Blending Play Therapy with Cognitive Behavioral Therapy

Evidence-Based and Other Effective Treatments and Techniques

Athena A. Drewes, Athena A. Drewes

• Publisher: Wiley
• Year: 2009
• ISBN:
  9780470495520
• Edition: 1
• Topic: Psicologia
• Subtopic: Terapia cognitivo-comportamentale

In today's managed-care environment, therapeutic techniques must be proven to be effective to be reimbursable. This comprehensive volume is written by leaders in the field and collects classic and emerging evidence-based and cognitive behavioral therapy treatments therapists can use when working with children and adolescents. Step-by-step instruction is provided for implementing the treatment protocol covered. In addition, a special section is included on therapist self-care, including empirically supported studies. For child and play therapists, as well school psychologists and school social workers.

SECTION V

INTEGRATION AND APPLICATION OF PLAY-BASED TECHNIQUES WITH CBT

THE PURPOSE OF this section is to help readers become aware of the many practical play-based techniques and resources available for working with children and adolescents across a variety of treatment approaches. Many verbal CBT treatments help children and adolescents deal with affect regulation, create narratives of their trauma and experiences, improve self-esteem and coping skills, and address cognitive distortions and low frustration tolerance. Chapters in this section offer play-based techniques and strategies that address these same areas, while engaging children and adolescents, and simultaneously sustain their interest and motivation in a playful manner. This section is rounded out with a chapter on how together cognitive behavioral approaches along with expressive activities can be utilized in family therapy.

Susan Knell and Meena Dasari in the first chapter give an overview of Cognitive Behavioral Play Therapy and its phases. The authors include a list of the various play materials to include in the therapy space, along with how to use puppets and other play materials effectively with CBT and children. The chapter is peppered with practical approaches and ways to implement and respond verbally in the session with cognitive and behavioral interventions. A section is devoted to troubleshooting and how to handle common problems. A case study rounds out the chapter and brings to life the various materials that were previously discussed.

The second chapter by Susan Trachtenberg Paula narrows the focus to play therapy techniques that can be utilized for affect regulation. The author deftly weaves in the various play therapy and play-based activities, while breaking down the treatment components through the use of a case study that is presented so the reader can see the practical application of the various techniques and rationale. This chapter becomes a how-to for even the seasoned clinician in the best way to utilize play therapy within CBT.

Diane Frey in Chapter 18 offers a plethora of creative techniques with which to help address self-esteem, coping skills, and cognitive distortions. She helps the reader understand the benefits of play therapy and CBPT for any age client, even adults, especially when the client is resistant to the treatment process. Many of the techniques were created by the chapter author and are fun-filled and easy to use. A case study helps bring alive the application of the previously read techniques that are spelled out as she goes through the sequential phases of treatment.

Chapter 19 by Eva Feindler offers a practical, hands-on focus of playful strategies and techniques to help children manage their anger and aggression as a result of frustration. The author describes several CBT programs that help to strengthen the emotional and social competence of young children. In particular she focuses on bibliotherapy and an array of play-based programs designed to help young children identify, understand, and manage their emotions in fun-filled ways. This chapter is a practical tool for working with any type of population.

In Chapter 20 Ann Cattanach offers the reader a rich narrative experience both in reading the case studies and stories of the children being helped to create their own personal narrative and in her flowing prose about the process. The author offers a historical perspective on the use of narrative therapy in play therapy, as well as insight into the creative narrative process and how best to structure the activity for participation by children and adolescents. Detailed descriptions of materials needed, use of toys for pretend play, and rules when playing together are useful for the beginner in entering the child’s narrative world. Child clinicians and play therapists working with sexually abused and traumatized children have found that the telling of a personal narrative of the abuse is helpful and therapeutic in the healing process. This chapter offers a clear guideline in how best to set up that process.

This section ends with Chapter 21 by Steve Harvey on how to use expressive activities for family problem solving in therapy. A family case study follows with the author sharing his rationale for using various play-based activities and making clear their implementation. It is a practical guide for creating a safe and playful environment where the full family can enjoy participating.

