Play therapy

Play therapy is a special way to help children express their feelings and solve problems using play. It takes advantage of the natural way children explore the world around them. This method is very helpful for children who might be too young or too upset to talk about difficult things happening in their lives.

Experts believe play therapy is very effective in supporting children’s growth and helping them understand themselves and others better. It is used with children from babies up to young adults. During play therapy, children can show their thoughts and emotions through imaginative play while feeling safe and trusted by the therapist or caregiver.

In recent years, play therapists in many places have joined professional groups and follow strict rules to make sure they provide the best care for children. This helps make sure that every child gets the support they need in a kind and understanding way.

Play as therapy

Jean Piaget showed that play is very important for children because 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 of helping children by using play to talk about their feelings and problems. It is very useful for children who find it hard to talk about what they are feeling. Through play, children can express 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 in artefacts since ancient 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 started to see play as important for learning. Many famous educators 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 express 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, comparing it to talking with adults. 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 can be divided into two basic types: non-directive and directive. Non-directive play therapy is a gentle method where children are encouraged to play, hoping this will help solve their problems. It is often seen as a type of therapy focused on feelings. Directive play therapy is more structured, with the therapist guiding children through play to work on emotional and behavior issues. Both types of play therapy have shown benefits.

Jessie Taft, Otto Rank’s American translator, and Frederick H. Allen developed an approach called relationship therapy. This method focuses on the emotional bond between the therapist and the child, giving the child freedom and strength to make choices.

Virginia Axline, a child therapist from the 1950s, applied Carl Rogers’ ideas to children. Rogers explored how the therapist’s relationship could help, leading to a method called Client-Centred Therapy. Axline described her ideas in her article, ‘Entering the child’s world via play experiences’. She also wrote Dibs in Search of Self, which tells about a year’s worth of play therapy sessions.

Nondirective play therapy

Non-directive play therapy may include helping children through play without much guidance. It is based on the idea that if children can speak and play freely in a safe space, they will naturally work through their problems. This method is gentle and flexible, suitable 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’ theories for children in 1946 and is often seen as the founder of this method. Different techniques fall under non-directive play therapy, such as sandplay therapy, play therapy with toys, and Winnicott’s Squiggle and Spatula games.

Using toys in non-directive play therapy helps children express their feelings better than talking alone. Toys like animals, dolls, hand puppets, soft toys, crayons, and cars are popular because they spark imagination and creative play.

Sandplay

Sandplay therapy, using a tray of sand and small figures, 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 her version “sandplay”. Allowing someone to freely play with sand and objects in a small tray can help them work through feelings. The therapist gives little guidance, letting the person create scenes in the sand. After finishing, the person may talk about their creation or not, and the therapist responds supportively without interpreting.

Winnicott's Squiggle and Spatula games

Donald Winnicott believed that play is essential for true self-expression. He used two play techniques: 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 within reach for the child to play with. Winnicott thought this helped children connect with the object they play with.

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 and inviting place where someone can play freely while staying connected to others. Playing can also involve a transitional object, like a teddy bear, which feels both real and made-up to a small child. Winnicott believed this helps children develop creativity and honesty in relationships.

Research

Play therapy has been a popular and accepted therapy for children for over sixty years. Some critics have questioned if it really works and suggest using other methods with more proof, like Cognitive behavioral therapy. They say therapists focus more on playing than on research. Lebo argued against play therapy in 1953, and Phillips again in 1985, saying it lacks strong research. Many studies have small groups, making it hard to know if it works for everyone, and many only compare play therapy to a basic group, not to other therapies. Recent researchers have done bigger studies with more comparisons.

Outside of psychoanalysis, research on using toys in non-directive play therapy is limited. Dell Lebo found that, out of over 4,000 children, those who played with recommended toys versus non-recommended or no toys during therapy were no more likely to talk to the therapist. Recommended toys include dolls or crayons, while non-recommended toys might be marbles or a checkers board. There is debate about which toys to use, often based on intuition rather than research. However, some research shows that choosing toys carefully can make therapy more effective. Good toys should help the child connect, allow for strong feelings, and be easy for the therapist to understand.

