Clinical Applications of the Therapeutic Powers of Play

Case Studies in Child and Adolescent Psychotherapy

Eileen Prendiville, Judi A. Parson, Eileen Prendiville, Judi A. Parson, Judi Parson, Eileen Prendiville, Judi Parson

• Publisher: Routledge
• Year: 2021
• eBook ISBN: 9781000359404
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Clinical Applications of the Therapeutic Powers of Play provides a way to link abstract theory with practice-based knowledge and vice versa, navigating the complexities of clinical reasoning associated with age-sensitive, and most often non-verbal psychotherapies.

The book invites readers into the world of child psychotherapy and into the play therapy room. It equips them to explore, discover and identify the therapeutic powers of play in action, within traditional and nature-based therapeutic environments. Using embodiment-projective-role, it navigates the developmental stages linking play and the achievement of physical, emotional, and social identity. With captivating stories of hope and repair, the book deconstructs the therapy process to better understand how play facilitates communication, fosters emotional wellness, increases personal strengths, and enhances social relationships.

This comprehensive text will help the therapist navigate through the world of child and adolescent psychotherapy and explain the therapeutic powers of play through relevant clinical case studies.

Part I

The landscape

You are invited to travel into the world of child psychotherapy and right into the play therapy room. An embodiment-projective-role lens is provided to equip you to explore, discover and identify the therapeutic powers of play in action. The landscape includes traditional, clinical and nature-based therapeutic environments.

Chapter 1

Children speak play

Landscaping the therapeutic powers of play

Judi A. Parson

Play is full of contradictions! Eberle (2014, p. 232) states that

Play can be challenging or soothing, rough or gentle, physical or intellectual, mischievous or well mannered, orderly or disorderly, competitive or cooperative, planned or spontaneous, solitary or social, inventive or rule-bound, simple or complex, or strenuous or restful …

This complexity makes play difficult to define, yet we do know when we see it and we do know when it is absent. Brown (2010) identifies a number of play properties and states that play is fun, it is done for its own sake, it is voluntary, in play there is a lost sense of time, and it feels so good that you want to keep doing it. Eberle (2014) defines play according to six basic elements namely these: anticipation, surprise, pleasure, understanding, strength and poise. Eberle goes on to expand on these elements to identify kindred terms as well as when a play element is no longer play: for example, when anticipation becomes obsession, surprise becomes shock or terror, or understanding becomes indifference and so on (Eberle, 2014). Chazan (2002) and Brown (2010) also differentiate play from pre-play (selecting and setting up toys and play materials), non-play (needing to take a drink or snack, or read the instructions or chatting with the therapist) and play interruptions (when the child abruptly stops the play or non-play sequence due to rising tension within the session and may be signalled when the child needs to go to the bathroom or check where their parents are). Play therapists are interested in understanding multiple contexts and aspects within the child’s play landscape.

Play activity is infinitely variable and is identifiable by the non-verbal attributes of focused concentration, purposeful choice of toy or object and specific affective expression.

(Chazan, 2002, p. 28)

There are multiple types and descriptions for play including the following: sensory, gross motor, rough and tumble, exploratory, construction, problem solving, pretend, projective, traumatic or abreactive play, role play, games, musical expression, arts and craft activities and nature play. However, within this book a clear developmental alignment is presented through the embodiment-projective-role (EPR) sequence (Jennings, 1999) and incorporates many, if not all, of the play activities mentioned earlier in relation to the therapeutic powers of play landscape.

Play is not secondary to the therapy – it is the therapy

Healing happens through play! The play, in play therapy, is not a trick or lure, or even a warm-up exercise, nor is it a pre-requisite into conversation. It is, however, both the therapeutic medium and the process which promotes growth and development. Just as enzymes produced in the body act as a catalyst to bring about specific biochemical reactions to transfer, change or join molecules within the physical body, the therapeutic powers of play are the enzymes to transfer, change, join and aid in the digestion of emotional material and facilitate movement towards optimal psychosocial and emotional health and well-being. In play children are safe to draw on any number of possibilities, to pretend and process unresolved material, to change the emotional tone of past memories and to allow for the transfer of previously intrusive memories to past memory. In essence, play is the developmentally appropriate medium for children in therapy.

