Early Child Development and Care

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Play therapy: a review

Maggie L. Porter , Maria Hernandez‐Reif & Peggy Jessee

To cite this article: Maggie L. Porter , Maria Hernandez‐Reif & Peggy Jessee (2009)
Play therapy: a review, Early Child Development and Care, 179:8, 1025-1040, DOI:
10.1080/03004430701731613

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Early Child Development and Care
Vol. 179, No. 8, December 2009, 1025–1040

Play therapy: a review

Maggie L. Porter, Maria Hernandez-Reif* and Peggy Jessee

Human Development and Family Studies, University of Alabama, Tuscaloosa, Alabama, USA
(Final version received 8 October 2007)
Taylor and Francis Ltd
GECD_A_273098.sgm

This article discusses the current issues in play therapy and its implications for play
Early
10.1080/03004430701731613
0300-4430
Original
Taylor
02007
00
mhernandez-reif@ches.ua.edu
MariaHernandez-Reif
000002007
Childhood
&Article
Francis
(print)/1476-8275
Development(online)
and Care

therapists. A brief history of play therapy is provided along with the current play
therapy approaches and techniques. This article also touches on current issues or
problems that play therapists may face, such as interpreting children’s play,
implementing effective techniques, limit setting and how to deal with cultural issues,
as well as using play therapy with children from special populations (e.g. children
with disabilities and post-traumatic stress disorder).
Keywords: play therapy; play techniques; play therapist; limit setting

Play therapy is an interpersonal process whereby through play a trained therapist helps
children with behavioural, emotional and traumatic problems, and facilitates children’s
learning of coping skills (Hall, Kaduson, & Schaefer, 2002). Play is an appropriate thera-
peutic mode because young children frequently have difficulty verbalising their feelings.
Through play, children may lower their barriers and better express their feelings. Addi-
tionally, play is an active process that may allow a child to play out stresses and trauma,
and may eventually lead to a mastery over the stress or trauma (Mulherin, 2001). For play
to be beneficial from a therapeutic viewpoint, it should include: (1) opportunities for diag-
nostic assessment, (2) a working relationship with the therapist, (3) a breaking down of
defences, (4) facilitating articulation, (5) providing a therapeutic release, and (6) prepar-
ing children for future life events (Mulherin, 2001). Play therapy is also a wonderful tool
for parents to learn, under a trained therapist, to facilitate better relations with their
children. Play is an important instrument for children because developmentally play spans
the space between concrete understanding and abstract thinking, giving children the
opportunity to categorise their real-life experiences that are often complex and abstract.
Also, through play children achieve control and learn new coping skills as their behav-
iours are shaped (Ray, 2004).

History
During the past 60 years, play therapy has become a well-known and popular treatment
method (Hall et al., 2002). Early psychoanalysts, such as Sigmund Freud (Freud, 1909),
Anna Freud (1928) and Melanie Klein (1932), discussed the importance of play as a form
of psychoanalysis and therapy for children. These early theorists developed play theories
and conceptualised using play, in lieu of free association, to facilitate the therapeutic

*Corresponding author. Email: mhernandez-reif@ches.ua.edu

ISSN 0300-4430 print/ISSN 1476-8275 online

© 2009 Taylor & Francis
DOI: 10.1080/03004430701731613
http://www.informaworld.com
1026 M.L. Porter et al.

