Integrating Play Therapy in the Home-Based Setting Module

Module Sections:

Introduction & Pre-test

Welcome to the Course

Welcome!

Play Therapy Poem

I tried to teach my child from books

He gave me only puzzled looks

I tried to teach my child from words

They passed him by, often unheard

Despairingly, I turned aside

"How shall I teach this child?", I cried

Into my hand he placed a key,

"Come," He said, "and play with me."

-Anonymous

This online learning module is designed to provide an overview of integrating play therapy in the home-based environment.

  • In this course we will explore the following topics:
  • Theoretical foundation from which play therapy was developed
  • The stages of play therapy and assessment processes
  • Models of play therapy
  • Issues and ideas for integrating play therapy into the home setting
  • Examine the role of the therapist in the play therapy process
  • Applying play therapy with a common family

Play therapy has a strong foundation rooted in theory. This course will discuss theories that have influenced the development of play therapy including client-centered, Gestalt, Adlerian, Jungian, Filial, Theraplay and others. Play therapy has its roots clearly embedded in child development. The successful play therapist understands developmental theory especially the contributions of Piaget and Erickson.


Module Objectives

This module will guide your exploration and increase your general knowledge about integrating play therapy in the home-based setting. The objective of this module is to accomplish the following:

  • Recognize the importance of play therapy and who play therapy can impact
  • Explore the theoretical foundations of play therapy
  • Define the five major techniques of play therapy
  • Apply strategies and techniques to play therapy in home-based environment

Adults often suppress their ability to play thus negatively impacting the interactions in their child's world. For adults, play is often educational. Think about how often the adult asks a child what color a toy is rather than simply engaging with the child in play. Play therapy can provide an opportunity for the parent and therapist to be truly present with a child because they participate with the child in the problem solving process. A parent and the therapist will also learn about self through the play therapy process. One cannot participate in the play therapy process without being impacted.

Play therapy provides an opportunity for self-discovery and self-growth. Moustakas (1981 in Landreth, 1991) states:

  • "The challenge of therapy is to serve, to wait with interest and concern for the child to activate the will and to choose to act, to dare to pursue what is present in the way of interest and desire. This calls for unusual patience and an unshakable belief in the child's capacity to find the way, to come to terms with the restraints and tensions of living, a belief in the child's powers to listen inwardly and to make choices that are self-enhancing"(p. 60).

The play therapist believes in the inherent ability of the child to move the process in the direction it needs to go. The therapist believes in the child's ability to resolve issues when provided with the means to do so, in a safe and secure environment.


Scope of the Issue

In the early 1900's Freud began describing his work with Little Hans and the development of Psychoanalytic theory. The contributions of Freud, von Hug-Hellmuth, Anna Freud and Melanie Klein influenced the beginning of play therapy. In the early years, the focus was on the exploration of the unconscious and free association in order to recall the past and gain insight. The primary relationship was with the parent and the therapist was the key contributor to the progress of therapy.

Anna Freud and Melanie Klein began using play with their child clients as they believed that play was the medium for the most free expression of self. This belief remains core to play therapy today. Play was a means to help children feel comfortable dealing with the difficulties or traumas that plagued them. Freud hoped to use play to help children become trusting of the process in order to reach the psychoanalytic or talk therapy level.

Klein viewed play as more symbolic with important meaning. Klein actually developed the first "rules" for play therapy of "no hurts" – cannot hurt self, therapist or toys. Although she still believed that children could not get better unless they gained insight into the past, Klein emphasized the importance of the therapist possessing a genuine interest in children which was a new concept. Prior to that, children were not valued in the same way. As summarized in Filley and Robertson, (Theories and Techniques in Play therapy, 2006):

"In the psychoanalytic approach to play therapy, no attempt is made to direct, reeducate, or pressure the child toward any predetermined direction or alternate course of action. Psychoanalytic theory promoted a working relationship between the child and the therapist; allowed for communication of wishes, fantasies and conflicts; promoted child's understanding of conflict by use of imagination; acknowledged wish fulfillment; accepted the child and conveyed to the child that he is loved and worthy of love; children are not tiny adults (Rousseau, 1792); play has purpose and can be looked at for meaning; realization that childhood disorders might be due to emotional factors; beginning model for direct therapy with children; collaborative view of therapy which included play observations and interviews with parents; and belief that play is the child's natural medium of expression."

Although Anna Freud made major contributions to play therapy, talk therapy is not considered a goal of the process. Helping a child work through issues through the child's natural medium play is the primary goal. Discussion of the issues through talk therapy is possible and may occur but is not a goal of play therapy.

Play Therapy Major Theoretical Orientations

 

Following the arrows down from the original theories, you will see how they influenced different approaches to play therapy in a contemporary sense. Some PT modalities, such as Theraplay, were influenced by more than one theory (ie, Theraplay was a mix of developmental and relationship theories). These mixed inflluence PT modalities are where you see the two arrows meet. Hope it helps! ©2006 DFilley.


Pre-Test

Click the link to respond to the following survey:


Establishing a Common Ground

Theoretical Foundation of Play Therapy

Play is essential to the child's development. It is the way "children learn what no one can teach them…By engaging in the process of play, children learn to live in our symbolic world of meanings and values, at the same time exploring and experimenting and learning in their own individual way." (Frank in Landreth, 1991) According to Piaget a person does not reach the ability for abstract reasoning until the age of eleven, therefore play is how children bridge the gap between concrete experience and abstract thought.

Through play, children are able to organize their experiences and it is a time when they feel most in control and secure.

  • Play is the language of the child
  • Play is how children communicate and act out their feelings and experiences
  • Play is a natural self-healing process for children allowing them to naturally and spontaneously express themselves and adjust to the changing world around them

When feelings or experiences are too intimidating, play allows the child to express directly what they cannot put words to because of their limited cognitive ability or because of the insecurity felt because of the experiences. Natural medium for self-expression, facilitates a child's communication, allows for cathartic release of feelings, can be renewing and constructive, and allows the adult a window to observe the child's world (Nickerson, 1973).


Why Play Therapy is Important

Play therapy provides children with a safe and secure atmosphere where they can work through their issues. The therapist provides the child with the means to work through issues while working alongside them without interpretation; it is a medium of expression solely based on the language of the child – play. Play therapy allows the child to work through issues in a manner that is congruent with the developmental level and through resources with which the child is most familiar.

The play therapy process, whether directive or nondirective, sandtray, or Theraplay, with the therapist only, or with the family, allows the child to interact with toys and other participants in a manner that is both cathartic and interventive. The child is able to engage with toys that are familiar (doll house, kitchen, games, art work, clay), or are fantasy based (puppets, imagery), or through storytelling (sandtray, puppets), or other activities of the child's creation. The child is able to act out the conflicts and create resolution to those conflicts. The child engages in activities that support the child's developmental age while the therapist gently encourages the movement that is controlled by the child's desired pace.

The Importance of Child Development

Children's play is impacted by their experiences and understanding how children play can assist you in understanding what a child is working through or in improving your interactions with them. Landreth (1991) explains that developmentally, children lack the cognitive and verbal ability to express their feelings and are emotionally unable to handle the intensity of these feelings or adequately express them in a verbal exchange.

