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PLAY THERAPY.
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Essay Subject:
Discusses its use for treatment of sexually abused children.... More...
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Paper Abstract:
Discusses its use for treatment of sexually abused children. Analysis of the play therapy technique, current uses, treatment outcomes, strengths and weaknesses. History of play therapy. Counseling children with play; encouraging self-expression. Creating a therapeutic relationship with child clients. Basis of play therapy in work of Carl Rogers and client-centered approach.
Paper Introduction:
Counseling children brings with it challenges that are unique and techniques are needed that are applicable to the needs of children (Erdman & Lampe, 1996, p. 374). Children are different from adults cognitively, emotionally, physically, and psychologically. They may lack abstract reasoning, may be egocentric, and establishment of rapport may take longer. Limited verbal skills may demand that the self be expressed through techniques of play therapy (Erdman & Lampe, p. 376).
The use of play therapy has been documented as early as 1919, when H. von Hug-Hellmeth used play to analyze a child by translating her observations of a child at play into symbols designed to detect hostile and sexual wishes toward the child's parents (Guerney, 1984, p. 291). Play therapy has been used with many types of disorders, including psychiatric, and medical. An examp
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Studies have found that most children are willing to participate indramatic medical play and most have had some experiences that they can drawfrom. 1 2-1 3). 1 1). Toys or other play objects help implement the processsince they are the child's mode of expression. In a study of 12 abused and 12nonabused children, ages one to five years, abused children weresignificantly more developmentally delayed by 8.4 months. (199 ). 215). 6. Thetraumatic event typically leads to an inability to get over the memory.Anger and violent acting out, are common symptoms that may result fromtrauma and PTSD. (2 ). While engaging in playwith others or in solitary, this child will exhibit sexualized behaviorsand language whether assuming the role of the aggressor or the victim. Some work with adolescents and adults. For Klein, play replacedverbal communication, and she believed that the child used the same symbolsin play as adults do in dreams, thus holding the key to the unconscious.She introduced toy cars, dolls, and animals to help stimulate the child'sfantasy. CBPT draws from cognitive and behavioral therapies, and uses playwithin a developmental framework; it was designed to treat preschoolchildren. Autism through the lifespan: the Eden model. The authors conclude that these effects are dueto filial therapy requiring the following: family involvement, taking focusoff an identified child patient, helping parents' to see their role in theproblem, enhancing parental leadership and boundaries, increasesdifferentiated relating with reduced polarizations between children andparents, and the highlighting of unhelpful or inappropriate systemicsequences (Johnson et al., pp. Non-directive techniques have been found to allow the child more latitude forthe expression of their inner world and trauma. 2. Findings have shown that filial therapy results in reduction of parentingstress. The therapist does not attempt to hurry the therapy along. An understanding of the strengths andweaknesses of play therapy with particular application for the sexuallyabused child, is needed to help facilitate its appropriate use. Play therapy. Levy believed that repetitive play, aswith Freud's concept of repetition compulsion, would allow the child tointegrate the trauma, and to assimilate the negative thoughts and feelings(Gil, 1991, p. For this study 224 therapistscompleted questionnaires, which asked how play was used in their practice,including how they used play, their knowledge or use of assessments withplay, and any constraints. Play therapy assists with changing the parent-childrelationship (Borrego et al., pp. 5). (1997). Journal of Child Sexual Abuse, 4(3), 1- 12.Knell, S. 22 ). This has beenfound to be an effective form of individual psychotherapy treatment fortraumatic memories. She believed that play offered thecontext and meaning of these symbols (Guerney, p. Childhood PTSD and dissociative symptoms are found to be linked. The therapist maintains a deep respect for the child's ability to solve his own problems if given an opportunity to do so. For this child, playtherapy was the first intervention. 172-3). It is recommended that the clinician be trained in the useof play therapy and that the method not be used to prove or disprove sexualabuse (pp. Journal of Child Sexual Abuse, 5(2), 37- 58.White, J., & Allers, C. M. 495). (1997). (1996). Silberg (2 ) further reports on dissociative symptoms and disordersin children and adolescents, including effects, and recommended treatments. Cognitive-behavioral techniques have been presented. In T. Billig and Weaver (1996) report a case of doll therapy used tohelp a child cope with limb loss. C., & Kanny, E. The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship (pp. In a case example, play and filial therapy approaches were applied,demonstrating their effectiveness. Follow-up at 18 months showed that the child needed norestraints and no longer participated in verbal insults or coprolalia(Olson & Houlihan, p. It is a short-term, intensive approach which involves theparents as observers and then co-therapists. Cox reports that child psychotherapists rate family therapy asunpopular. M. Youngchildren, ages two to six, engage in prelogical thinking. Itis unclear whether the dissociation occurs on a continuum from normal topathologic, or if it is pathological and discrete from normal. They may view the counselor and adults as authorities only.Establishment of rapport may take longer since it may be difficult to helpthe child understand that their best interests are being considered by onewho is not only an adult, but must report certain findings to otherauthorities. Journal of Child Sexual Abuse, 5(4), 1 5-121.Mowbray, C. As part ofthe multiple assessment of the client, the range and degree of emotionaleffects of the abuse are great and the assessment technique must be able todetermine them. This takes place in four phases, the building of the client-therapist relationship, gaining understanding of the client's lifestyle andperceptions, helping the client gain insight into these findings andinterpretations, and reorientation and reeducation of the client, all donewith play therapy skills (p. 291). The use of play therapy in the preparation of children undergoing MR imaging. A. (1991). 