2.

0 REVIEW ON PLAY THERAPHY

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 childrens 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 a form of counseling or psychotherapy that uses play to communicate with and
help people, especially children, to prevent or resolve psychosocial challenges. This is
thought to help them towards better social integration, growth and development, emotional
modulation, and trauma resolution.
Play therapy can also be used as a 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 of therapy session. Caution, however, should be taken when using play
therapy for assessment and/or diagnostic purposes, as fantasy play can, at times, be difficult
to distinguish between fantasy play.
According to the psychodynamic view, people (especially children) will engage in play
behavior in order to work through their interior obfuscations and anxieties. According to this
particular viewpoint, play therapy can be used as a self-help mechanism, as long as children
are allowed time for "free play" or "unstructured play." However, some forms of therapy
depart from non-directivness in fantasy play, and introduce varying amounts of direction,
during the therapy session.
An example of a more directive approach to play therapy, for example, can entail the
use of a type of desensitization or relearning therapy, to change troubling behaviors, either
systematically or through a less structured approach. The hope is that through the language
of symbolic play, such desensitization will likely take place, as a natural part of the
therapeutic experience, and lead to positive treatment outcomes.
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 (1712-1778), in his book Emile wrote
about the importance of observing play as a vehicle to learn about and understand children.
Friedrich Frbel, in his book The Education of Man (1903), emphasized the importance of

symbolism in play. He observed, play is the highest development in childhood, for it alone is
the free expression of what is in the childs soul. childrens play is not mere sport. It is full
of meaning and import. (Frbel, 1903, p. 22) 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. The case of Little Hans was the first case in which a
childs difficulty was related to emotional factors.
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. In 1919, Melanie Klein (1955) began to implement the technique of using
play as a means of analyzing children under the age of six. She believed that childs play
was essentially the same as free association used with adults, and that as such, it was
provide access to the childs unconscious. Anna Freud (1946, 1965) utilized play as a means
to facilitate positive attachment to the therapist and gain access to the childs inner life.
In the 1930s David Levy (1938) developed a technique he called release therapy. His
technique emphasized a structured approach. A child, who had experienced a specific
stressful situation, would be allowed to engage in free play. Subsequently, the therapist
would introduce play materials related to the stress-evoking situation allowing the child to
reenact the traumatic event and release the associated emotions. In 1955, Gove Hambidge
expanded on Levys work emphasizing a Structured Play Therapy model, which was more
direct in introducing situations. The format of the approach was to establish rapport, recreate
the stress-evoking situation, play out the situation and then free play to recover.
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 childs freedom and strength to
choose. Carl Rogers (1942) expanded the work of the relationship therapist and developed
non-directive therapy, later called client-centered therapy (Rogers, 1951). Virginia Axline
(1950) expanded on her mentor's concepts. In her article entitled Entering the childs 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 (Progressive Education,
27, p. 68).

In 1953 Clark Moustakas wrote his first book Children in Play Therapy. In 1956 he
compiled Publication of The Self, the result of the dialogues between Abraham Maslow, Carl
Rogers, Clark Moustakas and others, forging the Humanistic Psychology movement. Filial
therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy
during the 1960s. 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 1960s, with
the advent of school counselors, school-based play therapy began a major shift from the
private sector. Counselor-educators such as Alexander (1964); Landreth (1969, 1972); Muro
(1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute
significantly, especially in terms of using play therapy as both an educational and preventive
tool in dealing with childrens issues.
1973 Clark Moustakas continues his journey into play therapy and publishes his
novel "The child's discovery of himself". Clark Moustakas' work as being concerned with the
kind of relationship needed to make therapy a growth experience. His stages start with the
child's feelings being generally negative and as they are expressed, they become less
intense, the end results tend to be the emergence of more positive feelings and more
balanced relationships. Today, his daughter Kerry Moustakas continues his legacy as an
author and president of The Michigan School of Professional Psychology. 2004 Clark and
Kerry Moustakas publish Loneliness, Creativity and Love: Awakening Meanings in Life.
Play therapy can be divided into two basic types: nondirective and directive.
Nondirective play therapy is a non-intrusive method in which children are encouraged to
work toward their own solutions to problems through play. It is typically classified as a
psychodynamic therapy. In contrast, directive play therapy is a method that includes more
structure and guidance by the therapist as children work through emotional and behavioral
difficulties through play. It often contains a behavioral component and the process includes
more prompting by the therapist. Directive play therapy is more likely to be classified as a
type of cognitive behavioral therapy. Both types of play therapy have received at least some
empirical support. On average, play therapy treatment groups when compared to control
groups improve by .8 standard deviations.

