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Play Therapy

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 Play Therapy

Pidgeon, K., Parson, J., Mora, L., Anderson, J., Stagnitti, K., and Mountain, V.
Author information:

Kylie Pidgeon (BA, BSocSci(Psych)(Hons), GradDip Th, GradDip Psych) is a Provisional

Psychologist at Bridging the Gap, NSW. [email protected]

Judi Parson (PhD, M. Hlth Sc, MA - Play Therapy, Grad Dip Paediatrics) is a Paediatric
Registered Nurse, Play Therapist, Lecturer in Mental Health – Child Play Therapy, School of
Health and Social Development, Deakin University and President of the Australasia Pacific
Play Therapy Association. [email protected]

Lucinda Mora (M.App.Sc (OT), B.App.Sc (OT), Post Grad Dip Play Therapy) is an
Occupational Therapist, Play Therapist, Play Therapy Supervisor and Senior Clinical
Consultant at the Statewide Behaviour Intervention Service; Ageing, Disability and Home
Care; NSW Department of Family and Community Services. [email protected]

Jay Anderson (B.Psych. Post.Grad.Dip. Play Therapy) is a Psychologist, Specialist Child

Counsellor and Play Therapist, working in private practice in Western Australia at My Child
My Family, and a Director of the Australasia Pacific Play Therapy
Association. [email protected]

Karen Stagnitti (PhD, BOccThy, GCHE) is Professor Personal Chair in the School of Health
and Social Development, Deakin University. Karen has a specialised interest in children’s
play assessment and intervention. [email protected]

Vivienne Mountain (PhD, MA - Philosophy), MA - Art Therapy, BTh, BEd) is an Adjunct

Lecturer Melbourne College of Divinity, Relationships Educator with Life Works and in
Private Practice as Play Therapist and Family Counsellor. [email protected]

Abstract

Play therapy is an emerging therapeutic discipline, based on play as a child’s natural medium
of self-expression. Building on the work of Axline, Oaklander, Landreth and others, it is a
primarily non-verbal approach, in which children aged 2 to 12 are free to explore their
difficulties, hurts and feelings via play with toys, sand, puppets, clay, art, dance and music. A
secure and predictable relationship between child and therapist is crucial, in order for the
child to feel safe, accepted, and free to explore and grow. Assessed using measures such as
Goodman’s Strengths and Difficulties Questionnaire, approximately 80% of children display
a reduction in maladaptive behaviours. This improvement is consistent with UK and US
research, where play therapy is widely accepted. Play therapy has a growing evidence-base
and is effective in addressing difficulties including psychosocial issues, behavioural
disorders, chronic illness, trauma, abuse, ADHD, anxiety, stress, depression, grief and loss.
“Many things can wait; children cannot.

Today, their bones are being formed,

their blood is being made, their senses are being developed.

To them, we cannot say ‘tomorrow.’

Their name is today.”

—Gabriela Mistral, Nobel Laureate (1945)

Introduction

Angel did not know how to play. She scanned all the toys on the shelves or laid out on the
mat. She stood still, shoulders stiff, with a vigilant gaze. The lady with some glitter in her
hair and paint on her clothes said Angel could play with any of the toys that she liked, but
Angel sat still and silent on the couch for the first three sessions.

In session four, Angel went over to home corner and threw some dishes down onto the floor.
Then she noticed the baby dolls. Some were in prams and some were in cots. They had
blankets and bottles nearby. Angel took two of the baby dolls out of their cots and began
hitting them, calling them stupid, changing their clothes very roughly, and throwing them
around the room.

Angel was 5, and her father was diagnosed with cancer a year ago. Angel could not speak
much to anyone. At home when she tried to speak she was usually ignored or shouted at.
Mum said that she needed to be quiet ever since her father got sick. “We don’t want to upset
him again. Who knows what he might do to us this time!” Angel had lots of nightmares, but
she did not know who to go to for cuddles when she was afraid. At school she was scared that
she was going to do the wrong thing, so she tried to keep still during free time, and she never
volunteered an answer in class. She tried to write her name on some colouring-in once, but
only knew how to do the A. The other children spoke in sentences, so Angel’s toddler-like
vocabulary didn’t seem to be enough for the teacher. At lunchtime there were balls and
skipping ropes around, and the other children seemed to know how they worked. The other
children laughed and talked to each other while they played.
Angel’s older brother Tim had not fared much better. He got into fights at school and was
often in trouble. When Tim said he wished he was dead, Mum started crying more than usual.
She told Angel and Tim that she was sorry.

