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| REVIEW ARTICLE |
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| Year : 2018 | Volume
: 19
| Issue : 2 | Page : 82-89 |
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Therapeutic intervention for children through play: An overview
Basavaraj Shrinivasa1, Madina Bukhari2, G Ragesh3, Ameer Hamza4
1 PhD Scholar, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
2 MSW, Block Program Manager, Department of Rural Development, State Rural Livelihood Mission, Jammu and Kashmir, India
3 MSW, MPhil, PhD, Department of Psychiatric Social Work, Institute of Mental Health and Neurosciences (IMHANS), Calicut, Kerala, India
4 Additional Professor, Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| Date of Web Publication | 31-Dec-2018 |
Correspondence Address:
Mr. Basavaraj Shrinivasa
Department of Psychiatric Social Work, First Floor, Dr. M.V. Govindaswamy Building, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | 1 |
DOI: 10.4103/AMH.AMH_34_18
Play is children's innate mode of self-expression and a method through which they explore the world. It has important implication for overall (physical, psychological, and psychosocial) development of any children. Play therapy capitalizes on such therapeutic powers or changing mechanisms within play and considers its strategic use through trained professionals to promote specific therapeutic outcomes within therapeutic contexts. This review article aims to provide a brief description on the use of play as therapeutic agent for change, different processes expressed in play, therapeutic powers within the play, and major approaches to play therapy. An attempt has also been made to list out some of the research studies from the available literature to prove the efficacy of play therapy in different conditions. The article concludes with highlighting the current issues and challenges faced by play therapy practice as a therapeutic medium to be used with children and way forward has been suggested.
Keywords: Children, play, therapy
How to cite this article:
Shrinivasa B, Bukhari M, Ragesh G, Hamza A. Therapeutic intervention for children through play: An overview. Arch Ment Health 2018;19:82-9 |
| Introduction | |  |
Play is children's universal behavior and innate mode of self-expression. All children irrespective of their life going quite smoothly or experiencing certain complexities through the entire period of their development adopt play as a spontaneous way to express their emotions and thoughts just like adults use language.[1] It is the method most children use to explore the world and to comprehend the relationships, and it also helps them to understand the past and also to prepare for the future. Children are likely to have engaged in more than 15,000 h of play by 6 years of age.[2] Piaget believed that play is the child's way of assimilating new information into his/her view of the world and adapting to new situations.[3] It is not only central but also critical to a child's development that the right to rest and leisure, to engage in age-appropriate play and recreational activities, to freely participate in cultural life and arts have been recognized and promoted by the United Nations 1989 Convention on the Rights of the Child.[4]
Play has an important implication for physical, psychological, and psychosocial development of any children.[5] Since children get a chance to take on and try out different social roles which gives them better ability to understand the feeling of others, teach them the concepts of fairness, sharing, and social reciprocity which are crucial for the process of socialization. Usually, children learn to master the things through the safe process of play. This sense of mastering one's environment without any fear of consequences is crucial to a sense of self-worth and adequacy. When freedom is provided within structure, children feel encouraged to explore strategies, and this helps children develop confidence and self-efficacy which leads to healthy outcomes including reduction of anxiety and inculcation of more positive behaviors.[6] Thus, play is usually, though not exclusively, considered as the most developmentally appropriate medium utilized with children. Play therapy capitalizes on such therapeutic powers of play or changing mechanisms within play and considers its strategic use through trained professionals within therapeutic contexts to promote specific therapeutic outcomes.[6],[7]
Play therapy can be defined as an interpersonal process wherein a trained therapist systematically applies the curative powers of play to help the clients resolve their current psychological difficulties and help prevent future ones. The techniques used in play therapy specify how to use the play materials effectively in implementing the therapeutic power of play.[2] It is also defined as a means of creating intense relationship experiences between therapists and children or young people, in which play is the principal medium of communication.[8] It is a structured, theoretical-based approach to work with children which is ideally suited to their developmental level. Using the symbolic function of play, children are provided with a means to express their inner world more comfortable and safely since act takes place in fantasy. Thus, play therapy for children is similar to counseling or psychotherapy for adults.[2],[9]
Beyond its spontaneous therapeutic effect, play is considered as an important tool in clinical practice.[10] Play therapy or play-based interventions are widely used to facilitate communication between therapist and children and to help children's understanding of events. It is a better medium of communication as play itself may create emotional reactions and make such emotional reactions more powerful. In therapy, therapist can use a puppet animal or a telephone while interviewing the child to serve this purpose.[11] Child practitioners also use play in diagnostic assessments based on the idea that children may act out their true feelings with the help of carefully selected play materials. Further, play therapy can also be used in planning intervention with children. Here, therapist tries to understand the feelings which a child expresses through play and in turn help the child to understand the same. Through this children can be taught coping skills and helped in insight facilitation and overcome conflicts.[2],[12] Thus, considering the inherent element of play, play therapy has been widely used across settings, age and gender, clinical and nonclinical populations.
