Play Therapy as Treatment of Choice for Traumatized Children. Introduction

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1 Play Therapy as Treatment of Choice for Traumatized Children Introduction The fundamental basis of successful therapeutic work is geared toward one basic tenet therapeutic intervention should begin where the client is emotionally, cognitively and spiritually. When working with children, this basic tenet is no different. It is critically important to have knowledge of healthy childhood development and remain aware that play is the primary form of communication for all children. There is much debate regarding therapeutic practices in regards to abused and neglected children and while forensic specialists and psychologists frequently debate such issues, one thing remains true and is evident to those working with children in therapy treatment should be developmentally appropriate for each child, it should work from where the child is, not from a theory. The purpose of this section of the response is to discuss best practices in regards to children who are under the age of five and have experienced traumatic events. This report will discuss human development, include information regarding play therapy, and conclude with recommendations for best practices regarding play therapy with young children. Definition of Play According to Schriver, play is defined as,..the way children learn what none can teach them. It is the way they explore and orient themselves to the actual world of space and time, of things, animals, structure, and people. To move and function freely within prescribed limits. Play is children s work. (2001) Children learn many things through play. They learn to develop positive relationships with others, they learn to use play materials and equipment, they learn to take turns, they learn how to verbalize their needs and wants, they learn to understand the role of others in their life, and they learn to master skills (Schriver, 2001). There are four main characteristics of play. It is pleasurable, it serves no particular purpose, it is spontaneous and voluntary, and it actively involves the player (Schriver, 2001). Play helps children solve problems, it allows a child to express their needs, and it helps stimulate language growth (Schriver, 2001). Play Therapy For nearly 70 years, play therapy has been used to treat children who have psychological disorders or who have experienced trauma (Benedict, 2003). Playing is a normal part of a child s life and development (Lieberman, 1979) and as such, children who experience play therapy are able to deal with the emotions that are experienced after the traumatic event in a way that is developmentally appropriate for them. According to Charles E. Schaefer, One of the strengths of play therapy is the diversity of theoretical approaches that are currently being applied in clinical practice with children...this diversity is a reflection of the fact that there are a multitude of therapeutic change mechanisms inherent in play. Among the more well-known therapeutic factors of play are its communication, relationship-enhancement, ego-boosting, and self-actualization powers (2003). In play therapy, the actual act of playing becomes a child s primary form of communication to the therapist (Lieberman, 1979). Play therapy gives verbal and non-verbal children the opportunity to develop a relationship with the therapist and according to Erikson, is the most natural method of self-healing that childhood affords (Lieberman, 1979). When children play they can communicate about current and past events, can

2 use verbal and non-verbal expressions to describe events in their lives, and can safely develop play themes around the child s current problem (Lieberman, 1979). There are several different theoretical models of play therapy that may be used with children who have experienced trauma. Their modes can be directive, non-directive, or a combination of both. They range in theoretical orientation from psychoanalytic play therapy, which uses a Freudian approach, to cognitive behavioral play therapy, which uses a cognitive behavioral approach. For the purposes of this case we will focus on child-centered play therapy, which is a person-centered approach to working with children and object relations thematic play therapy (Schaefer, 2003). For younger children child-centered and object relations thematic play therapy are the treatments of choice. Child-Centered Play Therapy Wilson and Ryan have stated that,...a systemic approach of non-directive play therapy does have considerable merit in offering a flexible intervention that can be tailored to meet the individual needs of children and their families (2001). The child-centered play therapy approach is based on the assumption that a non-directive play therapy approach is the most effective because the therapist does not direct the treatment, allowing the child to be responsible for the direction of the treatment (Guerney, 2001). Child-centered, non-directive play therapy is based on Carl Rogers philosophy of personality development (1951) and is based on the principal that,...all individuals, including children, have the innate human capacity to strive toward growth and maturity if provided nurturing conditions (Guerney, 2001). Allowing the child a safe and nurturing environment allows the child to heal from their traumas and gain insights and perspective into what they are feeling and experiencing. According to Louise Guerney, there are five basic tenets to child-centered play therapy. The first is that the child directs the content of the play therapy and the therapist allows the child to follow their own path to healing and does not direct the therapy in any way (2001). The second is that child-centered play therapy is not problem oriented but instead it is successful because by its very nature this approach is able to be used with children with many different traumas without looking at symptoms and behaviors directly (Guerney, 2001). The third tenet is that words, symbols, and other expressions that the child uses to communicate in the play therapy session are not readily interpreted by the therapist, instead the therapist works toward the goal of providing a safe environment for the child to be able to expose their personal world at their own rate of expression (Guerney, 2001). The fourth tenet is that child-centered play therapy is a system that is dependent on the full use of the system and does not deviate from it s path, it is not a set of techniques or principles that are used at the therapists discretion (Guerney, 2001). The fifth and final tenet is that the therapist must believe in the fact that the child is the one who can best direct their healing and the therapist must provide full therapeutic support to the child (Guerney, 2001). In child-centered play therapy the child is the driving force behind the therapeutic process. The content of the child s play and the direction that the child takes the therapeutic