Nondirective Play Therapy

Nondirective play therapy, also called client-centered and unstructured play therapy,
is guided by the notion that if given the chance to speak and play freely under optimal
therapeutic conditions, troubled children and young people will be able to resolve their own

problems and work toward their own solutions. In other words, nondirective play therapy is
regarded as non-intrusive. The hallmark of nondirective play therapy is that it has few
boundary conditions and thus can be used at any age. This therapy originates from Carl
Rogers's non-directive psychotherapy and in his characterization of the optimal therapeutic
conditions. Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is
widely considered the founder of this therapy. Different techniques have since been
established that fall under the realm of nondirective play therapy, including traditional
sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms
is covered briefly below.
Play therapy using a tray of sand and miniature figures is attributed to Margaret
Lowenfeld, who established her "World Technique" in 1929. Dora Kalff combined
Lowenfeld's World Technique with Jung's idea of the collective unconscious and received
Lowenfeld's permission to name her version of the work "sandplay" (Kalff, 1980).As in
traditional nondirective play therapy, research has shown that allowing an individual to freely
play with the sand and accompanying objects in the contained space of the sandtray (22.5" x
28.5") can facilitate a healing process as the unconscious expresses itself in the sand and
influences the sand player.
When a client creates in the sandtray, little instruction is provided and the therapist
offers little or no talk during the process. This protocol emphasizes the importance of holding
what Kalff (1980) referred to as the "free and protected space" to allow the unconscious to
express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may
not choose to talk about his or her creation, and the therapist, without the use of directives
and without touching the sandtray, may offer supportive response that does not include
interpretation. The rationale is that the therapist trusts and respects the process by allowing
the images in the tray to exert their influence without interference.
Sand tray therapy can be used during family therapy. The limitations presented by
the boundaries of the sandtray can serve as physical and symbolic limitations to families in
which boundary distinctions are an issue. Also when a family works together on a sandtray,
the therapist may make several observations, such as unhealthy alliances, who works with
who, which objects are selected to be incorporated into the sandtray, and who chooses
which objects. A therapist may assess these choices and intervene in an effort to guide the
formation of healthier relationships.
Using toys in nondirective play therapy with children is another common method
therapists employ, a method which was derived from the creative toys used in Freud's
theoretical orientations. The idea behind this method is that children will be better able to

express their feelings toward themselves and their environment through play with toys than
through verbalization of their feelings. Through these actions, then, children may be able to
experience catharsis, gain more or better insight into their consciousness, thoughts, and
emotions, and test their own reality. Popular toys used during therapy are animals, dolls,
hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to
encourage dramatic play or creative associations, both of which are important in expression.