393). One phase of treatment include theadaptation phase, with interventions that allow for emotional expressionand cognitive processing of the event. Borrego, Urquiza, Rasmussen, andZebell (1999) point out the importance of play therapy techniques for thepromotion of a positive relationship between parents and children. The goal ofmaterials is for them to be easy to use and durably constructed towithstand strenuous handling. The program consisted of two 12-week parts, one for thechild and one for the family. Six principles are described as essential: the counselorinvolves the child in an active therapy process through play; the counselorexamines thoughts, feelings, fantasies, and environment of the child with aproblem focus, rather than a client focus; the counselor helps the childdevelop more adaptive cognitions and strategies; CBPT is structured,directive, and goal-oriented; empirically supported interventions are used;and interventions use baseline information and follow-up measures fortreatment. Results showed that storytellingled to very little insight into behaviors for children aged three, due tolimited vocabularies and involvement. In some cases, the parent is trained to be a play therapist (pp.9 -97). For example, effective commands,statements and behaviors, paraphrasing appropriate verbal statements,imitating appropriate behaviors, and praising positive statements andbehaviors, are employed during the play session (Borrego et al., p. 98-99). (1999). T. Adequate empirical studies regarding the outcome of play therapy fortreatment of sexually abused children, are lacking. Journal of Marital and Family Therapy, 25(2), 169-177.Kelly, M. The role of play in pediatric occupational therapy. Forexample, studies fail to use consistent definitions of play therapy orchild sexual abuse, qualifications and roles of the play therapist are alsopoorly defined, play therapy materials are nonstandardized, samples aresmall using case studies and no controls, and statistics based on theseresearch designs are limited (White & Allers, p. This disorder ischaracterized by a pattern of impulsive and antisocial behavior, and manyfactors are associated with its etiology, including the effects of trauma.Trauma is defined as that in which the child experiences intense feelingsof fear, horror, or pain with helplessness. In 1996, threebooks on childhood dissociative disorders were published and the use ofplay therapy was described for treatment of the disorder. Dissociation is a mechanism employed by some abused children to denyand avoid the pain of their trauma. Non-directive play therapy has been described as a preferred treatment fordissociative children, however data to support this theory is lacking(Cohen, 1999, pp. Pressdee, May, Eastman, and Grier (1997) report positiveeffects of play therapy to help young children become prepared for MRimaging. M. New York: Wiley- Interscience.Kottman, T. Evaluations of researchpertaining to this topic, have been criticized, to include studies withpoor methodological sections, and inadequate statistical design. However, findings areconsistent and results show that maltreatedchildren demonstrate play behaviors showing "developmental immaturity,opposition and aggression, withdrawal and passivity, self-deprecation andself-destruction, hypervigilance, sexuality, and dissociation" (White &Allers, 1994, p. Since this population bringswith it issues such as withdrawal and anxiousness, non-directive methodscan be reassuring, however they may not allow for the inability of thevictim to take responsibility for the direction of their intervention. It isrecommended that the older child, teen or adult be asked if play therapy ispreferred or if they would rather discuss their problem. Themes such as anger, distress, sadness, or concernwere noted. (1999). In fact, play therapy techniques have led to the awareness ofspecific effects that can be used to help screen this population. Individualized doll therapy with children experiencing limb loss. Mechanical toys are not recommended since they may thwartcreative play. Returning responsibility to the child, helpsincrease self-reliance, confidence, and responsibility for the child. (1997). (1996). Journal of Counseling and Development, 74(4), 374-382.Gil, E. Palaestra, 15(1), 16, 59.Axline, B. The abilities are completely different than whatis required for traditional talk therapy. Relationship Therapies appeared next. EPT was developed by K.O'Connor, and designed to consider all systems in diagnosis and treatment.It was to help the child resume normal development and meet needs, withoutinterfering with others. The healing power of play: Working with abused children. (1997). Handbook of PT. Play therapy isdescribed as the use of a variety of interventions, that utilize play mediato approach the child's perception. Interplay demonstrated concerns with relationshipswith self and others and problems understanding sexual forces andattachment needs. The therapist is tofurther set appropriate limits, act responsible, and demonstratesensitivity to the child's feelings by reflecting them back to the child(Johnson, Bruhn, Winek, Krepps, & Wiley, 1999, p. A suitcase can be packed with small scale furniture, dolls,toy soldiers, nursing bottles, a telephone, and drawing or paintinginstruments, and this can be carried easily to any location. Studies, although replete with methodological problems, havedemonstrated that play therapy is an effective intervention for the manyeffects of trauma. Hambridge took this concept one step further and recreatedthe trauma for the child to re-experience and use play for catharsis(Schaefer & O'Connor, 1983, p. 5. Following the relief from the teasing, Chriswas ready to participate in EMDR (Greenwald, pp. Findings have shown thatabused children demonstrate the following play behaviors: "developmentalimmaturity, opposition and aggression, withdrawal and passivity, self-deprecation and self-destruction, hypervigilance, sexuality, anddissociation" (p. D. L., Oppenheim, D., & Emde, R. Whether the play therapy should be focused or non-directive remains a subject of debate. Filial therapy hasshown to improve parent-child communication and child behavior, as well aspartner communication and communication in relationships with othersoutside the family system. 376). For Chris, the enemy was someone who teased himrelentlessly, and this method, after a full session, was found to beeffective instantaneously. Orthopedic Nursing, 15(6), 5 -55.Borrego, J., Urquiza, A. Dissociation in children and adolescents: a developmental perspective. 89). The phallic child presents an unusual set of circumstances, for whichplay therapy sessions have been found to be beneficial. The history of treating children with this disorder began in 1984, withthe description of the use of hypnosis for children and parents with thedisorder. Childhood Education, 76(4), 215-219.Johnson, L., Bruhn, R., Winek, J., Drepps, J., & Wiley, K. Children may act out in ways such as sticking apretend needle in a stuffed animal's eye and the animal crying out in pain. With non-directive therapy theindividual is viewed as having the ability to resolve their own problemsand grow. In a study of treatments of sexually abused children, 5 children werereferred for treatment of sexual abuse and findings were related to therapytechniques. 