THE HEALING POWER OF PLAY
The Child Therapies: Application in Work
with Abused Children
Closer than the moon, even closer than the depths of the seas, the minds of children seem to most people not only mysterious, but impenetrable. -J, ALEXIS BURLAND & THEODORE B. COHEN
Child therapy is described by Sours (1980) as “a relationship between the child and the therapist, aimed primarily at symptom resolution and attaining adaptive stability” (p. 275). Child therapy, as a separate and distinct type of work, has been evolving since 1909, when Freud first attempted psychotherapy with the now historic patient Little Hans. The term child therapy is often used interchangeably with the term play therapy although play was not used directly in the therapy of children until 1920 when Hermine Hug-Hellmuth
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began using play for the diagnosis and treatment of childhood emotional problems (Schaefer, 1980). Melanie Klein and Anna Freud formulated the theory and practice of psychoanalytic play therapy some 10 years later.
While most child therapists agree that play is the most effective medium for conducting therapy with children, others (Freiberg, 1965; Sandler, Kennedy, & Tyson, 1980) have raised questions as to whether play produces structural change, have pointed to the nebulous quality of play, and have dismissed it as consisting ofneither dream material nor free association. Schaeffer (1983) contends that “it is some what difficult for anyone interested in play and play therapy to gain a clear understanding of what is meant by the term play because no single, comprehensive definition of the term has been developed” (p. 2). However, the potential benefits of play are well documented. In his literature review Schaeffer found descriptions of play as “pleasurable,” “intrinsically complete,” “independent from external rewards or other people,” “noninstrumental, with no goal,” and “not occurring in novel or frightening situations.” Schaeffer suggests that play is person- rather than object-dominated.
Schaeffer (1980) further asserts that “one of the most firmly established principles of psychology is that play is a process of development for a child” (p. 95). Play has been alternately depicted as a mechanism for developing “prob lem-solving and competence skills” (White, 1966); a process that allows children to “mentally digest” experiences and situations (Piaget, 1969); an “emotional laboratory” in which the child learns to cope with his/her environment (Erikson, 1963); a way that the child talks, with “toys as his words” (Ginott, 1961); and a way to deal with behaviors and concerns through “playing it out” (Erikson, 1963). Nickerson (1973) views play activities as the main therapeutic approach for children because it is a natural medium for self-expression, facilitates a child’s communication, allows for a cathartic release of feelings, can be renewing and constructive, and allows the adult a window to observe the child’s world. Nickerson points out that the child feels at home in a play setting, readily relates to toys, and will play out concerns
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with them. Chethik (1989) makes an important point about the use of play as therapy: “Play in itself will not ordinarily produce changes…the therapist’s interventions and utiliza tions of the play are critical” (p. 49). In addition, the clinician must serve as a participant-observer, rather than a playmate. I believe that play in therapy must be facilitated by an involved clinician in a meaningful way. Some of the most frequent errors made in child therapy are allowing a child to play randomly over an extended period of time, ignoring the child’s play, and providing the kind of toys that do not promote self-expression.
As interest in child therapy has grown and as the num ber of child-specific referrals has increased, a variety of therapeutic techniques, games, and toys have also evolved. Play therapy has blossomed into a multifaceted and exciting field of study.
THE HISTORICAL DEVELOPMENT OF PLAY THERAPY
As mentioned earlier, Sigmund Freud in 1909 was the first to use play to uncover his client’s unconscious fears and concerns. Hermine Hug-Hellmuth began using play as a part of her treatment of children in 1920 (Hug-Hellmuth, 1921) and 10 years later, Melanie Klein and Anna Freud formu lated the theory and practice of psychoanalytic play therapy. This type of play therapy continues to be one of the most respected forms of child therapy, usually conducted by analysts.