3 play process are determined solely by the child in an environment where he/she feels safe to do so (Landreth/Sweeney, 2003). This approach is widely applicable because it does not rely solely on the child having an identified problem, instead this approach is based upon how the child feels about his/her self, allowing the focus to be on the child s point of view and the perceptions of life events are driven by the child s perspective (Landreth/Sweeney, 2003). Child-centered play therapy is one of the most thoroughly researched theoretical models, and the results are unequivocal in demonstrating the effectiveness of this approach with a wide variety of children s problems and in time-limited settings involving intensive and short-term play therapy (Landreth/Sweeney, 2003). Object Relations/Thematic Play Therapy Object relations/thematic play therapy is based on two assumptions of object relations theory. The first is that there is a focus on the relationship between the self and others and the second is that as development proceeds, interactions between a baby and the significant people in its life, as well as the baby s perceptions of these interactions, internalize and form templates or object relations (Benedict, 2003). Early relational traumas, such as abuse or neglect in childhood, make an impact on a child s ability to develop positive object relations, therefore, object relations/thematic play therapy should occur in childhood when the ability to change is the greatest (Benedict, 2003). There are many therapeutic goals with regards to object relations/thematic play therapy. The initial phase of therapy should always begin with establishing a secure relationship between the therapist and the child (Benedict, 2003). By combining both directive and non-directive therapy techniques, object relations/thematic intervention includes three components: child responsivity, developmental sensitivity, and the use of invitations (Benedict, 2003). A childresponsive intervention dictates the amount of direction the therapist uses in direct response to the child s needs (Benedict, 2003). A developmentally sensitive intervention involves continually changing and altering therapy depending on the developmental needs of the child thereby giving the child the assurance that the therapist is attuned to the child (Benedict, 2003). The third aspect of the intervention, using invitations, is used to challenge the child s internal working models (Benedict, 2003). Invitations are suggestions for play and different propositions for how to interact with the therapist and they may be accepted or rejected by the child (Benedict, 2003). The suggestions are directive, however, the open ended nature of the suggestions are somewhat non-directive in that the child can ignore or refuse any invitations that the therapist may offer (Benedict, 2003). Object relations/thematic play therapy was developed to address interpersonal traumas experienced by young children (Benedict, 2003). Several elements in this therapeutic intervention make it successful. The first is a secure base relationship between the therapist and the child, the second is the changing of the distorted object relations by looking at the child s play (Benedict, 2003). If these things are accomplished,...object relations/thematic play therapy can be an important tool in healing trauma and preventing adult mental health problems (Benedict, 2003).

