'
Floor Games (1911) inspired
Margaret Lowenfeld's play therapy Play therapy can be divided into two basic types: non-directive and directive. Non-directive play therapy is a non-intrusive method in which children are encouraged to play in the expectation that this will alleviate their problems as perceived by their care-givers and other adults. It is often classified as a
psychodynamic therapy. In contrast, directed play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioural difficulties through play. It often contains a behavioural component and the process includes more prompting by the therapist. Both types of play therapy have received at least some empirical support.
Jessie Taft (1933), (
Otto Rank's American translator), and Frederick H. Allen (1934) developed an approach they entitled relationship therapy. The primary emphasis is placed on the emotional relationship between the therapist and the child. The focus is placed on the child's freedom and strength to choose.
Virginia Axline, a child therapist from the 1950s applied
Carl Rogers' work to children. Rogers had explored the work of the therapist relationship and developed non-directive therapy, later called
Client-Centred Therapy. Axline summarized her concept of play therapy in her article, 'Entering the child's world via play experiences'. She described play as a therapeutic experience that allows the child to express themselves in their own way and time. That type of freedom allows adults and children to develop a secure relationship.(Progressive Education, 27, p. 68). Axline also wrote
Dibs in Search of Self, which describes a series of play therapy sessions over a period of a year.
Nondirective play therapy Non-directive play therapy, may encompass
child psychotherapy and unstructured play therapy. It is guided by the notion that if given the chance to speak and play freely in appropriate therapeutic conditions, troubled children and young people will be helped towards resolving their difficulties. Non-directive play therapy is generally regarded as mainly non-intrusive. The hallmark of non-directive play therapy is that it has minimal constraints apart from the
frame and thus can be used at any age. These approaches to therapy may originate from
Margaret Lowenfeld,
Anna Freud,
Donald Winnicott,
Michael Fordham, Dora Kalff, all of them child specialists or even from the adult therapist,
Carl Rogers' non-directive psychotherapy and in his characterisation of "the optimal therapeutic conditions".
Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is widely considered the founder of this therapy. Different techniques have since been established that fall under the realm of non-directive play therapy, including traditional sandplay therapy, play therapy using provided toys and Winnicott's
Squiggle and
Spatula games. Each of these forms is covered briefly below. Using toys in non-directive play therapy with children is a method used by child psychotherapists and play therapists. These approaches are derived from the way toys were used in
Anna Freud's theoretical orientation. The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalisation of their feelings. Through this experience children may be able to achieve
catharsis, gain more stability and enjoyment in their emotions, and test their own reality. Popular toys used during therapy are animals, dolls, hand puppets, soft toys, crayons, and cars. Therapists have deemed such objects as more likely to open imaginative play or creative associations, both of which are important in expression. Dora Kalff, who studied with her, combined Lowenfeld's World Technique with
Carl Jung's idea of the
collective unconscious and received Lowenfeld's permission to name her version of the work "sandplay". As in traditional non-directive play therapy, research has shown that allowing an individual to freely play with the sand and accompanying objects in the contained space of the sandtray (22.5" x 28.5") can facilitate a healing process as the unconscious expresses itself in the sand and influences the sand player. When a client creates "scenes" in the sandtray, little instruction is provided and the therapist offers little or no talk during the process. This protocol emphasises the importance of holding what Kalff referred to as the "free and protected space" to allow the unconscious to express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may not choose to talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may offer supportive response that does not include interpretation. The rationale is that the therapist trusts and respects the process by allowing the images in the tray to exert their influence without interference. Sandplay Therapy can be used during individual sessions. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to unconscious, symbolic material that can be further reflected in analytical dialogue. The ISST, International Society for Sandplay Therapy, defines guidelines for training in Sandplay Therapy as well as guidelines for becoming a teaching therapist.