8. Although there may continue to be discussion on the most effectivemethods within play therapy, use of this technique has been found to besuccessful with the sexually abused child. Play therapy allows for emotional expression andcognitive processing of events. Guidedmedical play allows children to relieve there distress from the illnessthrough imaginative play situations. Journal of Child Sexual Abuse, 4(1), 1.Schaefer, C. Sexuallyabused girls thought of themselves as ugly and sexually abused boys viewedthemselves as weak. Play in family therapy. Adlerianplay therapy combines individual psychology principles with those of playtherapy. Findingsshowed that play therapy was the most common modality for most goal areas.Child activities in therapy also demonstrated the predominance of playtherapy, with story/play occurring the most frequently which was followedby abuse disclosure and problem-solving regarding current issues (pp. 392). In a single-case study of Parent-Child Interaction Therapy(PCIT), the positive effects of this treatment, which included a playtherapy component, are reported. Research has also shown that these effects of play therapy, tend togeneralize to others, such as those siblings that were not included intreatment. Four treatment stages include assessment, introduction to playtherapy, middle stage (use of cognitive-behavioral and play activities),and termination (pp. In the 192 s, Melanie Klein developed Play Analysis, based onHellmeth's psychoanalytic work with children. Some themes were expressed by agesfour and five, including distress and aggression, however anger, sadnessand concern were not expressed. Kelly (1995) reports on factors associated with therapeutic changes inthe traumatized child, and proposes the use of play therapy for thesexually abused child. Can emotions and themes in children's play predict behavior problems? The Responsibility to make choices and to institute change, is the child's. 1). Prevention and intervention strategies with children of alcoholics. 26). Axline believed that children thrive in relationships ofunconditional positive regard. A mother requested therapy for her four-year-old son for separation anxiety, speech impediments, and refusing tofollow school directives. For this study, 51 children, agesthree, four, and five, completed 12 stories. Journal of Intellectual & developmental Disability, 23(4), 345-346.Bregman, O. (1994). Free symbolic play and assessment of the nature of child sexual abuse. Journal of Interpersonal Violence, 14(2), 2 8-211.Couch, K. They may repeatedly act out the trauma theyexperienced until they are told to stop. The therapist does not attempt to direct the child's actions or conversations in any manner. (1996). Treatment of sexually abused children: Interview technique, disclosure, and progress in therapy. Misconceptions regarding their illness or pain canalso result in heightened anxiety, confusion, and guilt. These attributes make the use of playtherapy for the sexually abused child, an appropriate choice. In K. T., & Bybee, D. Borrego, Urquiza, Rasmussen, and Zebell(1999) report that PCIT has been used to treat other problems, however itsuse with families at high risk for physical abuse, is lacking. Restating content, is the paraphrasing ofthe child's verbalizations, also used to build the relationship and conveyunderstanding and concern. The parents and their counselor observe the childand therapist, and learn. 7. Skills employed must be applicable tothe needs of children. Kindergarten and pre-kindergarten classrooms encourage playfocusing on health care themes. In a study evaluation of this program, playtherapy was found to be successful, demonstrating improved behaviors andcompetence (Emshoff & Price, p. Uses of Play Therapy Play therapy has been used with a variety of disorders, includingthose with psychiatric, and neurological and medical components.Psychiatric Disorders Beginning with psychiatric disorders, posttraumatic stress disorder(PTSD) offers an example of the use of this treatment for children. Children may lack abstract reasoning, may be egocentric, andmay be unable to see another's point of view. The use of child-centered play therapy and filial therapy with Head Start families: A brief report. Behavior Modification, 24(2), 2 2-222.Pressdee, D., May, L., Eastman, E., & Grier, D. (1996). Inthe last decade, interest in play therapy for this population hasincreased, however, evaluation of play therapy for the assessment andtreatment of childhood abuse trauma is still lacking (White & Allers, 1994,p. Previous studies have shown PCIT to effectively decrease childbehavior problems. In another study of play therapy used for treatment of effects oftrauma, adolescents with conduct disorder were studied by Greenwald (2 ),who reported on the effects of play therapy in a case example. Yawkey & A. Journal of Counseling and Development, 72(4), 39 -399.Zimmermann, P. Thereare many reported uses of play therapy in a medical setting, Billig andWeaver (1996) report the case of doll therapy used to help a child copewith limb loss. Physicalplay/exercise and limit setting were also frequently found. Clinical assessment of child victims and adult survivors of child maltreatment. They may lack abstractreasoning, may be egocentric, and establishment of rapport may take longer. Mowbray and Bybee reported the use ofplay therapy for the treatment of children who were victims of day caresexual abuse. Another experiment involving play therapy, provides further insightinto its use with different age groups. Sessions are to be fun,active, predictable and structured, and never involve physical hurting.Action rather than talk is used to direct therapy, by the counselor. Use of play therapy in the treatment of balance disorders. Bregman(1996) further points out that family therapy training lacks training forworking with children. Thus play was used to assist with the child'sdevelopment, within a systems perspective (O'Connor, 1997). (1994). J. History of Play Therapy Early traces of play therapy can be found in 1919, when H. These levels need to beunderstood. Therapist activitiesincluded four that occurred more frequently than others: playing games,telling stories, abuse questioning, and addressing self-blame. The very act ofsexual molestation results in the child learning that they do not have theright to make a personal choice, and this effect precludes the ability tomake a stand in their own therapeutic behalf (Rasmussen & Cunningham, 1995,p. The focus on filial therapy is to address problems that arewithin the parent-child relationship; it aims to teach the parentreflective listening, structuring, and limit-setting skills (p. Success led to the mother's realization of other difficultiesin her relationship with the father and therapeutic work to improve theirrelationship began (Johnson et al., pp. Teddy says "Hi!": Teddy bear clinics revisited. Play therapy and other outlets havebeen used during this phase, in many settings, including classrooms,particularly when dealing with disaster strategies (p. Numbers of parent-child interactionsincreased overall and became more reinforcing to both the parent and thechild (Borrego et al., pp. A. Play therapy as a component of PCIT results in positive relationshipchanges. 3 ). Journal of Child Sexual Abuse, 4(3), 31-44.O'Connor, K. Play therapy with sexually traumatized children: Factors that promote healing. 115). Its adapteduse with preschool children can be found with the Puppet-SentenceCompletion Task (by Susan Knell) (Knell, 1994). Theraplay, was developed by Jernberg in 1979. Axline describes the playroom and types of materials that can be used. In a caseexample of a 15-year-old boy (Chris), sentenced to a open residentialprogram after a month in a medium-security setting, play therapy was usedin conjunction with EMDR and other techniques. An example of a psychiatric disorder treated with playtherapy is posttraumatic stress disorder (PTSD) (Miller, 1999).Nondirective play therapy has also been described as a preferred treatmentfor dissociative children (Cohen, 1999). Playtherapy is used to motivate children. 