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ATHENA A. DREWES, PsyD, RPT-S, is Director of Clinical Training and APA Internship at The Astor Home for Children, a nonprofit multiservice mental health agency in New York. She is a Registered Play Therapist and Supervisor and past director of the Association for Play Therapy. She is the Senior Editor and chapter author of School-Based Play Therapy (Wiley), Cultural Issues in Play Therapy, and Supervision Can Be Playful.

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A practical and comprehensive guide that demonstrates how to merge play therapy practice with the benefits of cognitive behavioral evidence-based interventions

Blending Play Therapy with Cognitive Behavioral Therapy: Evidence-Based and Other Effective Treatments and Techniques helps child and play therapists and other mental health professionals become aware of the many hands-on play-based techniques and resources available across a variety of treatment approaches for working positively and effectively with children and adolescents.

Offering an in-depth view into how play therapy can help child and adolescent clients overcome a wide range of presenting problems, this resourceful book features informative coverage of:

• How to incorporate play as part of the treatment for children and adolescents with anxiety disorders
• Use of play therapy in parent-child interaction therapy
• Step-by-step instruction for implementing the treatment protocol covered
• Cognitive behavioral play therapy approaches for dealing with family treatment, trauma and abuse, and aggressive children

Filled with case studies and vignettes illustrating the therapeutic use of play and edited by a renowned expert in the field of play therapy, this insightful reference features contributions by many notable play therapists and renowned CBT specialists presenting a thorough guide to the best empirically based play therapy and play-based CBT treatments therapists can use when working with children and adolescents.

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A practical and comprehensive guide that demonstrates how to merge play therapy practice with the benefits of cognitive behavioral evidence-based interventions

Blending Play Therapy with Cognitive Behavioral Therapy: Evidence-Based and Other Effective Treatments and Techniques helps child and play therapists and other mental health professionals become aware of the many hands-on play-based techniques and resources available across a variety of treatment approaches for working positively and effectively with children and adolescents.

Offering an in-depth view into how play therapy can help child and adolescent clients overcome a wide range of presenting problems, this resourceful book features informative coverage of:

• How to incorporate play as part of the treatment for children and adolescents with anxiety disorders
• Use of play therapy in parent-child interaction therapy
• Step-by-step instruction for implementing the treatment protocol covered
• Cognitive behavioral play therapy approaches for dealing with family treatment, trauma and abuse, and aggressive children

Filled with case studies and vignettes illustrating the therapeutic use of play and edited by a renowned expert in the field of play therapy, this insightful reference features contributions by many notable play therapists and renowned CBT specialists—presenting a thorough guide to the best empirically based play therapy and play-based CBT treatments therapists can use when working with children and adolescents.

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Blending Play Therapy with Cognitive Behavioral Therapy

John Wiley & Sons

Chapter One

CHARLES E. SCHAEFER ATHENA A. DREWES

Play is as natural to children as breathing. It is a universal expression of children, and it can transcend differences in ethnicity, language, or other aspects of culture (Drewes, 2006). Play has been observed in virtually every culture since the beginning of recorded history. It is inextricably linked to how the culture develops poetry, music, dance, philosophy, social structures-all linked through the society's view of play (Huizinga, 1949). But how play looks and is valued differs across and within cultures (Sutton-Smith, 1974, 1999).

The use of fantasy, symbolic play, and make-believe is a developmentally natural activity in children's play (Russ, 2007). Play is not only central but critical to childhood development (Roopnarine & Johnson, 1994). For a variety of species, including humans, play can be nearly as important as food and sleep. The intense sensory and physical stimulation that comes with playing helps to form the brain's circuits and prevents loss of neurons (Perry, 1997). Play is so critical to a child's development that it is promoted by the United Nations 1989 Convention on the Rights of the Child, Article 31.1, which recognizes "the right of the child to rest and leisure, to engage in play and recreational activities appropriate to the age of the child and to participate freely in cultural life and the arts." Play is perhaps the most developmentally appropriate and powerful medium for young children to build adult-child relationships, develop cause-effect thinking critical to impulse control, process stressful experiences, and learn social skills (Chaloner, 2001). Play can provide a child the sense of power and control that comes from solving problems and mastering new experiences, ideas, and concerns. As a result, it can help build feelings of confidence and accomplishment (Drewes, 2005). Through play and play-based interventions children can communicate nonverbally, symbolically, and in an action-oriented manner.

