What is Play Therapy?

  • Jaskirat KanwalMasters of Science – MSc, Applied Neuropsychology. University of Bristol, UK

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Introduction

Play therapy is a type of psychotherapy that uses play and art as a means of expression and communication.1 Here, play is the primary medium and speech is the secondary medium. This is because recognising and explaining difficulties to others can be challenging when we don’t possess the words to link language to our experiences. In turn, play is an early, primary form of communication.

It is designed specifically for individuals who struggle to express themselves, understand their feelings and thoughts, and articulate their experiences through words. In most instances, this refers to children in need of therapeutic support but it can also be applied to adolescents and adults. In all, play therapy aims to address emotional, cognitive, behavioural, and mental health difficulties in a developmentally appropriate way.2

Understanding play therapy

There is a communication difference between adults and children largely because children need to possess the necessary language or articulation skills to communicate with others. In turn, children often demonstrate difficulty expressing themselves and their experiences to adults. Alternatively, adults may also misinterpret or completely miss a child’s verbal and non-verbal cues of expression.

Consequently, the child plays out feelings, emotions, and thoughts they may otherwise not be capable of meaningfully expressing through their words.3 In this sense, play holds symbolic representation and allows children to freely act out their inner feelings and deepest emotions at their own pace. 

Importance of play in human development

The significance of play stems from the fact that it serves as a primary means by which children learn, feel, explore, and make sense of the world. Play is thought to be a child’s natural mode of expressing their feelings and thoughts spontaneously and safely. Moreover, it encourages the development of new coping mechanisms and how to redirect inappropriate behaviours.

For instance, in play therapy sessions, individuals can explore and express themselves using the following media: drawing and painting, drama and puppetry, movement and music, water and clay, guided imagery and relaxation techniques, poetry, sand trays, and miniatures.

Throughout a child’s development, play is involved in emotional regulation, creativity, cognitive development, and socialisation. In this sense, play helps promote healthy brain development, adaptive coping skills, and resilience which can be used outside sessions.

Core principles and objectives

Several core principles underlie play therapy and guide its objectives and practice:

  • Acceptance and empathy – A non-judgemental, empathetic, and safe environment is created by the therapist to enable the patient to open up and feel understood
  • Self-expression – Play is a child’s primary form of communication, enabling them to freely and creatively express themselves
  • Symbolic communication – The materials and activities of play are symbolic representations of a child’s inner world, therefore their play provides a raw insight into their emotions, thoughts, and experiences
  • Therapeutic relationship – The therapeutic alliance between the client and the therapist is central to the healing process, fostering safety, trust, and collaboration. The therapist guides the client in their exploration and self-discovery
  • Emotional processing – Play allows the child to explore and process challenging emotions, thoughts, experiences, and conflicts at their own pace and comfort level

Types of play therapy

Whilst numerous variations of play therapy exist, the treatment styles can be categorised into one of the following ‘umbrella’ forms.

  • Directive play therapy – A more controlled environment where the therapist directs the session. They provide set instructions and supervise the child through specific play activities. Such activities are structured, task-based, and goal-oriented as the therapist is actively responsible for regulating the pace and intensity of the session4
  • Non-directive play therapy – A less controlled environment where the child directs the session. Here, allowing the child to take the lead promotes self-discovery and empowerment5

Research demonstrates the superiority of the non-directive approach over the directive approach given that it produces more significantly positive effects.6 This could be because children do not always require precise direction from the therapist so exploring at their own pace proves more beneficial.

More specific techniques of play therapy which are more tailored to the individual needs of the client include:

  • Child-centred play therapy – A non-directive approach where the child leads the session to explore at their own pace and level of comfort
  • Filial play therapy – Directly addresses family dynamics and parent-child attachments by training caregivers as therapeutic agents in the child’s play process7
  • Gestalt play therapy – Adopts principles of Gestalt theory by focusing on awareness, integration, and resolution of unfinished emotional experiences8
  • Theraplay – Structured play activities are employed to promote trust, attachment, and emotional regulation within the parent-child relationship9
  • Art therapy – Incorporates various art materials and techniques (e.g., painting, drawing, and sculpting) to promote symbolic communication, emotional processing, and self-expression10
  • Narrative play – Consists of storytelling, role play, and creative expression to reframe a child’s narrative and cultivate new healthier meanings of their experiences11
  • Pretend play – Encourages the child to explore different scenarios, promoting perspective, empathy, and problem-solving skills. This technique helps modify and replace maladaptive behaviours, cognitions, and emotions with new, healthier ones12