Efficacy

Play therapy has been considered to be an established and popular mode of therapy
for children for over sixty years. Critics of play therapy have questioned the effectiveness of
the technique for use with children and have suggested using other interventions with
greater empirical support such as cognitive behavioral therapy.nThey also argue that
therapists focus more on the institution of play rather than the empirical literature when
conducting therapy Classically, Lebo argued against the efficacy of play therapy in 1953, and
Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in
several areas of hard research. Many studies included small sample sizes, which limits the
generalizeability, and many studies also only compared the effects of play therapy to a
control group. Without a comparison to other therapies, it is difficult to determine if play
therapy really is the most effective treatment. Recent play therapy researchers have worked
to conduct more experimental studies with larger sample sizes, specific definitions and
measures of treatment, and more direct comparisons.
Research is lacking on the overall effectiveness of using toys in nondirective play
therapy. Dell Lebo found that out of a sample of over 4,000 children, those who played with
recommended toys vs. non-recommended or no toys during nondirective play therapy were
not more likely to verbally express themselves to the therapist. Examples of recommended
toys would be dolls or crayons, while example of non-recommended toys would be marbles
or a checker game. There is also ongoing controversy in choosing toys for use in
nondirective play therapy, with choices being largely made through intuition rather than
through research. However, other research shows that following specific criteria when
choosing toys in nondirective play therapy can make treatment more efficacious. Criteria for
a desirable treatment toy include a toy that facilitates contact with the child, encourages
catharsis, and lead to play that can be easily interpreted by a therapist.

Several meta analyses have shown promising results toward the efficacy of
nondirective play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an
effect size of 0.66 for nondirective play therapy. This finding is comparable to the effect size
of 0.71 found for psychotherapy used with children, indicating that both nondirective play and
non-play therapies are almost equally effective in treating children with emotional difficulties.
Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect
size for nondirective play therapy, with children performing at 0.93 standard deviations better
than non-treatment groups. These results are stronger than previous meta-analytic results,
which reported effect sizes of 0.71, 0.71 and 0.66. Meta analysis by authors Bratton, Ray,
Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with
nondirective play therapy. Results from all meta-analyses indicate that nondirective play
therapy has been shown to be just as effective as psychotherapy used with children and
even generates higher effect sizes in some studies.
There are several predictors that may also influence the effectiveness of play therapy
with children. Number of sessions is a significant predictor in post-test outcomes, with more
sessions being indicative of higher effect sizes. Although positive effects can be seen with
the average 16 sessions, there is a peak effect when a child can complete 35-40 sessions.
An exception to this finding is children undergoing play therapy in critical-incident settings,
such as hospitals and domestic violence shelters. Results from studies that looked at these
children indicated a large positive effect size after only 7 sessions, which provides the
implication that children in crisis may respond more readily to treatment. Parental
involvement is also a significant predictor of positive play therapy results. This involvement
generally entails participation in each session with the therapist and the child. Parental
involvement in play therapy sessions has also been shown to diminish stress in the parentchild relationship when kids are exhibiting both internal and external behavior problems.
Despite these predictors which have been shown to increase effect sizes, play therapy has
been shown to be equally effective across age, gender, and individual vs. group settings.

Directive Play Therapy

Directive play therapy is guided by the notion that using directives to guide the child
through play will cause a faster change than is generated by nondirective play therapy. The
therapist plays a much bigger role in directive play therapy. Therapists may use several
techniques to engage the child, such as engaging in play with the child themselves or

suggesting new topics instead of letting the child direct the conversation himself. Stories
read by directive therapists are more likely to have an underlying purpose, and therapists are
more likely to create interpretations of stories that children tell. In directive therapy games
are generally chosen for the child, and children are given themes and character profiles
when engaging in doll or puppet activities. This therapy still leaves room for free expression
by the child, but it is more structured than nondirective play therapy. There are also different
established techniques that are used in directive play therapy, including directed sandtray
therapy and cognitive behavioral play therapy.
Directed sandtray therapy is more commonly used with trauma victims and involves
the "talk" therapy to a much greater extent. Because trauma is often debilitating, directed
sandplay therapy works to create change in the present, without the lengthy healing process
often required in traditional sandplay therapy. This is why the role of the therapist is
important in this approach. Therapists may ask clients questions about their sandtray,
suggest them to change the sandtray, ask them to elaborate on why they chose particular
objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of
directives by the therapist is very common. While traditional sandplay therapy is thought to
work best in helping clients access troubling memories, directed sandtray therapy is used to
help people manage their memories and the impact it has had on their lives.
Roger Phillips, in the early 1980s, was one of the first to suggest that combining
aspects of cognitive behavioral therapy with play interventions would be a good theory to
investigate. Cognitive behavioral play therapy was then developed to be used with very
young children between two and six years of age. It incorporates aspects of Beck's cognitive
therapy with play therapy because children may not have the developed cognitive abilities
necessary for participation in straight cognitive therapy. In this therapy, specific toys such as
dolls and stuffed animals may be used to model particular cognitive strategies, such as
effective coping mechanisms and problem-solving skills. Little emphasis is placed on the
children's verbalizations in these interactions but rather on their actions and their play.
Creating stories with the dolls and stuffed animals is a common method used by cognitive
behavioral play therapists in order to change children's maladaptive thinking.

