Pedra Ane clearly recalls the battle that played out in her office several years ago. It was orchestrated by a 7-year-old client who deftly maneuvered several plastic Army figures even as he worked through some of his toughest, most deep-seated issues.
Ane, a counselor and registered play therapist who runs a private practice in The Woodlands, Texas, says the boy had grown up in a violent household with his brother and mother. They eventually moved to his grandmother’s house, but initially, the chaos continued. “Each session, he would spend long periods of time setting up soldiers all over the playroom in well-considered, strategic places,” Ane says. “The play consisted of the children being kidnapped from the dollhouse and tortured by the ’bad guys.’ This play scene repeated each week for over a month. The details were replicated with precision.”
But over time, a new character emerged: a rescuer for the children. “This rescuer held the bad guys away from the children at risk of personal injury and was willing to kill the bad guys to protect the children,” Ane says.
As his play evolved, the boy’s trust in his grandmother’s ability to protect and care for him was also growing, says Ane, a member of the American Counseling Association who taught public school for 18 years and worked as a school counselor. “Through his acting out of scenes where the rescuer was consistently successful at keeping the children safe, the boy began to see the possibility that his grandmother could be, and had been, consistent in her protection of him. Through his play, he gave her many opportunities to leave or to fail, yet she was always valiant, and each mission was accomplished in her efforts to protect the children. Seeing her success played out with toys gave him a concrete example of her consistency and success.”
Experts say play therapy is often perfect for kids because the techniques provide children with a developmentally appropriate means to communicate while also enabling them to work through tough times at least partially on their own. “Play therapy is very important to use with children because they don’t have the vocabulary, nor do they have the abstract thought, to describe and process what has happened in their lives,” Ane says. “Using toys gives them the tools that they readily understand to work through the issues they’re struggling with.”
“Play therapy is a developmentally responsive approach to helping children,” says Charles Myers, an assistant professor of counseling at Northern Illinois University. “It has a long history of research supporting its effectiveness in addressing a wide variety of presenting concerns. Play is the natural language of children, and through play, they learn about themselves and the world around them.” The traditional age range for clients in play therapy is 3 to 12, Myers says, but there is an increasing trend to use it with adolescent, adult and geriatric populations as well.
“All counseling needs to be responsive to an individual’s developmental level,” says Myers, a member of ACA and a registered play therapist supervisor. “By its very nature, traditional talk therapy is abstract.” Children in the prime ages for play therapy are more concrete in their thinking and use symbols to communicate abstract feelings and experiences that they can’t convey through words. “Play bridges that gap,” Myers says.
Children first
As with talk therapies, there are a variety of play therapy approaches — about 15 in all. Myers uses child-centered play therapy (CCPT), which is based on Carl Rogers’ person-centered therapeutic approach. “As a CCPT play therapist, I believe children have an innate ability to grow in a positive direction,” Myers says. “I provide children with a range of toys that facilitate their full expression of emotions. Children use toys and their play to communicate their experiences, to try on new roles, to gain understanding of the world around them and to make traumatic experiences manageable.”
The child-therapist relationship is the element that encourages healing, Myers says. “When the play therapist creates a warm and accepting environment, the child feels safe and supported and is able to make those changes that lead to growth. The basic CCPT skills play therapists utilize include tracking, reflecting, returning responsibility, encouragement, self-esteem building and therapeutic limit setting. Through these skills, play therapists communicate their caring and understanding to the child and facilitate change.”
Jeff Cochran, coordinator of the University of Tennessee Mental Health Counseling Program, is also a believer in the child-centered approach. Along with his wife, Nancy Cochran, he provides play therapy for at-risk children at a large elementary school with a high poverty rate in Knoxville. He echoes Myers in saying that the client-counselor relationship is incredibly important in play therapy. “You provide a variety of toys that are all designed for child self-expression. … [but] you’re the best toy in the playroom. It’s the child’s relationship with you that’s going to be therapeutic or not.”