Play is not only essential for promoting normal child development, but it has many therapeutic powers as well. All therapies require, among other factors, the formation of a therapeutic relationship, along with the use of a medium of exchange (Drewes, 2001). The use of play helps establish a working relationship with children, especially those who lack verbal self-expression, and even with older children who show resistance or an inability to articulate their feelings and issues (Haworth, 1964). The presence of toys and play materials in the room sends a message to the child that this space and time is different from all others. It indicates to the child that they are given permission to be children and to feel free to be fully themselves (Landreth, 1983).

Play is used in therapy by play therapists and child clinicians as a means of helping children deal with emotional and behavioral issues. Play therapy and the use of play-based interventions is by no means a new school of thought (Drewes, 2006). The use of play to treat children dates back to the 1930s to Hermione Hug-Hellmuth, Anna Freud, and Melanie Klein. Several adult therapies have since been adapted for use with children, such as child-centered play therapy adapted by Virginia Axline (1947), sandplay therapy evolving out of Jungian theory through Margaret Lowenfeld (1979) and Dora Kalff (1980), and cognitive behavioral play therapy by Susan Knell (1993).

In the safe, emotionally supportive setting of a therapy room, the child can play out concerns and issues, which may be too horrific or anxiety producing to directly confront or talk about in the presence of a therapist who can help them to feel heard and understood. The toys become the child's words and play their language (Landreth, 1991), which the therapist then reflects back to the child to foster greater understanding.

CURATIVE FACTORS OF PLAY

Therapists from differing theoretical orientations have long been interested in the healing or curative factors in psychotherapy. It is only over the past 25 years that child clinicians and researchers have looked more closely at the specific qualities inherent in play behavior that makes it a therapeutic agent for change (Russ, 2004). The goal is to understand what invisible but powerful forces resulting from the therapist-client play interactions are successful in helping the client overcome and heal psychosocial difficulties. A greater understanding of these change mechanisms enables the clinician to apply them more effectively to meet the particular needs of a client (Schaefer, 1999).

Freud wrote of insight, facilitated by the therapist's interpretations and analysis of transference (Schaefer, 1999), as the key component toward curing a client in psychoanalysis.

Yalom (1985) wrote about "therapeutic factors" or change mechanisms that he believed were inherent in group psychotherapy (Schaefer, 1999). They included acceptance, altruism, catharsis, instillation of hope, interpersonal learning, self-disclosure, self-understanding, universality, vicarious learning, and guidance (Schaefer, 1999). Bergin and Strupp (1972) offered critical factors that transcended theoretical schools of thought: counter-conditioning, extinction, cognitive learning, reward and punishment, transfer and generalization, imitation and identification, persuasion, empathy, warmth, and interpretation (Schaefer, 1999).

Schaefer (1999) was the first to describe the therapeutic powers of play. Based upon a review of the literature, he identified 25 therapeutic factors that will be discussed below.

Self-Expression

Developmental limitations in expressive and receptive language skills, limited vocabulary repertoire, and limitations in abstract thinking ability contribute to young children's difficulty in communicating effectively. Perhaps the major therapeutic power of play that has been described in the literature (Schaefer, 1993, 1999) is its communication power. In play, children are able to express their conscious thoughts and feelings better through play activities than by words alone. Children are naturally comfortable with expression through concrete play activities and materials (Landreth, 1993). Use of symbolic representation and expression through dolls and puppets provides emotional distance from emotionally charged experiences, thoughts, and feelings. Through indirect expression in play the child can gain awareness of troublesome affects and memories and begin the process of healing.

Access to the Unconscious

Through the specially chosen toys, games, and materials for their therapeutic and neutral stimulus qualities, the child can reveal unconscious conflicts via the defense mechanisms of projection, displacement, and symbolization (Klein, 1955). With the support of the play therapist in a safe environment, the child can begin to transform and integrate unconscious wishes and impulses into conscious play and actions (Schaefer, 1999).

Direct and Indirect Teaching

Play allows you to overcome knowledge and skills deficits in clients by direct instruction. For example, when you teach social skills to children using dolls, puppets, and role plays, the children are more likely to...