Handbook of Medical Play Therapy and Child Life

Interventions in Clinical and Medical Settings

Lawrence C. Rubin, Lawrence C. Rubin

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781315527833
• Edition: 1
• Topic: Medicine
• Subtopic: Pediatric Medicine

The Handbook of Medical Play Therapy and Child Life brings together the voices and clinical experiences of dedicated clinical practitioners in the fields of play therapy and child life. This volume offers fresh insights and up to date research in the use of play with children, adolescents, and families in medical and healthcare settings. Chapters take a strength-based approach to clinical interventions across a wide range of health-related issues, including autism, trauma, routine medical care, pending surgeries both large and small, injury, immune deficiency, and more. Through its focus on the resiliency of the child, the power of play, and creative approaches to healing, this handbook makes visible the growing overlap and collaboration between the disciplines of play therapy and child life.

Part I
Medical Play in a Variety of Settings

Chapter 1
Therapeutic Work With Children in Diverse Settings

Fraser Brown, Cindy Dell Clark, and Michael M. Patte

To play it out is the most natural auto-therapeutic measure childhood affords. Whatever other role play may have in the child’s development … the child uses it to make up for defeats, sufferings, and frustrations.

—Erik Erikson (1940, p. 561)

Through Different Lenses

Playworker

He’s profoundly deaf and a fluent signer. He has been removed from the family home without signed counseling or explanation. He knows that the playground is a safe place to explore his feelings, but our sign language skills are basic. This visit feels significant. He stands trembling in the cold and pours a bucket of dry powder paint over his head, then goes back for another color to take outside and tip again. We watch as layer after layer of color covers him. He stands alone, knowing he is observed. He trusts that he will not be interrupted by playworkers. He is matted with layers of color, pure and mixed. He has shown himself to be a mess. Layered in confusion, not knowing how to communicate this to himself, let alone anyone else. He doesn’t know the signs for the feelings he has, as hearing kids do not have the words for these concepts. So, he paints it all over his body. When he is ready, we shower, clothe, and comfort him as he needs (Wilson, 2014, p. 80).

Play Therapist

Charlie’s teacher says he rarely speaks, often hides in the corner, can’t express what’s wrong, and has little interaction with his peers; he finds it difficult to stay on task in the classroom.

First Session: Charlie stood quietly in front of me, not knowing what to do. My natural instinct was to help him make a choice, but as a therapist I knew this would be wrong…. Eventually he walked over to the figures on the table, and picking up the fighter planes one by one, he examined them, shook off the sand, and took them to the sink. After washing them, he put them back on the table. This was done in silence. He then went over to the puppets, picked up the tiger, and shook its head as if saying ‘no’. He whispered in its ear. He did this with all the puppets, picking them up and moving their heads from side to side—‘no’. He then turned the tiger puppet to face him and nodded to it. Finally, he matched up the puppets with the same figures from the table. I felt it was important for him to do this, as was washing the planes. Was he putting things in order? Perhaps he was at last able to control a moment of his life? (Amar, 2016).

Child Life Specialist

Today a patient accidentally dislodged his breathing tube, causing extubation to occur. The Pediatric Intensive Care Unit sprang into action, and I worked with the patient and his father to provide procedural and emotional support. Throughout the procedure I held the patient’s hand, as he was agitated and physically uncomfortable. I stayed by the patient’s side until the procedure was complete, and he was relaxed and comfortable.

Later in the day, I stopped by to provide normative play for the patient in the form of a favorite board game and to offer information about the pet therapy program in the hospital. As I left the room, the patient’s father said he really appreciated the care I provided his son throughout the day, and actually said that I had the most important job, which was to provide a sense of normalcy in the stressful medical setting. If you were to ask me at the time of the procedure whether the father even knew I was in the room, I would say probably not. He seemed distracted and distraught because his son was in pain. However, his comment holds an important lesson: no act of kindness, no matter how small or seemingly insignificant, ever goes unnoticed (Patte, 2010).

Occupational Therapist

“Oh no!” Jade (occupational therapist) exclaims loudly as >Bongk!< the shark bumps against her. The shark (i.e., ball) drifts back to Archer (boy receiving therapy for sensory integration issues) … he raises both hands to give it a shove. Jade hauls herself to an upright position, and being a bit more agile (when upright), twists and contorts, managing to avoid the shark as it rolls past her. Hmm, it seems Archer will have to come up with a better strategy. His grin broadens as he rolls the ball in (another) direction, taking it to the furthest reaches of the mats (in the therapy room). >Bongk!< But the ball merely snares and slows a little on the cushion beneath her feet. Archer can’t seem to get the grand bump he desires. He pulls the shark (ball) back, while Jade, looking down, prepares for her next bodily contortion. Archer gives a sidelong look; but instead of reaching for the shark (ball), he tips his head, raises his arms to shoulder height in front of him, opens his jaws as wide as they can possibly go, and latches onto Jade’s leg and makes the motion of taking a bite. He has her full attention (Park, 2005, p. 100).

Reflection

These vignettes, which are derived from the experience of practitioners in four different professions, are focused on the play of specific children. As such, they illustrate the complexity of children’s play. They introduce us to the possibility that play can be, at one and the same time, social, physical, instructive, and creative. It may help us to build relationships and develop a deeper sense of self. In his classic text The Ambiguity of Play, the developmental psychologist Brian Sutton-Smith defines play as “the potentiation of adaptive variability” (1997, p. 231). Elsewhere he suggests that play serves to provide us with a “belief in the worthwhileness of merely living” (1999, p. 254).