Play therapy can help in addressing a wide range of children’s issues, from adjusting to a divorce or overcoming separation anxiety to healing from traumatic events such as sexual abuse or a significant loss, says Cochran, a board member of the Counseling Association for Humanistic Education and Development, a division of ACA.
Ane uses a child-centered approach in which she follows the client’s lead. “I enter only as much as I’m invited to,” she says. “I reflect and I track what the client is doing. I don’t give judgments. I allow the child to play pretty freely with the toys. I am more of an observer, unless I am asked to join.”
Noting that some play therapists think it’s important never to ask their young clients questions, Ane says she asks questions for clarity. This allows her to ensure that her observations are accurate while reiterating to children that they are of value and that she respects their opinions, she says.
Terry Kottman, a registered play therapist supervisor, says she views play therapy broadly as any interaction that involves playful behavior, structured or unstructured play, storytelling, art techniques, games or sand tray strategies. Kottman developed the Adlerian approach to play therapy, which she describes as more directive and more focused on helping children gain insight into their own interpersonal and intrapersonal dynamics than child-centered play therapy.
Kottman, director of the Encouragement Zone, a play therapy training center in Cedar Falls, Iowa, says play therapy is usually the best therapy approach to take with children between the ages of 3 and 9 because their abstract, verbal reasoning skills are not fully developed. “With kids 9 or 10 and older,” she says, “I think play therapy is helpful in situations in which the child might be developmentally delayed or immature, or in which the child has been ’parentified’ or, for whatever reason, is too tight and needs to experience what it is like to be a kid.”
A parentified child is one who has been forced to assume a parental role in the family, Kottman explains. For example, if the parents are mentally ill or abuse alcohol or other substances. “Parentified kids tend to not know how to play, tend to not know how to be kids or how to have fun,” says Kottman, an ACA member. She might ask children growing up in these circumstances to write their name in shaving cream on the table or to make a pile of shaving cream and smush it around. “Part of the purpose is to help them remember or learn how to be silly and liked and not always have to have burdens or responsibilities. It helps them learn how to relax and be a little carefree. It also lets them practice how to share power with a safe adult.”
Of course, play therapy advocates must also be careful not to assume that the therapeutic intervention is automatically going to be right for every child just because he or she falls into the proper age range, Ane says. She recalls one 7-year-old client who walked into the playroom and said, “Can’t we just talk?”
“Knowing your clients and what’s best for them is important,” Ane says. “Being versed in a lot of different therapeutic techniques gives you the ability to know what you need to do with a specific client.”
Therapy in action
To the left as you walk into Ane’s office is a collection of toy animals and a dollhouse with figurines. Also close by are role-play items such as fairy wings, magic wands, superhero capes and purses with play credit cards and money, which Ane has found to be “very important” during the recession. To the right are baby dolls, a medical kit, plastic food and an assortment of puppets. Toward the back are toys that are categorized as aggressive — a Nerf pistol, a silver pistol that makes noise, a rubber knife, a Lone Ranger mask and rope. Ane learned through several play therapy courses that the way in which the playroom is set up is important. For example, she says, a child should never have to pass over an aggressive toy to get to a nurturing toy.
Ane lets her young clients decide which toys they want to play with. Usually, she says, they spend a few sessions exploring the different options. If a child is resistant to playing, Ane might start by engaging the child in a card game of his or her choice. The nature of card games is more structured and rule-oriented and, therefore, less overwhelming to the child, she explains.
Given enough time, “They’ll find what they need to play with,” Ane says. “It’s fascinating. They really do choose what they need to be working on.” Sometimes, the “right” toy comes as a surprise to Ane. One of her clients came to therapy after his father died. Despite being very angry about this loss, the child passed over the guns, the ropes and even the medical kit in favor of the food items. Ane says the boy used the food items to show that his dad, who had lost his life to cancer, hadn’t received enough nourishment. “The dad, toward the end, was not able to eat,” she says. “[The boy] was using those food items to express his reality of how his father had passed away.”