Further, according to Piaget, children are not developmentally able to engage fully in abstract reasoning or thinking until approximately age eleven (Craig & Kermis, 1995). This puts the child at a disadvantage for the regular "talk therapy" because their thinking is concrete. Play is a developmental process and the mechanism for developing problem solving and competence skills.

Children's cognitive abilities differ between intellectual stages according to Piaget. It is important to understand Piaget's cognitive developmental stages when using play therapy. Practitioners must set reasonable expectations in order for the client to achieve realistic goals. According to Piaget, it is important to remember that mentally healthy children cannot digress through his cognitive developmental stages. Below is a table of Piaget's Cognitive Developmental Stages. It is important to remember that the ages listed below are guidelines and may not clearly define each individual.

STAGE

AGE

CHARACTERISTICS

1. SENSORIMOTOR

Birth- 2 years

  • Learn through environment 
  • Motor development and reflexes are main focus
  • Can modify child's behavior with senses: frown, tone of voice

2. PREOPERATIONAL

Age 2-Age7

  • Child uses symbols to represent objects
  • Egocentric
  • Language development is main focus

3. CONCRETE OPERATIONS

Age 7-Age 11

  • Abstract thinking 
  • Ability to classify objects
  • Capable of problem-solving

4. FORMAL OPERATIONS

Age 11- Age 15

  • Can perform hypothetical and deductive reasoning
  • Thought is more abstract

Erickson (1963) refers to play as the emotional laboratory where a child learns to cope with his/her environment and deal with concerns. Play therapy allows allows a child to repeat past events and gain mastery.

According to Erik Erikson, man a person experiences eight stages of psychosocial development over the duration of the lifetime. Erikson's research is most notable for the "psychosocial crisis" that appears in each stage and must be resolved before one can successfully continuing on e to the following next stage. Taking into account Erikson's developmental stages is essential for successful play therapy. In comparison to Piaget's cognitive developmental theory, practitioners must set reasonable expectations in order for the client to achieve realistic goals.

Below is a summary of Erikson's psychosocial stages and the tasks within each stage.

 

STAGE

AGE

CHARACTERISTICS

1. TRUST VERSUS MISTRUST

Infancy-Age 2

  • Develop trust with consistent and nurturing care 
  • Child develops hope and confidence
  • Mistrust occurs with inconsistent care giving
  • Child develops depression, withdrawal

AUTONOMY VERSUS SHAME & DOUBT

Age 2- Age 3

  • Guidance is key from care givers
  • Children will develop autonomy and a sense of will 
  • Permissive, authoritarian, or rejecting care giving can result in shame & doubt

INITIATIVE VERSUS GUILT

Age 3- Age 5

  • Children model adult's
  • Child will develop a sense of purpose
  • Children will develop guilt if attempts at initiative are punished

INDUSTRY VERSUS INFERIORITY

Age 5- Age 12

  • School age children must tame impulses and attempt to work with others
  • Sense of competence occurs when adults support effort of industry
  • Lack of support will lead to sense of inferiority and helplessness may occur

IDENTITY VERSUS ROLE CONFUSION

Age 12- Age 19

  • Young adult creates a sense of self-identity by trying on different roles
  • Achieving identity leads to fidelity-the ability to sustain loyalties
  • Identity diffusion occurs if identity crisis is not resolved

Play itself will not ordinarily produce changes. The therapist's interventions and utilizations of the play are critical. The therapist is a participant-observer, not a playmate. Play is an intervention which is based on theoretical premises, and is used to facilitate change. Play therapy is defined as, "an interpersonal process wherein a trained therapist systematically applies the curative powers of play to help clients resolve their psychological difficulties" (Schaefer 1993, p. 3). "Play in itself will not ordinarily produce changes, therefore, the therapist's interventions and utilizations of play are critical" (Chethik 1989 as cited in Gil, 1994, p.4).


Stages of Play Therapy

Stages of Play Therapy

1. Exploratory Stage

Child explores the play room, their role, and the therapist's role

2. Testing for Protection Stage

Child begins acting out and "testing the waters" in regard to respect, safety, and protection. If the therapist "passes the test", then therapy can begin.

3. Dependency Stage

The child will begin disclosing and confronting their own emotions and pain. 

4. Therapeutic Growth Stage

Once the pain has been confronted, the child will feel more empowered and act out less.

5. Termination Stage

The child now has a new sense of control and empowerment and begins the stage of saying goodbye to the therapist and the safe, play environment.

The first and most basic stage is the exploratory stage. This begins immediately with the first session in which the child begins to explore the play room, and understand their role, and the therapist's role. As soon as the child begins to understand the roles of each individual, he/she moves into the second stage, the testing for protection stage. At this point, the child may begin acting out and 'testing the water' in regard to respect, safety, and protection. If the therapist, in a sense, passes their test, therapy can begin.

The dependency stage hits the real core of the therapy experience. This is where the child will begin disclosing and confronting their own emotions and pain. Once this pain has been confronted, the child enters the therapeutic growth stage in which they begin to feel more empowered and act out less. As the child gains a new sense of control and empowerment, the termination stage begins. The child must understand that they will soon have to say goodbye to the therapist and the safe, play environment. (Filley, D. Fundamentals of Play Therapy, KC Play Therapy Institute)


Kottman's 4 C's

Kottman (1999) suggests that every behavior has a purpose and children must master each of the four Crucial C's: courage, connect, capable, and count.

Courage: willingness to face life's tasks and take risks even when they do not know if they can succeed. When children have courage they feel hopeful, are resilient, and believe they can handle challenging situations; without courage they feel inferior and inadequate;, may give up without trying, and avoid challenges.

Connect: need to connect with others. When children feel connected they feel secure, are able to cooperate, can reach out and make friends, and feel they belong; without this sense of connection children feel isolated and insecure, and may seek attention (often negative attention) to have a place to belong.

Capable: need to feel they are competent and capable of caring for themselves. Children who feel capable have a sense of competence, self-control and self-discipline; they are self-reliant and can assume responsibility for themselves and their behavior; they believe they can do whatever they set their mind to; without this capable feeling children feel inadequate, frequently try to control others or let others know they cannot be controlled or become dependent on others or seek to overpower others.

Count: need to feel they are significant. Children who feel that they count, believe they can make a difference in the world and contribute to others around them; they feel valuable and valued and believe they matter; without this they feel insignificant, hurt, and may react to their feelings by trying to hurt others; they develop poor self-esteem, give up, try to intimidate others, or overcompensate by acting superior.

Kottman (1999) asserts that children need to achieve mastery in these areas and play helps them to do this. Oleander (1978) explains that her "goal is to help the child become aware of herself and her existence in the world. The process of work with the child is a gentle, flowing one – an organic event. What goes on inside you, the therapist, and what goes on inside the child in any one session is a gentle merging" (p. 53). As the therapist presents an environment that is free of interpretation and judgment, secure for the child to express self, the child will work through the issues that plague them and reclaim themselves.