| Process Expressed in Play | | |
Play enables the expression of a number of cognitive, affective, and interpersonal processes important in creativity which can be observed and assessed through verbal and behavioral expressions that emerge in play.[13] The theory and research in child development and child psychotherapy have considered these cognitive, affective, problem solving and interpersonal processes as very crucial in different areas of child development.[10],[13] [Table 1] provides the framework for processes expressed in play.[14]
| The Mechanism of Change in Play Therapy | | |
Understanding the changing mechanism or the inherent qualities in the play behavior is very much essential for the therapist to use play as therapeutic agent for change. Recognizing these invisible but powerful forces resulting from the therapist-client play interactions are crucial for using them effectively to match the needs of the clients and to help them to overcome their psychosocial difficulties.[15] Different approaches to play therapy with theoretical orientations identified various factors within the play which is therapeutic in nature. The application of the specific mechanism of change by the clinicians largely depends on how one conceptualizes the functions of play in child therapy. Through an extensive review of existing play therapy and related literature, Schaefer has identified 25 therapeutic factors involved in the play which can act as a guide for play therapy practitioners.[14],[15] Some of the important therapeutic elements of play therapy have been discussed below.
Self-expression
Children are naturally comfortable with expressing their internal states through concrete play activities and materials.[16] It is more so true with young children and children with limited vocabulary and abstract thinking ability. Children are able to express their conscious thoughts and feelings better through play activities than by words alone. Through indirect expression in play, a child can gain awareness of troublesome affects and memories and begin the process of healing. It includes expression through dolls, puppets, and miniatures of objects.
Access to the unconscious
Through the specially chosen toys, games, and materials for the therapeutic and neutral stimulus qualities, the children can reveal unconscious conflicts through the defense mechanisms of projection, displacement, and symbolization.[17] Through interpretations, the play therapists attempts to bring unconscious wishes and impulses into conscious play and actions.[14]
Abreaction
Through the use of play, children reenact and relive stressful and traumatic experiences and thus gain a sense of power and control over them. Through repetitive play, children show a natural tendency to cope with external events and traumas.[18]
Catharsis
Engaging in concrete play allows the children for the release and completion of previously restrained or interrupted affective release through emotional expression (e.g., crying) or activity (e.g., bursting balloons, pounding clay, or punching an inflated punching bag).[14] The importance of emotional release as a critical element in the psychotherapy has been recognized by most of the psychotherapists.[19]
Sublimation
Play can be effectively used to channelize the unaccepted impulses into substitute activities that are socially acceptable. The child who physically hits another may be redirected by therapists to express these impulses in “warlike” board games (like chess) or competitive sports activities.[14]
Competence and self-control
Play provides unlimited opportunities for the child to gain a sense of competence and self-efficacy that boosts their self-esteem. By engaging in activities such as construction play and gameplay, children learn self-control skills, i.e., to stop and think, plan ahead, and anticipate the consequences of different moves.[14]
Creative problem solving
Play and playfulness are associated with increased creativity and divergent thinking in children. Since in play the process is more important than the end product, children can freely, without fear of consequences, come up with novel combinations and discoveries that can aid them in solving their own problems and social problems.[2],[20]
Fantasy compensation
In play, children get the immediate gratification of their wishes. Impulses and needs which are blocked in real life find an outlet through fantasy.[14]
Behavioral rehearsal
In the safe environment of play, socially acceptable behaviors, such as assertiveness versus aggressiveness, can be rehearsed and practiced.[14]
Reality testing
Play experiences allow children to practice reading cues in social situations and can help differentiate fantasy from reality.[14]
Other than the above-listed factors there are some other elements such as empathy, attachment, alliance formation, metaphorical insight, stress inoculation, moral judgment, counter conditioning, relationship enhancement, competence, distraction, and self-awareness in play works when it is used professionally.