Mum telephoned the lady with some glitter in her hair and paint on her clothes. “It’s not their
fault. But I have noticed that Angel has changed. She's not the happy girl she used to be.
She's quiet and sad and sometimes gets angry. She's not doing very well at school and is
getting in trouble a lot. I didn’t think this would affect her or Tim quite so much. I can’t
change their father. Can play therapy help? What does play therapy do?”

What is Play?

Commentary on play dates back to the time of Plato (429 - 347 BC), who is quoted as saying:
“You can discover more about a person in an hour of play than in a year of conversation.”
Albert Einstein noted that “the highest form of research is play” (cited in Henniger, 1987),
and Friedrich Froebel, the creator of the first kindergarten supposed that “Play…. is the free
expression of what is in a child’s soul … play is not mere sport but full of meaning and
import” (1903).

Play is popularly considered to be spontaneous pleasurable behaviour, solely for amusement,

yet it is far more than that. Play is central to a child’s healthy cognitive, motor, linguistic,
emotional and social development (Ginsberg, 2007). Play is crucial for children’s creativity,
exploration, physical skills, self-regulation, interpersonal development and social learning.
The necessity of play for a child’s growth is undeniable.

Jean Piaget (1962) proposed that play bridges the gap between concrete experience and
abstract thought. That is, in play, a child deals in a sensory-motor way with objects as
symbols of something else abstract in the child’s experience. Children, who are
developmentally not yet able to engage fully in abstract reasoning until approximately age
eleven (Landreth, 2002), express themselves more freely and directly through self-initiated,
spontaneous play. A child may scribble furiously with sharp quick movements to express
anger or frustration, or sing quietly while sitting with a doll to express contentment. A fearful
child is likely to refrain from play, and a confused child may not be able to settle into one
play activity for an extended time.
Landreth (2002) further outlined that play provides a means through which feelings can be
communicated. Instead of verbalising particular situations, thoughts or emotions, a child may
use toys to communicate – e.g. shooting a dragon, locking up the bad guys, or punishing the
doll that represents a younger sibling. For many, this type of play is an example of how
children attempt to organise their experiences at a developmentally appropriate level, and
gain a sense of mastery and control in their life.

Stagnitti and Cooper (2009) explained that elements of play which include storytelling and
imagination are known precursors to language development and other functional skills such
as understanding context, narrative, predicting and planning. Further, play is a child’s
introduction to formal education, as children familiarise themselves with shapes, colours,
numbers, letters, and words.

The United Nations (1991) proclaim play as a “universal and inalienable right of childhood.”

The History of Play Therapy

Historically, play therapy has emerged from the conceptual understandings found in
psychoanalytic and humanistic psychology, psychotherapy and child development literature.
In Europe in the early 1900s, Melanie Klein and Anna Freud (the daughter of Sigmund
Freud) included play in their psychoanalytic treatment of children (Cattanach, 2008;
Donaldson, 2002; Landreth, 2012). In 1935, Margaret Lowenfeld first published Play in
Childhood documenting her in-depth observations of children whilst working at the ‘Clinic
for nervous and difficult children’ in London (Urwin & Hood-Williams, 1988). In the United
States, Virginia Axline focused her work on conceptualising and documenting Non Directive
Play Therapy (NDPT) by drawing from the humanistic and relational perspective of her
teacher and colleague Carl Rogers (Axline, 1969). Rogers (1951) was instrumental in
establishing treatment plans based on necessary and sufficient conditions for growth. These
included therapeutic congruence, unconditional positive regard, empathic understanding and
acceptance.

With a focus on child populations, Axline (1969) identified her eight principles for NDPT
where the therapist:

• Must develop a warm and friendly relationship with the child.

 • Accepts the child as she or he is.

• Establishes a feeling of permission in the relationship so that the child feels free to
express their feelings completely.

• Is alert to recognise the feelings the child is expressing and reflects these feelings
back in such a manner that the child gains insight into their behaviour.

• Maintains a deep respect for the child’s ability to solve their problems and gives the
child the opportunity to do so. The child is empowered to decide and to make choices.

• Does not attempt to direct the child’s actions or conversations in any manner. The
child leads the way, the therapist follows.

• Does not hurry the therapy along.

• Only establishes those limitations necessary to anchor the therapy to the world of
reality and to make the child aware of their responsibility in the relationship.