332). Definition of Terms Play Therapy. However it was concluded that it would be unreasonable toassume that a child with special needs would cease all negative behaviors,and the focus was on teaching more new positive behaviors. Sexually abused children is defined as anylewd or lascivious act upon or with the body, or any part of memberthereof, of a child (up to 14 years), with the intent of arousing,appealing to, or gratifying the lust or passions or sexual desires of suchperson or of such child by an adult (Schneider, 1997). Dolls need to have removable clothes. The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely. O'Connor & L. In a study of 5 physically abused children ages 22 months to 13years, oppositional and aggressive or passive-aggressive play behavior wasdemonstrated in 12 of the 5 . Play Therapy Defined Play therapy views play as a child's natural form of self-expression,and play is therefore a place for the child to process feelings andproblems. A review of behavioral treatments used for Lesch-Nyhan syndrome. Playtherapy is used for both assessment and treatment of this group (White &Allers). 391). O'Connor & L. 1122). Treating parents and children together: A feminist look at exclusionary practices in family therapy and in child psychotherapy. Cognitive concepts are thenapplied. 391). 111). Research has demonstrated the debilitating effects of child sexualabuse, however, most of the treatment literature is focused on adultsurvivors. 4). 39 ). More current approaches include Ecosystemic Play Therapy (EPT) andCognitive-Behavioral Play Therapy (CBPT). Playtherapy has been used with many types of disorders, including psychiatric,and medical. The use of play therapy with children, is preferredin individual child psychotherapy, and it does not exclude parents. Alternatively, Cox states that since it is notedthat children are always with a parent, whether the parent stays in thewaiting room or sits in the therapy room, it is incorrect to suggest thatindividual child psychotherapy even exists. On the other end of the spectrum, dissociation and alteredstates of consciousness can be found in everyday life with the use ofreligion, drugs, television, and sex. The goal of family treatment for PTSD is to restore the family to itsprior level of functioning. Thesexual abuse victim may lack assertiveness and they may also be reluctantto bring up issues out of a desire to please adults. Examples of the use of play therapy in a medical setting areplentiful. (1998). This new focusshifted from the past to the present, which is experienced within theclient-therapist relationship. Children may feelas if they have done something wrong and need to be punished. This group is at risk for behavioral andemotional problems and eventual addiction. Journal of Clinical Child Psychology, 19(1), 55.Kness, S. In addition, children may fear being separated fromtheir parents; this fear is made worse by being placed in an strange placewith unfamiliar people. Themes such as stealing candy, separationfrom parents, arguing, loss or abuse have been successfully investigated(Warren, Oppenheim, & Emde, 1996, p. M. Within the treatment sessions, thetherapist coaches the parent and the child, helping them to learn positiveand relationship-enhancing skills. Arguments regarding causes andeffects of dissociative symptoms remain, as does the discussion ofeffective treatments for this disorder. It is suggested that the children be instructed not to act out with otherchildren, stating for example that the other children are not sick, andthis sends the message that medicine is only used to make someone well(Jessee, Wilson, & Morgan, p. Abused and neglected children have low self-esteem and describethemselves as bad. Axline lists eight principles to guide the therapist: 1. Cognitive-behavioral play therapy. Interest in play therapyfor this population has increased over the last ten years, however,comprehensive evaluation of play therapy for the assessment and treatmentof childhood sexual abuse trauma is lacking (White & Allers, 1994). By the fifth session, child, parents, andcounselors are all involved in the session, with all parties participatingin the last 15 minutes. Play therapy techniques are found to be appropriate forthe expression of intense emotions in children. The therapist must demonstrate genuineinterest and acceptance of the child, and allow the child the freedom toexplore and express themselves, with no restraint. The child was able to understand amputation, physical limits andbody image, and care of the prosthetic (p. 395). 2 8-211). it uses playfultreatment methods to model healthy interactions between parents andchildren. Sexual abuse of children: Strengths and weaknesses of current criminology. For this studythe Eye movement desensitization and reprocessing (EMDR) approach isdescribed. Medical play therapy for children is discussed by Jessee, Wilson, andMorgan (2 ). Group play therapy can be an advantage when thechild's problems center around social issues (Axline, 1969, pp. Vernon (Ed.), Counseling children and adolescents, second edition. Followingextinction, systematic desensitization, and play therapy, this treatmentpackage resulted in the successful elimination of the SIB. PCIT, with its mother-child interaction component, allows forthe learning of new behaviors (pp. Other instances of dealing with children in a therapeutic settinginclude interviewing and assessment. For example, a typical question raised by thestudent of counseling, inquires regarding protocol for situations when thechild simply won't talk to the counselor. Cognitive-behavioral play therapy in the treatment of encopresis. 374). (1996). J. In a study of 29 sexually and 52 physicallyabused children ages five to 14 years, sexually abused children showed morefear and anxiety (White & Allers, p. Chris imagined himself as a comic bookartist; he turned the peer who was his enemy, into a roach, erased him andthen made him explode. Kottman provides an overview of play therapy skills. Abused children have also been found to demonstrate withdrawal intheir play behavior, with avoidance, fear, and a lack of cooperation orattentiveness when dealing with adults. F. Filial therapy includes play therapy.In this case parents or caregivers use play therapy with their ownchildren. It has been concluded that treatment of thispopulation requires techniques that will allow for the establishment of atherapeutic relationship and deal with the effects of the trauma. M. In fact, sexual behavior has been found to distinguish this group fromothers such as physically abused and nonabused. In one study, sexually abusedchildren (n=15) were found to be more passive but not particularly negativeor antisocial than physically abused (n=11) and nonabused children (n=1 ).In fact, this group would play alone unless approached, and then would behighly compliant to the adult's request (White & Allers, p. Playtherapy has been historically viewed as the most effective modality fortreatment of children. A mere visit to a doctor can be stressful for a child, andif the visit is due to