The trend in the mental health field is for evidence-based work. Unfortunately, not every therapist has training in or access to the protocols which are currently considered to be evidence-based. This does not mean empirical trends should be ignored or disregarded. Instead, therapists should strive to incorporate approaches which are, at minimum, empirically-informed and consistent with what the literature indicates should be addressed in our work with children and adolescents. In that manner, play-based interventions which focus on these areas can, and should be, incorporated into practice with children, adolescents, and families.
There is information which suggests an integrated approach to clinical work which incorporates evidence-based, directive, and nondirective models may be effective in addressing the diverse needs of the clinical population (Gil, 2006; Gil & Jalazo, 2009; Shelby & Felix, 2005). From a play therapy perspective, there is growing support for combining different theoretical models in a clinically grounded, integrated manner to address the needs of children, including those impacted by abuse and trauma (Gil, 2006; Kelly & Odenwalt, 2006; Kenney-Noziska, 2008b). The emphasis is placed on responding to the child’s needs versus strict allegiance to one theoretical school of thought. Being responsive to the child and adapting the therapeutic approach according to the child’s needs becomes essential and creates the context from which the therapist operates (Gil, 2006).
Prescriptive play therapy fits quite naturally with this perspective as the therapist has training in multiple theories and prescriptively selects their approach according to the needs, symptoms, & issues of the child (Schaefer, 2001). Models for incorporating play therapy into practice, such as the Structured Play Therapy Model by Jones, Casado, and Robinson (2003), provide the therapist with a framework for the timing and sequencing of directive play therapy interventions to avoid the pitfall of using directive activities in a manner in which the pacing of the techniques is inconsistent with the child’s needs.
Using a prescriptive approach in conjunction with the Structured Play Therapy Model referenced above, the following play-based activities may provide therapists with empirically-informed interventions to use in treatment with children and adolescents.
The therapeutic relationship is a common factor related to therapeutic efficacy & effectiveness and transcends all therapeutic approaches (Roberts & Yeager, 2006). For those working with children and adolescents, creating a child-friendly atmosphere assists in engaging children and adolescents and may facilitate the development of a stronger therapeutic alliance. As a result, dedicating clinical attention to this area is an important step. Play-based interventions can assist in this area.
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.
Another intervention, “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 depicted in the therapeutic story “Brave Bart: A Story for Traumatized and Grieving Children” (Sheppard, 1998). 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.
One empirically supported component in child mental health is providing skills for emotional identification, processing, & regulation (Saunders, Berliner, & Hanson, 2004). The literature suggests that people who use words to describe internal states are more flexible & capable of regulating emotions in a more adaptive way (Siegel, 2007). It is important to note that many verbal children have difficulty with words denoting emotions (Knell, 2009) & adolescents often suffer from a limited feelings vocabulary (Friedberg & McClure, 2002). Subsequently, activities which are geared toward facilitating emotional expression are essential components of our work.
Since many clients avoid discussing distressing emotions, “Revealing Your Feelings” (Kenney-Noziska, 2008a) was developed to facilitate emotional expression of “hidden” feelings. The therapist uses the “invisible” marker from the package of Crayola Color Changeable Markers™ to write various feelings inside shapes (i.e. squares, circles, triangles, etc.). Players take turns coloring a shape with one of the Color Changeable Markers™, revealing the feeling word written inside the shape. Each feeling is discussed and processed.
“Feelings Hide-and-Seek” (Kenney-Noziska, 2008a), a therapeutic version of the childhood game hide-and-seek, is another technique to facilitate emotional expression. In this activity, feelings are initially hidden, and through the course of hide-and-seek are found and discussed. Feelings are written on index cards that are hidden at varying levels of difficulty around the room. Players take turns finding the hidden feeling cards and processing a time they experienced the emotion written on the card.
Coping Skills Development
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).
“Balancing Out Your Feelings” (Kenney-Noziska, 2008a) emphasizes the concept that one needs sufficient adaptive coping strategies to manage emotional distress. In this technique, children quantify their level of emotional distress and, through the activity, this distress is offset by identifying a repertoire of adaptive strategies to cope with the distress.
“Bubble Wrap” (Kenney-Noziska, 2008a) is another developmentally appropriate technique for coping skills development. In this activity, construction paper and bubble packaging wrap provide a concrete representation of coping strategies to manage emotional distress. The child selects squares of construction paper to quantify their level of emotional distress. For each square of construction paper, the child identifies one adaptive coping strategy to manage the distressing emotion. The construction paper is taped onto the bubble wrap and the bubbles are popped to signify that the emotional distress can be reduced by using the coping strategy.
Cognitive-behavioral therapy is currently the most empirically supported protocol in the mental health field. Cognitive-behavioral approaches tend to be empirically supported and have been found effective in treatment with children and adolescents (Cohen, Mannarino, & Deblinger, 2006). Therefore, utilizing play-based techniques which are cognitive-behavioral in nature to build coping strategies may be effective (Gil, 2006; Saunders et al. 2004; Ross & O’Carroll, 2003).
“Positive & Negative Thinking” (Kenney-Noziska, 2008a) is a cognitive-behavioral intervention which facilitates an understanding of the interplay between thoughts, feelings, and behaviors and helps clients differentiate between adaptive and maladaptive cognitions. Index cards with positive and negative cognitions are selected by players and read out loud using the tone of voice that reflects how each thought would typically make the person feel. The player indicates whether the statement is a positive thought or a negative thought and places the index card onto a page with either a happy face or a sad face to signify how the thought would make them feel.
Another cognitive-behavioral intervention, “Don’t Lose Your Marbles,” provides a venue for identification of adaptive cognitions to replace specific maladaptive cognitions. The therapist and child identify approximately 6-10 maladaptive cognitions the client experiences related to a specific problem or issue. The board game Kerplunk® (Mattel) is played using the regular rules of play plus the additional rule that each time marbles fall during a player’s turn, that player must generate an adaptive/positive thought to replace one of the maladaptive/negative thoughts.
The importance of giving clinical attention to the termination stage of treatment cannot be overemphasized. 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.
Contemporary play therapy embraces both nondirective as well as directive approaches. Play therapy is far more than mere “play” and it is essential therapists remain informed of the empirical literature and use this information in their practice. The emphasis is on using empirical information in a manner which informs the play-based interventions utilized in practice. As therapists accompany children and adolescents on their journey of healing, the incorporation of empirically-informed play therapy interventions into practice may serve to support the therapeutic process. Play-based interventions serve to create a therapeutic process which is developmentally appropriate, engaging, and effective at addressing many clinical issues. To accomplish this, interventions utilized must be clinically grounded and informed by the literature and research which guides our field and serves our clients.
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.
About the Author
Sueann Kenney-Noziska, MSW, LISW, RPT-S, is a Licensed Independent Social Worker and Registered Play Therapist Supervisor specializing in using play therapy in clinical practice with children, adolescents, and families. She is an accomplished author, instructor of play therapy, guest lecturer, and internationally recognized speaker who has trained hundreds of professionals. Sueann actively serves in leadership roles in the play therapy community and has created original play-based techniques and interventions which have advanced the field of play therapy. She is founder and President of Play Therapy Corner, Incorporated, an organization dedicated to supporting and facilitating professional development for counseling and mental health professionals who use play therapy in their clinical practice. Sueann is author of “Techniques-Techniques-Techniques: Play-Based Activities for Children, Adolescents, & Families.” To contact the author, visit www.playtherapycorner.com