| Major Approaches to Play Therapy | | |
There are many different approaches to play therapy though there is a common understanding that play is the natural form of expression and communication for the children. Play has been used in different ways in different theoretical approaches depending on their theoretical underpinnings. These approaches provide the strong basis for the application of play therapy with wide range psychological/clinical conditions experienced by children and adolescents. Here, we have explained few important approaches to play therapy among many.
Psychoanalytic play therapy
Freud's analysis of little Hans (who was suffering from phobia) and his observations on the meaning of children's play pointed the way to the later development by Klein and Anna Freud of child psychoanalysis. They both believed and valued play therapy as a means for understanding and healing the unconscious conflicts by bringing into consciousness through the interpretation of children's play. Klein was of the opinion that child's play in therapy is like adult's free associations through which interpretations to children's unconscious can be made. Whereas Anna Freud's methods were aimed at helping children to consciously understand why they thought, felt and behaved in that particular way. Thus, psychoanalytic play therapist helps children to discover themselves and makes them to assume more responsibilities for their life. This therapy proved to be good at promoting resiliency and adaptability, helps those who need to reconcile themselves to limitations such as chronic illness or disabilities. Although time-consuming, helps disconnected children to attach to themselves and their families.[17],[21]
Object relation/thematic play therapy
Object relations play therapy is a relational, developmental approach to young children grounded in attachment-based object relations theory. This approach is most effective when used with children who have experienced relational trauma such as abuse, family violence, and disrupted attachment in their life as early as 5 years. According to propagators of this approach, the development of object relations over the 1st 3 years of life creates relatively enduring patterns of interpersonal relationships. Hence, it is believed that children who undergo relational trauma in their early life tend to develop disturbed attachment relationships or distorted object relations or negative ideas about themselves or others which leads to negative internal working model in the children. This approach uses play therapy techniques to provide a developmentally appropriate intervention for relationally traumatized children. Thus, object relations play therapy focuses on developing a secure-base relationship between the therapist and child in a play setting to help the child with difficulties experienced in interpersonal relationships.[22] Within this relationship, therapist works on the negative internal working model and challenges child to modify the maladaptive object relations in healthy directions.[23]
Cognitive behavioral play therapy
Cognitive behavioral play therapy (CBPT) developed with the work of Knell which is based on cognitive behavioral understandings incorporating the cognitive and behavioral interventions within the play therapy paradigm. Through the use of play, cognitive change is communicated indirectly, and adaptive coping skills are demonstrated through the modeling component. In CBPT, many of the cognitive therapy principles which are used with adults are applicable with minor modifications. Here, the focus of play therapist is more on psychopathology rather than personality development. It is brief, structured, problem-oriented, and directive in nature and emphasis on the involvement of children in the treatment process and to take the responsibilities for their expected behavioral changes.[24]
Narrative play therapy
This approach has been adapted from the narrative approach of David Epston and Michael White to work with children. This can be used in play therapy as a way of helping children express and explore their experiences of life. Narrative play therapy works on the basic principle that people's lives are constituted by stories which they tell themselves, and these stories provide them with the frame of reference through which they interpret their lives. This approach enables the therapists to help children communicate their difficult experiences and complex emotions through co-constructed stories. The aim of therapy is to separate the person from the problem and to help the individual to gain control.[25]
Release play therapy
This is another structured approach to play therapy developed by David Levy in America especially targeting children who have experienced traumatic events in their life. In this approach, children are engaged in free play until they are comfortable in the playroom. Then, therapist uses play to reenact the traumatic or stressful situations using specifically selected play materials. The main goal of this intervention with the children is to work through a particular painful or traumatic event and gaining mastery over the feelings engendered by it. This therapy is based on the premise of psychoanalytical idea that through re-enacting and re-experiencing a particular event, pent-up, or blocked-off feelings or emotions are released and eventually extinguished. Although children are free to play the way they want, play materials themselves are limited and selected to encourage children to play out their traumas.[26],[27]