Write a Journal Entry

Take time to reflect, then write in your HBFT journal about the following topic.

Consider some of the families you are working with and how these Crucial C's are evident or missing within those families.

Adults often suppress their ability to play thus negatively impacting the interactions in their child's world. For adults, play is often educational. Think about how often the adult asks a child what color a toy is rather than simply engaging with the child in play. Play therapy can provide an opportunity for the parent and therapist to be truly present with a child because they enter the child's problem solving process. A parent and the therapist will also learn about self through the play therapy process. One cannot participate in the play therapy process without being impacted. Play therapy provides an opportunity for self-discovery and self-growth. Moustakas (1981 in Landreth, 1991) states:

"the challenge of therapy is to serve, to wait with interest and concern for the child to activate the will and to choose to act, to dare to pursue what is present in the way of interest and desire. This calls for unusual patience and an unshakable belief in the child's capacity to find the way, to come to terms with the restraints and tensions of living, a belief in the child's powers to listen inwardly and to make choices that are self-enhancing" (p. 60).

The play therapist believes in the inherent ability of the child to move the process in the direction it needs to go and to be able to resolve the issues when provided with the means to do so, the safe and secure environment that includes the resources the child needs.


Directive Play Therapy

One approach to play therapy involves more active structuring by the therapist. The Directive play therapy approach assumes the therapist is responsible for the structure and direction of the therapy process. "Directive therapists structure and create the play situation, attempting to elicit, stimulate, and intrude upon the child's unconscious, hidden processes or overt behavior by challenging the child's defensive mechanisms and encouraging or leading the child in directions that are seen as beneficial." (Gil, Eliana. 1991. The Healing Power of Play. New York: Guilford Publications). The therapist will select activities and through these, challenge the child to work through the issues identified. The therapist has an active role in determining the direction and focus of therapy. Directive play therapy often involves a combination of cognitive and behavioral responses based on the activities that invite the child to engage with the toys and the therapist.

Directive therapy processes are often more short term in nature and may be more symptom-focused. For example, a child presenting with anger issues may be guided through the resolution of process through activities that identify and assist in controlling the angry reactions (Angry Kleenix Game, Boxing Balloons, etc.). A child with self-regulation issues may become involved in a series of activities that seek to escalate and deescalate behavior with the therapist assisting the child in learning to self-regulate (Red Light-Green Light followed by Mirroring, etc.). The resource section of this module contains several handouts that describe a variety of activities/interventions to coincide with a number of presenting issues.

There are a number of situations that make directive play therapy more appropriate than non-directive play therapy. When children struggle with engaging in play, more directive work may assist the child in becoming freer to engage in the future. When a therapist wants to address a particular issue and the child is not progressing through free play, then directive play therapy may be more appropriate. Family therapy and home-based therapy processes are more easily adapted to including play therapy. Play therapy allows young children to engage in the therapy process when the more traditional talk therapy may be too intimidating or difficult to keep children engaged. Finally, some issues such as attachment issues are more appropriately dealt with through directive therapy processes such as Theraplay described later in this module. Therapists may also use a combination of directive and non-directive play therapy approaches. The child may engage in free play and the therapist gradually introduces the stresses into the play situation. The child may then engage in free play again to help them recover from that stress.

Family therapy and specifically home-based therapy are specifically amenable to a more directive therapy approach. The therapist must determine ahead of time what the session should address and decide on the appropriate activities to draw the parents and children into interactions around the issues of concern. There are a number of family activities that are easily transportable to the home. The toolbox described in the resource section can assist the therapist in creating a portable play therapy process!


Nondirective Play Therapy

Carl Rogers is recognized as the founding father of client-centered therapy. During his practitioner years, Rogers challenged the more popular psychoanalytic, experimental, and behavioral therapists with his nondirective approach to therapy. Rogers disagreed with the current approaches to therapy arguing that the client was not able to reach self-realization and growth due to the therapists' authoritarian styles. Carl Rogers changed the history of therapy by shifting the focus to reflection of the client.

Non-directive play therapy approach is based on the assumption that the individual is capable of solving one's own problems. The rate of progress differs between individuals; however, successful therapy can only be achieved if the individual is willing to reorganize past experiences, attitudes, thoughts, and feelings (Axline, 2002). The non-directive approach to play therapy offers the individual the freedom to express oneself without judgment or pressure from the practitioner. Axline (2002) explains non-directive play therapy as, "an opportunity that is offered to the child to experience growth under the most favorable conditions. …the child is given the opportunity to play out his accumulated feelings of tension, frustration, insecurity, aggression, fear, bewilderment, confusion"(p. 15).

Axline's Eight Basic Principles of Nondirective Play Therapy

  1. The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible.
  2. The therapist accepts the child exactly as he is.
  3. The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely.
  4. The therapist is alert to recognize the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behavior.
  5. The therapist maintains a deep respect for the child's ability to solve his own problems if given an opportunity to do so. The responsibility to make choices and to institute change is the child's.
  6. The therapist does not attempt to direct the child's actions or conversation in any manner. The child leads the way; the therapist follows.
  7. The therapist does not attempt to hurry the therapy along. It is a gradual process and is recognized as such by the therapist.
  8. The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship.

Reprinted from Play Therapy, 2002 by Axline (pp 69-70)

The nondirective approach to play therapy is based on a nonintrusive relationship the therapist establishes with the client. This approach correlates with the client-centered approach first discussed by Carl Rogers. According to Rogers, there are three essential concepts to the child-centered theory of personality structure:

  • The person
  • The phenomenal field
  • The self

(Landreth, 1991)

Axline is recognized for her contributions to nondirective and directive approaches to play therapy in how she applied Rogers' client-centered approach (Gil, 1991).

Carl Rogers' Basic Elements of Therapy:

  1. The individual comes for help.
  2. The helping situation is defined.
  3. The counselor encourages free expression of feelings in regard to the problem.
  4. The counselor accepts, recognizes, and clarifies negative feelings.
  5. When the individual's negative feelings have been expressed they are followed by expressions of positive impulse, which make for growth.
  6. The counselor accepts and recognizes the positive feelings in the same manner as the negative feelings.
  7. There is insight, understanding of the self, and acceptance of the self along with possible courses of actions.
  8. Use of positive action along with the decreasing need for help.

Sandtray Play Therapy

History/Rationale:

Originally developed by Dr. Margaret Lowenfeld, the original practice of using a sandtray for therapeutic purposes was coined the term, "Lowenfeld World Technique" in 1979. Dr. Lowenfeld used metal trays with water, sand, and miniature toys- asking her clients to create "world pictures" (Homeyer, 1998). Since Dr. Lowenfeld's time, many other play therapists have adapted her original idea and used it in practice as well. Dora Kalff adapted the technique to a more Jungian approach and called it Sandplay Therapy (Homeyer, 1998). Present day sandtray therapy is a widely used method, but adapted to suit many different approaches; Lowenfeld, Jungian Sandplay, Gestalt, cognitive-behavioral, and many others (Homeyer, 1998).

