Über die Autorin bzw. den Autor

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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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 learn and remember the lessons. The use of fun and games captures children's attention and increases their motivation to learn.

Storytelling and the use of play narratives allow the child to join in interactive fantasy play with the therapist (Schaefer, 1999). This in turn can result in the child learning a lesson or solution to his/her problem (Gardner, 1971). This is a gradually paced, indirect method with room for repetition that allows for less emotional arousal than direct confrontation (Frey, 1993). Play narratives enable clients to organize their fragmented memories and experiences into a cohesive, meaningful story (Pennebaker, 2002).

Abreaction

Through the use of play, children reenact and relive stressful and traumatic experiences and thus gain a sense of power and control over them (Schaefer, 1999). Through repetitive play reenactments, the child is able to gradually mentally digest and gain mastery over horrific thoughts and feelings (Waelder, 1932). Children show a natural tendency to cope with external events and traumas through play. After the horror of 9/11, many children were observed building towers with blocks and crashing toy airplanes into them. "Post-traumatic play can be effectively used therapeutically. It is, in fact, the most potent way to effect internal change in young traumatized children" (Terr, 1990, p. 299).

Stress Inoculation

The anticipatory anxiety of upcoming stressful life events, such as a family move, starting school, birth of a sibling, or visit to a doctor or dentist, can be lessened by playing out the event in advance (Wohl & Hightower, 2001). By playing out with miniature toys exactly what to expect and using a doll to model coping skills, the strange can be made familiar and less scary to the child.

Counterconditioning of Negative Affect

Two mutually exclusive internal states are not able to simultaneously coexist, such as anxiety and relaxation or depression and playfulness (Schaefer, 1999). Thus allowing a child to play hide-and-seek in a darkened room can help in conquering fear of the dark. Or dramatic play with hospital-related toys can help to significantly reduce hospital-specific fears. Rea, Worchel, Upchurch, Sanner, and Daniel (1989) found hospitalized children's adjustment was significantly improved (anxiety significantly reduced) for the randomly assigned group that was encouraged to engage in fantasy play with both medical and nonmedical materials.

Fantasy play allows the child to move from a passive to an active role, for example the child can role-play giving an injection to a doll patient. Fantasy play also facilitates the expression of several defense mechanisms such as projection, displacement, repetition, and identification (Schaefer, 1999).

Catharsis

Catharsis allows for the release and completion of previously restrained or interrupted affective release via emotional expression (e.g., crying) or activity (e.g., bursting balloons, pounding clay, or punching an inflated bunching bag) (Schaefer, 1999). Emotional release is a critical element in psychotherapy (Ginsberg, 1993).

Positive Affect

While involved in play, children tend to feel less anxious or depressed. Enjoyable activities contribute to a greater sense of well-being and less distress (Aborn, 1993). In play, both children and adults are likely to elevate their mood and sense of well-being (Schaefer, 1999). Sustained high levels of the stress hormone cortisol can damage the hippocampus, an area of the brain responsible for learning and memory, which results in cognitive deficits that can continue into adulthood (Middlebrooks & Audage, 2008). Laughter and positive affects help to create the opposite effect, releasing mood-boosting hormones or endorphins, lowering serum cortisol levels, and stimulating the immune system (Berk, 1989). Play and playfulness and its potential for mirth and laughter become an antidote to negative affects such as anxiety and depression (Schaefer, 1999).

Sublimation

Sublimation allows the channeling of unacceptable impulses into substitute activities that are socially acceptable (Schaefer, 1999). The child who physically hits another may be redirected, helped to practice and learn through repetition alternative means of expressing negative feelings by using "war-like" board games (chess, checkers), card games (war), or competitive sports activities (Fine, 1956; Schaefer, 1999).

Attachment and Relationship Enhancement

Play has been found to facilitate the positive emotional bond between parent and child. Studies of filial therapy (Ray, Bratton, Rhine, & Jones, 2001; VanFleet & Guerney, 2003), Theraplay, and Parent-Child Interaction Therapy (Brinkmeyer & Eyberg, 2003; Hood & Eyberg, 2003) have shown success in promoting parent-child attachment and relationship enhancement (Drewes, 2006). Through step-by-step, live-coached sessions, the parent/caregiver and child create positive affective experiences, such as playing together, which results in a secure, nurturing relationship. Gains are reflected, via research, in improvements in parental empathy, increased perception of positive changes in the family environment, self-esteem, perception of child-adjustment, perception of the child's behavioral problems, along with the child's self-concept, and changes in the child's play behavior (Rennie & Landreth, 2000).

Moral Judgment

Piaget (1932) first asserted that children's spontaneous rule-making and rule-enforcing play in informal and unsupervised play situations was a critical experience for the development of mature moral judgment. Game play experiences help children move beyond the early stage of moral realism, in which rules are seen as external restrictions arbitrarily imposed by adults in authority, to the concept of morality that is based on the principles of cooperation and consent among equals (Schaefer, 1999).

Empathy

Through role-play, children are able to develop their capacity for empathy, the ability to see things from another's perspective. Role-playing different characters in social play has been found to increase altruism (Iannotti, 1978), empathy (Strayer & Roberts, 1989), as well as social competence (Connolly & Doyle, 1984).

Power/Control

Children feel powerful and in control during their play. They can make the play world conform to their wishes and needs (Schaefer, 1999). In marked contrast with the sense of helplessness children experience during a disaster, play affords them a strong sense of power and control. The child towers over the play materials and determines what and how to play during the therapy session. Eventually, this competing response (power) helps overcome the child's feelings of insecurity and vulnerability.

Competence and Self-Control

Play provides children with unlimited opportunities to create, such as through stories, worlds constructed in a sandtray or drawings, whereby they can gain a sense of competence and self-efficacy that boosts their self-esteem (Schaefer, 1999). In addition, by engaging in activities such as game playing or construction play, children can learn self-control through thought and behavior stopping that can help them to stop and think and plan ahead. As a result the child can anticipate the consequences of various potential behaviors and actions. These skills can be mastered through practice opportunities and positive reinforcement and can consequently then generalize into any number of settings (e.g., school, home, social settings).

Sense of Self

Through the play and child therapist's use of a child-led, child-centered approach (Axline, 1947), a child can begin to experience complete acceptance and permission to be himself without the fear of judgment, evaluation, or pressure to change. Through a commentary on the child's play, the therapist provides a mirror, figuratively speaking, by which the child can understand inner thoughts and feelings and develop an inner self-awareness (Schaefer, 1999). Play can also provide the opportunity for the child to realize the power within to be an individual in one's own right, to think for oneself, make one's own decisions, and discover oneself (Winnicott, 1971). Since this is often a unique experience, Meares (1993) noted that the field of play is where, to a large extent, a sense of self is generated. He concluded that play with an attuned adult present is where experiences are generated that become the core of what we mean by personal selves (Schaefer, 1999).

Accelerated Development

Preschool children's levels of development can advance in play beyond the ordinary accomplishments of their age period and function at a level of thinking that will only become characteristic later on (Schaefer, 1999). Vygotsky (1967) observed that children in play are always above their average age and their daily behavior.

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Excerpted from Blending Play Therapy with Cognitive Behavioral Therapy Copyright © 2008 by Athena A. Drewes . Excerpted by permission.
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