Psychoanalytic Play Therapy
Anna Freud and Melanie Klein wrote extensively about how they incorporated play into their psychoanalytic technique. Whereas the former advocated using play mainly to build a strong positive relationship between child and therapist, the latter proposed using it as a direct substitute for ver
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balizations. The primary goal of their approach was “to help children work through difficulties or trauma by helping them gain insight” (Schaefer & O’Connor, 1983). Anna Freud has repeatedly pointed out that “the essential task [of therapy] is to remove the obstacles that impede [the child’s] development and to allow his progressive develop mental forces and ego resources to complete the task of development” (Nagera, 1980, p. 22). Klein (1937) felt that an analysis of the child’s transference relationship with the therapist was the main source of insight into the child’s underlying conflict.
Freud and Klein took the basic concept of free associa tion, one of the basic precepts of adult analysis, and in its place substituted the child’s natural tendency to play (Nagera, 1980). They proposed that play uncovered the child’s unconscious conflicts and desires and that play was the child’s way of free-associating. While Klein proposed that the child’s play is “fully equivalent” to the adult’s free associations and “equally available for interpretation,” Freud’s theory viewed play not as an equivalent to adult fre<) associations but as an ego-mediated mode of behavior “yield ing a substantial body of data” but requiring supplementa tion from a variety of sources, including parents (Esman, 1983). Psychoanalytic play therapy, predicated on the analysis of resistance and transference, emphasizes the use of interpretation, recognizing the child’s ability to use play symbolically to manifest internal concerns. Nagera (1980) documents that even though significant differences existed in the theoretical tenets of Freud and Klein in the beginning, throughout the years there has been more of a convergence between the two theories. Fries (1937), a student of Anna Freud’s, delineates the distinctions between the two theories, emphasizing Freud’s preference to withhold inter pretation.
Esman (1983) describes the focus of play in psychoana lytic child therapy: “It allows for the communication of wishes, fantasies, and conflicts in ways the child can tolerate affectively and express at the level of his or her cognitive
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capacities” (p. 19). He goes on to say that the therapist’s function is to “observe, attempt to understand, integrate, and ultimately communicate the meanings of the child’s play in order to promote the child’s understanding of his or her conflict toward the end of more adaptive resolution” (p. 19).
Structured Play Therapies
In the late 1930s, a more goal-oriented therapy, known as “structured therapy,” was developed. This therapy emerged from a psychoanalytic framework and from a belief in the cathartic value of play and the active role of the therapist in determining the course and focus of therapy (Schaefer & O’Connor, 1983).
Anna Freud had initially found the use of affective release useful, but on the basis of later experience she en couraged this type of work only in cases of severe traumatic neuroses. David Levy (1939), stimulated by Anna Freud’s conclusion and by Sigmund Freud’s concept of “repetition compulsion,” introduced the concept of “release therapy” for children who had experienced trauma. Levy helped the child recreate the traumatic event through play. The goal of this type of play was to help the child assimilate the negative thoughts and feelings associated with the trauma by reenact ing it over and over again. Levy cautioned against using this technique too early in therapy, before a strong therapeutic relationship had been formed. In addition, he took care to avoid “flooding,” in which the child is overcome by strong emotions and thus unable to assimilate them.
Other well-known contributors to the literature on struc tured therapies include Hambidge and Solomon. Solomon (1938) thought that helping a child express rage and fear through play without experiencing the feared negative con sequences would have an abreactive effect. Hambidge (1955) was even more directive than Levy, who provided toys to facilitate the child’s recreation of the trauma: Hambidge facilitated the child’s abreaction by directly recreating the event or life situation in play.
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Otto Rank and Carl Rogers, also considered non-directive therapists, were the major proponents of relationship therapy, which is based on a particular theory of personality “which assumes that an individual has within himself not only the ability to solve his own problems but also a growth force that makes mature behavior more satisfying than im mature behavior” (Schaefer, 1980, p. 101). This type of therapy promotes the full acceptance of the child as he/she is, and stresses the importance of the therapeutic relation ship. Moustakas (1966), another prominent leader in the field of child therapy, emphasizes the genuineness of the therapist as pivotal to the success of therapy. He strongly advocates the importance of the here-and-now as the nucleus of therapeutic success. Axline (1969) also gives credence to the importance of the therapeutic relationship, viewing it as the “deciding factor” (p. 74). Axline’s writings, particularly the widely touted book Dibbs in Search of Self (1964), have clearly delineated the benefits and desirability of nondirec tive therapy.