From these beginnings, several different theoretical models of play therapy have emerged.
Based on Axline’s principles, the most well-known is Non-Directive or Child-Centred Play
Therapy (CCPT) which has been further developed by Garry Landreth and colleagues
(Ginott, 1937; Guerney, 1994; Homeyer & Landreth, 1998; Landreth, 2012; Landreth &
Bratton, 1998; Landreth, 1978, 2001; Landreth & Hendricks, 1977; Landreth & Wright,
1997; VanFleet, Sywulak, & Sniscak, 2010; West, 1996) and integrated into teaching parents
or guardians the principles found in CCPT, known as Filial Play Therapy (Guerney, 2000;
Guerney & Guerney, 1987, 1989; Smith & Landreth, 2003; VanFleet, 2005; VanFleet, Ryan,
& Smith, 2005).

What is Play Therapy?

Play therapy is a therapeutic modality wherein play is the principle therapeutic factor.
Because play is a child’s natural medium of communication, play therapy is an ideal modality
in which to allow children to express their feelings and deal with their emotional problems. In
essence, play therapy is for children what ‘talk therapy’ or counselling is for adults.

Landreth (2012, p. 11) defines play therapy as:

… a dynamic interpersonal relationship between a child (or person of any age) and a
therapist…who provides selected play materials and facilitates the development of a
safe relationship for the child ... to fully express and explore self (feelings, thoughts,
 experiences, and behaviours) through play, the child's natural medium of
communication, for optimal growth and development.

Play therapy provides the child with a consistent and predicable therapeutic relationship and
environment in which to explore their fears, difficulties, struggles and pain, as well as hopes,
dreams and fantasies. The underpinning assumption of play therapy is that, given this
relationship and environment, the child has the inner resources to bring about growth and
change in their own lives.

Play therapists utilise a range of theoretical models which are founded on varying therapeutic
disciplines including: Child-Centred, Gestalt, Adlerian, Psychoanalytic, Jungian, Object
relations, Family Therapy, Eriksonian, and Cognitive Behavioural. The play therapy model
utilised by a play therapist will vary depending on the therapist’s specific training and
theoretical orientation.

The more traditional approaches, such as CCPT, move at the child’s pace. Other approaches
view the therapist as the expert and utilise more directive approaches, such as Cognitive
Behavioural play therapy (Drewes & Cavett, 2012) and Prescriptive Play Therapy
(Goodyear-Brown, 2010). This differentiation between directive and non-directive
approaches has led to the development of other models that incorporate both styles of
engaging with a child.

An example of an emerging model is the Play Therapy Dimensions Model (PTDM; Yasenik
& Gardner, 2012). This PTDM model is an integrative model, as is considers how the
therapist responds to the specific needs of the client by examining the therapeutic needs as
they occur on two dimensions: the conscious/unconscious dimension and the directive/non-
directive dimension. This creates four quadrants (See Figure 1):

• Non-intrusive responding (unconscious/non-directive)

• Co-facilitation (unconscious/directive)

• Active utilization (conscious/non-directive)

• Open discussion and exploration (conscious/directive)

Figure 1. Yasenik and Gardener’s Play Therapy Dimensions Model.

The Play Room

The necessary elements within the play room are: the child, the therapist, the relationship
formed by the child and therapist, the play therapy room and the play room contents. The
play therapy space is usually a designated room, set up in a particular and predictable way.
Within the room, there are a wide range of expressive tool and toys. These may include art
and craft materials, dress-ups and masks, a home corner/kitchen, musical instruments,
puppets, figurines, toy animals, toy weapons and military characters, a toy medical kit,
superheroes, books, vehicles, building blocks, a dollhouse and dolls, balloons and balls, a
sand tray, toys for dance and movement, and a table with clay. Some describe the play
therapy room as needing to contain something to represent everything in the child’s world.
Some play rooms contain model court houses or prisons, if these settings are poignant for the
child. Guerney (2001) outlined that a range of toys allow a child to understand that a range of
behaviours are permitted in the playroom. Toys that support issues of aggression, regression,
independence and mastery are as important as toys that foster nurturing, acceptance and
contentment.

The Play Therapy Process

In the play therapy process, the therapist first undertakes a thorough parent/carer consultation,
obtaining a concise history in relation to the child’s development, functioning, and present or
past concerns. Regular reviews are conducted with parents, teachers and others involved in
family support. Most children participating in play therapy are between 2 and 12 years of age,
however, this may vary. For example, a child who has a cognitive or developmental delay
may participate in play therapy at an older chronological age.