Several studies have shown positive results for non-directive play therapy. A study by LeBlanc and Ritchie in 2001 found an effect size of 0.66, similar to psychotherapy for children. A study by Ray, Bratton, Rhine, and Jones in 2001 found an even larger effect size of 0.93, meaning children improved more than those who did not get treatment. Another study by Bratton, Ray, Rhine, and Jones in 2005 also found a large effect size of 0.92. These results show non-directive play therapy can be as effective as other therapies for children, and sometimes even better.

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, like in hospitals or shelters, may respond well after just 7 sessions. Involvement of parents in sessions can also help reduce stress in the parent-child relationship when children have behavior problems. Despite these factors, play therapy works well for children of different ages, genders, and whether done in groups or individually.

Play Therapist Training

Many counselors starting as play therapists need more knowledge to be effective. Training happens through university programs, workshops, and studies to improve their skills. Studies show that those trained at the university level have better skills, attitudes, and knowledge. Children with disorders and behaviors need therapists with these skills for play therapy to work well. Understanding child development and how play helps is important.

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). This includes 150 hours of play therapy instruction, 350 hours of supervised client contact, and 35 hours of supervision with observations.

Directive play therapy

In the 1930s David Levy developed a method called 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 and release emotions.

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. Stories have purposes, and therapists may create meanings from children’s stories. Games are chosen for the child, and themes and character profiles are given in doll or puppet activities. 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. Because trauma can be very hard, this therapy aims to create change now, without long healing. 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. A 2001 study by Ray, Bratton, Rhine, and Jones found directive play therapy had an effect size of .73 compared to .93 for non-directive. A 2005 study by Bratton, Ray, Rhine, and Jones found directive therapy had an effect size of 0.71, while non-directive had 0.92. 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 like boredom, forgetting techniques, or lack of access. 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, though SPARX alone is not more effective than standard CBT. Some studies show RPGs combined with Adlerian Play Therapy techniques increase psychosocial development. ReachOutCentral helps youth and teens with thoughts, feelings, and behavior, and ReachOutPro offers tools for clinicians to engage patients.

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. The Journey to Wild Divine’s developers call their products tools, not games, but they have game elements. Freeze Frame’s design resembles an Atari system, with three simple games using psychophysiological feedback. Both showed changes in depression levels. A biofeedback game for anxiety, Relax to Win, also helped with broader treatments. Extended Attention Span Training (EAST), made by NASA to test pilots’ attention, was changed to help with ADHD. Brain waves were monitored while playing video games on PlayStation, and game difficulty changed with attention. This treatment works like traditional ADHD intervention.

Several online or mobile games have been noted for helping with disorders beyond anxiety and mood. Re-Mission 2 targets children, designed for today’s digital youth. Mobile apps for anxiety, depression, relaxation, and mental health are available on Android Play Store and Apple App Store. Many are low-cost or free, and simplicity can still help. Playing Tetris for three minutes can reduce cravings, longer play may reduce flashbacks from posttraumatic stress disorder, and a visual-spatial game like Tetris or Candy Crush, played after a traumatic event, might prevent future flashbacks.

Efficacy

While using electronic media in therapy is new, the devices themselves are familiar to children. A newer addition is virtual reality (VR) equipment, which both adolescents and clinicians may need to learn. The term for early studies with VR is Virtual reality exposure therapy (VRET). This research is based on traditional exposure therapy and has been found more effective than a wait list control group, though less effective than in-person treatments. One study compared a typical longer treatment with shorter VRET sessions and found VRET patients were less effective at the six-month mark.

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 in the West to explore their use as therapeutic tools. These games, by their nature, are “directive” due to internal algorithms governing gameplay. The evolution of electronic games has made them more diverse, complex, realistic, and social, mirroring the benefits of traditional play by offering a safe space to process strong emotions.

