Play Therapy

Contributors:
Dee C. Ray, University of North Texas

Description of Play Therapy

Play therapy is a mental health intervention in which trained play therapists apply a systematic theoretical model using therapeutic relationship and play to help clients “prevent or resolve psychosocial difficulties and achieve optimal growth and development” (Association for Play Therapy, 2019). Although therapists have facilitated play therapy with adult and adolescent populations, play therapy is primarily a developmentally-appropriate intervention for children aged 3-12 years. Play therapy is considered a counseling modality in which therapists use play as the primary language of the therapeutic relationship. The use of play in therapy is grounded in the developmental understanding that children express themselves more fully when using toys and materials than just their words. Although individuals may use play techniques in general counseling, the term play therapy is reserved for counselors who are trained in the application of play therapy and are certified in play therapy procedures (see www.a4pt.org/page/CredentialsInfo).  

Axline (1947) outlined the principles of play therapy through emphasizing the primacy of relationship, acceptance, permissiveness, safety, attunement to feelings, belief in the child’s ability to solve problems, allowance of child-directed play, patience with the process, and limit-setting. The goal of the play therapist is to establish an environment and relationship in which a child feels safe, secure, and free to express all aspects of experience and perception. Landreth (2012) noted that children in play therapy learn to respect themselves, express their feelings responsibly, be creative and resourceful in solving problems, assume responsibility for themselves, experience self-control and self-direction, accept themselves, as well as make choices and be responsible for those choices.

Therapists typically conduct play therapy in a playroom supplied with toys that are carefully selected and encourage the expression of a wide range of feelings by a child (Ray & Landreth, 2015). Toys and materials are chosen based on characteristics that allow for expression, therapeutic value, and building relationships (see https://cpt.unt.edu/recommended-toy-list). The setting often determines the size of the playroom, yet rooms should be large enough to allow for open space and movement. The play therapist facilitates play through building a safe, accepting, and permissive relationship with a child. Play therapy responses include reflecting content and feeling, facilitating the relationship, encouraging, esteem-building, promoting decision-making, facilitating creativity, reflecting patterns or themes, and limit-setting (Ray & Landreth, 2015).

The ethical application of play therapy requires that a counselor be firmly grounded in a theoretical rationale for practice and well-trained in a play therapy approach. Play therapy is more than using toys and materials in a counseling office. Play therapists use the interpersonal process and therapeutic powers of play to facilitate the development of the person of the child. Counselors interested in play therapy typically seek out further certification or credentials specializing in more in-depth understanding and application of play therapy.

Intervention Strategies

Play therapy is one of the longest-running mental health interventions still in effective use today, with play therapy accounts dating back to the 1930s and effectiveness research dating back to the 1940s (Bratton, Ray, Rhine, & Jones, 2006). As a counseling modality, therapists can approach play therapy from a wide range of theoretical orientations. First facilitated as a psychoanalytic technique, various theoretical orientations include systematic applications of play therapy for child clients. The most popular play therapy orientations among practitioners are child-centered play therapy (CCPT), Adlerian (AdPT), Theraplay, Gestalt, Jungian, and cognitive-behavioral.   By far, CCPT is recognized as the most successful approach to play therapy in the United States (Lambert et al., 2005) due to copious effectiveness research studies, recognition as an evidence-based approach, and thoroughness of training available. Although CCPT is noted as most used among play therapists, Theraplay, AdPT, and Gestalt have also been supported by limited effectiveness research. The Substance Abuse and Mental Health Services Administration (https://www.samhsa.gov/ebp-resource-center) recognized CCPT, Adlerian, and Theraplay as evidence-based interventions, and the California Evidence-Based Clearinghouse for Child Welfare (www.cebc4cw.org) recognized CCPT and Theraplay as promising evidence-based interventions. The Association for Play Therapy regularly publishes summaries of play therapy research (https://www.a4pt.org/page/Research) to keep play therapists updated with the latest findings.