Filial/family play therapy
Bernard and Louise Guerney developed a form of play therapy called filial play therapy in the 1960s. Filial play therapy is an eclectic technique combining the elements from both play and family therapy. Here, single parent or both the parents are taught effective ways of conducting nondirective play sessions with their children. Parent/s is/are taught basic play therapy principles and skills which they practice under the supervision of the therapist with their child. This therapy is highly effective in enhancing parent–child relationship. This has also has been used successfully with oppositional behaviors, relationship problems, and traumatic events by strengthening parent–child relationship.[28],[29]
Fair play therapy
Fair play therapy is based on the preposition that children need to be dealt with equitably, and that troubled children have probably not had this kind of experience. The aim of this approach is to construct conditions in which such a child can begin to learn relatively adaptive ways of solving problems and building interpersonal relationships. Therapist actively involves in the play and focus on give and take, at times leading and at times following and even at times, taking the relatively passive role of observer/interpreter. Here, the child is helped to become aware of and expected to be more responsible for the consequences of his/her behavior.[30]
Prescriptive play therapy
Kaduson, Cangelosi, and Schaefer recommend the use of multiple constructs. They claim strict adherence to one theory may be less effective for treating children. The cardinal premise of the approach is that the more tools clinicians have in their therapeutic box, the more effectively they can treat a wide range of disorders.[31] A prescriptive, client-responsive play therapy approach can be useful for children, teens, and adults experiencing a variety of issues.[4] Within the prescriptive approach, the trained play therapist selects the framework and interventions best suited to the clients' needs. Therapist creativity and flexibility are essential ingredients to the success of the prescriptive approach.
| Research Evidence | | |
Despite the progress made in the field of play-based intervention studies, the research related to play or play therapy has been criticized for the lack of its scientific rigor and high reliance on the anecdotal reports or case studies as its research base. However, meta-analytic studies on the effectiveness of play interventions found average to large mean effect size.[32],[33] In the [Table 2] we have listed few play-based intervention studies conducted on different conditions among the children, although it is not an exhaustive list.
| Play Therapy: Current Issues and Challenges | | |
Although the play therapy has proved to be effective across settings, age, and gender, clinical and nonclinical populations, efficacy of play therapy as a psychotherapeutic medium to be used with children has been facing a number of issues and challenged by the critics on many grounds. Among them, the most important being the research methodology which has been used to conduct play therapy-based studies. Although there are growing numbers of publication in this particular area including reports from interventional studies, still large numbers of them are based on the narratives of the therapists through which its efficacy cannot be determined. Even when testing the efficacy of play therapy was attempted,[34],[35],[36],[37],[38] it was done on a small number of subjects with the absence of comparison with other therapeutic interventions used with children, which limited the generalizability of the findings of these studies. Another important issue in the field of play therapy is the critical need for an increase in the number of specially trained professionals to conduct and supervise the sessions. Although there are established professional organizations on play therapy in few parts of the world which are regulating the training requirement for the professionals/therapists in the field and offering professional training, such organizations are not spread uniformly throughout the globe resulting in lack of consistency in terms of quality and content of these programs currently. Due to the scarcity of infrastructure, trained workforce and pressure of time, long-term play therapy sessions may not be feasible in resource-constrained countries. Another important issue which is encountered in the practice of therapeutic interventions through play is the nonavailability of culturally appropriate toys for the sessions. These are some of the issues which are hindering the growth and use of play therapy as a therapeutic intervention to work with children currently.
