Play therapy

Play therapy is a special way to help children share their feelings and solve problems by playing. It uses the natural way children learn and explore. This method helps children who might be too young or too upset to talk about hard things.

Experts think play therapy is very good for helping children grow and understand themselves and others better. It is used with children from babies up to young adults. In play therapy, children can show their thoughts and feelings through pretend play while feeling safe and trusted by the therapist or caregiver.

In recent years, play therapists have joined professional groups and follow strict rules to give children the best care in a kind and understanding way.

Play as therapy

Jean Piaget showed that play is important for children. It helps them show their feelings when they can't use words. When children play, they learn more about themselves and get better at using their skills. This makes them feel confident and good about what they can do.

Playing also lets children try out new ideas and solve problems in fun ways. It helps them think creatively and deal with big feelings. Through play, children can act out tough situations in a safe way, which helps them feel better and understand themselves more.

General

Play therapy is a special way to help children by letting them use play to talk about their feelings and problems. It is great for children who find it hard to talk about what they are feeling. Through play, children can show their emotions and learn better ways to handle them. This can help children grow, make friends, and feel happier.

Play therapy can also help doctors understand why a child might be acting in a strange way. By watching how a child plays with toys like play-houses or dolls, a therapist can learn more about the child’s feelings and thoughts. This helps them find the best way to support the child. Play lets children work through their worries in a safe way, and it can be a powerful tool for healing.

Origins

Children's play has been seen since very old times. In the 1700s, a writer named Rousseau said that watching play helps us understand children better.

From Education to Therapeutics

In the 1800s, teachers in Europe began to see play as important for learning. Many famous teachers talked about this, including Friedrich Fröbel, Rudolf Steiner, Maria Montessori, L. S. Vygotsky, Margaret Lowenfeld, and Hans Zulliger.

Hermine Hug-Hellmuth was one of the first to use play to help children show their feelings. She gave children toys and watched their play to learn more about them. Later, Melanie Klein used play to understand young children’s thoughts. Anna Freud also used play to help children feel comfortable with a therapist.

One early story about play helping a child was told by Sigmund Freud in 1909. He worked with a little boy who was very scared of horses. Freud suggested the boy’s dad watch his play, which helped understand the boy’s feelings.

Models

Play therapy has two main types: non-directive and directive. Non-directive play therapy is gentle. It lets children play freely to help solve problems. It focuses on feelings. Directive play therapy is more structured. The therapist guides children through play to work on emotions and behavior. Both types help children.

Jessie Taft, Otto Rank’s American translator, and Frederick H. Allen created relationship therapy. This method focuses on the bond between therapist and child, helping the child make choices.

Virginia Axline, a child therapist from the 1950s, used Carl Rogers’ ideas for children. This led to Client-Centred Therapy. Axline wrote about her ideas and also wrote Dibs in Search of Self, about play therapy sessions.

Nondirective play therapy

Non-directive play therapy helps children through play with little guidance. It is based on the idea that children will solve problems if they can play freely in a safe space. This method is gentle and works for any age. It comes from ideas by Margaret Lowenfeld, Anna Freud, Donald Winnicott, Michael Fordham, Dora Kalff, and Carl Rogers. Virginia Axline adapted Carl Rogers’ ideas for children in 1946 and is often seen as the founder of this method. Techniques include sandplay therapy, play therapy with toys, and Winnicott’s Squiggle and Spatula games.

Using toys helps children express feelings better than talking. Toys like animals, dolls, hand puppets, soft toys, crayons, and cars are popular because they spark imagination.

Sandplay

Sandplay therapy uses a tray of sand and small figures. It started with Dr. Margaret Lowenfeld in 1929, inspired by H. G. Wells’ Floor Games. Dora Kalff later combined this with Carl Jung’s idea of the collective unconscious and named it “sandplay”. Playing with sand and objects in a tray helps work through feelings. The therapist gives little guidance, letting the person create scenes in the sand. The person may talk about their creation or not, and the therapist responds supportively.

Winnicott's Squiggle and Spatula games

Donald Winnicott believed that play is important for self-expression. He used the squiggle game and the spatula game. In the squiggle game, one person draws a shape for the other to build on. In the spatula game, a medical tongue depressor is placed for the child to play with. Winnicott thought this helped children connect with the object.