In the 1960s the behavior therapies, based on the principles of learning theory were developed. Such therapies apply the concepts of reinforcement and modeling to relieve behavior problems in children. The behavioral approaches are precise ly concerned with the problem behavior itself, not with the past or with feelings that might have preceded or accom panied the behaviors. No attempts are made to achieve affective release, to do cathartic or abreactive work, or to help children express feelings. Behavioral approaches are applied directly to children in the playroom or are taught to parents for use in the home. This type of therapy has broad applica tion to childhood problems, particularly those that stem from a lack of adult guidance and limit setting. Within this framework play is used as a means to an end, not as inherent ly valuable in and of itself.
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Slavson (1947) experimented with group situations in 1947, guiding latency-age children through activities, games, and arts and crafts designed to help them “release emotional and physical tensions” (p. 101). In 1950, Schiffer developed what began to be known as “therapeutic play groups” (Rothenberg & Schiffer, 1966) in which children could interact freely with minimal intervention from the clinicians. The unique aspect of this type of therapy, according to Schaefer (1980), is that “the child has to learn to share an adult with other children” (p. 101). Group therapy enjoys a certain contemporary popularity, partly because it can be provided at lower cost and partly because there has been a growing belief in the effectiveness of this modality. Yalom (1975) documents numerous “curative” benefits provided by group therapy, including the following: installation of hope, universality, imparting of information, altruism, corrective recapitulation of the primary family group, development of socializing tech niques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. Kraft (1980) elucidates that effective group treatment must contain the following elements:
Leadership, preferably with male and female co-therapists, involves developing cohesiveness, identifying goals for the group, showing the group how to function, keeping the group task-oriented, serving as a model, and representing a value system. In carrying out these tasks, the leader may offer clarification of reality, analysis of transactions, brief educational input, empathic statements acknowledging his own feelings and those of members, and at times delineat ing the feeling states at hand in the group. (p. 129)
Group therapy has traditionally been believed to have application to the treatment of abusive parents (Kempe & Helfer, 1980). A treatment approach used effectively with abusive parents is known as Parents Anonymous (PA), founded in California in 1970. PA uses a formerly abusive parent as a group facilitator in addition to the mental health professional. There are currently over 1,200 PA groups in the United States.
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Another very well-known treatment model, Parents United, relies heavily on the group format. Parents United was established in 1975 by Dr. Hank Giarretto as the self help component of the Child Sexual Abuse Treatment Pro gram (Giarretto, Giarretto, & Sgroi, 1984), now known as the Community as Extended Family. Separate groups are formed for the incestuous parents and for the non-abusive partners. The children’s groups are known as Daughters and Sons United, and the groups for adult survivors are known as Adults Molested as Children (AMAC) groups. There are currently over 135 active Parents United programs across the United States.
Mandell, Damon, et al. (1989) wrote a useful and timely book on group treatment for abused children, with parallel treatment for caretakers. Throughout the book the authors use different play techniques to help the children open up about their abuse and to build trust among themselves. They defined the objectives of group treatment as follows:
• Define acceptable behavior of group members and intro duce a respect for boundaries.
• Promote group interaction and reinforce cooperative efforts.
• Introduce and encourage the discussion of common exw periences to reinforce a feeling of togetherness and promote group cohesion for both children and caretakers.
• Improve self-esteem through validation of individual feelings and ideas, acknowledging each member’s im portance in contributing to the group experience.
• Help group members to understand the purpose of the group.
• Enhance caretakers’ capacity to begin to view their children with increased sensitivity, understanding and empathy. (p. 27)
Another pilot project, by Corder, Haizlip, and DeBoer (1990), used structured group therapy to treat sexually abused children ages 6 to 8, and focused on issues comparable to those of Mandell and associates. The goals in the pilot project included integrating the trauma, improving self-es teem, improving problem-solving skills, self-protection for
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the future, improving ability to seek help, and enhancement of the child’s relationship to the nonabusive parent.
In another preliminary group project with sexually abused boys, Friedrich, Berliner, Urquiza, and Beilke (1990) advocate more open-ended therapy and selection of group members by developmental level (not chronological age) in order to promote better peer interaction.