illness or accident, the trauma is exacerbated,particularly if the child needs to be restrained or is forced to endurepainful procedures. In clinicalsessions, play therapy was used to ascertain the meanings of different lifeevents, for the child. Content, style, and emotionaltones were identified. Most play therapists work with children, primarily between the ages ofthree and twelve. This process can take place in a directed or non-directedmanner. & Weaver, K. Pediatrics, 1 3(5), 1112-1122.Erdman, P., & Lampe, R. The sentence-completion task, a protective technique, is used toelicit information about the child's thoughts and feelings. Psychoanalytic theory continued to influence treatment and led toStructured Therapies such as Levy's Release Therapy, designed to helpchildren who had suffered a trauma. Other studies have found that play for thesechildren tends to be action-oriented to cope with stress, with lowfrustration tolerance, and with more physical aggression, hostility, orabuse toward others. Planned medical play allows the child toparticipate in their own learning process and as a result, understand whatis happening to them (Jessee, Wilson, & Morgan, p. (2 ). New York: Wiley & Sons.Olsen, L., & Houlihan, D. 4. Parent-child interaction therapy with a family at high risk for physical abuse. J. 9, 11, 16,22-23, 25). Kelly reports that the sexually abused childrepeatedly returns to three processes during treatment, the testing of thetherapeutic relationship, addressing the traumatic experience, and undoingdenial. Horton and Cruise (1997) further support the use of play therapy forthe clinical assessment of the child victim of sexual abuse. 1 5-112). Beyond Axline's principles of play therapy, Kottman describes Adlerianplay therapy, cognitive-behavioral play therapy, and theraplay. Journal of Clinical Child Psychology, 27(1), 28-34.Miller, L. 16, 59). Pressdee, May, Eastman,and Grier (1997) recommend the use of play therapy to help young childrenbecome prepared for MR imaging, based on their own success with thetechnique. A., & Zebell, N. Clinical radiology, 52(12), 945-947.Rasmussen, L. Successful treatments of this population haveemployed the use of play in therapy. Examples include child abuseor assault, automobile accidents, fires, and the witness of violence. Head Start programs serve children ages three to five years, and forthis age group, expression by means of play has been shown to be effective. Another case of a split identity and disavowed behavior wastreated successfully with psychoanalytic play therapy. When olderchildren or teens are involved, materials may be extended to include craftand carpentry tools, office supplies, complex games or therapeutic games.The efficacy of play therapy has been established for children andadolescents with aggressive behavior, conduct disorder, anxiety, withdrawnbehavior and depression, attachment disorders, and attention-deficithyperactivity disorder. Results showed that play was an importantmethod of motivating children and it was also used as a treatment orreinforcer. Cognitive-behavioral play therapy (CBPT), developed by Susan Knellcombines cognitive and behavioral concepts within the play therapytechniques. Tools used vary and maytypically include items such as dolls, doll house and furniture, nursingbottles, toy soldiers or army equipment, squirt guns, paper dolls, stuffedanimals, puppets, clay, crayons, paints, sand, water, peg-pounding sets,toy telephones, newspapers, pictures, empty baskets, and all types ofplayhouse items. Focused play therapy and non-directive play therapy: Can they be integrated? 374). 338-34 ). Play therapy with abused children: A review of the literature. Peoplewho have been severely traumatized may dissociate or develop pseudo-memories. American Journal of Psychotherapy, 49(3), 428-439.Jessee, P. Braverman (Eds.). Sexually Abused Children. C. It is believed that the sexually abused child anticipatesabusive sexual interaction with others, which may be subtle or coercive.It is also possible that the hypervigilance may be a manifestation of thegeneral level of anxiety. Treatment of children brings with itchallenges due to lack of interest, attention, and motivation. The American Journal of Family Therapy, 27(1), 21-34.Mordock, J. Since empirical findings regarding treatment of theseeffects with play therapy are lacking, it appears that further study of theuse of play therapy for assessment and treatment of this population iswarranted. J. The therapist takes responsibility for guiding and interpreting indirective therapy. Thus it was hypothesized that the use of play therapy, orspecifically filial therapy with families served by Head Start, wouldresult in reduced stress levels for these families. (1999). (1999). The toys should also help the child and therapist establish apositive relationship, test limits, increase self-control, enhanceunderstanding, reenact experiences, and improve self-image. Treatment of children sexually abused in a day care setting. Play therapy is proposed as a model to address these events. M. (2 ). Tracking, isused to describe the child's behavior, to the child, in an effort to conveythat what the child is doing is viewed as important, thus building thechild-therapist relationship. Infact, play therapy has been used to demonstrate the child's unconsciousprocess, their cognitive processes and behaviors, and the family or socialsystem (Cox, 1997, p. Researchers attempt to identify psychiatric disorders orother behaviors through interpretation of the child's play. These were based on Otto Rank'stheory of birth trauma and its effect on development. Women & Therapy, 2 (2), 89-1 .Emshoff, J. Counseling children brings with it challenges that are unique andtechniques are needed that are applicable to the needs of children (Erdman& Lampe, 1996, p. A room that is set aside and appropriately furnished is helpful but notessential; play therapy can take place in the corner of any room.Equipment that allows for the viewing of the session, such as one-wayscreens are also helpful, but not necessary. Much of the focus on this group hasincluded attention to child abuse and domestic violence, however, otherinstances such as disaster stress and bereavement due to homicide alsoresult in PTSD, and this patient group has unique therapeutic challengesthat play therapy has been found to successfully assist with (p. Asand box makes a nice setting and it is a medium for aggressive play(things can be pounded and buried and gotten rid of) (pp. (1983). Treatment of the abused child is known to be critical and morestudies are needed regarding the best approach. Toy selections are described in more general terms than with Axline.For Kottman, toys or play materials need to allow for many emotional andcreative expressions, be interesting to the child, facilitate verbal andnonverbal investigation and expression, encourage mastery, and be sturdyand safe. Child Maltreatment, 5(2), 119- 136.Warren, S. Play is considered to be one of the most effective ways of reducingthe child's stress level. New York: Gilford.Gold-Steinberg, S. Play therapy in counseling settings. 