Efficacy

Winnicott thought that “Playing happens in the space between the baby and the mother-figure…. The start of playing is linked to the baby’s trust in the mother figure”. He used the term “potential space” for a safe place where someone can play freely while staying connected to others. Playing can involve a transitional object, like a teddy bear, which feels both real and made-up. Winnicott believed this helps children develop creativity and honesty.

Research

Play therapy has been popular for over sixty years. Some critics question if it works and suggest using other methods with more proof, like Cognitive behavioral therapy. They say therapists focus more on playing than on research. Many studies have small groups, making it hard to know if it works for everyone. Recent researchers have done bigger studies with more comparisons.

Research on using toys in non-directive play therapy is limited. Dell Lebo found that children who played with recommended toys were no more likely to talk to the therapist than those who did not. Recommended toys include dolls or crayons. There is debate about which toys to use. However, some research shows that choosing toys carefully can make therapy more effective.

Several studies have shown positive results for non-directive play therapy. These results show non-directive play therapy can be as effective as other therapies for children.

Predictors of effectiveness

Factors that can affect how well play therapy works include the number of sessions, with more sessions leading to better results. Positive effects can be seen after 16 sessions, but the best results happen after 35–40 sessions. Children in crisis may respond well after just 7 sessions. Involvement of parents in sessions can also help. Play therapy works well for children of different ages, genders, and whether done in groups or individually.

Play Therapist Training

Many counselors need more knowledge to be effective play therapists. Training happens through university programs, workshops, and studies. Studies show that those trained at the university level have better skills. Play therapists usually need a Master’s degree or higher in a mental health subject and skills in Child Development. After getting a degree, they need more classes and work to become a Registered Play Therapist (RPT).

Directive play therapy

In the 1930s David Levy developed release therapy. It focused on a structured way to help. A child who faced a stressful situation could play freely, then the therapist would introduce materials related to the stress, allowing the child to replay the event.

In 1955, Gove Hambidge built on Levy’s work with a “structured play therapy” model. This approach was more direct, establishing rapport, recreating the stressful situation, playing it out, and then free play to recover.

Directive play therapy believes guiding children through play with directions leads to faster change than non-directive play therapy. The therapist plays a bigger role, using techniques like playing with the child or suggesting topics. This therapy still allows free expression but is more structured than non-directive play therapy. Techniques include directed sandtray therapy and cognitive behavioral play therapy.

Directed sandtray therapy is often used with trauma victims and includes more “talk” therapy. The therapist’s role is important here. Therapists may ask about the sandtray, suggest changes, ask why certain objects were chosen, and sometimes change the sandtray. Using directions is common. While traditional sandplay helps access memories, directed sandtray therapy helps manage memories and their effects.

Filial therapy, created by Bernard and Louise Guerney in the 1960s, trained parents to use child-centered play sessions at home. With school counselors appearing in the 1960s, school-based play therapy became more common, used as an educational and preventive tool for children’s issues.

Roger Phillips in the early 1980s suggested combining cognitive behavioral therapy with play interventions. Cognitive behavioral play therapy was developed for children aged two to six, using toys like dolls and stuffed animals to model coping strategies and problem-solving skills. Little focus is on children’s words, more on their actions and play. Creating stories with dolls and stuffed animals helps change children’s thinking.

Efficacy

The effectiveness of directive play therapy is less proven than non-directive play therapy, but it still shows benefits. Although directive therapy’s effects are lower, they are still like those of psychotherapy for children. This may be because there are fewer studies on directive therapy. More research could make the effects more similar.

Application of electronic games

The popularity of video games has led to studies on their use in therapy. While many studies focus on video game violence and addiction, some mental health practitioners are interested in using games as tools. These are “directive” tools because they follow set rules. With electronic media now common, games have become more diverse, complex, realistic, and social. The similarities between electronic and traditional play suggest similar benefits. Video games are split into “serious” games made for health or learning, and “off-the-shelf” games that can be used in therapy.

Research

Most research on electronic games in therapy focuses on helping with depression in adolescents. Some games are made for children with anxiety and ADHD. The same company plans to create treatments for children on the autism spectrum and those with Major depressive disorder. The preferred method is Cognitive behavioral therapy (CBT), but it has limits. Therapists hope electronic games can address these issues. Early research with small groups suggests further study is needed.

