A psychologist outlines key tips to run an effective play therapy session and offers advice to help navigate your relationship with both the child and parents or caregivers.
Play therapy is growing in popularity, acceptance and use in Australia, but in order to run an effective session, there are some key considerations for psychologists to keep in mind.
"Play therapy is an evidence-based, developmentally appropriate counselling method for children. It uses play-based interventions facilitated by a therapist who is trained in play therapy", says Jacki Short, Principal Psychologist, Registered Play Therapist and Director of Sydney Centre for Creative Change.
Children are not little adults, she says, which is why they require unique therapeutic solutions designed with their needs and communication styles in mind.
"Children don't have the same cognitive capacity as adults. They don't have the same emotional windows of tolerance for difficult feelings, and they don't have the skills or confidence to use talk-based therapies in the ways we do as adults.
"Many children do not want to come to counselling. These children might have had] previous negative counselling experiences of being interrogated with questions that make them feel unsafe or expected to talk about things that they might not want or be ready to talk about.
"That's why it makes sense to find ways to work with them therapeutically that use their natural language which is, by and large, the language of play."
Importantly, child-centered play therapy isn't about "curing, fixing or changing" the child, says Short. Instead, it's about helping to build a sense of safety for and autonomy in children, so they feel ownership over their decisions, where and when this is appropriate.
"When they're confident that they can make choices about how, with what and when they play, they're going to be more relaxed and play out what's of concern to them," says Short. "It's going to be easier to see, hear and support them in that change than it would be if we're doing talk-based therapy."
"When we work with children, it's really important not to expect five-year-olds to make case plans for themselves and set goals for therapy. That's an adult-informed model that we're trying to fit into child therapy, and it just doesn't work." - Jacki Short, Principal Psychologist, Registered Play Therapist
Different types of play therapy
Just as talk-based therapy has various angles and approaches, so too does play-based therapy.
"There are directive methods of play therapy where we might ask children to draw a picture of their family, for example, then there are less directive forms, which we call child-led or child-centred play therapy (CCPT). This is where we invite children to play in a way that's just right for them."
While Short says there's no one-size-fits-all approach to play therapy, she notes there are sometimes indicators that might signal whether a directive versus child-centred approach is more appropriate.
"For example, child-centred approaches are usually more appropriate for very young children or in presentations where I'm not necessarily clear, and neither are the parents, about why the child's behaviour has suddenly changed. [It's also often a useful approach] for complex issues which can be hard for children to talk about, like child sexual assault."
Despite being a passionate advocate for the benefits of play therapy, Short says there will be instances where it might not be appropriate. For example, a child might need support developing social skills. In this instance, Short might work directly with parents or caregivers to provide strategies to support their child, or work with the child individually and then in a group to teach and practice specific skills.
She also might not recommend play therapy if a child requires support to manage a specific phobia or specific anxiety presentation.
"If they have OCD, for example, I'd work in a really different way than I would in CCPT; we'd be doing more behavioural-based interventions".
Working with parents or caregivers
"Adult conversations need to happen between adults," says Short. "Sit down and have a designated session, or sometimes more, to get a clear understanding of what the problems are, how they impact the family, what's been tried before, what's worked or not worked, what support the family might need, in addition to supporting the child, then make a clear assessment and treatment plan, based on need."
As well as being informed by the parents or caregivers, the plan could also include the perspectives of other adults in the child's life, with parental permission, such as grandparents, teachers or childcare workers.
"When we work with children, it's really important not to expect five-year-olds to make case plans for themselves and set goals for therapy. That's an adult-informed model that we're trying to fit into child therapy, and it just doesn't work.
"Asking a young child something like, 'On a scale of 1 to 10, how much do you think your behaviour has changed?' is not appropriate. These are conversations we should be having with the parents."
This is why it's important to do assessments and reviews with the adults only. This helps to ensure the child's experience of therapy remains child-centered and focused on play.
Once a plan has been established with the relevant adults, Short says it's appropriate then to have a brief 'handover time ', prior to the start of play therapy, where you speak with both the parent and the child together, so the child knows why they are there and what they can expect from the sessions.
Following a prearranged number of child play therapy sessions, review sessions with parents need to be consistently facilitated.
"We work very closely with parents because they're key stakeholders and critical people in this change process. If we don't have parents on board, it can be harder to see the progress that's being made outside of the playroom."
Another consideration to keep in mind when working with parents is to set realistic expectations.
"Some of the things they ask for might not be reasonable or beyond the scope of our counselling role. You need to be really clear that you require an assessment phase with parents before you see children, to be sure about what the parents are wanting and what you can reasonably provide."