Cognitive perspective

Emotions, thoughts, and learning are physical, brain-shaping events. Neurons that fire together, wire together - meaning, brain cells that activate together form neural pathways maintained by and form the basis of a child’s cognition.13 Early life experiences are fundamental in the development of the brain.14

Research highlights that cerebral pathways linking higher and lower brain structures are strengthened when a child is assisted in linking words to feelings. It increases their ability to deal with emotions, stress, and thoughts later on in life.15,16,17

The sessions allow children to safely explore their identity, and work through difficulties to promote positive growth.

When is play therapy used?

For children aged 3-12 years, play therapy is a useful clinical therapeutic intervention for:

Whilst typically used for children, play therapy can benefit people of all ages.18 Individuals affected by the following may benefit from play therapy:

Role of the therapist

Play therapists are qualified mental health professionals who have undergone intensive academic and clinical training. These therapists are trained to work alongside children facing behavioural, emotional, and cognitive difficulties to help them understand what is happening.

The therapists provide an open, secure, and trusting space for self-discovery to explore emotions and thoughts without fear of judgment. Through observation, reflection, and interpretation, therapists help children make sense of their play, promoting insight, self-awareness, and emotional growth.19

Therapists personalise their approach to each child depending on their needs, preferences, and developmental level. The customised approach ensures the intervention is targeted, engaging, age-appropriate, and culturally sensitive. Furthermore, the therapist promotes a sense of structure and safety by establishing clear boundaries and routines. However, they allow for flexibility to accommodate the child's individual preferences.

This collaboration ensures the client is supported and empowered in their healing journey. The importance of the therapeutic alliance extends beyond the child, as a trusting partnership must be formed between therapist and caregiver due to their critical role in supporting the child's therapeutic journey and implementing strategies outside of sessions.

Benefits of play therapy

The significance of play should be acknowledged and understood in a therapeutic context, particularly when dealing with young individuals or those who struggle to express themselves.

Through play, children learn various skills and undergo numerous experiences, which help them form a sense of who they are whilst simultaneously learning to understand that other people can be different to them. In this sense, identity and relationship development alongside the correction of any unresolved trauma can be achieved through play therapy.

Overall, play therapy offers an effective approach to promoting psychological wellbeing and emotional growth.

Psychological benefits for children

  • Emotion regulation – Play therapy is a safe and secure environment for children to express and regulate their emotions as well as foster the development of coping strategies 
  • Enhancing communication skills – Play helps children to non-verbally and symbolically communicate their experiences, feelings and thoughts
  • Building self-esteem and confidence – Play therapy boosts self-esteem and self-efficacy by fostering a sense of competence and capability in children through creative activities
  • Resolving trauma and anxiety – Play therapy is a non-threatening approach to trauma processing as it provides a means of safely revisiting and reframing the narratives of traumatic events in a supportive environment

Psychological benefits for parents and caregivers

  • Strengthens parent-child relationship – Parent-child attachments and bonds are enhanced through play therapy by improving empathy, communication, and understanding 
  • Managing stress and improving family dynamics – Helps families navigate challenging situations healthily by equipping them with cooperation, resilience, and problem-solving skills
  • Promoting effective parenting strategies – Parents gain insight into their child’s behaviours, emotional needs, and developmental milestones, providing them with practical skills to support their emotional growth and wellbeing

Challenges and considerations

Cultural considerations in play therapy

Diversity

Play therapists must be sensitive to those of various cultural backgrounds, values, and beliefs.20,21 A client’s communication style, family dynamic, cultural norms, and help-seeking behaviour must be considered. In turn, the therapist must adapt and individualise their approach according to their client’s respective needs.

Language and expression 

When working with families from diverse backgrounds, a language barrier may hinder complete understanding and awareness. In turn, to facilitate understanding and engagement, the therapist must utilise non-verbal communication and creative expression techniques.

Cultural competence

Play therapists should endeavour to continuously improve their cultural competence through self-reflection, ongoing education, and consultation with culturally diverse communities and colleagues.

Addressing resistance and scepticism

Misconceptions 

Play therapy is often misconceived as “just play” and its effectiveness as a legitimate therapeutic intervention is questioned.22 To combat this, play therapists should educate others using an evidence-based approach emphasising the principles and therapeutic benefits of play therapy.