Child-Centered Play Therapy

Based on person-centered theory and recognizing that relationship is the primary therapeutic factor, CCPT focuses on facilitating an environment of safety, acceptance, and empathic understanding to unleash the child’s natural tendency toward self- and other-enhancing growth (Ray, 2011). In CCPT, the play therapist trusts the child’s inner direction to move toward positive development, resulting in belief in the child’s ability to self-direct play. CCPT is most effective when a counselor can provide, and a child can perceive, an environment and relationship accepting of the child’s internal world that leads toward personal integration and functionality (Ray & Landreth, 2015). In addition to being recognized by SAMHSA and CEBC as evidence-based, CCPT is recognized by APA Division 53 Society of Clinical Child and Adolescent Psychology as an evidence-based practice for disruptive behaviors (Kaminski & Claussen, 2017), and researchers have thoroughly supported its use through two meta-analyses (Lin & Bratton, 2015; Ray, Armstrong, Balkin, & Jayne, 2015) in addition to dozens of randomized controlled trials.

Resources: Center for Play Therapy: https://cpt.unt.edu/

Landreth, G. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY: Routledge.

National Institute of Relationship Enhancement: https://nire.org/

Ray, D. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York, NY: Routledge.

Theraplay

Based on attachment and developmental theories, theraplay is a relational and play-based intervention in which the play therapist uses the therapeutic relationship to re-create experiences of secure attachment (Booth & Jernberg, 2010). Theraplay applies interactive play between counselor and child to facilitate shared positive emotions within a safe relationship. The counselor structures playful interaction to enhance the child’s ability to establish relationships with caretakers and others. Characteristics of theraplay include a focus on the here and now, preverbal activity, multisensory touch, playfulness, and interaction, as led by the play therapist. Several studies, including randomized controlled trials, have supported the effectiveness of theraplay (Siu, 2009, 2014; Weddig, Coleman, & Geider, 2011).

Resources: The Theraplay Institute: https://theraplay.org/theraplay

Booth, P., & Jernberg, A. (2010). Theraplay: Helping parents and children build better relationships through attachment-based play (3rd ed.). San Francisco, CA: Jossey-Bass.

Adlerian Play Therapy (AdPT)

AdPT combines the theoretical tenets of individual psychology with the modality of play therapy. Kottman (2009) offered seven goals of Adlerian play therapy including helping the client: a) gain an awareness of and insight into lifestyle; b) alter faulty self-defeating apperceptions and move from private logic to common sense; c) move toward positive goals of behavior; d) replace negative strategies for belonging and gain significance with positive strategies; e) increase his or her social interest; f) learn new ways of coping with feelings of inferiority; and g) optimize creativity and begin to use his or her assets to develop self-enhancing decisions about attitudes, feelings, and behaviors (p. 244). Through play therapy, the AdPT counselor enacts the four phases of individual psychology including building a relationship with the client, exploring the client’s lifestyle, helping the client gain insight into his or her lifestyle, and learning and practicing new skills (Kottman & Meany-Walen, 2016). Researchers supported the effectiveness of AdPT as evidenced by one randomized controlled trial (Meany-Walen, Bratton, & Kottman, 2014) and several evidentiary studies.

Resources: League of Extraordinary Adlerian Play Therapists. (2019). https://leapt.arlo.co/w/

Kottman, T., & Meany-Walen, K. (2016). Partners in play: An Adlerian approach to play therapy (3rd ed.).  Alexandria, VA: American Counseling Association.

Gestalt Play Therapy

The focus in Gestalt play therapy is to use play materials and techniques to help the child become more aware of their processes. Through greater awareness, the child will be able to restore healthy self-regulation and become aware of both internal and external ways of experiencing and interacting with the environment in more practical ways to get needs met (Carroll, 2009). The Gestalt play therapist structures multiple play methods to facilitate the child’s expression and awareness of feelings and experiences. Although researchers have not yet recognized Gestalt as an evidence-based approach, it is a play therapy orientation that has some supporting research (Farahzadi, Bahramabadi, & Mohammadifar, 2011).