Generally, the therapist and child meet weekly for sessions of between thirty and fifty
minutes. As with all forms of therapy, the number of sessions undertaken will depend on the
child’s presenting issues, the particular therapist’s approach, and available funding. Some
children with mild issues may see improvement after 6 or 12 sessions, where children with
complex issues may require up to forty-eight sessions, or more.

In most play therapy modalities, the therapist gives limit-setting statements, designed to
provide safety and boundaries. Norton and Norton (2002) outline that there are ‘absolute
limits’ (the child will not hurt themself or the therapist), ‘clinical limits’ (all the toys remain
in the playroom, the child is encouraged to remain in the play room for their allocated time,
when the session ends, the child leaves the room) and ‘reactionary limits’ (the child does not
deliberately break the toys). The play therapist conveys the limits to the child in a firm and
consistent way. Many children desire to test these boundaries. In response to this occurring,
Guerney (2001) outlined that a combination of the acceptance of the child's wish or
determination to defy the rules, along with the authoritative stance of the therapist that the
rules are adhered to, is one of the most powerful therapeutic phenomena in child-centred play
therapy.

Therapeutic Stages in Play Therapy

A number of play therapists have described a discernible pattern in the therapeutic process of
children's play in therapy (see Landreth, 2002; Nordling & Guerney, 1999; Moustakas,
1997). Norton and Norton (2002) illustrate the therapeutic stages of play therapy as follows
(see Figure 2):

THERAPEUTIC STAGES IN PLAY THERAPY

Testing for
Exploratory Stage Dependency Stage Therapeutic Growth Stage Termination Stage
Protection
B
Improvement

A
Level of Presenting Problem

C
D

Time

Establishment of Trust Expression of Needs Empowerment and Closure Separation

© 1993 Byron Norton

Figure 2. Norton and Norton’s Therapeutic Stages in Play Therapy.

• The Exploratory Stage involves the establishment of trust. The child becomes familiar
with the room by exploring the environment, and the therapist begins to build a
relationship with the child, consistently responding in a particular way.

• The Testing for Protection Stage is characterised by expression of the child’s needs.
In this stage, the child must know that the therapist will accept them and the feelings
that they share. The child may be tentative in sharing emotions. As trust grows,
progress continues.

• The Dependency Stage involves greater expression of needs. The child works through
a number of emotional themes that are personally meaningful. The child may engage
 in regressive play or dramatic play and use fantasy play to disguise the content. The
therapist continues to respond or participate in a particular way.

• The Therapeutic Growth Stage is characterised by empowerment and closure. The

nature of the play changes as the child gains mastery and greater emotional
understanding. The play becomes more interactive and cooperative and shifts
progressively further away from dependency towards mastery.

• The Termination/Closure Stage involves separation and cessation of the relationship.

Stage duration varies from child to child – sometimes lasting only long enough to be
recognisable, while others last for many sessions. Consistent with all stage theories,
regression is seen shortly after establishment of trust. Parents and carers may notice
deteriorating behaviours at home or in other environments shortly after play therapy
commences, due to the child uncovering, exposing and examining their own hurts or
difficulties. Experienced play therapists will provide assurance that empowerment and
improvement will follow.

Neurobiology and Attachment

Contemporary neuroscience and psychotherapy theories suggest that health and well-being is
related to increasing levels of growth, complexity and integration within the human brain.
Neurologically, this means that well-functioning neural networks should be continually
communicating and forming new connections. In daily life, the result of an integrated brain is
greater ability to self-regulate, love, relate, play and learn (Cozolino, 2010). The goal of
scientifically informed psychotherapy is therefore to foster integration in the brain. In
keeping with best practice in adult therapy (Hubble, 1999), the primary way this integration
occurs during play therapy is in the building of a working alliance between child and
therapist. In addressing childhood trauma, leading researchers and clinicians Perry and
Szalavitz (2006) stress the importance of this relationship: “Humans are inescapably social
beings. . . Relationships are the agents of change…” (pp. 230-231). Similarly, Siegel and
Hartzell (2004) add:

It is not just inheritance that determines human development. Genes determine much
of how neurons link up with each other, but equally important is that experience
 activates genes to influence this linkage process. How we treat our children changes
who they are and how they develop . . . Nature needs nurture (p. 34).

