Play Therapy for disaster victims.

1. Play Therapy
1. Historical foundations including who developed it, where, what was the rationale for it?
Introduced by Anna Freud and in the 1928 in Europe.
Rationale: Practitioners of play therapy believe that this method allows the child to manipulate the world on a smaller scale,
something that cannot be done in the child's everyday environment. By playing with specially selected materials, and with
the guidance of a person who reacts in a designated manner, the child plays out his/her feelings, bringing these hidden
emotions to the surface where s/he can face them and cope with them. In it's most psychotherapeutic form, the teacher is
unconditionally accepting of anything the child might say or do. The teacher never expresses shock, argues, teases,
moralizes, or tells the child that his/her perceptions are incorrect. An atmosphere should be developed in which the child
knows that s/he can express herself/himself in a non punitive environment. Yet, even though the atmosphere is permissive,
certain limits may have to be imposed such as restrictions on destroying materials, attacking the teacher, or going beyond a
set time limit.
2. Theoretical underpinnings, assessment and intervention techniques, method of evaluation & termination.
Theoretical underpinnings: Play Therapy emerged from elements of Child Psychotherapy with the specific theoretical
foundations emerging from the Humanistic Psychology tradition, Attachment theory, and free association/talk therapy.
Assessment & intervention techniques:
1. The therapist and child can get acquainted by sharing information about themselves based on the color of
the card from a deck of cards. For example, the intervention “Ice Breaker” (Kenney-Noziska, 2008a), a
modified version of the game Don’t Break the Ice™ (Milton Bradley), provides a play-based medium for the
therapist and child to get acquainted by sharing information about themselves based on the color of the sticker
on the underside of the game’s ice cubes.
2. “All Tied Up” (Kenney-Noziska, 2008a), highlights the importance of Addressing and processing abusive
and traumatic events using a large puppet or stuffed animal which is tied up in yarn labeled with symptoms.
This serves to symbolize the need to address symptoms and issues via treatment to avoid being “all tied up.”
Until these symptoms are explored and addressed, the individual remains “all tied up” with the problems.
3. The first play therapy techniques often used on a child are drawing and painting. In this technique, a child is
given a blank page onto which they can create whatever they want, often revealing much about their inner
worries and concerns. Drawing and painting is a valuable play therapy assessment tool which enables
therapists to help the child literally draw connections between what they create and themselves.
4. Music works in much the same fashion, allowing children to express their emotions and manipulate their
feelings through the energy of the music.
5. Molding and manipulating clay allows kids to build up and even destroy what they have made, expelling or
physically manipulating their emotions using the clay.

2. 6. One of the most common play therapy techniques is the use of story-making, which is the basis of
sand play, therapeutic storytelling, and puppetry. Sand play involves choosing miniatures to
manipulate within a sand tray world which the child can create and control. By listening to the story
and working with the child on the course of the story, a therapist can help the child express emotions
and work through their feelings.This same technique can be used with therapeutic storytelling during
which a story, relating to the child’s issues, is told so that emotions can be explored using imaginary
characters, and a positive outcome can be controlled.
7. Puppets are another method for a child, or a therapist acting for the child, to safely explore a
situation and control the outcome or explore various outcomes.
8. Some children require structures and rules in order to safely explore their feelings, and therapeutic
board games are one of the play therapy techniques which afford a more structured type of
exploration for these children.The games are geared to mimic a real world situation, and allow the
child to safely control the outcome.
9. Creative visualization is a play therapy technique where the child is guided to visualize positive
outcomes for difficult and perhaps even anger-provoking situations.This technique is a helpful tool,
taught to children at a play therapy session, and sometimes practiced alone or with a parent at home.
Method of Evaluation and Termination:
Evaluation: A cornerstone of therapeutic work with children and adolescents often includes
providing skill development for coping with emotional distress. Therefore, play therapists should
target coping skills development. With abused and traumatized children, the literature suggests
victims who utilize adaptive coping skills, including active strategies such as deep breathing or
cognitive strategies such as positive self-talk, are better able to emotionally self-soothe and self-
protect(Bogar & Hulse-Killacky, 2008). Development of adaptive coping strategies to reduce anxiety,
stress, anger, & fear should be conducted during the early stages of treatment and prior to recalling
details of abuse or trauma as recalling this material may induce these symptoms(Ross & O’Carroll,
2003).
Termination: During the termination stage, reviewing and acknowledging the child’s growth and
progress as well as crediting the child with the changes they have accomplished should occur (Cohen
et al. 2006; Jones, Casado, & Robinson, 2003). This can be accomplished through the play-based
activity “Farewell Fortune Cookies” (Kenney-Noziska, 2008a) in which therapeutic questions related to
termination are presented to the child or adolescent for review and discussion.Topics for questions
include reviewing skills acquired in therapy, placing closure on the therapeutic relationship, and
instilling hope for the future. Questions are written and taped on the outside of individually wrapped
fortune cookies. Players take turns selecting a “farewell fortune cookie” and responding to the
corresponding therapeutic question.