Sandtray therapy is one of the most versatile approaches to play therapy that can create an environment of total immersive creativity for the client. Not only can this medium illuminate non-verbalized issues, but it also allows for a safe, comfortable distance between the client and therapist, allows for a sense of client control, and creates a unique setting for symbolism, metaphors, and storytelling.

Recommendations:

Although sand and water were the original mediums used, rice, cornmeal, and small beads have been added to the list of mediums as well. Examples such as rice and beads allow for easier cleanup, especially when being used in a home-setting. Trays work best if they are waterproof and made of either plastic or wood. They should also be blue to emulate sky or water. Although a 30"x20"x3" tray is recommended (Homeyer, 1998), smaller or more transportable trays may be used in home-based therapy work.

Miniature types, shapes, and sizes may vary and there are 12 main categories of miniatures that should be included in a sandtray therapy kit. These include:

  • People
  • Animals
  • Buildings
  • Vehicles
  • Vegetation
  • Fences
  • Nature Items
  • Fantasy
  • Spiritual
  • Landscape
  • Household

(Homeyer, 1998).


Setting up a Sandtray

Setting up a sandtray may be more difficult in a home-setting due to the fact that it can be awkward to transport, has many different pieces, and can be a bit messy. However, many of the benefits of using such a tool can override such deterrents. Some tips that may help make the therapy session run smoother include:

  • Find a tray with a tight lid for easy, no-spill transporting
  • Use a medium that allows for easy clean-up and bring a blanket/table cloth for placing under the tray to catch access water, sand, or toys.
  • Find miniatures that are truly miniature for easier storing, transporting, and use in a smaller sandtray.
  • Use a spray bottle of water for clients to dampen sand instead of a bottle of water. Lighly misting the sand will assist in keeping the sand from floating in the air when moved.
  • Make use of disposable items such as straws, toilet paper tubes (for sand tunnels and such), etc. that can be thrown away after the session.
  • Use a rolling suitcase to pack items in, instead of carrying the tray and items from home to home.

Overview:

Ask the client or family to create a picture in the sand using the miniatures and the sand in any way they wish. The therapist should remain in the background positioned to view the development of the picture without intruding in the work space. The therapist should pay close attention to the selection of miniatures (including those selected and rejected), placement of miniatures, and the verbal and nonverbal expression during the creation of the picture. When creating a family sand tray the therapist should also attend to how the family works together, who takes leadership, how each contribute or does not contribute, and how members respect the contributions of each other in the development of the picture.

Interpretations:

Types of Worlds :

  1. Empty World- 1/3 of the tray has no miniatures
  2. Unpeopled World- no people in the tray (excluding soldiers)
  3. Closed/Fenced World- uses fences to enclose parts of the tray and create boundaries
  4. Rigid World- rigid lines, rows, shapes
  5. Disorganized World- chaotic world, no order or organization
  6. Aggressive World- aggressive picture, full of battles, fighting, war, etc.

(Filley, 2005)

Processing the Sand Tray:

  1. Ask the client or family to title the picture
  2. Ask the client or family to tell a story about the tray
  3. Take time to silently look at the sandtray from several angles
  4. Discussion of the tray should actually only take about 15-20 minutes. When asking questions about the tray remain within the story told and in third person. Even if characters are identified as self or family members, continue to refer to them as "this character" or "this person" or "this lion". Ask questions about relationships between the characters, movement of the characters, obstacles present, etc. For example, "how would things be different if this lion went across this bridge." Always remain in character when processing the tray and hover above the tray. It is important to respect the tray as the clients and not move the miniatures. If movement is necessary, it is important to ask the clients permission to move the miniature. Remember, it is the client's tray!
  5. Have a poloroid camera available to take a picture of the sandtray for both the file and if the client would like a picture of the tray.
  6. When complete the home-based therapist should discuss dismantling the tray and ask if the client would like to assist in this process.
  7. Much of the work for the client in sandtray therapy is done after the process has been complete and throughout the week. The actual involvement is cathartic in itself and the client often will think about the work in the days and weeks following. It is not necessary to revisit the tray in subsequent sessions. Also recreating the tray typically is inadequate because the moment has passed and the story would be different.

Filley, D. (2005). Sandtrays in play therapy: beginner manual. KCPlay: www.kcplay.com. Homeyer, L. & Sweeney, D. (1998). Sandtray: a practical manual. Royal Oak, MI: Self-Esteem Shop.


Filial Therapy

History and Rationale

Filial therapy differs from most other approaches due to its incorporative nature. Its main goal is to incorporate parents into the therapeutic process- teaching them to be their child's main support system and teacher; thus, placing the main focus on the child/parent relationship as opposed to the client/therapist interaction.

Filial, which literally means 'of or pertaining to a son/daughter in relation to the parent' (Ryan, 2007) was a radical form of therapy when it was first proposed over 30 years ago by Drs. Bernard and Louise Guerney (VanFleet, 2003). It was originally proposed as an intervention form of therapy for children between the ages of 3-10 who had severe adjustment problems (VanFleet, 2003). Guerney marketed the new technique by convincing professionals that if parents could be trained to a particular competency level, they could create noticeable, positive, emotional changes in their children (Ryan, 2007).

Before Filial therapy was practiced, the child's guardians had been viewed as the main sources of conflict and strife in the child's life. These parents were expected to be separated from the therapeutic process. However, Filial Therapy changed the way therapists viewed the child's caretaker- seeing them instead as the 'primary therapeutic agents' for their child's future (Ryan, 2007). These parents are now being trained in skills such as reflective listening, responding to their child's feelings, limit setting, and building self-esteem (Schumann, 2002). Professionals reason that by fostering positive behavior and skills in an already established parent-child relationship, the child would reap the benefits of having the continued parental influence after the therapy was completed. In addition, many professionals argue that the client drop-out rate is lower due to the nature and capacity of the parental involvement (Ryan, 2007).

More recent studies have proven the following benefits to using Filial Therapy:

  • Client drop-out rates decrease
  • The child's presenting problems improve dramatically
  • Parents' knowledge and skill levels improve
  • Parents' acceptance and understanding of their child improves
  • Parents' stress levels decrease
  • Parents' satisfaction with the results of the therapy is increased
  • Three and five year follow-up studies show such gains are usually maintained (VanFleet, 2003).

However, this does not mean that Filial Therapy is for every client and every parent. The following are circumstances when Filial Therapy should not be utilized:

  • If parents are unable to comprehend and understand the basic skills taught in Filial Therapy.
  • If parents are completely emotionally unavailable to their children
  • If parents are the perpetrators of abuse
  • If the child is unable to creatively or symbolically play (VanFleet, 2003).

Overview of Filial Therapy

Because Filial Therapy incorporates both parents and children, it can be seen as a cross between play and family therapy. Two methods of conducting Filial therapy are most common: group and individual.