During play therapy, the therapist remains attuned to the child’s needs, and ‘mirrors’ the child
as they play; physically copying the child’s play actions, in such a manner as to reflect the
child’s play actions back to them. In this way, the child gains insight into their behaviour, and
experiences the natural consequences of their actions. Further, social bonding neural
networks, such as the mirror neuron system are activated in a relationship in which this type
of reciprocity occurs. In the child’s brain, neuropeptides and opioids are released, leading to
the child feeling a sense of well-being and contentment (Golding & Hughes, 2012). This
reduces feelings of anxiety or anger, and improves the child’s immune system (Badenock,
2008). This act of mirrored play allows the child to safely operate at reduced levels of stress
while in the therapeutic space, activating neural growth hormones supportive of new learning
(Cowan & Kandel, 2001).

Conversely, chronic stress prevents meaningful play. A child who has experienced trauma,
severe loss or grief, witnessed violence, endured chronic stress, or demonstrates insecure
attachment is largely unable to play. This in turn means the child feels reduced connection to
others, is less able to form meaningful relationships and therefore remains in a state of self-
preservation. Thus the lower brain, which is responsible for regulating basic safety and
survival processes, such as breathing, blood circulation and arousal regulation, impairs higher
order brain functions such as speech and language and socio-emotional communication
(Perry, 2009).

Treatment of this state of chronic stress is achieved via bottom-up sensory-motor regulatory
approaches through child-centred play therapy (Gaskill, 2010). In addition, filial therapy, or
the inclusion of a parent-child treatment, is recommended to target disrupted attachment,
often having most impact on these lower brain centres (Barfield, Dobson, Gaskill & Perry,
2012).

Play itself is a creative process and enhances every domain of a child’s development (Perry,
2001). Recent research suggests that the neural networks for creativity are located in multiple
regions of the brain which are all working together, truly making creative play a whole of
brain process (Kaufman, 2013). Activating a child’s creative networks leads to desired
therapeutic outcomes of growth, complexity and brain integration. Relaxed and engaged play
physiologically interrupts the stress cycle (Vayle, 2013) and reduces chronic stress and
heightened arousal.

In play therapy, the therapist acts as a secure attachment figure for the child, providing
necessary predictability and safety, allowing the child to rest from allocating attention to
safety and survival. Although this experience only occurs in the playroom, the child
neurologically develops an understanding of safety and predictability. Capacity for growth
and development is therefore increased, and becomes transferable to other spheres of life.

Measurement

Measuring progress through play therapy is as important as it is in any therapy modality.

Goodman’s Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) is
internationally used by play therapists to measure the child’s observable behaviours pre and
post-treatment. Typically, the SDQ is completed by both the child’s parent or carer and the
child’s teacher in order to gather comprehensive data from the home and school or pre-school
environments. The SDQ incorporates scales of:

1) Emotional symptoms (5 items) e.g. often unhappy, downhearted or tearful

2) Conduct problems (5 items) e.g. often fights with other children or bullies them
3) Hyperactivity/inattention (5 items) e.g. easily distracted, concentration wanders
4) Peer relationship problems (5 items) e.g. rather solitary, tends to play alone
5) Pro-social behaviour (5 items) e.g. considerate of other people’s feelings

As well as providing insight into a child’s score on each scale, adding scales 1-4 together
generates a total difficulties score (the pro-social behaviour scale is excluded from this total
difficulties score). From the total difficulties score, an indication of the overall
severity/clinical significance of presenting problems can be obtained. A score of 16-25
indicates some risk, 25-29 indicates considerable risk, and 30+ indicates extreme risk.
Generally, the higher the initial scores, the more therapy sessions the child will need in order
to return to normal levels of functioning.

A number of other scales and assessments are used play therapists, including the Spence
Anxiety Assessment (Spence, 1998), the Symbolic Play Test (Lowe & Costello, 1988) and
the Test of Pretend Play (Lewis & Boucher, 1997). Another assessment tool, the Child-
Initiated Pretend Play Assessment (ChIPPA; Stagnitti 2007), assesses both conventional-
imaginative play and symbolic play in the same play assessment. It considers the quality of a
child’s ability to spontaneously self-initiate pretend play and measures the child’s ability to
sequence their play actions and use symbols in play. Children who are struggling in their play
may not use all the toys, may demonstrate poor ability to start a play idea, or may have
moved a lot of the toys but have no overall linking narrative. The ChIPPA has been used for
children with cerebral palsy (Pfeifer et al., 2012), children with acquired brain injury (Fink,
Stagnitti & Galvin, 2012), children with pre-academic problems (Stagnitti, Unsworth &
Roger, 2000) and children with autism (O’Connor & Stagnitti, 2011; Stagnitti, 2010).