"We need to slow them down and say, "I really want to talk to you about what your needs and expectations are.' One of the biggest challenges in working with a secondary client or with a mandated client, and children always are, is being clear about what the parent wants for their child and what they expect of the play therapist."
Another thing that's sometimes challenging for parents is when and how information will be communicated to them and when and how they can communicate with the play therapist.
"I think it's really important that we don't do a parent review session immediately after a play therapy session and have the parent and child change spots in the waiting room… that's not really the appropriate time.
"Similarly, when a parent comes to drop their child off and they want to tell you everything that's happened on the weekend, that's not the right time and place. Be clear about when and how information sharing happens and contract for that beforehand. The play therapy session times for children really need to be protected time for children."
Tips for running a play therapy session
First and foremost, any psychologist running a play therapy session needs to undergo specific training.
"Working with younger children and working with children in play therapy does need specific training. It's not something you can just read about in a book," says Short.
"[Sometimes] new therapists who are working with children who haven't had any specific training in play therapy think they have to adapt adult models to work with children, but they don't work.
When it comes to running an effective child-centred session, it's important that we don't default to known ways of interacting with children outside of a therapeutic setting.
"We're so used to praising children, saying things like, "That's a wonderful puppet show!" but we don't do that [in CCPT]. We don't suggest they draw a picture of something. We don't pick up the [nurse doll] and say, "Look, this is the helpful nurse" – we don't label the toys or lead the play in any way. So it's a simple method in one sense, but it's hard to learn because it requires some unlearning."
Despite talking not necessarily being the primary source of communication in a play therapy session, that doesn't mean there's no space for it. Psychologists just need to be aware of how they're speaking with the child.
"I'm not going to ask a child-specific questions about how they felt about X,Y, Z because that can be really traumatising for them."
Instead, she suggests following the lead of the child.
If/when a child is ready to share what's important to them, they'll do it in the way that's right for them.
When acquiring toys to use in a play therapy session, Short suggests having multiple options that help children convey a wide range of emotions and experiences.
"If they want to tell angry or sad stories, you should have materials that can facilitate that. I think materials, particularly for CCPT, that aren't structured in any way are best. So, you want to pack away your UNO cards – they're great for directive work and relationship building, but not for child-centred play therapy."
Measuring progress in a play therapy session is also very different to how you'd measure progress with an adult client, says Short. Avoid taking notes during the session so you can remain present with the child.
You also can't expect a child to offer verbal confirmation that they are progressing with their goals. This is why it's so important to have parent review sessions, she says.
"For instance, if a child has suddenly started having really big meltdowns at home, and nobody knows why, what I want to gather from parents in my review sessions is whether or not that has improved."
You might also seek parent/caregiver permission to contact their school to speak with teachers about their behaviour at school, she adds.
You can also look out for behavioural changes that are taking place in the playroom, she adds.
"For instance, you might be working with a highly anxious child who is finding it difficult to separate from their parents. Over time are you noticing if the separation becomes easier, that it happens more quickly, and that the child settles into play more promptly than they might previously? These are indications of positive change."
Who is play therapy for?
A common misconception about play therapy is that it's only effective for very young children, but it can be useful for young people of all ages, says Short.
"It really depends on their developmental age rather than their chronological age. But, generally, 2-3 years old can be a great age to start some form of play therapy, particularly CCPT.
"In order for play therapy to be effective, we need to have children use toys in a way that's potentially representational. That this doll isn't just a nurse, it could be me, or mummy, or Nan, or my carer, or themselves. Until children can think representationally, they're not going to be able to use play in a therapeutic way. Normally, the acquisition of language is a marker that children can start to think representationally."
For children who may have developmental delays or who have experienced trauma, the age of appropriateness of play therapy might be later in their life.
"The upper limit is generally at around 10-12, but it can be younger or older than that. I've worked with children who are 15 who love this method, but they've had significant challenges in their life and have missed some critical milestones because of trauma."
Even when you hit that upper limit for toy-based play therapy, you can still transition into different types of play for slightly older children, or those who are more cognitively advanced.
"If play is the language of children, often music is the language of teenagers. Find other creative ways that invite clients of different ages to express themselves, to explore what their experiences are, and to be able to transit through difficult times to better times."
"That might be through music, games, art, movement, drama or sand trays. There's an array of different creative therapies that children, adolescents and adults can use to understand experiences and separate from them so as to see them in a new light and feel distant enough, so the experience feels less threatening and easier to manage."