Group:

With less difficult issues, Landreth's 10-Week Group Filial Therapy model is used (Ryan, 2007). This involves taking a group of parents and training them in the Filial therapy methods and skills. The parent(s) are encouraged to practice in a play session at home, with indirect supervision from the therapist. This occurs over a 10-week period of time. The parent will often videotape the special play time with the child and review the tapes with the therapist. The therapist assists the parent in establishing boundaries, maintaining consistency with the few rules established, and building in encouragement and support for the child's positive interactions.

Individual:

With moderate levels of difficulty, individual Filial work is conducted over a 20-week period. In the individual sessions, each child has individual sessions with parent(s). The model includes:

  • Assessment phase in which family members have initial interviews and give consent to work with the Filial Therapy program.
  • Observation of the family in a play session by the filial therapist.
  • Demonstration session in which the therapists demonstrates a mock Filial Therapy session for the child/children and parents
  • Parent training period lasting usually three sessions in which the therapist demonstrates helpful skills and tools for the parents in order to assist their children through the therapy process
  • Six directly supervised play sessions with responses from the therapist (Ryan, 2007). After this last stage, the play sessions are conducted within the home setting and occur less frequently in the office setting.There is a more indirect supervision process for about ten sessions when the therapist is viewing the videotapes with the parents. Throughout the filial therapy process, the therapist provides feedback and helps the parents to generalize and incorporate their new play and parenting skills into everyday life (Ryan, 2007).

Within the Home

One of the indications for using home-based therapy is to help the family who has difficulty generalizing the work done in the office to the home environment. Filial Therapy is a natural process used by the home-based therapist because much of the work of filial therapy occurs in the home. By using this approach, therapists can assess the home environment and the interactions between the parent and child.. This not only allows the therapist to determine whether Filial therapy is the appropriate approach to use with each family, but it also provides the therapist with an "inside look" at the interactions and situations that take place at home. The therapist is able to adjust techniques, skills, and approaches to fit the needs of the family.

Therapists who work in the home may find it easier to do the following things :

  • Determine if the participants will respond positively to Filial therapy
  • Create a needs assessment
  • Assess the home environment
  • Assess the family interactions
  • Assess the cultural dynamic of the family
  • Teach the skills and practice them within the setting in which they will be used

Theraplay

In the 1960's Ann Jernberg launched a program with Head Start in Chicago to provide psychological services for children. What she found was that effective treatment was long term and expensive and there were not enough centers to address the needs of the families needing services. As a result, Jernberg and colleagues began to develop a treatment program that was based on the models of healthy parent-infant interaction as well as the work of Austin Des Lauriers and Viola Brody. Des Lauriers approach was highly intrusive and intimate in the interactions between the child and therapist that included direct body and eye contact. Brody focused on the nurturing relationship between the therapist and child that included touch, holding, rocking and singing. (Jernberg, A.M. & Booth P.B. 2nd Edition. Theraplay: Helping Parents and Children Build Better Relationships Through Attachment-Based Play. 1999. San Francisco: Jossey-Bass).

"The goal of Theraplay treatment for all children is three-fold: to help the child replace inappropriate solutions and behaviors with healthy, creative, and age-appropriate ones; to increase the child's self-esteem, and to enhance the relationship between the child and her caretakers. Theraplay therapists do this by being vigorous and engaging, all the while working to establish a real relationship between the child and adult, by ignoring fantasy, and focusing on what is going on in the present between them." (p. 4) The Theraplay process involves an assessment period (3-4 sessions), treatment process (10-20 sessions), and follow-up period (4-6 sessions spaced over a year). (Jernberg 1999) The assessment process involves an extensive interview with the child's caregivers, the administering of the Marschak Interaction Method (MIM), and a feedback session with the caregivers. It is during this feedback session that the Theraplay therapist will outline the treatment process for the family. There are four dimensions of the Theraplay process: Structure, engagement, nurturing touch, and challenge. A Theraplay session will typically involve activities from each area.


Four Dimensions of Theraplay

The following information is taken directly from Theraplay Activities by Dimension, The Theraplay Institute, www.theraplay.org.

Structure:

Children with attachment/trauma issues often engage in power struggles with caregivers in an effort to maintain control over the interactions and relationship. In Theraplay, the goal of structure is to relieve the child of the burden of that control. "The adult sets limits, defines body boundaries, keeps the child safe, and helps to complete sequences of activities" (p.1). Some examples of structure activities are:

  1. Peanut Butter and Jelly: Say "peanut butter" and have the child say "jelly" in just the same way. Repeat five to ten times varying loudness and intonation.
  2. Pop the Bubble: Blow a bubble and catch it on the wand. Have the child pop the bubble with a particular body part, for example, finger, toe, elbow, shoulder or ear. This is a structured way of playing with bubbles. Bubbles readily capture the interest of young children and can be used as an engaging activity either in this structured form or in a manner that invites more spontaneity (for example, by having the child pop all the bubbles as quickly as she can.)
  3. Mother May I?: parent gives instructions to the child to do something, for example, "Take three giant steps toward me." Child must say "Mother May I?" before responding to the command. If the child forgets, she must return to the starting line. The goal is to have the child come to her parent and get a hug on arrival
  4. Hide Something on Child and Find It: One adult hides and the other finds, for example, notes directing the finder to do something with the child ("Pop Sara's cheeks"); or find a cotton ball and give a soft touch, or find food and feed it to the child

Engagement:

Children with attachment/trauma issues often find it difficult to stay connected with a caregiver in positive ways. The goal of engagement is to "establish and maintain a connection with the child, to focus on the child in an intense way and to surprise and entice the child into enjoying new experiences" (p.3).

  1. Check up: Check body part, such as nose, chin, ears, cheeks, fingers, toes, knees to see if they are warm/cold, hard/soft, wiggly/quiet, and so on. Count freckles, toes, fingers and knuckles.
  2. Blowing Over: Sit facing the child and holding hands (or cradle the child in your lap), have the child "blow you over." Fall back as the child blows. Once the child understands the game, you can blow her over.
  3. Mirroring: Face the child, move your arms, face, or other body parts and ask child to move in the same way. For a very active child you can use slow motion or vary the tempo. Take turns as the leader.
  4. Hide and Seek: Hide the child under a blanket or under pillows and ask the parent or other adult to find the child. Parents should be coached to make appreciative comments about their child as they look for him and to find him quickly if he is young and impatient. A big hug is in order once the child is found.

Nurture:

Children with attachment/trauma issues often feel that they are unloved. The goal of nurture is to "reinforce the message that the child is worthy of care and that adults will provide care without the child having to ask" (p.4).

  1. Caring for Hurts: Check hands, feet, face and so forth, for scratches, bruises, hurts or "boo-boos." Put lotion on or around the hurt with cotton ball, or blow a kiss. Check for healing in the next session. (Note, for children sexually abused powder is a substitute for the lotion).
  2. Feeding: Have a small snack and drink available for all sessions. Take a child on lap or face seated child. Feed the child, listen for crunches, noticing if the child likes the snack and when the child is ready for more. Encourage eye contact.
  3. Twinkle Song: Adapt the words of "Twinkle, twinkle little star" to the special characteristics of the child. "What a special boy you are/Dark brown hair, and soft, soft cheeks/Bright brown eyes from which you peek/Twinkle, twinkle, little star/What a special boy you are." Hold the child in your arms and touch the parts you refer to as you sing.
  4. Blanket Swing: Spread a blanket on the floor and have the child lie down in the middle. The adults gather up the corners and give a gentle swing while singing a song. At the end bring him down for a "soft landing." Position parents so they can see the child's face. If the child is fearful of being lifted off the floor, rock him gently back and forth while he remains in contact with the floor.