Role-playing games (RPGs) are common in therapy. Players take on roles, and outcomes depend on actions in a virtual world. Psychologists can learn about the player’s ability to create or experiment with new identities. RPGs are often seen as a safe way to play, reducing risk of exposure or embarrassment. The well-known RPG used in treatment is SPARX. Set in a fantasy world, SPARX users play seven levels, each teaching a technique to overcome depressive thoughts and behaviors. Studies find SPARX compares to CBT-only therapy.

Other applications

Biofeedback media, which measures heart rate, skin moisture, blood flow, and brain activity to teach stress management, is used in treating anxiety disorders. Games using this equipment are new, with few on the market. Several online or mobile games have been noted for helping with disorders beyond anxiety and mood.

Efficacy

While using electronic media in therapy is new, the devices themselves are familiar to children. The term for early studies with virtual reality (VR) is Virtual reality exposure therapy (VRET). This research is based on traditional exposure therapy.

In the future, clinicians may use electronic media to assess patients, motivate them, and help with social interactions. Current limited data suggests combining traditional therapy with electronic media may be the most effective.

The commonality of video games in recent years has sparked interest among some mental health practitioners to explore their use as therapeutic tools. Video games are generally categorized into two types: “serious” games designed specifically for health or educational purposes, and “off-the-shelf” games that were not originally created for clinical use but can be repurposed for therapeutic settings.

Research

Most current research on electronic games in therapeutic contexts focuses on alleviating symptoms of depression, particularly in adolescents. However, some games have been specifically developed for children with anxiety and Attention deficit hyperactivity disorder (ADHD). The preferred therapeutic approach remains Cognitive behavioral therapy (CBT), though it faces limitations. Therapists hope electronic games can address these challenges.

Role-playing games (RPGs) are the most commonly used type of electronic game in therapeutic interventions. In these games, players assume roles, and outcomes depend on actions taken in a virtual world. Psychologists value RPGs for insights into a patient’s ability to create or experiment with alternative identities. Additionally, RPGs are often perceived as an inviting and safe way to engage in treatment. SPARX is the most well-documented RPG used in treatment. Set in a fantasy world, SPARX guides users through seven levels, each lasting about half an hour, teaching techniques to overcome depressive thoughts and behaviors. Studies have found SPARX comparable to CBT-only therapy.

Other applications

Biofeedback media, which measures physiological responses like heart rate, skin moisture, blood flow, and brain activity to teach stress management and relaxation techniques, is another area of interest. While the development of electronic games using biofeedback is still nascent, some existing products show promise. Several online-only or mobile games—Re-Mission, Personal Investigator, Treasure Hunt, and Play Attention—have been specifically noted for their use in treating disorders beyond anxiety and mood conditions.

Efficacy

Although the integration of electronic media into therapy is a new field, the devices themselves are familiar to most Western children. Looking ahead, clinicians may utilize electronic media for patient assessment, as a motivational tool, and to facilitate both social in-person and virtual interactions. Current data, though limited, suggests that combining traditional therapy methods with electronic media may yield the most effective treatment outcomes.

Play therapy in literature

In 1953, Clark Moustakas wrote a book called Children in Play Therapy. Later, in 1956, he worked with other experts to develop new ideas about helping people. In 1973, he wrote another book named The child's discovery of himself. His work helped build good relationships to support children.

Today, many books talk about play therapy and different ways to use it. The Association for Play Therapy lists these books on their website. Some titles are 101 Play Therapy Techniques, A Handbook of Play Therapy with Aggressive Children, and ADAPT: A Developmental Attachment-based, Play Therapy. These books show how play therapy can help children in many situations.

Parent/child play therapy

Play therapy is a helpful way for children to learn, understand their feelings, and make sense of the world. It can help children who are dealing with things like difficult feelings, behavior challenges, or trouble with language.

There are different ways that parents can take part in play therapy with their children. One method, called Filial Therapy, started in the 1960s. In this method, parents learn how to play with their children in a special way to help them work through difficult feelings.

Another method, Theraplay, began in the 1970s. It teaches parents to play with their children in ways that copy the fun, caring interactions that babies enjoy with their parents. This helps improve behavior and emotional health.

For children with autism, a method called Floortime was created in the 1980s. It uses play to help improve social and communication skills. Recent methods, like Playful Parenting and Child Parent Relationship Therapy, encourage parents to connect with their children through fun activities to solve emotional and behavior problems.

Play therapy can also help improve how well children read and think, especially for those who struggle in school. It strengthens the bond between parents and children, helping them feel safer and more connected.