Kottman incorporates play therapy into part of every session with most of her clients, including teens and adults. “I use puppets, figures, toys, etc., along with storytelling, art, active games, board games and sand tray play therapy with elementary-school-age kids, and storytelling, art, active games and sand tray play therapy with adolescent and adult clients,” says Kottman, the author of Play Therapy: Basics and Beyond, the second edition of which ACA is publishing this fall. “I also use play therapy techniques in my consultation with parents and teachers — and sometimes even a principal or two — and when I work with families.”
With younger elementary-age clients, Kottman starts with play therapy and switches to other modalities if the client isn’t responding or engaging, but “since I have a wide range of play materials, this has seldom been the case.” With older elementary-age clients, she gives the choice of playing or talking. Almost all of them want to incorporate some element of play, she says, whether sketching, fiddling with toys or doing something else.
With teen and adult clients, Kottman usually starts by asking them to talk about their situations. “If the talking isn’t moving us where we want to go, I always consider switching to play,” she says. She often suggests transitioning to sand tray play therapy, doing an art activity or playing an active game, which can assist these older clients in viewing things from another perspective, gaining a deeper understanding of their problem or making a shift in their thinking, feeling or behavior.
Kottman also tailors the intervention to the specific client. With kids who are physical, she might try something sports-related. With kids who are artistic or musical, she’ll look to art or music interventions. With one teenage client who had very low self-esteem, Kottman came up with the idea of making insecurity and security blankets. She had the client take a piece of fleece fabric and a fabric pen and write down all the things she told herself when she was feeling down (for example, “I’m stupid. I can’t do well at school”). Then the girl wrote a counterpoint list on a different piece of fabric (for example, “I rock at school”).
The exercise clicked for Kottman’s client. “She said, ’So I get to choose if I wrap myself in the security blanket or in the insecurity blanket?’” Exactly right, Kottman told her.
School play
When Nicole Anderson, a licensed professional counselor and child development specialist at an elementary school in Fairview, Ore., first meets with a student, she begins by creating a family tree with the child. “While I ask questions about who is in their family, the child will draw all the family members,” says Anderson, an ACA member who also runs a private practice outside of school hours and volunteers her time providing free therapy to children in foster care. “I don’t get too specific because I like to see who the child draws and does not draw. I ask the child to draw a picture of what the family does together — not using the words ’likes to do together.’ I want to see where family members are placed, what they are doing, how colorful or big each one is.”
Anderson also inquires about how the family interacts. “I ask what happens at home when something goes wrong. I try not to use the word ’punishment.’ Maybe just ’If your mom or dad asks you to do something and you don’t, what happens?’ I also ask about family routines: ’What is something that happens every day when you’re home?’ I also ask, ’If you could change the activity the family is doing, what would you be doing instead?’”
Another of Anderson’s favorite introductory techniques is a matching game that features about 40 cards with pictures on them. Anderson and the client turn the cards facedown, mix them up and try to find two matching cards. “It really helps me understand the child’s ability to recall and follow directions, [plus their] listening skills, impulse control and how they manage feelings if they win or lose,” she says. “It is usually the first game we play in my office together.” Anderson also plays Uno with clients but adds Ungame cards into the stack that feature feeling and situation questions. In addition, she makes comic strips of coping skills with the students.
Anderson employs play therapy not only in working with individual children at her school but also in leading groups. Some of her group play techniques include puppet shows, art work and “feelings to faces” pictures, in which students draw pictures to represent feelings that are more complex than happy, sad or mad. Group members then try to guess what the feeling is before the picture is put up on the wall. “The group stuff is so great because the kids start reflecting to each other things that are happening in group so I don’t have to as often,” Anderson says. “For example, ’Wow, Joe, your picture has hitting in it.’ Or if one of the kids is upset with the rules, ’Joe doesn’t like that he lost his turn, but he’ll get another one soon.’ Simple things like that. After a year or so, the kids start to figure out they are here because they have things in common. Some of those conversations are powerful for them.”
