Play Therapy: Effectiveness and Evidence in Child Treatment

Introduction to Play Therapy

Play therapy is a way to allow children from preschool age to just prior to adolescence — roughly ages 2 through 12 — to express themselves about issues, feelings, and emotions through different types of play. Because it is systematic and uses a guided approach to reach the inner issues of a child, it is often used in situations in which children are incapable of expressing themselves in any other way. It is also used as one tool of diagnosis; for example, a therapist might observe a child playing with toys to determine the cause of a behavioral problem. The objects chosen, the patterns that emerge, the personification displayed, and the way a child interacts with characters in play often lead to a deeper understanding of underlying issues (Landreth, 2002).

Even a brief review of the literature finds that play therapy is quite effective as a counseling model for children and adolescents. Having its documented origins in Ancient Greece, it has moved through time to the point where it is now an accepted and well-researched form of therapy. For instance, children in the midst of parental divorce acted out less, were less angry and withdrawn, and were more likely to accept change in their lives when given the chance to work through some of their issues through play therapy (Burroughs, Wagner, and Johnson, 1997). Play and art therapy — also considered a type of play — when combined, can also be quite effective in decreasing aggressive behaviors, especially in children who are victims of abusive or substance-abusing households (Springer, Phillips, Cannady, and Kerst-Harris, 1992). Since 1990, there has been an increased effort to implement well-designed and controlled play therapy studies. Two particular studies show conclusive evidence that play therapy plays a significant role in improving emotional coping skills, decreasing aggressive or non-responsive behaviors, and allowing children to open up with the therapist (LeBlanc and Ritchie, 2001; Ray, Bratton, Rhine, and Jones, 2001).

Theoretical Foundations and Developmental Context

The psychodynamic theory holds that cognitive change may often result from exploring interpersonal relationships with both animate (humans and pets) and inanimate objects (play items). A child examines and explores their imagination through these inanimate objects, and children will often engage in play behavior in order to work through their inner anxieties. Play can be seen as a self-help mechanism when a child is allowed unstructured or free play. From a developmental point of view, play is essential for building cognitive resources, self-reliance, and acculturation (Drewes, 2009).

Jean Piaget notes that most children below the age of 11 or 12 lack a fully developed capacity for abstract thought, which is necessary for meaningful verbal expression and for understanding complex, disparate issues, motives, and feelings. Unlike adults, children are more likely to communicate not through words — they lack the vocabulary to express what they are thinking — but through the world of imagination and play (Piaget, 1999). Thus, in play therapy, the act of play takes the place of vocabulary and serves as the vehicle for "communication between the child and the therapist on the assumption that children will use play materials to directly or symbolically act out feelings, thoughts, and experiences that they are not able to meaningfully express through words" (Bratton et al., 376).

Overview of Current Research

Play is clearly an important part of a child's life — it is voluntary, instinctual, and normally associated with pleasure, enjoyment, and positive outcomes. It may consist of imaginary interpersonal relationships and building images from inanimate objects, and it is a key factor in how children develop, socialize, and acquire culture. Play is so important to the human psyche that as children age it becomes increasingly structured and organized — what we call games or sports. However, for decades, modern psychologists have debated how effective play therapy intervention actually is, and whether structured play therapy treatment is a viable option within the contemporary therapist's toolbox (Ray et al., 376). Since play therapy is typically used to treat children's emotional and behavioral problems, it is important to identify which techniques are efficacious, which are marginal, and which appear to have little or no effect.

Still, many scholars believe that, despite the increase in studies, a body of credible scientific evidence does not yet exist that completely validates play therapy as the primary option in child-based treatment. Children facing medical procedures, however, do show a reasonably solid foundation for play therapy interventions, and enough studies have been conducted since the late 1970s to provide robust data suggesting that structured play therapy — as opposed to nondirective or diversionary play — has measurable effect. Even children exposed to puppet shows or other outside interventions showed considerably less anxiety regarding upcoming medical procedures than a control group (Phillips, 2010).

In contrast, another scholarly perspective holds that enough evidence already exists to demonstrate the efficacy of play therapy. Proponents note that evidence-based treatment standards are the current criteria for measuring research effectiveness. While some earlier studies involving play therapy were too subjective, it is important that all play therapy research, like any professional research, follow established methodological standards for determining efficacy. The distinction is that Phillips (2010) does not believe those standards have been met, while Baggerly and Bratton argue that not only has steady progress been made, but that evidence-based standards actually confirm the efficacy of play therapy (Baggerly and Bratton, 2010).

Conclusion

Phillips' argument is important in that it "reminds us of current evidence-based standards and challenges us to initiate methodologically sound studies" (Baggerly, 35). However, when we critically examine the research conducted since 1985, we find that "because most play therapy research uses the design of play therapy vs. absence of intervention," it remains difficult to conclusively state that play therapy is the most effective treatment available (Bratton, 386). The more pressing question, perhaps, is not whether play therapy is superior to every other modality, but whether the field should focus on refining its methodological tools so that its effects can be more precisely measured and demonstrated — thus providing clearer answers about the overall efficacy of play therapy for the children who need it most.

References

Association of Play Therapy. (2001, June). Play therapy. Association Newsletter, 20, p. 20.

Baggerly, J., & Bratton, S. (2010). Building a firm foundation in play therapy research: Response to Phillips. International Journal of Play Therapy, 19(1), 26–38.

Burroughs, M., Wagner, W., & Johnson, J. (1997). Treatment of children of divorce: A comparison of two types of therapy. Journal of Divorce and Remarriage, 27(2), 83–99.

Drewes, A. E. (2009). Blending play therapy with cognitive behavioral therapy. New York: Wiley.

Landreth, G. (2002). Play therapy: The art of the relationship. New York: Routledge.

LeBlanc, M., & Ritchie, M. (2001). A meta-analysis of play therapy outcomes. Counseling Psychology Quarterly, 14(2), 149–163.

Phillips, R. (2010). How firm is our foundation? Current play therapy research. International Journal of Play Therapy, 19(1), 13–25.

Piaget, J. (1999). Play, dream, and imitation in childhood. New York: Taylor and Francis/Routledge.

Ray, D., Bratton, S., Rhine, T., & Jones, L. (2001). The effectiveness of play therapy: Responding to the critics. International Journal of Play Therapy, 10(1), 85–108.

Springer, T., Phillips, J., Cannady, L., & Kerst-Harris, E. (1992). CODA: A creative therapy program for children in families affected by abuse of alcohol or other drugs. Journal of Community Psychology, 20(1), 55–74.