The therapeutic powers of play framework

During the 2017 International Play Therapy Study Group (IPTSG) hosted by Professor Emeritus Charles Schaefer, Fairleigh Dickinson University, I presented on ‘Puppets in play therapy’. I used a novel methodical approach called Integrating, Theory, Evidence and Action (ITEA) (Hitch, Pepin, & Stagnitti, 2014) to systemically review the literature. This approach incorporates several steps including the following: creating a clinical question, choosing a suitable framework or model to provide a lens to examine the literature, identifying the search strategy and databases and deconstructing and analysing the extracted data in order to reconstruct and subsequently transfer and utilise the data in a way to give back meaning to clinical practitioners (Hitch et al., 2014). I chose the TPoP as the framework to answer the question ‘How does puppet play enhance the therapeutic effect for children (age range 0–18 years) requiring therapy?’ But as part of the process to identify the TPoP in action, I developed a graphic (see Figure 1.1) to systematically record and summarise findings in order to quickly extract coded data and calculate which of the major categories and the specific therapeutic powers of play were represented in each paper. While the image presented here is in greyscale, I colour coded the major categories, using neon highlighter pens, pink, yellow, green and orange, to aid the data extraction process of the ITEA. I must acknowledge my colleague Kate Renshaw, who was accurate with the highlighter pen, who validated the coding methodology, and together we reviewed and cross checked all 55 articles.

Figure 1.1 The therapeutic powers of play: 20 core agents of change.
Note: Graphic created by Judi A. Parson adapted from Schaefer C. E., & Drewes A. A. (2014). The therapeutic powers of play: 20 core agents of change. (2nd ed.). Hoboken, N.J: John Wiley.

The IPTSG attendees appreciated the graphic as a simple visual aid that captured the essential therapeutic powers of play at a glance. But what the ITEA did was provide a way to evidence the therapeutic effect (i.e. the change mechanism) as presented in the literature, and while puppet play was the focus of the presentation, the TPoP graphic could be adapted to investigate any phenomena within play therapy literature and/or clinical practice. The beauty of integrating various forms of evidence using the ITEA method provided accessibility to other ways of knowing which could be included to inform the clinical direction and action required based on the specific topic matter or problem. This is a useful method because it is a fundamental necessity for child and adolescent psychotherapists and play therapists to know what, why, how and when the play within the clinical intervention produces positive change in the child client. Thus, the TPoP framework provides a powerful lens to examine the literature as well as clinical cases, which in turn informs clinical reasoning and decision making before, during and after the therapeutic intervention.

The TPoP were first coined by Schaefer (1993) when he identified 14 basic mechanisms of change and then later expanded these to 20 core agents (Schaefer, 2020). They may be explained, explored and understood through multiple ways and may be referred to as ‘for example, “therapeutic powers,” “change mechanisms,” “mediators of change,” “causal factors,” and “principles of therapeutic action”’ (Drewes & Schaefer, 2014, p. 1). However, the TPoP may be difficult to grasp initially, because of their trans-theoretical nature: they do not belong to one single model, but, rather, they present an abstract way to view and understand how play acts as the medium to ‘initiate, facilitate or strengthen their therapeutic effect’ (p. 2). The therapeutic powers of play have also been referred to as ‘the heart and soul of play therapy’ (p. 4), which signifies that they are essential knowledge to clinical practice.

As a threshold concept it is important for play therapists to understand the TPoP as core knowledge early on in their play therapy education and supervised practice. Meyer and Land (2003, p. 1) state that:

A threshold concept can be considered as akin to a portal, opening up a new and previously inaccessible way of thinking about something. It represents a transformed way of understanding, or interpreting, or viewing something without which the learner cannot progress. As a consequence of comprehending a threshold concept there may thus be a transformed internal view of subject matter, subject landscape, or even world view.