Resources: Oaklander, V. (1988). Windows to our children. Highland, NY: The Gestalt Journal Press.

West Coast Institute for Gestalt Therapy with Children and Adolescents: http://westcoastinstitute.us/

Blom, R. (2006). The handbook of gestalt play therapy: Practical guidelines for child therapists. London, UK: Jessica Kingsley. 

REFERENCES

Association for Play Therapy. (2019). What is play therapy? Retrieved from https://www.a4pt.org/default.aspx

Axline, V. (1947). Play therapy. New York, NY: Ballantine.

Booth, P., & Jernberg, A. (2010). Theraplay: Helping parents and children build better relationships through attachment-based play (3rd ed.). San Francisco, CA: Jossey-Bass.

Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36, 376-390.  http://doi.org/10.1037/0735-7028.36.4.376   

Carroll, F. (2009). Gestalt play therapy. In K. O’Connor, & L. Braverman (Eds.), Play therapy theory and practice: Comparing theories and techniques (2nd ed., pp. 283-314). Hoboken, NJ: Wiley.

Farahzadi, M., Bahramabadi, M., & Mohammadifar, M. (2011). Effectiveness of Gestalt play therapy in decreasing social phobia. Journal of Iranian Psychologists, 7, 387-395.

Kaminski, J., & Claussen, A. (2017). Evidence base update for psychosocial treatments for disruptive behaviors in children. Journal of Clinical Child & Adolescent Psychology, 46, 477-499. http://doi.org/10.1080/15374416.2017.1310044

Kottman, T. (2009). Adlerian play therapy. In K. O’Connor, & L. Braverman (Eds.), Play therapy theory and practice: Comparing theories and techniques (2nd ed., pp. 237-282). Hoboken, NJ: Wiley.

Kottman, T., & Meany-Walen, K. (2016). Partners in play: An Adlerian approach to play therapy (3rd ed.). Alexandria, VA: American Counseling Association.

Lambert, S., LeBlanc, M., Mullen, J., Ray, D., Baggerly, J., White, J., & Kaplan, D. (2007). Learning more about those who play in session: The national play therapy in counseling practices project (Phase I). Journal of Counseling & Development, 85, 42-46. https://doi.org/10.1002/j.1556-6678.2007.tb00442.x

Landreth, G. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY: Routledge.

Lin, Y. W., & Bratton, S. C. (2015). A meta-analytic review of child-centered play therapy approaches. Journal of Counseling & Development, 93, 45-58. https://doi.org/10.1002/j.1556-6676.2015.00180.x

Meany-Walen, K., Bratton, S., & Kottman, T. (2014). Effects of Adlerian play therapy on reducing students’ disruptive behaviors. Journal of Counseling & Development, 92, 47-56. https://doi.org/10.1002/j.1556-6676.2014.00129.x

Ray, D. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York, NY: Routledge.

Ray, D., Armstrong, S., Balkin, R., & Jayne, K. (2015). Child-centered play therapy in the schools: Review and meta-analysis. Psychology in the Schools, 52, 107-123. https://doi.org/10.1002/pits.21798

Ray, D., & Landreth, G. (2015). Child-centered play therapy. In D. Crenshaw, & A. Stewart (Eds.), Play therapy: A comprehensive guide to theory and practice (pp. 3-16). New York, NY: Guilford.

Siu, A. F. Y. (2009). Theraplay in the Chinese world: An intervention program for Hong Kong children with internalizing problems. International Journal of Play Therapy, 18(1), 1-12.

Siu, A. F. (2014). Effectiveness of Group Theraplay® on enhancing social skills among children with developmental disabilities. International Journal of Play Therapy, 23(4), 187-203. doi:10.1037/a0013979

Wettig, H. H. G., Coleman, A. R., & Geider, F. J. (2011). Evaluating the effectiveness of Theraplay in treating shy, socially withdrawn children. International Journal of Play Therapy, 20(1), 26-37.

Published: June 2020
Updated: June 2020