| Conclusion and Way Forward | | |
Play therapy is developmentally appropriate means to work with children and to bring about change in their internal distress. This has been implicated in wide variety of clinical and nonclinical conditions as an aid to work with the younger population. Therapeutic play allows the children to express them freely since it will done in accordance with their pace and it has also emerged as a major approach in the counseling field. However, proper ongoing training and supervision are very much essential for the competent and ethical practice. Such training, supervision, and certification have to be spread across the globe and made available so that people who aspire to take play therapy as their profession can avail the service. To inculcate the interest and raise orientation of child mental health practitioners in play therapy, various aspects related to play therapy and child development needs to be included in the course curriculum. Simultaneously, researches need to be conducted using the rigorous scientific methodology to prove the ground for play therapy as an effective medium to work with children.[42]
Financial support and sponsorship
This work is supported by Junior Research Fellowship awarded by the University Grant Commission, Government of India, New Delhi (Ref No. 1290/NET-June, 2013) to the first author of the manuscript.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Axline VM. Play Therapy-The Inner Dynamics of Childhood. Worcestershire: Read Books Ltd.; 2013.  |
| 2. | Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, NJ: Jason Aronson; 1993. |
| 3. | Piaget J. Play, Dreams and Imitation in Childhood. Abingdon: Routledge; 2013. |
| 4. | Schaefer CE, Drewes AA. Therapeutic powers of play and play therapy. In: Drewes AA, editor. Blending Play Therapy with Cognitive Behavioural Therapy: Evidence Based and Other Effective Treatments and Techniques. Hoboken, New Jersy: John Wiley & Sons, Inc.; 2009. p. 3-16. |
| 5. | Isenberg J, Quisenberry NL. Play: A necessity for all children. Childhood Educ 1988;64:138-45. |
| 6. | Ginsburg KR; American Academy of Pediatrics Committee on Communications, American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics 2007;119:182-91. |
| 7. | Milteer RM, Ginsburg KR; Council On Communications And Media, Committee On Psychosocial Aspects Of Child And Family Health. The importance of play in promoting healthy child development and maintaining strong parent-child bond: Focus on children in poverty. Pediatrics 2012;129:e204-13. |
| 8. | Wilson K, Ryan V. Play Therapy: A Non-Directive Approach for Children and Adolescents. 2 nd ed. Oxford: Elsevier Health Sciences; 2005. |
| 9. | Landreth G. Play Therapy: The Art of the Relationship. Muncie, IN: Accelerated Development, Inc.; 1991. |
| 10. | Russ SW. Play, creativity, and adaptive functioning: Implications for play interventions. J Clin Child Psychol 1998;27:469-80. |
| 11. | Landreth GL, Homeyer LE, Sweeney DS. Play therapy interventions with children's problems. Northvale, NJ: Jason Aronson; 1996. |
| 12. | Reddy LA, Files-Hall TM, Schaefer CE. Empirically Based Play Interventions for Children. Washington DC: American Psychological Association; 2005. |
| 13. | Russ SW, Schafer ED. Affect in fantasy play, emotion in memories, and divergent thinking. Creativity Res J 2006;18:347-54. |
| 14. | Schaefer CE. Curative factors in play therapy. J Prof Couns 1999;14:7-16. |
| 15. | Russ SW. Play in Child Development and Psychotherapy: Toward Empirically Supported Practice. Mahwah, New Jersey: Lawrence Erlbaum Associates, Inc.; 2003. |
| 16. | Landreth G. Self-expressive communication. In: Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, N.J.: Jason Aronson; 1993. p. 41-63. |