Challenge:

Children with attachment/trauma issues often have security issues and are afraid to take risks. The goal of the challenge is "to help the child feel more competent and confident by encouraging the child to take a slight risk and to accomplish an activity with adult help" (p. 6).

  1. Balloon Between Two Bodies: Hold a balloon between you and the child (such as between foreheads shoulders, elbows) and move across the mat without dropping or popping the balloon. See if you can do this without using your hands.
  2. Cooperative Cotton Ball Race: You and the child get on hands and knees at one end of the room. Take turns blowing a cotton ball (or ping pong ball) to the other side of the room. You can try to better your time on repeated trials. A competitive version would be for each to have his own cotton ball and see who can get it across the room first.
  3. Pillow Push: Place a large pillow between you and the child. Have the child push against the pillow trying to push you over.
  4. Tangle: Standing in a circle, all cross their arms in front of themselves and take the hands of the two others in the circle, deliberately creating a tangle of hands. Participants then untangle without breaking the handholds. It is okay to slide hands around in the grip or to face different ways when untangled. It adds fun to put lotion on everyone's hands first.

The activities in each dimension are done in a very positive, warm, spontaneous, upbeat and fun manner. The last activity in each dimension listed above is one easily completed with a parent or caregiver present. It is advised that two therapists are involved in the treatment process with one therapist working with the child and the other therapist observing and interpreting with the parents. There are hundreds of Theraplay activities for each dimension and therapists often create their own activities! Theraplay activities are easily adapted to the home environment. The "equipment" is often the child himself or things that are easily transportable so Theraplay works well in the home environment. For more information on Theraplay and certification see the Theraplay Institute at www.theraplay.org


Murphy Family Vignette

Carla Murphy and her 4 children have been referred for HBFT due to fighting amongst the siblings. Carla has been divorced 3 times. The children consist of 12 year old Michael and 11 year old Kevin who are biological bothers. Ten year old Marcos (IP) is from Carla's second marriage. Marcos's father is not involved in the family as he has been imprisoned since Marcos was 2. Marcos has also been involved in stealing from his family as well as from the school. The school has reported that Marcos is defiant and recently has been "bullying" children on the playground. The fourth child is 7 year old Jeremiah from Mom's third marriage. Mom reports Marcos is especially combative with Jeremiah.

Carla is of Hispanic origin. Her first husband, Michael, Sr. is involved with his children and tries to help when he is able. Her second husband, Charles was imprisoned on drug charges and burglary. He is not expected to be released from prison for another 5 years. Carla's third husband, Richard lives in the area but does not initiate contact with Jeremiah. His position is that when Jeremiah wants to see him, he will make himself available. Carla's mother is also involved in the family and a tremendous support for her and the children. The children often spend the night with their grandmother. Carla works full time at the local university as a secretary. She reports she is often tired when she arrives home and becomes easily irritated with the fighting in her home. She states that Marcos's aggression has been increasing of late and she is concerned about possible legal ramifications if he continues stealing and hurting other children.

Marcos has seen a therapist individually in the past however Carla reports it has not been helpful. The therapist has indicated that Carla has been unable to follow through on the parenting practices they have talked about in session and in the parenting classes Carla has attended. The therapist suggested home-based therapy to assist Mom in working with all the children and learning to apply the ideas she has learned through therapy and group.


Forming a Unified Framework

Attachment Theory

Attachment theory can be considered the foundation of mental health work with children. As clinicians understand the importance of attachment in a child's development, they are better able to understand the difficulties children present with for therapy. When infants experience a relationship with a caregiver that is secure and consistent, the child is able to develop enduring connections in future relationships. A healthy attachment is not something the caregiver or child develops alone. It is something a child and caregiver create together in an ongoing relationship. James (1994) defines a secure attachment as "a love relationship that is caring, is reciprocal, and develops over time. Attachment provides the nurturance and guidance that foster gradual and appropriate self-reliance, leading to mastery and autonomy" (p .24). When John Bowlby first began discussing the importance of attachment he described it as the "lasting psychological connectedness between human beings" (p . 69)

Infants instinctively need to attach to that secure base with their caregiver. The development of this secure base is critical to the infant's development of a trusting relationship with a caregiver and ultimately for future relationships. The Trust Cycle is how the infant learns to interpret emotional responses in others and in turn, how to respond to those emotional responses. This cycle is how a child learns how to trust through everyday experiences. The four components of the trust cycle are:

  1. Need on the part of the infant (e.g., hunger, needing a diaper changed)
  2. Emotional response (e.g., crying, fussing)
  3. Gratification (e.g., the caregiver provides food or comfort)
  4. Trust (e.g., the child learns that someone will help him in a time of need)

Cain, p. 19

This trust cycle is closely aligned with Erickson's first stage of development, trust vs. mistrust. As Cain states: "the caregivers ability to read the infant's social cues, and the infant's ability to give the necessary social cues, are critical to the attachment process. "(p. 19) Over time it is expected that the caregiver will be able to distinguish between cries of hunger, irritability, fear, illness, etc. and respond accordingly. The infant learns he is not alone in the world and can count on someone else to help meet his needs thus creating that reciprocal relationship and secure base. As the child develops with this secure base, he will also be able to differentiate and separate from the caregiver toward greater independence. The caregiver naturally establishes boundaries for the child and the child tests these boundaries as he explores and learns and develops. Some refer to this time as the Terrible Twos!

According to the Evergreen Psychotherapy Center: Attachment Treatment and Training Institute children who develop a secure attachment base will do better in the following areas over time:

  • Self-esteem
  • Independence and autonomy
  • Resilience in the face of adversity
  • Ability to manage impulses and feelings
  • Long-term friendships
  • Relationships with parents, caregivers, and other authority figures
  • Prosocial coping skills
  • Trust, intimacy and affection
  • Positive and hopeful belief systems about self, family and society
  • Empathy, compassion and conscience
  • Behavioral performance and academic success in school
  • Promote secure attachment in their own child

The Attachment Figure

The attachment figure is the person who is primarily responsible for the infants overall care specifically attending to the needs of feeding, diapering and comforting. This may be a parent, grandparent, caregiver or some other person in an infant's life who is attending to the needs of the child the majority of the time. This person is crucial to the child being able to create that secure base and ultimately develop the skills and abilities necessary for successful relationships later on. When the trust cycle or Erickson's initial stage of trust vs. mistrust is interrupted, because of an event (e.g., hospitalization, separation) or a caregiver simply is unable to provide the security the child will learn to depend on self for security. In working with children with attachment issues, it is vitally important to also understand the caregiver's attachment history. In order to engage the caregiver in a successful treatment process, the caregiver must have the ability to participate fully. Understanding the caregiver's attachment history will assist the therapist in designing a treatment process with or without the caregiver that will meet the child's attachment needs.