1 1-1 2). It also emphasizes mastery and predictable structure (pp. 391). Other structured therapies include Active PlayTherapy, by Solomon, which was used to treat impulsive and acting-outchildren, based on the catharsis principle; rage and fear were expressedthrough play. Hunter (1995)presents findings of a case study of a ten-year-old boy. Caseexamples demonstrate that as the cycles progress and the child becomesoverwhelmed and returns to denial of therapy, the urge to play out issues,results in the child voluntarily returning to play (pp. N. He then made thetherapist the doctor and stated that each could help the other, using foodto fill needs of hunger and using doctoring to care for hurts or ills.Appropriate behavioral interventions to be used, in the selected fosterhome and adoptive home, were based on the findings that were learnedthrough play therapy sessions (p. 31-41). Integrating play therapy in the treatment of children with obsessive-compulsive disorder. The author suggests thatwith proper use, free symbolic play can be used to understand and treatsexual abuse. Miller(1999) reports on the effects of PTSD. Pellegrini (Eds.), Child's play: Developmental and applied. Studies have also shown that play therapy ishelpful for children who have been abused or who suffer from divorce,grief, adoption, illness, and severe trauma (Kottman, 1999, pp. Counselors do agree however, that treatment of the abused childis critical and more studies are needed regarding the best approach. Adapting basic skills to counsel children. This work influenced Virginia Axline's treatment approach for troubledchildren. Acceptance by thetherapist, of the child and the child's free expression, further allows forthe process to take place. For example, with the use of dolls, the child acted outa scene in which the child was abandoned by his mother and the child soughthis mother for the rest of his life, until he joyously re-united with her.In another instance the child pretended to be a baker with the use of a toyoven, and Play Doh which was used to make cookies. (1998). For this treatment approach, eyes are rapidly moved from sideto side while the most distressing part of a traumatic memory is recalledand the process continues until the distress is alleviated. With the use of pretend medicalequipment, the child is able to express thoughts and feelings, resolveconflicts, and achieve mastery and coping through the assimilation ofreality. Ecosystemic PT. For sexually or physically abused children, it isbelieved that this behavior may be a way of acting out an identificationwith the abuser (White & Allers, p. New York: Wiley-Interscience.Schneider, J. They may have no concept oftime. Literature findings report that abused children demonstrate thefollowing behaviors during play therapy: "developmental immaturity,opposition and aggression, withdrawal and passivity, self-deprecation andself-destruction, hypervigilance, sexuality, and dissociation" (White &Allers, p. Research on treatment strategiesis sparse. 73-74).These eight principles provide an accurate portrayal of the therapeuticrelationship aspired to in non-directive play therapy. Mowbray and Bybee (1995) reported results of outpatient therapy for 56children who were victims of day care sexual abuse. Families in Society, 77(7), 453.Bromfield, R. 53-55). The authors concluded that there is a need to increaseemphasis of play in curricula and continuing education (p. Journal of Counseling and Development, 76(1), 94-1 4.Hunter, J. 428-432). 1-5). Trauma isproposed as a key to understanding conduct disorder. Stuffed animals and dolls help the child act out feelings of anger,fear, and loss of control. The author notes that a child's freesymbolic play has been used as an assessment tool in many instances such asfor autism, thought disorders, hyperactivity, and depression. 216). (1969). Kottman describes the goals of play therapy to include the following:enhancement of self-acceptance, confidence, and reliance; increasedunderstanding of self and others; exploration and expression of feelings;increased ability for self-enhanced decisions; practice of self-control andresponsibility; exploration of alternate perceptions of situations andrelationships; learning and practicing of problem-solving skills andrelationship-building skills; and increased feeling vocabulary with theincreased formation of emotional concepts (p. Numbers of parental praises and descriptions increased, whilenumbers of negative child behaviors decreased. Therelationship between trauma, dissociation, and memory is not clear. Virginia Axline describes non-directive play therapy,where the child directs and interprets. (1995). PCIT points out the importance of play therapy techniques for thepromotion of a positive relationship between parents and children. 331-332). Olsen and Houlihan (2 ) report onthe use of play therapy as a treatment option for Lesch-Nyhan syndrome.This disorder is genetic and results in hyperuricemia, choreoathetosis,mental retardation, and self-mutilation. Journal of the American Academy of Child and Adolescent Psychiatry, 35(1 ), 1331- 1337.Wershba-Gershon, P. In spite of these problems, studies have consistently concluded thatplay therapy has been effective for the treatment of the child sexual abusevictim. Autism offers another example of a disorder that has benefited fromthe use of play therapy. (1984). The therapist is alert to recognize the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behavior. In K. Braverman (Eds.), Play Therapy: Theory and practice. Zimmermann and Santen (1997) further report that the use of adoll or teddy bear has been found to be an effective way to reach childrenregarding many of their health needs (p. J. Researchhas demonstrated that physically abusive parents are distinguished fromnonabusive ones, since abusive parents lack positive parent-childinteractions and they engage in aversive discipline strategies that areless effective. Fifteen years of dissociation in maltreated children: Where do we go from here? L. Cognitive andlanguage delays have also been found comparing abused and neglected infants(White & Allers, p. 332-338). In some cases, play objects were used to inflict self-harm (White & Allers, p. 156-162). Types of therapyplanned included play therapy as the most frequently planned approach (47%to 8 %), individual therapy was commonly planned for, and family therapywas planned for between 2 % to 53% for all goals. This research study will critically explore existing literatureregarding play therapy for children. Outcomes of Play Therapy for Sexually Abused Children Research has demonstrated the disastrous effects of sexual abuse ofchildren, however, most of the treatment literature is focused on adultsurvivors. Next a focus on the concept oflimit setting within the therapeutic relationship was noted (Shaefer &O'Connor, 1983). Although the trauma may result in many differentsymptoms, the development of conduct disorder is found in some cases (pp.146-7). Techniques that work effectively with adults may need to bemodified for working with children. (2 ). The importance of the therapeuticrelationship was brought to the forefront. She translated her observationsfrom watching a child at play, into symbols that were designed to detecthostile and sexual wishes toward the child's parents (Guerney, 1984, p.291). One group received play therapy, another received verbal andplay therapy, and ranges of individual sessions were one to 97.Relationships between disclosure and improvement ratings were not found fordifferent groups. 