process in young children (Bratton, Ray, Rhine, & Jones, 2005; Leblanc & Ritchie, 2001).
Later, Piaget (1962) elaborated on play and its role in children’s cognitive development.
Virginia Axline (1947), another early play theorist, developed a school of play therapy
based on beliefs that children possess an innate power to heal themselves when given the
ideal therapeutic conditions. This form of therapy became known as client-centred, non-
directive or unstructured play therapy (LeBlanc & Ritchie, 2001). From these early practi-
tioners and the clinical work that they generated, play evolved into a feasible psychological
intervention for children.
Currently, many different types of play therapies exist, including those that have been
adapted to work with special populations of children, such as abused, developmentally
delayed and physically challenged. These play therapy approaches are discussed in a later
section of this article. In this article, we also match appropriate play therapy approaches for
varied disorders and conditions in early childhood. The general aim of this article is to
provide professionals, who work with children and families, an introduction to play therapy
from its evolving history to how play can serve as a developmentally appropriate therapeu-
tic approach for helping children with specific conditions or issues. In particular, the review
covers play therapy for alleviating anxiety, anger, depression, frustration, irritability, social
interaction difficulties, coping problems and symptoms associated with trauma in children
with behavioural, mood disorders or emotional problems. In addition, current guidelines
are reviewed for becoming a trained play therapist, as well as interpreting children’s play,
limit setting and raising cultural awareness to promote optimal therapeutic outcomes. Brief
sections are included describing play games and manipulative toys that may be used in play
therapy sessions. This review is expected to promote a greater interest in play therapy and
to generate research to better document and enhance the effectiveness of play therapy
techniques.

Play therapy approaches

In this section, play therapy approaches are grouped and reviewed. In considering the most
optimal play therapy approach to use, the therapist should consider the contextual factors
of the case (e.g. who will be involved, where will the therapy take place, etc.) and the
expected outcome (e.g. reduce anxiety, improve parent–child relationship, etc.).
Filial or family play therapy, also known as child relationship enhancement therapy, is
based on the concept of parents playing the role of therapists. Because of the widespread
shortage of mental health care professionals, this approach advocates to teach parents basic
therapy skills to improve their relationship with their children (Ray, Bratton, & Brandt,
2000). This type of play therapy allows both the parent and the child to work towards a
healthier relationship.
The idea of the parent being the therapist for the child dates to Sigmund Freud and to
Moustakas (1959) in the late 1950s. In the 1960s, Guerney (1964) recognised the value of
parents conducting play sessions with their children and pioneered the idea of training six
to eight parents in a group format to teach them how to become their children’s play thera-
pist. Guerney’s (1964) filial therapy involves three stages: Stage 1 focused on training the
parent on concepts of child-directed therapy, including being emphatic, allowing the child
to be expressive through play, accepting the child and communicating to the child that his/
her needs and feelings are understood by the parent, in addition to helping the child take
responsibility and understand limit setting; Stage 2 begins with the parent conducting play
therapy at home and reviewing the progress of the home sessions with the parent group and
supervisor; and Stage 3 is the final stage and consists of the parent terminating the group
 Early Child Development and Care 1027

sessions. Ultimately, filial therapy is expected to strengthen parent–child relationships and