Guilt and shame are often feelings a child with attachment issues are most familiar with and comfortable expressing. These are often expressed through various acting out behaviors, demonstrating to the caregiver that they are not needed and that the child cannot be controlled. The severe temper tantrums when not getting what she wants, the sometimes intentional attacks on what the child perceives as important to the caregiver, and the general defiance can all be representations of this guilt and shame the child feels. During infancy the child did not experience that secure and consistent attachment base and therefore that trust cycle was never established. The child responds with cautiousness and defensiveness. Parents of children with attachment issues often express frustration because they may have a great day with a child only to have the child end it with some acting out behavior. More than likely, this is a result of that insecurity the child experiences as a result of feeling vulnerable. Power struggles occur often with children with attachment or trauma histories. These children need to have a sense of control and will battle continuously for that control.


Factors Influencing Attachment

Personal safety is a fundamental attribute of attachment security. Humans are most successful when there is a strong sense of personal safety and this sense begins in infancy. When safety is threatened, a person will seek security often through fight, flight or freeze. When children are in exploration of their world, they are exploring relationships with others and relationships with others plus objects or events. This exploration is characterized by primary and secondary intersubjectivity () Primary intersubjectivity is the discovery of the infant and parent relationship or person-to-person relationship. Secondary intersubjectivity is the discovery of the infant's world specifically, people, objects and events or person-to-person-to object relationship. Hughes describes the three important aspects of intersubjectivity – shared affect, shared attention and shared intentions . Shared affect is what Hughes refers to as affect attunement. "Through attunement, the infant feels receptive to and connected to his parent, and also is able to begin to regulate his affective states through first co-regulating his affective state with his parent's affective state ." (p.3) In infancy the basic interactions such as eye contact, facial smiles and expressions, voice tone, movements and gestures influence the infants ability to discover her parent as well as herself. When those verbal and nonverbal communications are absent or minimal the infant learns she is not important and begins to struggle with being able to develop other socialization abilities or behavior problems that often bring a child in for therapy. It is for this reason that understanding a parent's attachment history is critical in treating the child with attachment issues. When a parent is able to respond to the child in a consistent and reciprocal manner, that parent is able to create a strong sense of security for the infant. Inability to do this could result in the child being unable to engage in trusting relationships with the parent and others. Their sense of the world and relationships could be skewed.

Assessing Attachment

Cain (2006 ) reports on Mary Ainsworth's research in Uganda and Baltimore with home-based work and the identification of three patterns of attachment. Main and Soloman (1990) later added a fourth pattern. Ainsworth identified the three styles through the use of an assessment called the "Strange Situation Behavioral Assessment. The four styles of attachment described in Cain's work are:

  1. Secure: A child who is securely attached has a bond with a caregiver that is based on trust and consistency. The caregiver responds with warmth and is responsive and sensitive to the child's needs. The caregiver is sensitively attuned to the infant and learns to differentiate between the cries for hunger, comfort, diapering or other issues. The securely attached infant is affectionate and easily comforted. As a toddler they are problem solvers and can accept help when uncertain or having difficulty with a task. The child is becoming self-reliant, is curious and sociable.
  2. Insecure-avoidant: The avoidant child's play tends to have many unresolved conflicts. These children struggle with fantasy play and tend to be aggressive in their play and relationships. As they age they become more sullen and oppositional. They seek to prove to others that they can do anything without help and do not need others to get needs met. The avoidant child typically has had a parent who was uncomfortable with physical touch in infancy and typically avoided physically comforting the child. One would expect these children to have spent more time in cribs or car seats rather than in a caregiver's arms or lap.
  3. Insecure-ambivalent: The ambivalent child often lacks self-reliance skills, has little interest in problem solving and may appear distressed and whiney. This child will often be very clingy and have difficulty disengaging from the caregiver reacting with anger or passivity when the caregiver is unpredictable in response to the child. The child may be coercive and timid in response to the inconsistent responses of the caregiver. It is not uncommon that the relationship with the caregiver becomes a pursuer-distancing one that is unfulfilling to both.
  4. Insecure-disorganized: The disorganized child has developed extreme ways of dealing with situations. The child often has experienced severe abuse and neglect and is unable to organize responses to situations. This child may seem disoriented most of the time unaware or frozen. Common mannerisms may be rocking, pulling their ears and avoiding eye contact. The caregiver has been resistant to requests for contact from the child. In addition, the disorganized attachment has been linked to maternal depression, substance abuse and poverty.

Understanding the child's behavior in relationship to these four attachment styles is necessary to determining the appropriate treatment strategies for the child. It is also necessary in determining the ability of the parent or caregiver to participate in treatment. A thorough developmental history is a significant part of the attachment assessment. It is the assessment process that determines the type of play therapy to integrate into the treatment process.


Assessment in Play Therapy

The assessment process in play therapy is crucial to successful play therapy. The clinician must seek to understand the child's past and present functioning, specific traumatic events leading to the conditions for which treatment was sought, experience and meaning of the events to the child, child's strengths and problem areas, and resources available to the child. According to Filley there are five primary assessment and treatment goals

  1. To assess the extent of the client's emotional vocabulary: how well can the child talk about his/her emotional state
  2. To assess the client's self-perception of his/her emotional life
  3. To target feelings that need particular therapeutic intervention
  4. To build relationships
  5. To assess client's self-perception of family dynamics

A thorough understanding of the child's background with, developmental history including relevant medical history beginning with conception and birth, social history, and school history are essential to creating a treatment plan that will address the issues presented.

The Assessment Process

The three step process should involve:

  1. Interview with the parents as well as an interview with the child. Assessment requires the therapist to stay present with the child and help them to find safe ways to express themselves. The therapist should be attuned to the child's sense of his/her own emotions and family experiences (e.g. sadness, anger, loneliness, fear, etc.). The therapist will be "listening" with all senses as the play is followed.
  2. Observations of the parents as they discuss their concerns about their child. The therapist should attend to how the parents interact (agree or disagree about the problem), their insight into the problem and how it relates to the family situation, their attempts to resolve the issues, how they feel about treatment options, how they feel about being involved in the treatment process, and how they interact with the child.
  3. Verbal interview as well as activities the family does together and separately. For example, the Family Art Assessment is an excellent way of understanding how the family works together. In this assessment, a large piece of newsprint is taped to a wall. Each family member is provided with one marker, each of a different color. The instructions for the family are: "using only your marker, draw a picture together but you cannot talk or make verbal noises to communicate." The family would draw for about 10 minutes with 3 minute and 1 minute warnings. The therapist draws the activity to a close asking the family to discuss a title for the picture and write it on the picture. The family is then asked to tell a story about the picture. Following this the paper is turned over and the family is asked to repeat the exercise with talking. The therapist is looking for how the family works together, how did they start, how they take turns, what their roles were, how they use body language to send messages, how they problem solve knowing they cannot talk, did they draw over someone's picture, ask permission to change a picture, and which drawing was easier to do for each member and why. The therapist makes observations about the process; the relationships expressed, and help the family to reflect on these observations and their experiences. In high conflict families members will often stay in their own section except for the powerful person who will often move throughout the picture.

