental death, friend/sibling death, pet, sad all the time, lots of existential questions, divorce transition)
- Has the child experienced major trauma? (non-relational: car accident, animal attack, witnessing scary events)
- Has the child experienced attachment trauma or “relational” trauma? (witnesses domestic violence, triangulated by divorced parents, victim of DV)
- Is the child emotionally rigid? Do they lack of emotional vocabulary?
- Is the child asking for therapy?
Non-directive Experiential Play Therapy, An Introduction
Play Therapy is a demonstrated effective intervention for children who have experienced trauma caused by motor vehicle accidents, medical procedures, violence seen or felt, neglect, adoption issues, divorce, loss, or other difficult transitions during their development. Impacts of trauma are experienced in thought, in emotion, in body sensations and in behavior and reactions to situations in the present. Because traumatic situations take emotional work to process, children are distracted from their normal “developmental tasks” and later may act younger than their chronological age. Children with impasses in their development due to high stresses in their pasts are able to express their difficult experience in metaphors created in play. In play they resolve their “unfinished business” caused by trauma and succeed in completing the developmental task left undone.
Play Therapy proceeds in stages of exploration, testing-for-protection, working, and integration. In the non-directive experiential play therapy process, children first explore the play environment and then “test for protection,” gradually displaying a variety of behaviors to see where the therapist holds boundaries. Within the play therapy context, the child is allowed full expression short of hurting themselves or the therapist, or damaging objects or damaging the environment.
Emotional safety allows for vulnerability, which arises when difficult truths are expressed. A child in play will gradually experience a sense of safety by enacting some behavior (“testing-for-protection”) and checking the therapist for consistency, as well as checking for the absence of contact breaks, boredom, or defensiveness when holding boundaries. Assured, the child will feel emotionally safe. Thoughts, feelings, speech and action can happen without fear of reproach or over-reactions. In order for the intervention to proceed, the child must express metaphors of their conflicted experience through play activity or speech, and so creating safety for this expression is an important task for the therapist.
When the child is satisfied that the container for their ‘work’ will be held safe, they will express previously repressed feelings and elicit fulfillment of previously unmet needs. The therapist acts in response to the lead of the child, without asking questions or directing play, occasionally using simple words to validate the child’s activities and feelings. The child is given free reign to direct the play and is not performing or meeting the needs of an adult. The therapist’s goal is for the child to feel “seen” in their story, and through being seen, the child resolves the impasse of the past and returns to the tasks appropriate for their age. Through the “working” stage of therapy, the child’s home and school behavior may become more expressive as they experience success in attempting to get their needs met. When the need for expression and understanding is satisfied, the behavior of the child turns age appropriate and relational (involving and caring for others).
A clinical case illustrates the course and impact of play therapy. “Sarah,” at seven, was acting inappropriately in her school environment, disrupting and upsetting her classmates and teacher. Her history included some profound neglect and unsafe environments. Her behavior evoked concern from the school and she was referred to play therapy. Through 24 sessions, she repeatedly played out a story of waking up in her bedroom when an intruder was present. There were also themes of nourishment (filling open containers with sand), power and control, and physical touch. In time, Sarah’s experiences of lack of safety, nutrition, privacy, and attention were felt by the therapist, who shared his ability to hold these strong and difficult feelings (“regulation of affect”), and her experience and emotions were seen and heard by the therapist. Relational play increased while disturbing behaviors at school and home tapered off. In some cases the introduction of EMDR, Brainspotting, and other trauma resolution protocols, when appropriate, can reduce treatment time.
What can a parent do?
Children having problems with their own feelings may misinterpret their parents’ and others’ actions and assume harmful intent. They may act confused, insecure, or angry and feel victimized for little apparent reason. The parent may not be able to meet the child’s need because the child is confused about what’s happening and may not be able to form an understandable request. Without the ability to express verbally they must express through play, the language of children.
Consider the experience of a child. More often than not the communication from others is directive or inquisitive. A child is told what to do next (although often in the form of a question in some cultures) or queried about their opinion or experience. For example, when picked up at school, a child might hear, “how was your day?” or “was the new teacher nice?” which the child must answer. Creating a time, even briefly, where the child directs the experience and is not required to produce any action or speech can be an important opportunity for the child to develop self-direction and confidence.
A structured play session has two participants, the child and the parent. It has a specific beginning and ending time, from twenty minutes to an hour. The time should be held without the possibility of interruption from phone calls or other family members. The time should be respected and not cancelled.
The toys available will be used to demonstrate experiences in metaphor and therefore should range in type. A minimal set includes a “bop bag”, cuddly animals, drawing paper and crayons or markers, constructions toys such as Legos, plastic soldiers, food toys such as fake food and dishes, people dolls or puppets, and a plastic gun or rubber knife. Many parents object to toy weapons and a rule can be made that these toys are only used during this special play time. The theme of power and control, a common struggle for children, is easier to play out with toys that represent power. It can be difficult to see a child act out violence, but unless the child is actually hurting the parent or herself (in which case boundaries should be swiftly and consistently enforced) the play continues.
In the play, the parent pays full attention. By reflecting the child’s feelings and actions the parent demonstrates understanding and acceptance of this child’s feelings. The parent avoids criticism, praise, questions, direction, advice, interruption, teaching, or initiating new activity. Statements that reflect feelings like “you’re confused about what to do next,” or even simpler single-word reflections like “sad” can affirm the child’s experience.
Through this process the parent will learn about the child’s experience in the world and in the family and the child will learn that their emotions are acceptable and manageable, which is a great gift for any child.