Winnicott's Squiggle and Spatula games Donald Winnicott probably first came upon the central notion of play from his collaboration in
wartime with the psychiatric social worker,
Clare Britton, (later a psychoanalyst and his second wife), who in 1945 published an article on the importance of play for children. By "playing", he meant not only the ways that children of all ages play, but also the way adults "play" through making art, or engaging in sports, hobbies, humour, meaningful conversation, etc. Winnicott believed that it was only in playing that people are entirely their true selves, so it followed that for psychoanalysis to be effective, it needed to serve as a mode of playing. Two of the playing techniques Winnicott used in his work with children were the
squiggle game and the
spatula game. The first involved Winnicott drawing a shape for the child to play with and extend (or vice versa) a practice extended by his followers into that of using partial interpretations as a 'squiggle' for a patient to make use of. The second involved Winnicott placing a spatula (medical tongue depressor) within the child's reach for her/him to play with. Winnicott considered that babies will be automatically attracted to an object, reach for it, and then discover what they intend to do with it after a while. "Potential space" was Winnicott's term for a sense of an inviting and safe interpersonal field in which one can be spontaneously playful while at the same time connected to others. Playing with a transitional object can be an important early bridge "between self and other", which helps a child develop the capacity to be creative and genuine in relationships. Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as
Cognitive behavioral therapy. Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies included small sample sizes, which limits the generalisability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment. Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons. indicating that both non-directive play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups. and 0.66. Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behaviour problems. Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings. Play therapist requirements may differ from state to state, but generally, play therapists need a Master's degree or higher degree in a mental health related subject. They must also have demonstrated skills in the field of Child Development. After obtaining a degree, additional classes and work is needed to obtain a certification as a Registered Play Therapist (RPT). Additional work includes: 150 documented hours of instruction, specific to play therapy, a minimum of 350 direct client contact hours (under Supervision of someone who is a Registered Play Therapist Supervisor RPT-S), and 35 hours of direct supervision with 5 session observations.
Directive play therapy 's wooden Construction kit, 1782–1852 SINA Facsimile In the 1930s David Levy developed a technique he called release therapy. His technique emphasized a structured approach. A child, who had experienced a specific stressful situation, would be allowed to engage in free play. Subsequently, the therapist would introduce play materials related to the stress-evoking situation allowing the child to reenact the traumatic event and release the associated emotions. In 1955, Gove Hambidge expanded on Levy's work emphasizing a "structured play therapy" model, which was more direct in introducing situations. The format of the approach was to establish rapport, recreate the stress-evoking situation, play out the situation and then free play to recover. Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself. Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities. This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives. The filial approach emphasizes a structured training program for parents in which they learn how to employ child-centered play sessions in the home. In the 1960s, with the advent of school counselors, school-based play therapy began a major shift from the private sector. Counselor-educators such as Alexander (1964); Landreth; Muro (1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute significantly, especially in terms of using play therapy as both an educational and preventive tool in dealing with children's issues. Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate. Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of
Aaron Beck's cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy. In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children's verbalizations in these interactions but rather on their actions and their play. Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists to change children's maladaptive thinking.
Efficacy The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have. The commonalities between electronic and traditional play (such as providing a safe space to work through strong emotions) infer similar benefits. Video games have been broken into two categories: "serious" games, or games developed specifically for health or learning reasons, and "off-the-shelf" games, or games without a clinical focus that may be re-purposed for a clinical setting. Use of electronic games by clinicians is a new practice, and unknown risks as well as benefits may arise as the practice becomes more mainstream.
Research Most of the current research relating to electronic games in therapeutic settings is focused on alleviating the symptoms of depression, primarily in adolescents. However, some games have been developed specifically for children with anxiety and
Attention deficit hyperactivity disorder (ADHD), The same company behind the latter intends to create electronic treatments for children on the
autism spectrum, and those living with
Major depressive disorder, among other disorders. The favoured approach for mental health treatment is through
Cognitive behavioral therapy (CBT). While this method is effective, it is not without its limitations: for example, boredom with the material, patients forgetting or not practicing techniques outside of a session, or the accessibility of care. It is these areas that therapists hope to address through the use of electronic games. Preliminary research has been done with small groups, and the conclusions drawn warrant studying the issue in greater depth.