Play Therapy is Effective for Which Presenting Problems?

Play therapy has an established and growing evidence-base and has been proven to be
effective in addressing myriad of presenting problems in children. These presenting problems
include:

• psychosocial issues, such as shyness, anxiety, stress, poor communication, grief and
loss;
• behavioural problems such as aggression, poor motor co-ordination, self-harming,
and attention deficit hyperactivity disorder;
• responses to family and relationship problems, such as family violence, parental
separation, attachment disorders, trauma and abuse;
• educational issues such as poor organisational skills, poor planning and execution of
tasks, poor story comprehension, and
• disability including autism, psychosis, sensory impairment and intellectual
impairment.

Results
A summary of the effectiveness of play therapy, presented by Play Therapy International and
Play Therapy UK in 2011 showed that, based on data from 8026 cases, between 74% and
83% of children receiving play therapy showed a positive change (Thomas, 2011). The
percentage of girls who showed improvement (79%) was slightly higher than boys (73%). It
was also found that younger children showed a greater percentage of positive change than
their older counterparts: 80% at age 6 compared with 71% at age 12. Children who presented
with more severe problems showed greater positive change; for those considered abnormal/at
risk, 76% showed a positive change, for those at considerable risk, 82% showed a positive
change, and for those at extreme risk, 88% showed a positive change. Of the children who do
not show positive change, some experience an unplanned exit from play therapy, due to
funding restrictions or family circumstances, before the therapeutic growth stage had taken
place.

Applications of Play Therapy in Specific Settings

Further applications of play therapy are regularly emerging in situations where children can
be assisted to work through a range of difficulties.

Government Departments and Family Intervention Services

Play therapy is already operating with great success in government departments such as
Family and Community Services (FaCS), and Aging Disability and Home Care (ADHC).
Within ADHC, a play therapy pilot was established to address the psychiatric and severe
emotional and behavioural problems experienced by children suffering Intellectual Disability.
Of the 31 children in the program, 74% had a secondary diagnosis, the two most prevalent
being Autism (35%) and ADHD (29%). It was hypothesised that a non-directive approach
would be most appropriate for children with Intellectual Disability as they many have limited
choice and control in their world (Brown & Brown, 2005).

Pre and post therapy scores showed significant improvement in the children’s presenting
issues after an average of 16 sessions. Parents also reported many qualitative changes in the
children’s emotional, behavioural and social presentation, including increases in use of
general and emotion-specific language at home and articulating words more clearly and
correctly. There were extensive changes in children’s capacity to self-regulate, such as:
initiating a calm physiological state, expressing feelings, and seeking affection and comfort
from parents. Socially, the children attuned to others, took turns, developed problem solving
strategies, sought out interaction and began to develop friendships. These findings are
consistent with existing literature (Demanchick, Cochran & Cochran, 2003; McMahon, 1992;
Swan, 2011), and suggest profound change for a group of previously isolated and vulnerable
children.
Of the subgroup with autism, many parents commented on the social and behavioural
differences in their children. For example, some children began to make independent choices
in daily life, others made eye contact, some started to hug their parents and others started
communicating verbally with their peers and parents rather than using aggression to meet
their needs. These findings are congruent with other research on autism and play therapy
(Josefi & Ryan, 2004; Levin, 2005; Parker & O’Brien, 2011, Scanlan, 2007) and suggest play
therapy is beneficial for children with autism.

Within Non Government Organisations (NGO’s), play therapy successfully operates in

Brighter Futures Family Support and Intensive Family Support services, assisting to provide
positive outcomes for vulnerable families. Further to this, play therapy has an effective
service to offer children at risk within the juvenile justice system. Partnerships between play
therapy services and health, education and disability agencies are recommended.

Play Therapy in Special Educational Settings

Play therapy has also been demonstrated to be an effective intervention in special school
educational settings. Stagnitti, O’Connor and Sheppard (2012) found that children in a
specialist play program increased in their social competence and language ability compared
to children who were not involved in the program. A comparison of a play based curriculum
versus a traditional curriculum showed that the play based children improved significantly
more in narrative language, complex play ability and social cohesion than children in the
traditional curriculum (Reynolds, Stagnitti, & Kidd, 2011).

Within 7 sessions in individual therapy, children showing signs of autism were shown to have
improved in the areas of representational thinking, using symbols in play, social turn taking,
understanding use of the toys, and emotional involvement in the play (Stagnitti & Casey,
2011). These skills promote greater skills in self-regulation and social competence in later
life. Play based intervention in school would be beneficial for target groups that included
children with autism, pre-academic problems and developmental delay.