2 7). Examples of play found with thisgroup, are the child who repeatedly rolls worms out of clay, or the childwho tries to force one toy into another (White & Allers, p. The self-injurious behavior (SIB)is the most prominent feature of the disorder. The family environment is animportant influence on all children, and particularly with COAs.Intervention strategies tend to focus on skills building and alternativeactivities, that exclude drugs and build self-efficacy (pp. Limited verbal skills may demand that the self be expressed throughtechniques of play therapy (Erdman & Lampe, p. The history of play therapy is said to be based on the work of CarlRogers (1951) who developed the client-centered approach for adult therapy. J., Rasmussen, R. 393). 112). Withinthe play therapy format, the therapist uses social reinforcement to assistwith the positive behavioral changes. Medical play for young children. Other recurrentpatterns of play found with this group are unimaginative and literal playand repetition and compulsion. 41). Playing out the feelings in this manner is thought to allow thechild to be themselves, and bring problems to the surface to either dealwith or let them go. 391). Kottman further states that play therapy techniques cannot be learnedsimply by reading a book. 169). Standard interviews and diagnostictechniques have been shown to produce poor results with children under theage of eight. According toPiaget's stages of cognitive development, the young child is pre-operational and may believe that being sick is a result of a bad thought oraction, and that the illness is due to an external phenomenon coincidingwith the illness (p. M., & Moore, D. In a study of 37 physically abused children and 37nonabused, ages 4.6 to 14 years, abused children had significantly lowerself-concepts and had less friends and were less ambitious. It allowsthe expression and reworking of a trauma and it is a source of informationfor the health care provider. Greenwald discusses the use of play therapy with EMDR. In a study of one individual with this disorder, play therapy was usedto allow the subject to verbalize thoughts and feelings. M. Educational requirements andclinical experience necessary for the practice of this modality are listedby the Association for Play Therapy and the Canadian Association for Childand Play Therapy/International Board of Examination of Certified PlayTherapists (p. International Journal of Offender Therapy and Comparative Criminology, 44(2), 146-163.Guerney, L. G., & Santen, L. Thus parents and their relationship with theirchildren, receive coaching, as new behaviors are learned (pp. G. Findings were explained, with theconclusion that emotional conflicts are overcome by fictional aggressionand thus feelings such as sadness are not expressed (Warren, Oppenheim, &Emde, p. von Hug-Hellmeth used play to analyze a child. Denver: Love Publishing.Knell, S. Information regardingoverall generalization to the home environment also was not available; theresearch took place in a medical center and home visits did not occur.Follow-up visits showed that negative behaviors had increased, at five and16-months. J., Deitz, J. In A. Couch, Deitz, and Kanny (1998) examined roles that play is helpful inoccupational therapy for preschoolers. Anna Freud also used play as a means of creating a therapeuticrelationship with clients who were children. 172-3). O. Mostchildren made progress during therapy and there was no indication thatstructuring the sessions to help with disclosure, had any adverse effects.Results did indicate that structure was needed initially and ongoing, toobtain disclosure (Mordock, 1996, pp. It is suggested that these materials should beplaced in the same location for each session (pp. Cognitive-behavioral PT. The therapist accepts the child exactly as he is. Therapy with children has been discussed in relation to treatingparents and children together, with further regard for family therapy andchild psychotherapy. These parents also have negative expectations regardingtheir child's behavior and have a greater acceptance of corporalpunishment. It has been found thatthese children assume all adult relationships will include sexual contact,to the point of inviting the therapist or demonstrating other inappropriatebehaviors such as masturbating, or grabbing others. It is a gradual process and is recognized as such by the therapist. 119-132). It is suggested that an integrationof both might provide the most appropriate solution (Rasmussen &Cunningham, 1995, p. 3. Children are different from adults on many levels, includingcognitive, emotional, physical, and psychological. The phallic child: Its emergence and meaning in a clinical setting. London: Erlbaum.Horton, C. Children of Drug Abusers and Alcoholics, an early intervention programfor high-risk children (COAs) ages four to ten, consisted of play therapyactivities for the child alone and the child and the parent in aninteraction group. Developmental play age, is recommended as an assessment technique forthe evaluation of child abuse or neglect. (1998). (1999). 376). Thechild makes most decisions that come up in the play session, which helpsthem practice and increase mastery and control. Using the child'smetaphor, is the nature of the communication in play therapy, which returnsresponsibility to the child. B., & Cruise, T. 293). In the case of two seven-year-oldfemales, one received play therapy and results showed that this therapy wasbeneficial in the treatment of the disorder (p. International Journal of Offender Therapy and Comparative Criminology, 41(4), 31 -324.Silberg, J. Child & Adolescent Social Work Journal, 12(6), 435.Cohen, J. A trauma-focused individual therapy approach for adolescents with conduct disorder. Play observation is part of the interviewing process to quicklydetermine cognitive developmental level. 1331). Play therapy. Numbers of parentalcommands decreased, and child compliance rates increased, showingacquisition of discipline skills. 1112-1118). New limit-settingskills resulted in effective leadership skills which replaced control-basedstrategies. Feelingsof shame, negative self-concept, treatment resistance, and psychosocialadjustment were all addressed with this technique (p. Emshoff and Price (1999) studied prevention and intervention techniquesfor these children. Since it has been shown that play therapyis an effective method of treatment for children, and for treatment oftrauma, it is reasonable to recommend play therapy for the treatment ofsexually abused children. Play Therapy is defined as a therapeutic situation,directive or non-directive, that employs the use of play materials as amodality in which the client processes feelings and problems (Axline,1969). American Journal Occupational Therapy, 52(2), 111-117.Cox, N. Zimmermann and Santen (1997) further report the effective use ofa doll or teddy bear to reach children regarding their health needs. (1997). K. 1331). After tensessions, biting, head banging, neck snapping, spitting, and vomiting werereduced to zero occurrences per hour and stayed at that level for the finalfive sessions. 169). Focus tended to be on symbolic expressions of sexual oraggressive conflict with parents, and it was thought that insight intothese dynamics would help to change the inappropriate behavior (Guerney, p.293). (1999). 