3. Evidence-Based knowledge including strengths and Limitations
Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years. Critics of
play therapy have questioned the effectiveness of the technique for use with children and have suggested using other
interventions with greater empirical support such as cognitive behavioral therapy.They also argue that therapists focus more on
the institution of play rather than the empirical literature when conducting therapy Classically, Lebo argued against the efficacy
of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas
of hard research. Many studies included small sample sizes, which limits the generalizability, and many studies also only
compared the effects of play therapy to a control group.Without a comparison to other therapies, it is difficult to determine if
play therapy really is the most effective treatment. Recent play therapy researchers have worked to conduct more experimental
studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.
Research is lacking on the overall effectiveness of using toys in nondirective play therapy. Dell Lebo found that out of a sample of
over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during nondirective play
therapy were not more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or
crayons, while example of non-recommended toys would be marbles or a checker game.There is also ongoing controversy in
choosing toys for use in nondirective play therapy, with choices being largely made through intuition rather than through
research. However, other research shows that following specific criteria when choosing toys in nondirective play therapy can
make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child,
encourages catharsis, and lead to play that can be easily interpreted by a therapist.
Several meta analyses have shown promising results toward the efficacy of nondirective play therapy. Meta analysis by authors
LeBlanc and Ritchie, 2001, found an effect size of 0.66 for nondirective play therapy.This finding is comparable to the effect size
of 0.71 found for psychotherapy used with children, indicating that both nondirective play and non-play therapies are almost
equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001,
found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than
non-treatment groups.These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71, 0.71,
and 0.66. Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being
treated with nondirective play therapy. Results from all meta-analyses indicate that nondirective play therapy has been shown to
be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.
There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a
significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes. Although positive effects
can be seen with the average 16 sessions, there is a peak effect when a child can complete 35-40 sessions. An exception to this
finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters.
Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the
implication that children in crisis may respond more readily to treatment Parental involvement is also a significant predictor of
positive play therapy results.This involvement generally entails participation in each session with the therapist and the child.
Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids
are exhibiting both internal and external behavior problems. Despite these predictors which have been shown to increase effect
sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.

7. References
Bogar, C.B., & Hulse-Killacky, D. (2006). Resiliency determinants and resiliency processes among female adult survivors of childhood
sexual abuse. Journal of Counseling Development, 84, 318-327.
Cohen, J.A., Mannarino, A.P., & Deblinger, E. (2006). Treating trauma and traumatic grief in children and adolescents. New York:
Guilford Press.
Friedberg, R.D., & McClure, J.M. (2002). Clinical practice of cognitive therapy with children & adolescents. New York: Guilford Press.
Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective approaches. New York: Guilford
Press.
Gil, E., & Jalazo, N. (2009). An illustration of science and practice: Strengthening the whole through its parts. In A.A. Drewes (Ed.),
Blending play therapy with cognitive behavioral therapy: Evidence-based and other effective treatments and techniques
(pp. 41-68). Hoboken, NJ: John Wiley & Sons.
Jones, K.D., Casado, M., & Robinson, E.H. (2003). Structured play therapy: A model for choosing topics & activities. International
Journal of Play Therapy, 12(1), 31-47.
Kelly, M.M., & Odenwalt, H.C. (2006). Treatment of sexually abused children. In C.E. Schaefer, & H.G. Kaduson (Eds.), Contemporary
play therapy: Theory, research, and practice (pp. 186-211). New York: Guilford Press.
Kenney-Noziska, S. (2008a). Techniques-techniques-techniques: Play-based activities for children, adolescents, and families. West
Conshohocken, PA: Infinity Publishing.
Kenney-Noziska, S. (2008b). The sexual abuse literature & considerations for play therapists. Association for Play Therapy Mining
Report, October 2008, 1-3.
Knell, S.M. (2009). Cognitive-behavioral play therapy: Theory and applications. In A.A. Drewes (Ed.), Blending play therapy with
cognitive behavioral therapy: Evidence-based and other effective treatments and techniques (pp. 117-133). Hoboken,
NJ: John Wiley & Sons.
Roberts, A.R., & Yeager, K.R. (Eds.). (2006). Foundations of evidence-based social work practice. New York: Oxford University Press.
Ross, G., & O’Carroll, P. (2004). Cognitive behavioural psychotherapy intervention in childhood sexual abuse: Identifying new direction
from the literature. Child Abuse Review, 13(1), 51-64.
Saunders, B.E., Berliner, L., & Hanson, R.F. (Eds.). (2004). Child physical and sexual abuse: Guidelines for treatment (Revised Report:
April 26, 2004). Charleston, SC: National Crime Victims Research and Treatment Center.
Schaefer, C.E. (2001). Prescriptive play therapy. International Journal of Play Therapy, 19(1), 57-73.
Shelby, J.S., & Felix, E.D. (2005). Posttraumatic play therapy: The need for an integrated model of directive and nondirective
approaches. In L.A. Reddy, T.M. Files-Hall, & C.E. Schaefer (Eds.), Empirically based play interventions for children (pp.
79-103). Washington, DC: American Psychological Association.
Sheppard, C.H. (1998). Brave bart: A story for traumatized and grieving children. Grosse Pointe Woods, MI: Institute for Trauma and
Loss in Children.
Siegel, D. (2007). The mindful brain: Reflection & attunement in the cultivation of well-being. New York: W.W. Norton & Company.