Role-playing games (RPGs) are the most common type of electronic game used as part of therapeutic interventions. These are games where players assume roles, and outcomes depend on the actions taken by the player in a virtual world. Psychologists are able to gain insights into the elements of the capability of the patient to create or experiment with an alternate identity. There are also those who underscore the ease in the treatment process since playing an RPG as a treatment situation is often experienced as an invitation to play, which makes the process safe and without risk of exposure or embarrassment. The most well-known and well-documented RPG-style game used in treatment is
SPARX. Taking place in a fantasy world, SPARX users play through seven levels, each lasting about half an hour, and each level teaching a technique to overcome depressive thoughts and behaviours. Reviews of the study have found the game treatment comparable to CBT-only therapy. However one review noted that SPARX alone is not more effective than standard CBT treatment. There are also studies that found role-playing games, when combined with the
Adlerian Play Therapy (AdPT) techniques, lead to increased psychosocial development.
ReachOutCentral is geared toward youth and teens, providing
gamified information on the intersection of thoughts, feelings, and behavior. An edition developed specifically to aid clinicians, ReachOutPro, offers more tools to increase patients' engagement.
Other applications Biofeedback (sometimes known as applied psychophysiological feedback
) media is more suited to treating a range of anxiety disorders. Biofeedback tools are able to measure heart rate, skin moisture, blood flow, and brain activity to ascertain stress levels, with a goal of teaching stress management and relaxation techniques. The development of electronic games using this equipment is still in its infancy, and thus few games are on the market.
The Journey to Wild Divine's developers have asserted that their products are a tool, not a game, though the three instalments contain many game elements. Conversely, Freeze Framer's design is reminiscent of an
Atari system. Three simplistic games are included in Freeze Framer's 2.0 model, using psychophysiological feedback as a controller. The effectiveness of both pieces of software saw significant changes in participants' depression levels. Extended Attention Span Training (EAST), developed by
NASA to gauge the attention of pilots, was remodeled as an ADHD aid. Brain waves of participants were monitored during play of commercial video games available on
PlayStation, and the difficulty of the games increased as participants' attention waned. The efficacy of this treatment is comparable to traditional ADHD intervention. Several online-only or mobile games (
Re-Mission, Personal Investigator, Treasure Hunt, and Play Attention) have been specifically noted for use in alleviating disorders other than those for anxiety and mood. Re-Mission 2 especially targets children, the game having been designed with the knowledge that today's western youth are immersed in digital media. Mobile applications for anxiety, depression, relaxation, and other areas of mental health are readily available in the
Android Play Store and the
Apple App Store. The proliferation of laptops, mobile phones, and tablets means one can access these apps at any time, in any place. Many of them are low-cost or even free, and the games do not need to be complex to be of benefit. Playing a three-minute game of
Tetris has the potential to curb a number of cravings, a longer play time could reduce flashback symptoms from
posttraumatic stress disorder, and an initial study found that a visual-spatial game such as Tetris or
Candy Crush, when played closely following a traumatic event, could be used as a "'therapeutic vaccine" to prevent future flashbacks.
Efficacy While the field of allowing electronic media a place in a therapist's office is new, the equipment is not necessarily so. Most western children are familiar with modern PCs, consoles, and handheld devices even if the practitioner is not. An even more recent addition to interacting with a game environment is
virtual reality equipment, which both adolescent and clinician might need to learn to use properly. The umbrella term for the preliminary studies done with
VR is
Virtual reality exposure therapy (VRET). This research is based on traditional
exposure therapy and has been found to be more effective for participants than for those placed in a
wait list control group, and facilitate social in-person and virtual interactions. Current data, though limited, points toward combining traditional therapy methods with electronic media for the most effective treatment. ==Play therapy in literature==