Critical Incident Intervention

Play therapy has also been effectively used as a critical incident intervention for children.
Critical incident intervention may occur in prisons, domestic violence shelters, or in shelters
set up immediately following natural disasters. Play therapy is usually used in modified form
when applied to short-term community crisis intervention, such as was the case after the
Victorian bushfires of February 2009. The Australasia Pacific Play Therapy Association
(APPTA) was one of many groups who offered practical support following the bushfires,
sending a number of play therapists to attend some of the worst affected areas. Therapeutic
play spaces were set up in school halls, libraries and classrooms, and play tools including fire
trucks and other emergency vehicles were provided. Bratton, Ray, Rhine and Jones (2005)
reported an inverse relationship between number of sessions and treatment effect size in
critical incident play therapy. These results suggest that, in keeping with early intervention
principles, children in crisis respond more readily to treatment provided at the time of crisis,
rather than delaying treatment onset.

Asylum Seeker, Refugee and Linguistically Diverse Populations

Providing effective therapy is essential for asylum seeker and refugee populations who are
known to regularly suffer from post-traumatic stress (Vincent, Jenkins, Larkin, & Clohessy,
2013). However, verbal therapy can be problematic when the client and therapist do not share
a common language. Play therapy is effective in this regard, as it is a primarily non-verbal
approach, and it has demonstrated effectiveness for children who experience trauma and
abuse (Drewes, 2001; Homeyer & Landreth, 1998; Ogawa, 2004). It is therefore suggested
that play therapy be recognised, considered and researched as a suitable therapy modality for
asylum seeker and refugee populations, and non-English speaking populations.

Hospitalised Children

It is well documented that when children require hospitalisation and medical procedures that
it can be stressful for the child and the child’s family (Hagglof, 1999; Parson, 2004, 2008,
2009). In Sweden, in order to mitigate and relieve the child’s stress, every child admitted to
hospital since 1977 has been allocated a play therapist (Hall & Cleary, 1988). However, in
Australia, hospital based play therapists are extremely limited, particularly in rural and
regional areas (Parson, 2009). Play therapy could assist in preparing children for potentially
painful medical procedures, and be used as a complementary psychosocial health care
service.

The Value of Early Intervention

Early intervention services, such as play therapy, are regularly estimated to provide a far
greater return than the initial investment. While large scale studies are yet to be conducted
regarding the cost-benefit ratio of play therapy in Australia, The University of New South
Wales Social Policy Research Centre estimates that across a broad range of early intervention
strategies, the cost-benefit ratio ranges from between $2.36 to $19.10 for every $1 spent
(Valentine & Katz, 2007). Parents for Children’s Mental Health in Ontario Canada (2013)
surmise that for every $1 spent on early intervention and treatment of mental illness in
children and youth, an estimated $7 will be saved to the economy.

Mental illness is the single largest contributor to the disability burden in Victoria, Australia,
and accounts for 70 per cent of the disease burden in young people (The Boston Consulting
Group, 2006). Since it is estimated that 70 per cent of childhood mental health issues can be
solved with early intervention and therapy (Parents for Children's Mental Health, 2013), can
society afford to delay investment in early intervention services?

The benefits of early intervention extend well beyond the financial arena. Families report
greater stability, improved satisfaction in family relationships, and reduced child behaviour
management problems. This in turn promotes child safety, as reduced levels of household
stress contribute to increased safe parenting practices, and reduced notifications of child
abuse and neglect (Productivity Commission, p. 77). Appropriate intervention for children
not only benefits the child and family, but also has broader community benefits. Large scale
early intervention programs report societal benefits such as “longer term savings from
improved educational outcomes, better labour market participation, reduced dependence on
public assistance and lower levels of criminal activity” (Karoly, 2001, p. 2). The growing
body of evidence from post-play therapy assessments are consistent with these findings, as
most children demonstrate increased ability to learn, improved mental health, and improved
pro-social behaviour.

While early intervention services remain out of reach for many children who need them, the
economic, social and criminal cost to the Australian economy grows as demand on services
increases at the tertiary end of the service continuum. In New Zealand, in 2001, the
Department of Corrections estimated the costs and benefits for a range of preventive
interventions, designed to reduce the chance of imprisonment. These estimates revealed that
identifying a behaviour disorder and providing an early intervention program for a child in
the primary school years would cost $5000 per child, as compared with $255 000 per
offender later in life, at a cost benefit ratio of 1:51 (Jacobsen, 2002).