| 17. | Klein M. The psychoanalytic play technique. Am J Orthopsychiatry 1955;25:223-37. |
| 18. | Oremland EK. Abreaction. In: Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, N.J.: Jason Aronson; 1993. p. 143-65. |
| 19. | Ginsberg BG. Catharsis. In: Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, N.J.: Jason Aronson; 1993. p. 107-41. |
| 20. | Sawyers JK, Horn-Wingerd DM. Creative problem-solving. In: Schaefer CE, editor. The Therapeutic Powers of Play. Northvale, N.J: Jason Aronson; 1993. p. 309-22. |
| 21. | Freud A, editor. Indications for child analysis. In: The Psycho-Analytical Treatment of Children. New York: International Universities Press; 1945. p. 67-93. |
| 22. | Lieberman AF, Van Horn P. Don't hit My Mommy: A Manual for Child Parent Psychotherapy with Young Witnesses of Family Violence. Washington, D.C.: Zero to Three Press; 2004. |
| 23. | Benedict HE. Object relations/thematic play therapy. In: Schaefer CE, editor. Foundations of Play Therapy. New York: Wiley; 2003. p. 281-305. |
| 24. | Knell SM. Cognitive-behavioral play therapy. J Clin Child Psychol 1998;27:28-33. |
| 25. | Cattanach A. Narrative play therapy. In: Schaefer CE, Kaduson HG, editors. Contemporary Play Therapy: Theory, Research, and Practice. New York: Guilford Press; 2007. p. 82-99. |
| 26. | Levy DM. “Release therapy” in young children. Psychiatry 1938;1:387-90. |
| 27. | Levy DM. Psychic trauma of operations in children: And a note on combat neurosis. Am J Dis Children 1945;69:7-25. |
| 28. | Guerney L, Guerney B Jr. Integrating child and family therapy. Psychother Theory Res Pract Train 1987;24:609. |
| 29. | Guerney L. Filial therapy into the 21 st century. Int J Play Ther 2000;9:1. |
| 30. | Peoples C. Fair play therapy: A new perspective. J Psychol 1979;102:113-7. |
| 31. | Kaduson H, Cangelosi D, Schaefer C. Child Therapy Series. The Playing Cure: Individualized Play Therapy for Specific Childhood Problems. Lanham, MD: Jason Aronson; 1997. |
| 32. | Leblanc M, Ritchie M. A meta-analysis of play therapy outcomes. Couns Psychol Q 2001;14:149-63. |
| 33. | Bratton SC, Ray D, Rhine T, Jones L. The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice 2005;36:376-90. |
| 34. | Dogra A, Veeraraghavan V. A study of psychological intervention of children with aggressive conduct disorder. Indian Journal of Clinical Psychology 1994;21:28-32. |
| 35. | Dutta R, Mehta M. Child-centered play therapy in management of somatoform disorders. J Indian Assoc Child Adolesc Ment Health 2006;2:85-8. |
| 36. | Jafari N, Mohammadi MR, Khanbani M, Farid S, Chiti P. Effect of play therapy on behavioral problems of maladjusted preschool children. Iran J Psychiatry 2011;6:37-42. |
| 37. | Jones EM, Landreth G. The efficacy of intensive individual play therapy for chronically ill children. Int J Play Ther 2002;11:117. |
| 38. | Kot S, Landreth GL, Giordano M. Intensive child-centered play therapy with child witnesses of domestic violence. Int J Play Ther 1998;7:17. |
| 39. | Raman V, Kapur M. A study of play therapy in children with emotional disorders. NIMHANS Journal 1999;17:93-8. |
| 40. | Naderi F, Heidarie A, Bouron L, Asgari P. The efficacy of play therapy on ADHD, anxiety and social maturity in 8 to 12 years aged clientele children of Ahwaz metropolitan counseling clinics. J Appl Sci 2010;10:189-95. |
| 41. | Schottelkorb AA, Swan KL, Jahn L, Haas S, Hacker J. Effectiveness of play therapy on problematic behaviors of preschool children with somatization. J Child Adolesc Couns 2015;1:3-16. |
| 42. | Ray DC, Schottelkorb A, Tsai MH. Play therapy with children exhibiting symptoms of attention deficit hyperactivity disorder. Int J Play Ther 2007;16:95. |
[Table 1], [Table 2]
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