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. This emerging practice of integrating electronic games into therapy is still in its early stages, with both unknown risks and potential benefits as it gains mainstream acceptance.

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 same company behind these interventions plans to expand to treatments for children on the autism spectrum and those living with Major depressive disorder. The preferred therapeutic approach remains Cognitive behavioral therapy (CBT), though it faces limitations such as patient boredom, forgetting techniques outside sessions, or accessibility issues. Therapists hope electronic games can address these challenges. Preliminary research with small groups suggests the need for more in-depth studies.

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, minimizing risks of exposure or embarrassment. 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, though SPARX alone is not more effective than standard CBT. Research also indicates that RPGs combined with Adlerian Play Therapy (AdPT) techniques can enhance psychosocial development. ReachOutCentral targets youth and teens, offering gamified information on thoughts, feelings, and behavior, while ReachOutPro provides clinicians with tools to increase patient engagement.

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. The Journey to Wild Divine’s developers describe their products as tools rather than games, though they incorporate game elements. Freeze Frame’s design resembles classic Atari systems, featuring three simple games that use psychophysiological feedback as a controller. Both The Journey to Wild Divine and Freeze Frame have demonstrated significant changes in participants’ depression levels. Relax to Win, a biofeedback game initially designed for anxiety symptoms, was found to have broader therapeutic applications. Extended Attention Span Training (EAST), originally developed by NASA to assess pilots’ attention, was adapted as an ADHD aid. By monitoring brain waves during commercial video games on PlayStation, the difficulty of games adjusts based on participants’ attention levels. The efficacy of this treatment is comparable to traditional ADHD interventions.

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. Re-Mission 2, in particular, was designed with children in mind, recognizing the prevalence of digital media in today’s youth. Mobile applications for anxiety, depression, relaxation, and other mental health areas are widely available on the Android Play Store and the Apple App Store. The widespread availability of laptops, mobile phones, and tablets means these apps can be accessed anytime, anywhere. Many are low-cost or free, and their simplicity can still provide benefit. Studies suggest that even short sessions, such as playing Tetris for three minutes, can curb cravings, while longer playtimes may reduce flashback symptoms from posttraumatic stress disorder. Initial research also indicates that visual-spatial games like Tetris or Candy Crush, when played shortly after a traumatic event, could act as a “therapeutic vaccine” to prevent future flashbacks.

Efficacy

Although the integration of electronic media into therapy is a new field, the devices themselves are familiar to most Western children. An emerging addition is virtual reality (VR) equipment, which both adolescents and clinicians may need to learn to use properly. The overarching term for preliminary studies using VR is Virtual reality exposure therapy (VRET). This research builds on traditional exposure therapy and has shown effectiveness compared to a wait list control group, though it is less effective than in-person treatments. One study compared a typical, lengthier treatment with shorter VRET sessions and found that while VRET patients initially responded well, their effectiveness was significantly lower at the six-month mark.

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 his first book, Children in Play Therapy. Later, in 1956, he worked with other experts to help shape a new way of thinking about helping people. In 1973, he published another book called The child's discovery of himself. His work focused on building good relationships to help children grow.

Today, many books explain play therapy and different ways to use it. The Association for Play Therapy has a list of these books on their website. Some titles include 101 Play Therapy Techniques, A Handbook of Play Therapy with Aggressive Children, and ADAPT: A Developmental Attachment-based, Play Therapy, among others. These books show how play therapy can help children in various 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 be used to support children who are dealing with things like trauma, autism, behavior challenges, or trouble with language.

There are different ways that parents can take part in play therapy with their children. One of the first methods, called Filial Therapy, started in the 1960s. In this method, parents learn how to play with their children in a special way that helps the child work through difficult feelings and behavior problems.

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, especially for children who have trouble connecting with others.

For children with autism, a method called Floortime was created in the 1980s. It uses play to help improve social and communication skills. More 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.