Resistance 

Initial resistance to actively participating in play therapy is typically demonstrated due to mistrust, apprehension, or discomfort. Here, it is vital that the play therapist is patient and empathetic with their client and gently encourages them over time to engage in the therapeutic process.

Parental concerns

Parents may be concerned or reserved when it comes to play therapy, often because they are unfamiliar or sceptical with the approach and its potential outcomes.23 Play therapists should open up dialogue with caregivers by addressing any concerns or questions to foster a trusting and collaborative dynamic between them.

Overall, acknowledging and addressing these challenges when it comes to play therapy is vital in ensuring the practice is effective and culturally responsive.

Summary

Play therapy is a powerful and effective therapeutic intervention to help those who struggle to communicate with words to express and overcome a wide variety of behavioural, emotional and relational challenges present in children and their families. Play therapy is utilised to uncover self-expression, creativity, and healing. Children are encouraged to explore their feelings, thoughts and experiences in this safe and supportive environment to facilitate resilience, emotional growth and psychological well-being.

Despite being helpful and reaping numerous benefits for clients, play therapy faces numerous challenges and obstacles. Nevertheless, there remains optimism and determination to advocate for greater funding, recognition, and access to play therapy services so that more people can be supported.

References

  1. Kool R, Lawver T. Play therapy. Psychiatry (Edgmont) [Internet]. 2010 Oct [cited 2024 Feb 15];7(10):19–24. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989834/
  2. O’Connor K. The value and use of interpretation in play therapy. Professional Psychology: Research and Practice [Internet]. 2002 [cited 2024 Feb 15];33(6):523–8. Available from: https://psycnet.apa.org/record/2002-06634-002
  3. Bratton SC, Ray D, Rhine T, Jones L. The efficacy of play therapy with children: a meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice [Internet]. 2005 [cited 2024 Feb 15];36(4):376–90. Available from: https://psycnet.apa.org/record/2005-09654-006
  4. Obiweluozo PE, Ede MO, Onwurah CN, Uzodinma UE, Dike IC, Ejiofor JN. Impact of cognitive behavioural play therapy on social anxiety among school children with stuttering deficit. Medicine (Baltimore) [Internet]. 2021 May 14 [cited 2024 Feb 15];100(19):e24350. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133212/
  5. Axline VM. Nondirective therapy for poor readers. Journal of Consulting Psychology [Internet]. 1947 [cited 2024 Feb 15];11(2):61–9. Available from: https://psycnet.apa.org/record/1947-03736-001
  6. Crenshaw DA, Brooks R, Goldstein S. Play therapy interventions to enhance resilience [Internet]. Guilford Publications; 2015 [cited 2024 Feb 15]. 268 p. Available from: https://books.google.co.uk/books?hl=en&lr=&id=JUn-CAAAQBAJ&oi=fnd&pg=PP1&dq=Crenshaw,+D.+A.,+Brooks,+R.,+Goldstein,+S.,+%26+Baron,+S.+(Eds.).+(2015).+Play+therapy+interventions+to+enhance+resilience.+Guilford+Press.&ots=264t-h4paC&sig=ChscUI4MwoPq-SgESzIA3KKinqk&redir_esc=y#v=onepage&q&f=false
  7. Rye N. Filial therapy for enhancing relationships in families. J Fam Health Care [Internet]. 2008 [cited 2024 Feb 15];18(5):179–81. Available from: https://pubmed.ncbi.nlm.nih.gov/18973091
  8. Carroll F. Gestalt play therapy. In: Play therapy theory and practice: Comparing theories and techniques, 2nd ed [Internet]. Hoboken, NJ, US: John Wiley & Sons Inc; 2009 [cited 2024 Feb 15]. p. 283–314. Available from: https://psycnet.apa.org/record/2010-04804-007
  9. Money R, Wilde S, Dawson D. Review: The effectiveness of Theraplay for children under 12 - a systematic literature review. Child Adolesc Ment Health [Internet]. 2021 Sep [cited 2024 Feb 15];26(3):238–51. Available from: https://pubmed.ncbi.nlm.nih.gov/32767491/