Another example of a drawing exercise that can be easily done in the home is asking each member to draw a picture of their family in the rain. Rain is often considered a metaphor for grief or loss. Using this exercise in assessment, the therapist is looking for the activity in the picture (playing), do they have protection (umbrella, boots, outer wear), is there any sign of hope (colors, sun, rainbow), are there elements suggesting fear or doom (lightening, blackness). The members can share their pictures in session and these can suggest how members may be feeling or coping. In the resources section of this module is a section on drawing exercises.

Art is a wonderful activity for children and adults. Oleander states that

"the very act of drawing, with no therapist intervention whatsoever, is a powerful expression of self that helps establish one's self-identity and provides a way of expressing feelings" (p. 53).

Often children have a much easier time with these creative experiences because they are less concerned about being proficient in their art work. Adults tend to be hesitant to engage and more critical of the outcome. Interactive games and story-telling also provide important information for the therapist to understand the problem and the relationships in the family.


Using Strategies and Techniques

Cultural Sensitivity in Play Therapy

Each geographic area, religion, institution, group, family, and person has their own identity, culture, and practices that make them who they are. Being culturally sensitive and aware is one of the most important keys to becoming a competent and compassionate therapist.

Play therapy is no exception. In fact, play therapy [because of its creative and multi-dimensional interactions] is one of the biggest areas where cultural competence is absolutely necessary.

But where should therapists begin? They should first begin exploring themselves- their personal identity, group identity, culture, practices, and values. By having a strong personal identity and awareness, a therapist will have a base, or building block, on which to start their exploration of cultures and practices that differ from their own.

After exploration has occurred and a personal identity discovered, Eliana Gil and Athena Drewes suggest doing three things: (1) Building sensitivity, (2) Obtaining knowledge responsibly, and (3) Developing active competence, moving from knowledge to behavior (Drewes, 2005). The first, building sensitivity, entails starting on a journey of awareness in regard to personal biases, stereotypes, etc. During this stage, therapists should also read books and articles about other cultural practices, trying to understand and empathize with other cultures and groups (Drewes, 2005).

The second stage, obtaining knowledge responsibly, means exactly what it says. As the therapist explores different cultures and begins to gain understanding, the therapist should begin "practicing with accountability", or working with experienced colleagues to allow for exposure, feedback, and direction (Drewes, 2005). This practice of holding yourself and others accountable for cultural competence is the beginning of a life-long journey of maturity and humble realizations.

Lastly, the therapist may move into the stage of developing active competence. This level may be the hardest of them all to achieve- taking the knowledge that has been gained in the last two levels and converting it into actions. This not only takes confidence, but also thought, care, and purpose. The therapist must make a choice to change behavior, thoughts, and biases in and out of the therapy room. If this can be achieved, the therapist will "remain aware of self, behavior, and the client's response to each clinical behavior" (Drewes, 2005).

Drewes, A., Gil, E. (2005) Cultural issues in play therapy. New York, NY: The Guilford Press.


Applying the Framework & Post-Test

Murphy Family Vignette

Carla Murphy and her 4 children have been referred for HBFT due to fighting amongst the siblings. Carla has been divorced 3 times. The children consist of 12 year old Michael and 11 year old Kevin who are biological bothers. Ten year old Marcos (IP) is from Carla's second marriage. Marcos's father is not involved in the family as he has been imprisoned since Marcos was 2. Marcos has also been involved in stealing from his family as well as from the school. The school has reported that Marcos is defiant and recently has been "bullying" children on the playground. The fourth child is 7 year old Jeremiah from Mom's third marriage. Mom reports Marcos is especially combative with Jeremiah.

Carla is of Hispanic origin. Her first husband, Michael, Sr. is involved with his children and tries to help when he is able. Her second husband, Charles was imprisoned on drug charges and burglary. He is not expected to be released from prison for another 5 years. Carla's third husband, Richard lives in the area but does not initiate contact with Jeremiah. His position is that when Jeremiah wants to see him, he will make himself available. Carla's mother is also involved in the family and a tremendous support for her and the children. The children often spend the night with their grandmother. Carla works full time at the local university as a secretary. She reports she is often tired when she arrives home and becomes easily irritated with the fighting in her home. She states that Marcos's aggression has been increasing of late and she is concerned about possible legal ramifications if he continues stealing and hurting other children.

Marcos has seen a therapist individually in the past however Carla reports it has not been helpful. The therapist has indicated that Carla has been unable to follow through on the parenting practices they have talked about in session and in the parenting classes Carla has attended. The therapist suggested home-based therapy to assist Mom in working with all the children and learning to apply the ideas she has learned through therapy and group.


Applying the Murphy Family Vignette

In understanding the struggles Marcos and the Murphy family are facing, completing a thorough family and social history would be critical. There are several concerns that are apparent in establishing a working relationship with the family.

What attachment issues might be relevant with the Murphy family? How would you describe Marcos's attachment style: secure, insecure-avoidant, insecure- ambivalent, or insecure-disorganized? What assessment strategies might you utilize to understand this issue more fully?

Consider the struggles in the relationship between Marcos and Jeremiah and the influence of the parental father figure – the absence of Marcos's father and the inconsistency of Jeremiah's father. 

What assessment techniques could be utilized to understand family functioning? It is essential to include the three step assessment process described previously.

It would be helpful to include a combination of individual and family assessments that consider attachment issues, cultural issues and loss issues.

If attachment is an issue, there are several attachment activities that are mentioned in the module and in the resources that would assist the therapist in helping the family to overcome the attachment injuries and create a more secure family system.

What cultural issues should be considered in working with Marcos as well as the entire family?

Consider the cultural implications of using various strategies with the family. Mrs. Murphy is of Hispanic origin yet the therapist is not certain of the cultural origins of the children's fathers.  The children are often with their maternal grandmother and is this involvement out of necessity due to Mom's work schedule or because the children feel good about being there or because the grandmother has typically been a caregiver for the family?

As the therapist understands the various concerns for the Murphy family, establishing a course of treatment that includes all members is critical. This would involve activities that are goal directed and culturally sensitive. The activities chosen in play therapy should be part of a process of therapy that will assist the family in achieving a specific goal. For example, Marcos displays anger and aggression. If one goal is to assist him to more appropriately deal with anger, the activities chosen should help the therapist and family to understand the anger, assist Marcos in developing more appropriate ways to self-regulate and help the family to also more appropriately respond to Marcos.

What approach would you take in working with this family?

What would the advantages and disadvantages be to utilizing a:

Directive approach

Non-directive approach

Sandtray

Theraplay

Filial Therapy

Each of these approaches will offer unique opportunities to the family in teh resolution of the issues presented.


Pre/Post Test

Click the link to respond to the following survey:


Cultural Animal Meanings

Click the link to view the Cultural Animal Meanings table:

 

Audio Companion: Integrating Play Therapy