4 Best Practices for Play Therapy The establishment of a best practice model is based on an industry standard as reflected in research and various studies. In play therapy there is not an established best practice model. The industry recognizes two modes of treatment as being effective, directive and non-directive therapy. Directive play therapy uses a cognitive behavioral model and non-directive play therapy is driven by the child. In non-directive therapy the therapist does not direct where the direction of the therapy is headed. It has been found that four aspects to the play therapy intervention are important to the child feeling successful in treatment. They are: the importance of the therapeutic relationship, the termination of this relationship, the children s attitude to talking, and the importance of having fun (Carroll, 2002). The Trauma Awareness and Treatment Center (TATC) has chosen to use a combination of several models in its practice with children, depending on the developmental stage of the child and the nature of the problems being addressed. This eclectic practice allows the therapist to use the type of play therapy that best fits the client and his or her situation. The following discusses the best practice model that is utilized by the TATC. Characteristics of the Successful Play Therapist Play therapists must have several qualities in order for the therapeutic intervention to be a positive, healing experience. First and foremost, successful play therapists are able to provide a safe and healthy environment for the children they are treating. It is also important that the therapist give attention to the child s personal circumstances to ensure that there is enough support from his/her caregivers. The caregiver s own emotional needs should not supercede the needs of the child (Wilson/Ryan, 2001). Therapists should also keep their own worries, concerns, and thoughts about external situations away from their work with the children (Carroll, 2002). Children should be protected from adult conversations between caregivers and therapists, and adult opinions about others involved in children s lives should be kept from children as often as possible. Confidentiality, and the constant maintenance of that confidentiality, is a vital component of the therapeutic relationship (Carroll, 2002). The maintenance of confidentiality has been viewed as an indication of the therapist s willingness to help the child through difficult therapeutic processes (Carroll, 2002). Play therapists should be kind and friendly in addition to being relaxed and calm when dealing with children who are upset or angry (Carroll, 2002). They should be helpful and understanding, easy to talk to, and exude a willingness to assist the child in dealing with feeling of anger (Carroll, 2002). Therapeutic Process: Session Dynamics Therapeutic sessions have a defined beginning and an end. Developing set routines in order to assist the child in entering the therapy room allows for consistency and safety in the therapeutic process. Children begin to recognize these rituals and are able to identify that the therapist is cognizant of their needs and wants (Carroll, 2002). The issue of choice is very important for children who have experienced trauma and abuse. Children should be given

5 choices in the playroom, this allows them to feel valued and appreciated and in control of the process (Carroll, 2002). Choices in the playroom can also be used along with directive play therapy techniques as long as children are comfortable and express no resistance with the suggestions given by the therapist. When talking with children, therapists should be aware of the child s comfort level and allow the children to maintain control over the conversations (Carroll, 2002). When answering children s questions about things that may be happening in their life (ie. adoption procedures, legal procedures, medical procedures) the therapist should exhibit empathy and warmth and be sure that the discussion with the child takes place on the child s developmental level (Carroll, 2002). Therapists should make it a habit to give children warnings when the end of the session is approaching, this allows them to mentally prepare for the ending of the therapeutic time with the therapist (Carroll, 2002). Given that problem behaviors may be present early on in treatment, and that efficacy of treatment deteriorates after too many sessions, LeBlanc and Ritchie have determined that sessions is the optimal number for treating children (2001). In terminating therapy, children should be allowed to understand the ending of therapy, express their feelings about therapy ending, be given two to three weeks to process the termination of therapy, and be given some sense of control over the therapeutic process ending (Carroll, 2002). This allows children to better understand how termination of therapy effects them and how they can successfully take the lessons they have learned in therapy and apply them to future situations. Therapeutic Process: Involving the Parents When parents are involved in the therapy process, support is given to both the parents and the child, which facilitates a positive therapeutic healing process. Wilson and Ryan have completed studies that look at play therapy as a mode to allow children to deal with their problems and in conjunction, improve parenting skills for parents who are involved in the therapeutic process. When parents are appropriately involved in the therapeutic process the result is that individual play therapy brings about changes in the whole family system, improving the system dramatically (Wilson/Ryan, 2001). By involving parents in the therapeutic process and focusing not only on the child s healing process but also the parents communication skills and capabilities, significant improvements have occurred not only in the children s behavior but in the parent s parenting skills as well (Wilson/Ryan, 2001). Therapeutic Process: The Use of Psychosexual Education Materials There is very little research regarding the use of psychosexual educational materials with children who have been sexually abused. In 1992, Krivacska stated that before a therapist uses psychosexual education materials in therapy, the therapist must ensure that the child can use the material appropriately, is ready to learn about the content of the material, can make good judgements about when to use the information, and accept a healthy responsibility for the content as it is presented (Rubenzahl/Gilbert, 2002). In a study by Rubenzahl and Gilbert, it was found that the four most common reasons that clinicians use psychosexual educational materials is, To correct misinformation about sexuality, to help promote healthy sexuality and relationships, to reduce clients guilt and confusion, and to prevent future abuse (2002). Therapists using this