392). White and Allers reviewed the literature pertaining to play therapyfor treatment of abused or neglected children. The authors conclude that although individual therapy andpaper-and-pencil techniques are helpful in their own way, they are limited,and more is needed. With reflecting feelings, of the child or playobjects, the relationship is deepened and the child is helped to furtherexpress and understand. the child leads the way; the therapist follows. Physically and sexually abused children demonstrate hypervigilantbehaviors. For example, play therapy has shown potential for thetreatment of dissociation, self-injurious behavior, relationship problems,and other trauma effects. 9 ). Play episodes may reveal a dream-likestate or disconnectedness from the immediate environment. Journal Emergency Nursing, 23(1), 41-44. 392). Thus counselors of children needto become aware of characteristics and needs of this population (Erdman &Lampe, 1996, p. The therapy is reported to have bridgedthe communication between the health care providers, the patient and thefamily. Forexample, toy or play materials may be rubbed or poked in the genital oranal areas (White & Allers, p. 391). B. The use of play therapy has been documented as early as 1919, when H.von Hug-Hellmeth used play to analyze a child by translating herobservations of a child at play into symbols designed to detect hostile andsexual wishes toward the child's parents (Guerney, 1984, p. Atheraplay counselor works with the child and the interpreting counselorworks with the parents. COAs deal with the alcoholism of their parents and itseffects, for many years. Aufsesser (1999) reports on the use of play therapy for balance inchildren suffering from necrosis of the left hemisphere of the cerebellum.In this instance, treatment goals include improvement of coordinatedmovements and increased stability. (1996). 1 7). (1995). New York: Ballantine Books.Billig, T. Non-directive principles can help build therapeutic rapport and directapproaches can lead toward specific goals. ReferencesAufsesser, P. A more reasonable solutionmight be to actively involve both the parent and the child in thetherapeutic situation and play therapy offers a possible solution to thisproblem. (1999). This patternsuggests the need for booster sessions over time to compliment the program. (1995). The mother was taught filial therapy skills.After implementing the techniques, the mother reported that she was havingfun with her son, and finding her own child within. 114-115). 21). The use of puppets in play therapy. Braithwaite (1998) reports that play therapyalong with holding therapy, and facilitated communication, are used fortreatment of autism in children and adults.Neurological/Medical Play therapy is used for treatment of disorders related toneurological and medical challenges. Pouting, crying, being silent, laughing, fighting, orfidgeting are all natural means of expression for the child. (1995). She attempted to developindividual uses of symbols rather than use a preexisting set of symbols,for the understanding of the child. In this case, however, a limitation of the study was that thefindings regarding the sibling were not included. 5 ). Children are viewed as become bored or being distracted duringfamily sessions, and in many cases of family therapy, children aredismissed readily to focus on the marital relationship (p. Play therapy: Theory and practice. This is viewed as further support for the effectiveness of theintervention. Sexual behavior has been found in studies of sexually abused children. E., & O'Conner, K. For Kottman the play therapy space would ideally measure around 12feet by 15 feet, have privacy, washable wall and floor coverings, securelyattached shelves for child access to toys, a small sink with cold water,and countertop space for artwork, a marker or chalkboard, a small bathroomattached, noise reducing acoustical ceiling, wood or plastic furniture, aone-way mirror and observation equipment, and a location where noise is nota concern (pp. Results of this study demonstrated that PCIT led todecreases in the child's behavioral problems and decreases in stresslevels. Play therapy hasbeen used to help children enact traumatic events and symbolically achieveresolution. Unpleasant experiences can be minimized. Child Maltreatment, 4(4), 331-342.Braithwaiter, M. 37, 42). Children are different from adults cognitively,emotionally, physically, and psychologically. (1997). Johnson, Bruhn, Winek, Krepps, and Wiley (1999) further report on theuse of play therapy techniques in family therapy. Wershba-Gershon (1996) discusses the use of free symbolic play andassessment of child sexual abuse. (1995). Limiting, is practiced to protect the childand therapist from harm and enhance self-control and responsibility (pp.1 4-11 ). In another study, sexually abused children revealed theabuse details in their stories, drawings, or symbolic play (Mordock).Whether directive or non-directive methods or both should be used with thispopulation, may remain questionable, however, play therapy has been foundto be the treatment of choice, yielding positive results. Recommendation of Play Therapy for Sexually Abused Children Research studies regarding negative consequences of sexual abuse forchildren have been reported. A limitedsophistication regarding verbal skills may demand that the self beexpressed through techniques of play therapy (Erdman & Lampe, p. Includedin the literature review will be a presentation and analysis of the playtherapy technique, the history of play therapy, current uses of playtherapy, and treatment outcomes of play therapy. Efforts are to validate the child's emotionalreaction, minimize secondary stresses, and provide support while helpingthe child regain a feeling of safety. American Journal of Orthopsychiatry, 69(4), 495-514.Greenwald, R. The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible. a. Children of alcoholics (COAs) present another constellation ofproblems for which the use of play therapy has been found to be beneficial. Play therapy helps toprovide a safe situation where the child can explore and ventilate theiraffective experience (p. However, Greenwald points out that treatment programstend to be week when it comes to the workingthrough phase. Treating posttraumatic stress disorder in children and families: Basic principles and clinical applications. Gold-Steinberg and Logan (1999) report the successful use of playtherapy for the treatment of obsessive-compulsive disorder in children.Play therapy techniques were shown to be helpful in a case study. Counseling Children With Play Counseling children brings with it challenges that are unique to thisclientele. Efficacy of behavioraltreatments with SIB have been documented, however the use of theseinterventions with Lesch-Nyhan syndrome have yielded limited results (p.2 2). 112-113). Facial expressions, physical acts and comments were noted, aswas coherence, interest, and involvement. For example,children are asked to compete stories that the investigator begins, withtoys, dolls, and play furniture. Toys mustrepresent five categories: family/nurturing, scary, aggressive, expressive,and pretend/fantasy toys. (1999). Children in play and play/talk groups, both revealedabuse details in stories, drawings, symbolic play or metaphors.
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