Some studies indicate that 20% of children have some form of psychological problem (Venables (1983); Rutter, Cox et al (1975); Jeffers & Fitzgerald (1991); Porteous (1991) etc.) and that 70% of these are helped through the use of psychological based therapies such as play and creative arts. The 1999 British government survey estimated that 10% of children have a mental health problem. It is also essential to realise that mental health, like physical health, is as much about prevention as cure.
Many children need support in emotional literacy. Others have behaviour or mental health problems at some stage that prevents them from fulfilling their full potential.
Conditions that therapeutic play and play therapy can help to alleviate – a check list
Our greatest natural resource is the minds of our children. But 20% of children in the UK have an emotional, behaviour or mental health problem.
Do you know a child who?
- Is not realising its full potential – academically, or socially?
- Has nightmares or has disturbed sleep?
- Is at risk of being/is excluded from school?
- Has suffered trauma?
- Has suffered emotional, physical or sexual abuse?
- Is adopted or fostered or in the process of being?
- Suffers because of separated/divorced parents?
- Suffers from anxiety, stress or phobias?
- Has suffered a loss or bereavement of any kind?
- Is withdrawn or continually unhappy?
- Is ill, disabled, or autistic?
- Finds it difficult to make friends?
- Quarrels frequently with peers or siblings?
- Bullies others or is bullied themselves?
- Displays inappropriate behaviour?
- Doesn’t play?
Then you need to know how play and creative arts therapies can help.
Guidelines for Referral Based upon the Observation of Children’s Play
These guidelines are based upon an extract from Children’s Imaginative Play published by the Greenwood Publishing Group August 2002. The author Shlomo Ariel PhD is a clinical psychologist and supervisor of clinical psychology and marital and family therapy in Israel.
Integrative play diagnosis and play therapy can be carried out properly only by specially trained professional therapists. However, lay persons – parents, educators and other carers of children – who are worried about a child under their care, can include careful observations of the child’s spontaneous play in their sources of information about the child’s emotional condition. It should be stressed that not every aspect of children’s play, or, for that matter, non-play behaviour, that might look to an adult worrying is really a cause for concern. Perfectly normal young children are often irrational, irresponsible, and absurd. The make-believe play of well-adjusted children often includes themes of patricide, matricide, suicide, sadism, and a whole assortment of ideas that might look way out, bizarre and crazy from an adult standpoint.
What in children’s play should be a cause for concern then? In some cases the very lack of such frightening elements. Suppose for instance that a child has been going through extremely stressful experiences, e.g. death of a parent, abuse, traumatic divorce or the like. If his or her make believe play exhibits at that period no trace whatsoever of these experiences but depicts an ideal, beautiful world without any trouble or difficulties, it would be reasonable to surmise that this child is not coping with the bad experience well and perhaps has no way of working through his or her emotional reactions. In this case it would perhaps be advisable to refer the child to professional counselling or play therapy.
Another feature of children’s play that can be viewed as an indication for referral to therapy is obsessive, persistent repetition of certain negative signified contents. For instance, if a child has brought up the theme of matricide in his make-believe play once or twice, among a variety other contents, this is not necessarily a cause for concern. But if a child plays only about matricide, over and over again, for weeks on end, then this should perhaps be taken as an alarm.
Another sign of possible serious difficulties is what looks like a persistent loss of the distinction between play and reality. This can take various forms, e.g. fear of toys, as if they can really do harm, slipping from play aggression to real aggression toward people, animals or objects and insisting stubbornly that the imaginary make-believe characters and events are real.
Parents and other carers are also advised to be watchful of signs of regression in play. If for instance a six year old child whose make-believe play used to be highly developed appears to have gone back to the earliest stage of make-believe play development and remains only there for a considerable period of time this is perhaps a sign of regression due to emotional distress.
It should be stressed however, that identifying emotional distress which requires therapy should never be based only on the child’s make-believe play. The functioning of the child in all areas of life should be taken into account. Make-believe play is only one of a variety of sources of information that should be considered.
The Therapeutic Play Continuum
Play is now widely recognised as being beneficial in the emotional development of children. It has a therapeutic value. With the growth of play therapy, play work and the use of therapeutic play skills there is widespread confusion about the roles of each and the skills required to be a proficient practitioner. PTUK has developed definitions of each of the main terms. They are related graphically to each other in the Therapeutic Play Continuum diagram.
Therapeutic Play Continuum
Since there are overlaps between each application they may best be considered on a therapeutic continuum to deal with differing levels of severity of emotional, behavioural and mental health problems in children.
The Applications of Play
The main therapeutic applications of play are:
Our definition of play is ‘A physical or mental leisure activity that is undertaken purely for enjoyment or amusement and has no other objective’. There are other areas of human activity that may also be defined in this way hence the need for contextual elaboration.