Understanding that threshold concepts are transformative, this book aims to transform the reader’s comprehension of the subject matter (clinical applications of the therapeutic powers of play) through the experience and wisdom of internationally distinguished authors who have contributed to this edition. Schaefer and Drewes (2014) presented a list of 20 core agents of change in four distinct categories, namely that play (1) facilitates communication, (2) fosters emotional wellness, (3) increases personal strengths and (4) enhances social relationships (see Figure 1.1). The specific therapeutic powers of play are now briefly summarised and italicised for easy recognition throughout this chapter.

Facilitates communication

Children speak play! Play therapists are educated to speak play too because play is the most developmentally accessible means of communicating with children. Play facilitates self-expression because children may not have or do not want to use words when concrete forms of expression provide a more age-appropriate way to convey meaning. For example, children, through selecting and arranging toys in specific ways, drawing a picture of their family or crafting a playdough image of a snake or snail, provide information as subjective content. However, the play therapist may understand the play activity through a range of cues that are expressed, including affective, cognitive, developmental and narrative components (Chazan, 2002). Thus, through play actions, children are able to show and tell their thoughts and feelings when words alone may be insufficient. While play may facilitate conscious thoughts and feelings, it also provides an entry point into unconscious material. Access to the unconscious enables the child (or older person) to use defence mechanisms such as projection, displacement, symbolism and/or fantasy to pretend as a process to communicate meaning (Schaefer, 2020). Spontaneous play is informed by implicit memories which may not need to be brought to consciousness. Play provides the medium to externalise internal problems that can be concretely and symbolically expressed. Play also provides opportunities for both direct teaching, such as learning to play in new ways to learning a new coping strategy for anxiety, and indirect teaching, such as writing a therapeutic story to re-frame life events. It was interesting to note that, in the ITEA study within the category ‘facilitates communication’, specifically self-expression was identified to be the most frequently recorded therapeutic power in the puppet play therapy study (Parson, 2017). Alyssa Swan and Sue Bratton (chapter 9) extend on this summary to provide deeper insights into how the TPoP facilitate communication.

Fosters emotional wellness

Catharsis is a psychotherapeutic term used to describe the release of strong emotions including anxiety, stress, anger or fear. In play therapy children may experience play as cathartic when they engage in some physical activities such as hitting or popping a balloon, which allows for the release of muscle tension and negative affect (Schaefer, 2020). Abreaction is the term used to describe the reliving of a previous frightening or traumatic experience. It is important for the play therapist to be aware of abreactive play so that the child may be supported to re-create, re-direct and re-experience events through play (Parson & Renshaw, 2017) and in the safety of a therapeutic relationship. Children spontaneously engage in literal or symbolic abreactive play in child-led sessions to foster emotional health and well-being.

Play is fun! Being in a state of play evokes positive emotions: feelings of joy, a facial expression with a smile and the sound of laughter are visible cues. Play can be useful for counterconditioning fears by gradually exposing an identified fear using specific techniques to desensitise individuals to replace negative thoughts and feelings with more positive ones. The therapeutic powers of play may be activated during stress inoculation whereby the play therapist introduces or prepares a child or older person for a potentially stressful experience prior to actual real-life experience. An example of this is role-playing going to school for the first time or preparing for a medical procedure. The final TPoP in this section refers to stress management whereby specific play techniques or games can be used to reduce both physical and emotional signs of stress and in some cases distress. Examples of stress management could include creating and colouring in mandalas or zentangles, using fidget or sensory toys and play materials, listening to or playing music and using guided imagery, such as those found via smiling minds app, to help the child relax. Lorri Yasenik (Chapter 10) extends on this summary to provide greater clinical insights into how the TPoP foster emotional wellness.

Enhances social relationship

One of the most significant aspects of play therapy is the development and maintenance of the therapeutic relationship. The therapist creates safe, playful and healthy conditions for change by taking a humanistic stance. Carl Rogers (1957, 2012), in his person/client-centred therapy, identified the three core optimal conditions: congruence, unconditional positive regard and empathy. Play therapists are informed by, and embody, these qualities to focus on the child’s inter...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedications
• Contents
• Figures and Tables
• Editors
• Contributors
• Foreword
• PART I: Landscape
• PART II: Travelling through the continents
• PART III: Connecting the four corners of the world
• Conclusion
• Index