  10. Bosgraaf L, Spreen M, Pattiselanno K, van Hooren S. Art therapy for psychosocial problems in children and adolescents: a systematic narrative review on art therapeutic means and forms of expression, therapist behavior, and supposed mechanisms of change. Front Psychol [Internet]. 2020 Oct 8 [cited 2024 Feb 15];11:584685. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578380/
  11. McLuckie A, Rowbotham M. Narrative play therapy with families. In: Play therapy with families: A collaborative approach to healing [Internet]. Lanham, MD, US: Jason Aronson; 2013 [cited 2024 Feb 15]. p. 113–46. Available from: https://psycnet.apa.org/record/2014-01051-005
  12. Combs-Lane AM, Davis JL, Fricker AE, Acierno R. Behavioral therapy instructions. In: Hersen M, Sledge W, editors. Encyclopedia of Psychotherapy [Internet]. New York: Academic Press; 2002 [cited 2024 Feb 15]. p. 233–6. Available from: https://www.sciencedirect.com/science/article/pii/B0123430100000283
  13. Shatz CJ. The developing brain. Scientific American [Internet]. 1992 [cited 2024 Feb 15];267(3):60–7. Available from: https://www.jstor.org/stable/24939213
  14. Riggs NR, Greenberg MT, Kusché CA, Pentz MA. The mediational role of neurocognition in the behavioral outcomes of a social-emotional prevention program in elementary school students: effects of the paths curriculum. Prev Sci [Internet]. 2006 Mar 1 [cited 2024 Feb 15];7(1):91–102. Available from: https://doi.org/10.1007/s11121-005-0022-1
  15. Hariri AR, Bookheimer SY, Mazziotta JC. Modulating emotional responses: effects of a neocortical network on the limbic system. NeuroReport [Internet]. 2000 Jan 17 [cited 2024 Feb 15];11(1):43. Available from: https://journals.lww.com/neuroreport/abstract/2000/01170/modulating_emotional_responses__effects_of_a.9.aspx
  16. Pennebaker JW. Putting stress into words: health, linguistic, and therapeutic implications. Behav Res Ther [Internet]. 1993 Jul [cited 2024 Feb 15];31(6):539–48. Available from: https://pubmed.ncbi.nlm.nih.gov/8347112/
  17. Fossati P, Hevenor SJ, Graham SJ, Grady C, Keightley ML, Craik F, et al. In search of the emotional self: an fMRI study using positive and negative emotional words. Am J Psychiatry [Internet]. 2003 Nov [cited 2024 Feb 15];160(11):1938–45. Available from: https://pubmed.ncbi.nlm.nih.gov/14594739/
  18. Doyle K, Magor-Blatch LE. “Even adults need to play”: Sandplay therapy with an adult survivor of childhood abuse. International Journal of Play Therapy [Internet]. 2017 [cited 2024 Feb 15];26(1):12–22. Available from: https://psycnet.apa.org/record/2017-00140-002
  19. Senko K, Bethany H. Play therapy: an illustrative case. Innov Clin Neurosci [Internet]. 2019 May 1 [cited 2024 Feb 15];16(5–6):38–40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659989/
  20. Vaughn K. Play therapist’s perspectives on culturally sensitive play therapy. University of New Orleans Theses and Dissertations [Internet]. 2012 May 18; Available from: https://scholarworks.uno.edu/td/1491
  21. Gil E, Pfeifer L. Issues of culture and diversity in play therapy. In: Handbook of play therapy, 2nd ed [Internet]. Hoboken, NJ, US: John Wiley & Sons, Inc.; 2016 [cited 2024 Feb 15]. p. 599–611. Available from: https://psycnet.apa.org/record/2016-24968-033
  22. Clack G, Crowley K, Waycott L, Price J, Birdsey N. Childcare practitioners’ knowledge and perceptions of play therapy. British Journal of Play Therapy [Internet]. 2010 Nov 19 [cited 2024 Feb 15];6(1):19-. Available from: https://researchportal.bath.ac.uk/en/publications/childcare-practitioners-knowledge-and-perceptions-of-play-therapy
  23. VanFleet R. Understanding and overcoming parent resistance to play therapy. International Journal of Play Therapy [Internet]. 2000 [cited 2024 Feb 15];9(1):35–46. Available from: https://psycnet.apa.org/record/2001-00559-003

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Jaskirat Kanwal

Masters of Science – MSc, Applied Neuropsychology. University of Bristol, UK

Jaskirat currently works in pharmaceutical care and in the mental health sector. Given their extensive background in psychology, they’re currently seeking to undertake their DClinPsych. They hope to study further, and continue in academia and research, with hopes to ultimately become an HCPC registered clinical neuropsychologist.

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