6 approach to play therapy must keep in mind that they need to tailor the coverage of psychosexual education to meet the clients needs (Rubenzahl/Gilbert, 2002). Therapeutic Process: Healing One of the goals of therapy is to help people heal and adjust after a traumatic life event. Often when children are exposed to a positive therapeutic process they are able to heal from the trauma(s) that they have experienced. In order to foster this healing process, a therapist should consider the child s cognitive-developmental capabilities to understand the trauma, their immediate emotional reactions, and the long-term adaptation or outcome from the experience (Shapiro, 1994). Children have the capability to fully heal from their traumatic experience if they are given age appropriate information that will allow them to express the complex feelings regarding the healing process (Shapiro, 1994). If the child has not been traumatized, engaging in play therapy according to these principles should allow the child to achieve greater emotional balance and health. Conclusion There are many things that dictate whether or not a child can heal from a traumatic experience. The therapist plays a major role in the healing process not only with their behaviors but also with their ability to work from a theoretical foundation that assesses where the child is not only developmentally but emotionally as well. Caregivers also play a major role in the treatment effectiveness of a therapeutic intervention and including parent(s) and/or the child s other caregivers in treatment is crucial to completing a successful intervention (LeBlanc/Ritchie, 2001). Therapeutic interventions should be non-directive although, directive therapy can be used when the child is cognitively and emotionally able to respond to certain directive techniques. Finally, Children have much to teach us, if we can find ways to listen (Carroll, 2002). All those invested in helping a child heal from a traumatic experience should adhere to the fundamental tenet that therapy begins where the client is emotionally, cognitively and spiritually.

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8 Rossman, B.B. & Rosenberg, M.S. (1998). Multiple Victimization of Children: Conceptual, Developmental, Research, and Treatment Issues. New York: M.S. Haworth Maltreatment and Trauma Press. Rubenzahl, S.A. & Gilbert, B.O. (2002). Providing Sexual Education to Victims of Child Sexual Abuse: What is a Clinician to Do? Journal of Child Sexual Abuse: Research, Treatment & Program Innovations for Victims, Survivors and Offenders, 11(1), Schriver, J.M Human Behavior and the Social Environment: Shifting Paradigms in Essential Knowledge for Social Work Practice. Boston: Allyn and Bacon. Shapiro, E.R. (1994). Grief as a Family Process: A Developmental Approach to Clinical Practice. New York: Guilford Press. Siegal, D.J. (1999). The Developing Mind: How Relationships and the Brain Interact to Shape who we are. New York: Guilford Press. Sweeney, D.S. & Landreth, G.L. (2003). Child-Centered Play Therapy. In C.E. Schaefer (Ed.), Foundations of Play Therapy (pp ). New Jersey: John Wiley & Sons, Inc. Wilson, K. & Ryan, V. (2001). Helping parents by working with their children in individual child therapy. Child and Family Social Work, 6(3),

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