Group therapy is not without its controversy. I have often heard the concern that the group might inadvertently en courage the child to overidentify with the victim role and that groups have the potential of “contaminating” one child with the emotional concerns of another. Yet another concern, which I share, is that sometimes groups are run in random ways, go on for indefinite periods of time, lack clear goals, and suffer from inconsistent and inexperienced leadership. However, these concerns are discussed in the book by Man dell and associates and do not undermine the potential benefits of the group experience.
Sand Tray Therapy
No summary of the major models of child therapy would be complete without making note of the significant contribution of Dora Kalff (1980), who created sand therapy. Sand therapy, based on the principles ofJungian therapy, sees the sand tray as symbolic of the child’s psyche. The sand therapist inter prets the child’s use of symbols and placement of objects in the tray and observes the child’s passage through distinctive phases of healing. While many child therapists use sand play in their therapy, this type of play therapy stands alone, embedded in its own theory and technique.
THE TECHNIQUES OF CHILD THERAPY
The theoretical frameworks highlighted earlier-the psycho analytic, existential, behavioral, and Jungian-are the major frameworks for conducting child therapy; almost every known technique can be subsumed under one of these head
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ings. It is important to distinguish between the child therapies and the child therapy techniques. The child therapies are based on a theoretical framework; the techni ques are chosen to implement therapy based on those con ceptual frameworks. Some of the child therapies are flexible enough to incorporate a variety of techniques whereas others restrict the therapeutic approach.
DIRECTIVE VERSUS NONDIRECTIVE PLAY THERAPY
Yet another way to categorize the types of therapy employed with children is to differentiate between directive and non directive styles of play therapy. Nondirective or client centered play therapy, promoted by the relationship therapists, is nonintrusive; it parallels the client-centered approach created by Carl Rogers (1951). Axline (1969) is credited with the creation of this specific kind ofplay therapy, and she distinguished between nondirective and directive therapy by simply stating, “Play therapy may be directive in form-that is, the therapist may assume responsibility for guidance and interpretation-or it may be nondirective; the therapist may leave responsibility and direction to the child” (p. 9). The child is allowed and encouraged to choose the toys to play with and is given the freedom to develop or terminate any particular theme. Guerney (1980) cites two major fea tures of client-centered therapy: First, the client-centered approach is “viewed as promoting the process of growth and normalization” and, second, the therapist “must rely on the child to direct this process at his or her own rate” (p. 58). The non-directive therapist observes the child’s play, often af firming verbally what is seen. Guerney states, “The realiza tion of selfhood via one’s own map is the goal of non-directive play therapy” (p. 21).
The nondirective therapist cultivates hypotheses that are tested over time; interpretations are used sparingly and then only after a great deal of observation. Nondirective therapists give the child concentrated attention and refrain
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from answering questions or giving directives. Axline (1964) demonstrates the use of nondirective therapy in her classic work Dibbs in Search of Self. Nondirective techniques are always helpful in the diagnostic phase of treatment and, as Guerney (1980) points out, have been shown to be effective with a wide range of problems.
The basic difference between the nondirective and direc tive approaches rests in the clinician’s activity in the therapy. Directive therapists structure and create the play situation, attempting to elicit, stimulate, and intrude upon the child’s unconscious, hidden processes or overt behavior by challeng ing the child’s defensive mechanisms and encouraging or leading the child in directions that are seen as beneficial. Nondirective therapists are “actually controlled, always centered on the child, and attuned to his/her communica tions, even the subtle ones” (Guerney, 1980, p. 58). Directive therapies are by nature more short-term, more symptom oriented, and less dependent on the therapeutic transference than are nondirective therapies.
The directive therapies are multitudinous and include, among other things, behavior therapies, Gestalt therapy, filial therapy, and family therapy. Certain specific techni ques, such as puppet play, story-telling techniques, certain board games, and various forms of artistic endeavor, lend themselves to being employed in therapy in different ways: A nondirective therapist might provide the child with ample opportunities for art work or story telling with puppets whereas a directive therapist might ask the child to draw specific things or tell an exact story.