Anderson recalls one student with selective mutism who spoke only with family members and select peers. In an effort to work on speaking goals, Anderson used puppets and a puppet stage in a group setting with the student and two of her peers. “I put sheets of construction paper over part of the ’stage’ so that I could not see the student’s face behind the stage. Initially, the two peers came up with storylines and did most of the talking while encouraging the student to have her puppet talk. She had the puppet whisper into the other puppets’ ears, but within four months, she was actually using regular voice for puppet talk.”
The student was able to make one- to three-word statements and was eventually able to speak to Anderson during individual sessions. “By end of the year, we were able to put the masks away and the student was able to perform reading assessments with me. To that point, we had tapes of the student reading, but she had not read to an adult at school. This was a big deal and a great way to work through the anxiety of selective mutism.”
A new perspective
One unique benefit of play therapy shouldn’t come as a surprise. Namely, it’s fun, Kottman says. “Although counseling can be serious business, it doesn’t have to be,” she says. “By using play and play therapy techniques, the counselor invites the client into a relationship in which he or she can make changes in an unthreatening, nurturing environment.”
In addition, most people learn better through doing than through talking, Kottman says. Play therapy techniques offer clients opportunities to shift their perspectives, gain new reference points and practice new behaviors, she says.
The symbolic nature of playing through one’s issues is also a strength of the technique, Kottman says. “Because play therapy is rooted in metaphoric, symbolic communication, clients can explore their issues in an indirect way. This creates a situation in which resistance and defensiveness on the part of the client can often be prevented or eliminated.”
Kottman calls play therapy’s ability to shift how a client thinks about a problem and give it new context a “metaphoric switch.” For example, instead of one dollhouse, Kottman has two, which sometimes ushers in a breakthrough for young clients whose parents are getting divorced. Kottman explains that she has two dollhouses because kids often go back and forth between two homes. “The kids will say, ’Other kids live in two houses, too?’ It somehow gives [the idea] permission,” she says.
Ane also mentions how play therapy’s metaphoric aspect can help clients see things from a new perspective, often unlocking the door to progress. A recent client was playing with Ane’s dollhouse, but instead of filling it with people, he had substituted animals. It was evident the animals represented family members, Ane says, but it was initially unclear which animal corresponded to which family member.
“The animals were interacting as group or family members would,” she says. “The aggressive animal was acting within the expected realm of behaviors — yelling, threatening, refusing to give care. The boy stated, ’This one’s the mom. She’s like our mom.’ He sighed deeply and changed activities. After that session, he was able to talk about his family dynamic more directly.” That’s sometimes the way play therapy works best, Ane says. “It’s the vehicle for transferring more symbolic information into concrete information.”
At Anderson’s school, play therapy helps students work through their issues without feeling as if they’re in trouble. Initially, she says, some students view her as the “interviewer,” akin to human services personnel, police officers or caseworkers who come to their homes and speak with their family members. “After play begins, the child recognizes that I play by the rules, that I will play fairly and that they can lead the play. We gain trust faster than most talk therapies would dream of,” Anderson says. “I think in child therapy, we are the keeper with the child, meaning images and experiences might be shared that I now can keep with the child and I will not punish them for it. I will still treat them respectfully.”
Sometimes, play therapy can even override the status quo in the child’s outside world, says Cochran, who coauthored the recent book Child-Centered Play Therapy: A Practical Guide to Developing Therapeutic Relationships With Children with William Nordling and Nancy Cochran. “Children in play therapy can make progress even if the systems they live in don’t change as much as we’d like them to,” he says.
On occasion, the child’s progress even serves as a spur for the family to make positive changes so it can continue to accommodate the child’s new behavior, Cochran says. In other instances, the family doesn’t change, but the child still improves. “While I would never give up on helping the family, if it’s a situation such that the adults in the family can’t change as much as I’d like them to, it doesn’t mean the child can’t turn his life around and make progress through play therapy,” he says.