CHAPTER 16

CBPT: Implementing and Integrating CBPT into Clinical Practice

SUSAN M. KNELL
MEENA DASARI

COGNITIVE BEHAVIORAL PLAY therapy (CBPT), which was developed by incorporating cognitive and behavioral interventions within a play therapy paradigm, was introduced into the psychotherapy literature in the 1990s. Prior to its inception, most play therapy techniques were based on either psychodynamic or client-centered theories. With both of these earlier theoretical approaches, play therapy was unstructured and guided by the child. CBPT provided a novel theoretical approach to child psychotherapy, in that the most significant differences between CBPT and other play therapies are its structure, psycho-educational components, and goal-directed and collaborative approaches (i.e., guided by both child and therapist). A more comprehensive description of the theory and applications of CBPT can be found in Chapter 4.

Descriptions of the theory and applications of CBPT have been published in the literature (Knell, 1993a, 1993b, 1994, 1997, 1999, 2000, 2003; Knell & Beck, 2000; Knell & Dasari, 2006; Knell & Moore, 1990; Knell & Ruma, 1996, 2003). Several of these writings include case examples describing the successful use of CBPT with children with selective mutism (Knell, 1993b); separation anxiety (Knell, 1999); anxiety disorders (Knell, 2000; Knell & Dasari, 2006); and histories of sexual abuse (Knell & Ruma, 1996, 2003). CBPT has also been used with children who have sleep problems (Knell, 2000a), who are acting out (Knell, 2000), and who are experiencing parental divorce (Knell, 1993a). A number of writings include more specific and detailed descriptions of the application of CBPT, including transcribed therapy sessions (Knell, 1993b) and commentary about specific clinical decision making (Knell, 1993b, 1997).

CBT with children has been shown to be effective in treating several emotional and psychosocial problems, such as depressive disorders, anxiety disorders including obsessive compulsive disorder and posttraumatic stress disorder, attention deficit hyperactivity disorder, anger, sleep problems, and grief (Kendall, 2006). Although such empirical support is not specific to the implementation of CBT in play, CBPT may be effectively adapted for the treatment of these disorders as well, given that similar cognitive and behavioral techniques are used. The major difference is that CBPT is implemented within a play therapy modality.

The present chapter will extrapolate from this literature by discussing the implementation of CBPT and the methods for integrating into clinical practice. A discussion of the use of play materials, such as puppets and other toys, will be included. The importance of play assessment, as part of the CBPT process will be considered. The integration of empirically supported cognitive and behavioral techniques within a play therapy paradigm will be discussed. Unique to this chapter will be very real-life oriented, “how to” descriptions highlighted with actual case examples. Finally, implications for clinical practice are reviewed.

HISTORICAL USE OF PUPPETS AND OTHER PLAY MATERIALS IN PLAY THERAPY

PUPPETS

Puppets have long been used as a medium to reach children and to provide a means for communication within the therapy context. Seminal work by Bender (1952) encouraged the use of puppets. Puppet play may be active (e.g., having children create their own stories) or vicarious (e.g., producing a puppet show) (Bender & Woltmann, 1936). In Bender and Woltmann’s work, which is now more than 70 years old, the authors discussed the need to “reach” children who were being treated for severe behavioral problems. They found that puppet play allowed children to project their own problems onto the puppet characters. Therefore, the puppet shows were thought to serve as a vicarious means of expression for the children to explore conflicts without producing significant anxiety.

Irwin (1985) suggested the use of puppets for individual assessment of children’s current functioning. Puppets were chosen due to the richness of expressive material produced through the child’s spontaneous play. The child was asked to select various hand puppets and to create a pretend television story. At the end, the clinician interviewed the characters and the puppeteer in order to follow up on clinical hypotheses and to seek clarity from the child and the “characters” in the story. This method was also developed for use with families (Irwin & Malloy, 1975).

In 1991, Irwin presented an extensive review of the use of puppets to aid in diagnosis and treatment of children and families. For younger children, she reported that puppet play was less censored and more openly full of conflict. In addressing developmental considerations in using puppets, Irwin noted, “Young children often present their conflicts with startling clarity and lack of disguise, thus helping illuminate the diagnostic picture (Irwin, 1991, p. 620). In a review of clinical and research literature using puppets, Irwin (2000) hypothesized that puppets offer universality and ambiguity in terms of identification, and an avenue through which the child’s fantasy can appear.