Efficacy

The efficacy of directive play therapy has been less established than that of
nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also
effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play
therapy was found to have an effect size of .73 compared to the .93 effect size that
nondirective play therapy was found to have. Similarly in 2005 meta analysis by authors
Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while
nondirective play therapy had an effect size of 0.92. Although the effect sizes of directive
therapy are statistically significantly lower than those of nondirective play therapy, they are
still comparable to the effect sizes for psychotherapy used with children, demonstrated by
Casey, Weisz and LeBlanc. A potential reason for the difference in the effect size may be
due to the amount of studies that have been done on nondirective vs. directive play therapy.
Approximately 73 studies in each meta analysis examined nondirective play therapy, while
there were only 12 studies that looked at directive play therapy. Once more research is done
on directive play therapy, there is potential that effect sizes between nondirective and
directive play therapy will be more comparable.

Parent/Child Play Therapy

Several approaches to play therapy have been developed for parents to use in the
home with their own children.Training in nondirective play for parents has been shown to
significantly reduce mental health problems in at-risk preschool children. One of the first
parent/child play therapy approaches developed was Filial Therapy (in the 1960s - see
History section above), in which parents are trained to facilitate nondirective play therapy
sessions with their own children. Filial therapy has been shown to help children work through
trauma and also resolve behavior problems.
Another approach to play therapy that involves parents is Theraplay, which was
developed in the 1970s. At first, trained therapists worked with children, but Theraplay later
evolved into an approach in which parents are trained to play with their children in specific
ways at home. Theraplay is based on the idea that parents can improve their childrens
behavior and also help them overcome emotional problems by engaging their children in
forms of play that replicate the playful, attuned, and empathic interactions of a parent with an
infant. Studies have shown that Theraplay is effective in changing childrens behavior,
especially for children suffering from attachment disorders.

In the 1980s, Stanley Greenspan developed Floortime, a comprehensive, play-based

approach for parents and therapists to use with autistic children. There is evidence for the
success of this program with children suffering from autistic spectrum disorders. Lawrence
Cohen has created an approach called Playful Parenting, in which he encourages parents to
play with their children to help resolve emotional and behavioral issues. Parents are
encouraged to connect playfully with their children through silliness, laughter, and
roughhousing.
In 2006, Garry Landreth and Sue Bratton devleoped a highly researched and
structured way of teaching parents to engage in therapeutic play with their children. It is
based on a supervised entry level training in child centered play therapy. They named it
Child Parent Relationship Therapy. These 10 sessions focus on parenting issues in a group
environment and utilizes video and audio recordings to help the parents receive feedback on
their 30 minute 'special play times' with their children. More recently, Aletha Solter has
developed a comprehensive approach for parents called Attachment Play, which describes
evidence-based forms of play therapy, including nondirective play, more directive symbolic
play, contingency play, and several laughter-producing activities. Parents are encouraged to
use these playful activities to strengthen their connection with their children, resolve
discipline issues, and also help the children work through traumatic experiences such as
hospitalization or parental divorce.