Training and professional recognition of Play therapy in Australia

Worldwide, play therapy is gaining recognition as an effective psychosocial and mental

health treatment modality. In some countries, Play Therapy has already become a protected
title, for example in USA, Canada and South Africa. Play therapy is not yet a recognised as a
distinct professional title or allied health service in Australia.

Currently, play therapists registered under the Access to Allied Psychological Services
(ATAPS) or Better Outcomes programs are able to offer play therapy services to their clients
under this scheme. The number of families who will benefit from play therapy will further
increase if play therapy is given professional recognition as an approved therapeutic
intervention by government funding programs.

The undergraduate training of play therapists are commonly nursing, occupational therapy,
counselling, psychology and education. In 2015, a Master of Child Play Therapy will become
available via Deakin University, in Geelong, Victoria. The course will be offered off campus
with intensive on-campus units and will include a range of play therapy techniques using
humanistic, systemic and emerging models of play therapy. This approach gives this degree a
clear theoretical and evidence-based foundation which is required for further progression of
play therapy in Australia. Play therapy research projects are currently being undertaken with
eleven research students across at least five states.

Currently, the three play therapy associations in Australia provide various and some
overlapping services: clinical registration, educational opportunities and accreditation, and
professional networks. The Australasia Pacific Play Therapy Association (APPTA), the first
not-for-profit organisation, was formed in 2007, then Play Therapy Australasia (PTAU) a
branch of Play Therapy International (PTI) and more recently the Australian Play Therapists
Association (APTA). The three associations are forming networks and will campaign with a
united voice to showcase the benefits of play therapy within Australia. Further public and
political awareness of play therapy is necessary to support the professionalisation of play
therapy in its own right. Members of the public can access play therapy by contacting one of
the above associations.
Conclusion

Angel saw Beth, the lady with the glitter in her hair and paint on her clothes, about twenty-
four times. After twelve sessions Angel seemed to feel safer in the play room, and she let her
guard down a bit. She checked that Beth would help her with what she wanted to do in the
sand tray. She found the pack of bear cards and methodically pulled out the ones she wanted.
She put the rest of the cards standing up around the edges of the sand tray, just as she wanted
them. She asked Beth to help her spell out the words “Dad” and “me” in big writing on
cardboard, then she sat down for 10 minutes and concentrated with the scissors. She placed
the letters in the sand, and arranged the cards, just as she wanted them. Then she asked Beth
to take a picture.

Beth said that after 24 sessions, Angel’s total difficulties score came down from twenty-eight
to sixteen. Angel’s language has improved and she has started stringing sentences together.
Her dramatic play includes nurturing and caring for others, she laughs, and smiles, and her
aggression has decreased. It seems as though the weight of the adult world is off her
shoulders.

Angel’s kindergarten teacher recently telephoned Beth and said: “I can’t get over it! It’s like
she’s a different girl! She looks me in the eye and says good morning, she’s more settled in
class and seems more relaxed, which of course means she’s free to learn more effectively.
She told me that in free time she likes spending time in reading corner. She’s really
progressing with her schoolwork, and is catching up to the rest of the class. She says yes
sometimes now when other children ask her to play, and yesterday she even invited another
child to play with her and they made up a game together. They were giggling and running
around for most of lunchtime!”

Angel’s mother said that at home Angel is sleeping better and doesn’t have so many
nightmares. She’s eating a bit more and even laughs sometimes at the dinner table. She
recently received her first invitation to another child’s birthday party. Tim is doing well too,
he still gets angry, but he isn’t getting into so many fights. Angel even seems to have calmed
him down a bit too. All in all the family are doing better, Angel especially. She’s more like a
child now, with brighter eyes, more spring in her step, and a growing circle of friends. She
laughs, and learns, and plays.
 Acknowledgements

Special thanks are due to Carole Tozer, Ira Sproats Nick Zografos at Bridging the Gap, St
Marys, NSW; Barbara Camp and Elizabeth Hensby at Bridging the Gap’s Play to Grow,
Glenmore Park, NSW; Bree de la Harpe, Fiona Howell, Jennayah Killelea and Marisa Chilcott
at Be Centre, Warriewood, NSW; Louella Covich from Kids Cove Creative Therapy,
Bawlgowlah; and Catherine Gitau, Transforming Play, Nowra, NSW.
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