Benefits aside, counselors say play therapy also presents challenges. “The first hurdle to get over is really a beginning counselor’s hurdle — believing that therapy for a child can be child-led,” Cochran says. “Our natural inclination is to think children are natural learners, with the idea being that we need to teach them something, that it can’t come from them.” In some cases, however, the reality may be that people have tried to teach the child something, but something is standing in the way of the child’s success — something the child needs to work out for himself or herself, Cochran says. “Until [counselors] see it work,” he says, “it’s hard to get their mind around, ’I can really facilitate an environment where the child can lead and be responsible.’”
A second challenge, Cochran says, is articulating to parents how play therapy will help their child. First, listen to the parent, he advises, and then offer an anecdote about how the child might benefit from play therapy techniques. Myers adds that involving and educating parents or caregivers throughout the therapeutic process is an important ingredient in encouraging progress beyond the playroom.
At times, it can be a struggle to meet parents’ high expectations, Ane acknowledges. “The major challenge I face with play therapy is not necessarily with the children but with the adults in their lives who expect changes to come quicker or expect to be able to see something concrete instead of letting the child work at the child’s pace,” she says. “If I were working with an adult who had suffered a trauma, I don’t think anyone would expect that after three sessions the adult would be fine. But with children, people expect the results will be very quick.” Ane regularly reminds caregivers that children process things differently than adults do and that progress will take time.
Certain counselors will view the very nature of play therapy as a challenge, Cochran says. “Some counselors can look at play therapy and say, ’Well, if this is child-led, I can’t set goals, I can’t have a treatment plan and I can’t measure outcomes.’ And I would say, ’Yes, you can. And you really should.’” One way to accomplish this is by sitting down with the teacher or parents and setting up a few goals with a rating scale and a comment sheet, he says. The parents or teacher can provide regular feedback. Another option, he says, is to use a standard rating scale that measures a wide range of behavioral and emotional difficulties. The parents or teacher can also fill out the scale.
Getting started
Many of the counselors interviewed say the Association for Play Therapy (APT) is an excellent starting point for those interested in learning about and applying the play therapy technique in practice. APT’s website (a4pt.org) offers an e-learning center, credentialing information, approved centers of play therapy education and more.
APT is also a good place for counselors to look for conference and workshop trainings, as well as university course work in play therapy, Myers says. He adds that training should include learning not only about the play therapist’s functions and skills, but also about the nuances of the playroom and materials and the role of the parent in the process. “Counselors interested in using play in their practices need to seek training and supervision in play therapy as required in the ACA Code of Ethics,” Myers says. “In addition, counselors using play therapy need to have an understanding of the developmental stages and needs of childhood. It is important that counselors believe in the uniqueness of children, that they are not simply miniature adults, and that children are capable of positive self-growth.”
Anderson keeps a copy of Virginia Axline’s book Play Therapy on her bookshelf and references it often. But in addition to play therapy techniques, Anderson says a foundation in crisis intervention and abuse training is also important. “Kids don’t sugarcoat things, and if you get a disclosure, the child needs you to know what to do next,” she emphasizes.
Given the various play therapy approaches, Kottman says it’s important for counselors to take the same things into consideration when choosing an intervention for children as they would when choosing an intervention for adults. “People should think about their own beliefs about children, how children get into struggles and how children can change [when] thinking about the kind of play therapy they want to do,” she says.
Ane recommends budding counselors get as much training as they can while still in school by taking play therapy courses offered by their respective college or university. The benefit, she says, is that the training is semesters-long, as opposed to workshops, where the training is shorter and more sporadic. “Workshops are wonderful. They are phenomenal,” Ane says. “But it’s difficult to get a good foundation at workshops. Getting training three hours at a time can cause gaps in your education.”
Kottman reminds her fellow counselors that they don’t need every toy on the market to be an effective play therapist. It’s more important to get good training, get good supervision and remember to have fun, she says.
Ane urges counselors to respect the powerful opportunity to work with child clients. “Children are often not respected as autonomous human beings and typically don’t have the power to make decisions about their lives,” she says. “The playroom is their world. An hour in the playroom can give them the strength to make it through one more week. I feel very honored to go with children on that journey.”