Although various toys may be used in play therapy, puppets are the most commonly used play materials. They provide a nonthreatening means of expressing conflicts and feelings for the child and not by the child. From the child’s perspective, it may feel like the puppet is expressing the conflict or feeling and not the child, per se. There has been some thought that the hand manipulations required to guide the puppet may help the child enter the play (Woltmann, 1960). The child’s hand movements and voice are the carrier of the ideas, which, for the child, are expressed by the puppet.

In more recent literature, puppets have been used in the delivery of a wide variety of play therapies, including assessment and interventions for CBPT (Knell, 1993a, 1993b, 1999; Knell & Beck, 2000) In most cases of CBPT, the puppets are used as a means of delivering specific cognitive and behavioral interventions, through modeling and/or role-playing.

OTHER PLAY MATERIALS

Other play materials can be used to effectively implement CBPT. Numerous authors have written extensively about the use of other play materials in play therapy. In her book Play Therapy, Axline (1947) listed guidelines for play materials, a list that is still commonly quoted and used. However, an enormous number of toys have been developed in the 60 years since her book was written. Landreth and his colleagues (Landreth, 2002; Giorano, Landreth, & Jones, 2005), writing from a client-centered perspective, described the toys used to communicate experiences, feelings, and needs. He categorizes toys, acknowledging that they may be used in multiple categories, to areas of nurturance (dolls, bottle, medical kits), competence (blocks), aggression release (animals such as tiger, lion, alligator; soldier figures), real life (dollhouse and figures, play money), fantasy/dress up (hats, clothes, masks), and creative expression and emotional release (water, sand, art materials). Toys are organized, easily accessible to the child, and chosen by the child, rather than by the therapist.

At the other end of the continuum are play therapies that do not rely heavily on play materials. In a unique approach known as Ecosystemic play therapy, play materials are thought to be secondary to the therapist (O’Connor, 1997; O’Connor & New, 2003). In Ecosystemic play therapy, the focus is on the interaction between child and therapist, not the child and play materials. Children in Ecosystemic play therapy are not allowed free access to play materials, but rather the therapist chooses specific play materials, suited to the individual child, prior to each session.

In the CBPT literature, play materials are a critical component of therapy, with both child and therapist choosing appropriate materials either collaboratively or independently. As discussed in a subsequent section, the playroom is well stocked with a wide array of toys/play materials and, at times, an individual child’s presenting problems may require an object not typically found in the play room.

PHASES OF CBPT

INTRODUCTION AND ORIENTATION

It is important to orient and to prepare both the child and the parents for CBPT. Typically, the parents and therapist will meet together, without the child present, so that the therapist can complete a clinical interview to gather history and background information as well as obtain any rating scales from the parents. Also, if necessary, psycho-education on therapy structure and parental involvement should be provided. In addition to assessment, the CBP therapist can talk with the parents about preparing the child for therapy. The therapist can guide the parents in what to say to the child before he/she comes to the first session. Honesty is important, though the discussion should be developmentally appropriate. In a simple, noncritical way, the parents can describe their concerns and what they have done (e.g., talk to a therapist) to seek help.

Parents should avoid language or explanations that sound threatening (e.g., “You will need to behave or I’m going to tell the doctor what you are doing”), involve a lie (e.g., “We are going to play with friends”), or are bribes (e.g., “If you talk to the doctor, I’ll buy you a treat”) (Dodds, 1985). The parents can be coached to make a statement, such as,

We are concerned about how you are feeling. We know that you get nervous and worry about a lot of things. We went to talk to someone about it. She is a “feelings” doctor. She talks and plays with kids who are worried about things. Next time we go, you will go with us, and have a turn talking and playing with her.

It is recommended that parents also normalize the symptoms and experience (e.g., “she sees a lot of kids who worry and helps them”) as well as highlight the child’s strengths that will help in therapy (e.g., “getting along well with adults,” “smart”). It can also be helpful for the parents to describe the therapist (e.g., “she is nice”) or the office (e.g., “she has lots of fun toys”).

Bibliotherapy can also be used as a resource for preparing the child for therapy. The book, A Child’s First Book About Play Therapy (Nemiroff & Annuziata, 1990) provides an introduction to play therapy for 4...