For our purposes play may assist learning and self-development. It can be undertaken by individuals or groups of children spontaneously or as part of a planned activity. There isn’t any intervention so there is no need for clinical supervision, quality management, code of ethics or adult training. The only concern is that there is a physically safe environment. A question often raised today is whether children know how to play. This is probably a philosophical question since children’s play is a natural activity essential for their healthy development. It may be that children play differently from their forebears.
Neuroscience research confirms the importance of play for infants in developing children’s brains and minds. It has also been shown that exposure to metaphor and symbols, as used in play, has a beneficial effect upon the development of the brain.
The term play work is often associated with Play Worker. We see play work as an activity that uses play to engage children safely when their parents or carers cannot be present to look after them and/or to help them to learn.
The objectives of play work are not therapeutic, although some therapeutic benefit may occur as a secondary effect. The role of the provider is one of care and support. Play Workers do not normally receive or need clinical supervision.
Another example of the difference with therapeutic play is the use of games. Normally in play work games are played where rules are applied. In therapeutic play the child may make up, use and change the rules.
Play work may also be used in nursery or primary schools to assist the educational process.
Play therapy may be used to augment a play work service.
Therapeutic play work adds a therapeutic element to play work.
The prime objective is still care or work orientated with the therapeutic element as a secondary or supporting one.
It may be used to assist the child to reach a care or work objective by alleviating a slight or mild, one off emotional or psychological situation that is preventing the child from achieving the desired results.
A therapeutic relationship is not established. Because the therapeutic element is small, clinical supervision is not required provided that overall line management is provided. Anyone using therapeutic play, as opposed to therapeutic play work, should be bound by a code of ethics which would normally be laid down by the employing organisation.
It’s one of degree. Therapeutic play can only be used for slight to mild/moderate problems. The Register title is Certified Practitioner in Therapeutic Play Skills, who have to have clinical supervision and abide by the standards of the Register.
Please see: www.playtherapyregister.org.uk
Therapeutic play may also be used as a method of detecting more serious problems that may be dealt with by referring on to a play therapist, child psychotherapist or other mental health specialist. A therapeutic relationship is established and because there is a degree of clinical responsibility, clinical supervision is essential.
Therapeutic play has a valuable function in preventing slight or mild problems becoming worse. A recognised qualification is the PTUK accredited Certificate in Therapeutic Play course.
Filial play is a recent application that use play to help infants under the age of 3 as well as children up to the age of 14, in their mental and emotional development which for some reason, such as attachment issues, may be impaired. It is also designed to improve parent/child relationships.
Filial play also directly involves parent/s and carer/s. One method is to provide parents/carers with basic play therapy skills to use at home. However there are ethical issues to be considered as well as the pressure being put on parents to carry out therapy. The preferred PTUK approach is to provide coaching/mentoring for parents/carers in nurturing skills and how to play non-directively with their children. PTUK has recently accredited the APAC Filial Play Coach/Mentor Certificate course.
Play Therapy uses a variety of play and creative arts techniques (the Play Therapy Tool-Kit to alleviate chronic, mild and moderate psychological and emotional conditions in children that are causing behavioural problems and/or are preventing children from realising their potential.
The Play Therapist works integratively using a wide range of play and creative arts techniques, mostly responding to the child’s wishes. This distinguishes the Play Therapist from more specialised therapists (Art, Music, Drama etc.). The greater depth of skills and experience distinguishes the play therapist from those using therapeutic play skills. In order to become a PTUK Certified Play Therapist a minimum of 200 hours of supervised clinical work is required whilst in training. A total of 450 hours are required to become a PTUK Accredited Play Therapist.
The Play Therapist forms a short to medium term therapeutic relationship and often works systemically taking into account and perhaps dealing with the social environment of the clients (peers, siblings, family, school etc).
Clinical supervision is essential. Play therapy may be non-directive (where the child decides what to do in a session, within safe boundaries – see Axline’s rules), directive (where the therapist leads the way) or a mixture of the two. Play therapy is particularly effective with children who cannot, or do not want to talk about their problems.
Training to become a PTUK Certified Play Therapist requires successful completion of accredited Certificate and Diploma courses such as that provided by APAC.
Child Psychotherapy, clinical psychology and psychiatry are well established disciplines used to address children’s severe mental health and personality problems.
Child psychotherapy is a psychoanalytic treatment for children, young people, parents and families. Child and adolescent psychotherapists tailor their approach to the individual child and work in an age-appropriate way. During an individual session, young children do not usually talk directly about difficult things but will communicate through play using the toys provided. Older children may also play or draw whilst teenagers are more likely to talk about their feelings. Through the relationship with the therapist in a consistent setting, the child or young person may begin to feel able to express their most troubling thoughts and feelings. Confused, frightened, hurt, angry or painful feelings can gradually be put into words rather than actions.
Child Psychotherapists, Clinical Psychologists and Psychiatrists may acquire therapeutic play skills to support their other interventions or may be supported by a Play Therapist in a multi specialist team role.
There are often long waiting lists for consultations by these specialists. In some cases Play Therapists may be able to provide a holding role.