Clearly, play means different things to different people, which is why it is so hard to define (Sherwood & Reifel, 2010). Indeed, for a definition of play to be really tenable, it would have to be inclusive of, and apply to:

• Children and adults
• Animals and humans
• Both process and product
• Positive and negative forms
• Structured and unstructured forms
• Immediate and future benefits
• Passivity and performance
• Fleeting moments and long-lasting periods.

It is unlikely that any definition can address all these things, and so it is probably more helpful to focus on generalized descriptions rather than specific definitions. This is the approach adopted by numerous authors, including Catherine Garvey (1991) and Tina Bruce (2005). Consequently, it is common in the literature to find play described as having the following characteristics. It is:

1. Freely chosen, personally directed, and intrinsically motivated
2. Associated with positive effect, pleasurable, enjoyable, egalitarian, and so forth
3. Functional, but the emphasis is on process rather than product.

Despite the popular notion that play is more about process than product, it is nevertheless clear that play has a number of developmental outcomes, albeit the player may not necessarily be aware of them. These widespread benefits of play are summarized in Table 1.1, which is an abridged version of a much larger summary of the benefits of play (see Brown, 2014, pp. 12–14).

Thus, play may be seen to be a key factor at the heart of child development. However, its cathartic and therapeutic aspects are less widely recognized. In all the vignettes at the beginning of this chapter, the professional worker is trying to help a troubled child through a difficult period in their life, so that they may eventually regain some sort of emotional equilibrium. In each case, play is being used as the therapeutic medium. It is that aspect of play that forms the focus of this chapter, and we explore its use and value via the day-to-day practice of a number of professions.

Table 1.1 The Benefits of Play

KEY FACTORS Contributing to development while playing	OUTCOMES In the longer term, playing helps to produce:
Fun	Happiness and the continuation of brain plasticity
Freedom	A sense of independence, and an understanding of the parameters of risk, challenge, and danger
Flexibility	Broader horizons—an understanding of the world and an open-mindedness about its true potential
Social Interaction	Friendship groups and an understanding of social networks Transmission of children’s cultures
Socialization	Self-acceptance and a respect for the views and wishes of others
Physical Activity	Musculoskeletal development and physical health
Environmental Cognitive	Knowledge and understanding, and a sense of wonder about
Stimulation	the potential for expanding our horizons
Creativity and	Combinatorial flexibility leading to problem-solving skills,
Problem Solving	abstract thinking, and aesthetic appreciation
Self-Discovery	A unique individual personality; self-aware ness and self-confidence

Of course, it is arguable that children’s play is inherently therapeutic, and therefore children have it within themselves to cure their own ills. Freud (1900) suggested one of the functions of play was reconciliation; in other words, a process that enables children to come to terms with traumatic events. By ‘playing out’ the event, and possibly replaying it many times in lots of different ways, children can at one and the same time take control of the experience and gain a full understanding of it. This idea is hinted at in the opening line of the quote at the beginning of this chapter (Erikson, 1940). It is a theme taken up by Virginia Axline (1969), and applied to her professional practice, where she adopted (and promoted) a non-directive approach to play therapy. For Axline, the role of the play therapist is to create the conditions that enable the child to explore whatever has happened to them, so as to reconcile themselves to it, and hopefully have enough self-confidence to be able to move forward.

The renowned dramatherapist, Sue Jennings, in her groundbreaking book, Healthy Attachments and Neuro-Dramatic Play, introduces the idea of a “play to play therapy continuum, where playing can be considered a ‘preventative’ activity and play therapy a ‘curative’ activity.” She goes on to say that “there is a large gap in the middle where children are able to generate their own play to help themselves; this often does not need the intervention of play therapists” (2011, p. 64). Unfortunately, contrary to that optimistic view, in the more developed industrial nations there is an increasingly “large gap in the middle” where children are not able to generate their own play. This is due to a combination of sociocultural circumstances; for example, increase in traffic, suspicion of strangers, excessive emphasis on academic attainment, etc. (Gill, 2007). That is where playwork comes in. Put simply, the more sociocultural changes that restrict children’s freedom to play, the more we store up psychosocial problems for the future. That is why we need playworkers. In its most straightforward expression, playwork is compensatory in nature. It is about creating environments that enable children to generate their own play (Brown, 2014). Inevitably there is a therapeutic aspect to this. If Freud’s analysis is correct, it follows that children will use the playwork environment in the same way as any child engaged in free play would.

Thus, in therapeutic terms we can return to Jennings “play to play therapy continuum” and suggest the following: where children are able to play freely, they will be able to use their play as a naturally therapeutic medium and reconcile themselves to minor traumatic events. Where play is restricted, children may be able to attend a playwork project, where they will be able to play freely and engage in a similar reconciliation process. Where the traumatic events are more severe, the child may need a more focused and protected environment, where a play therapist is able to offer the reassurance of a personal, one-to-one relationship to help the child come to a solution.

Child life specialists and occupational therapists are also at this end of the continuum, albeit their approaches are sometimes more structured, because they may have very specific goals in mind.

However, we should perhaps end this section with a couple of caveats. First, as Piaget (1951) tells us, a lot of children’s play is actually repetition and practice of previously learned actions, so we should be very cautious when interpreting its meaning. That leads us to the second point, that is, that a child’s play may not mean what we think it does. It is often the case that play is ambiguous and/or paradoxical (Sutton-Smith, 1997). The most obvious example of this is play fighting—an activity that most mammals indulge in. ...