help prevent future problems.
More recently, Gary Landreth (1991) designed a structured 10-week programme to
teach parents the necessary play therapy skills to work with their children. The programme
is taught in a small-group format of six to eight parents who meet for two hours weekly for
10 weeks. The parents are instructed in basic methodology of child-centred play therapy
through instructional demonstrations and role play. In addition, parents are asked to only
practice 30 minutes a week with their children, and parents also come in once a week to do
a videotaped supervised session with their child. This approach is best with children
between the ages of 2 and 10, but principles may be adapted for teens also.
The main goals of current filial/family therapy are to improve and reinforce the relation-
ship between parent and child. These are accomplished through enhanced family interactions
and problem-solving strategies, increased affection, love and trust (Ray et al., 2000). This
process may leave parents feeling empowered and less stressed. Aims for children include
reducing symptoms, expansion of coping strategies, enhancing feelings of self-esteem and
worth and developing a positive view of their parents.
Client-centred play therapy or child-centred play therapy is appropriate when the ther-
apist and the child are from culturally different backgrounds and is also the favoured
approach of filial therapy (Ramirez, Flores-Torres, Kranz, & Lund, 2005). Client-centred
play therapy aims to have the therapist see the child’s point of view, value and accept the
child, not inflict beliefs or solutions on the child, and work within the child’s cultural family
values in order to promote a better chance of cooperation and positive outcomes (Ramirez
et al., 2005). Axline’s (1947) eight principles of play therapy are often cited as guidelines
for child-centred play therapy, which include the following: (1) develop a friendly relation-
ship with the child, (2) accept the child without question, (3) establish a permissive
relationship so that the child feels he/she may express his/her feelings freely, (4) recognise
and reflect the feelings that the child is expressing, (5) maintain respect for the child’s prob-
lem-solving skills, (6) let the child lead (e.g. let the child choose the activity or game) and
refrain from directing the child’s actions, (7) let the session progress naturally, without an
agenda, and (8) make limitations that are only necessary to make the child aware of his/her
responsibility in the patient–therapist relationship (Axline, 1947).
Adlerian play therapy is another popular play therapy that encourages the child to enter
into an equal association with an adult and to choose what, and how, he/she communicates
during therapy (Buckley, Snow, & Williams, 1999; Kottman, 1999). In this child-led
approach, a supportive environment is provided to promote acceptance and trust as chil-
dren are encouraged to learn through their feelings. This approach is especially effective
for children who perceive that their responses to adults do not matter. Adlerian play can
also be used to target misbehaviour. As specified in the Adlerian approach, there are four
goals of misbehaviour: (1) attention, (2) power, (3) revenge, and (4) feelings of insuffi-
ciency (Buckley et al., 1999).
Adlerian play therapy is also appropriate for helping children who have experienced
abuse or trauma, because typically their relationships with adults change. For example,
children may develop twisted views of themselves and the world around them. Adlerian
play therapy helps repair those relationships through learning how to interact with adults in
their lives through the play process (Buckley et al., 1999). The process of using Adlerian
play therapy with a child involves four different phases: (1) building a relationship, (2)
exploring the way the child lives, (3) helping the child understand his/her own lifestyle, and
(4) teaching the child to use problem-solving skills (Buckley et al., 1999; Kottman, 1999).
Typically, the processes also involve an adult, such as the parent or foster parent, with the
1028 M.L. Porter et al.

aim of assisting the child and parent to reflect on their individual lifestyles, as well as the
interaction between the child and parent(s), and recognise maladaptive behaviours that
need correction (Buckley et al., 1999). Adlerian play therapy also incorporates individual
psychology techniques aimed at helping with individual (i.e. child and/or parent) issues. In
addition, the child and parent(s) are involved in learning and practicing new behaviours and
strategies (Kottman, 1999). Recently, Adlerian play therapy has been enhanced with the
addition of the ‘Crucial Cs’ that children must master to develop healthy relationships. The
‘Crucial Cs’ include (1) connecting with others, (2) feeling capable, (3) counting, and (4)
having courage (see Kottman, 1999).
Child-centred and Adlerian play therapies (see this section below) are similar in that
the child is the leader and the therapist the follower. The therapist is there to provide a safe,
understanding and warm environment for the child (Landreth, Baggerly, & Tyndall-Lind,
1999). Child-centred play therapy is based on a deep understanding and belief in a child’s
ability to be beneficially self-directing. The pace of these approaches is set by the child. A
major point in child-centred play therapy is that children are always communicating. This
communication is not always verbal it may be body language, or play; because of this the
children are not required to verbalise emotions, stories or issues. The children may choose
to play or not, they lead and therefore learn how to become more functional. In summary,
child-centred play therapy helps children cope with their problems by providing a safe
environment where they are not pressured to talk or share, but instead are allowed to lead
the therapy session and explore their boundaries and independence. In child-centred play
therapy, the point is not to get children to vocalise but to provide developmentally appro-
priate methods so that children may explore issues they may have difficulty verbalising
(Landreth et al., 1999).
Non-directive play therapy is another type of play therapy that is often used with the
goal of enhancing speech and language skills and to promote and develop the use and
understanding of verbal language (Cogher, 1999). In non-directive play therapy, the thera-
pist starts at the child’s developmental level rather than aiming to improve the child’s skills.
The environment is structured by therapists, teachers or parents, with the child choosing the
type of play. The adult plays beside the child imitating and providing verbal comments that
are linguistically and contextually suitable for the situation (Cogher, 1999).
Five steps recommended in non-directive play to foster a child’s language and speech
development include: (1) establishing joint attention by following the child’s lead during
play, (2) challenging the child at a developmentally appropriate level by imitating the child’s
behaviours and actions, and then demonstrating how these behaviours can be altered or
extended, (3) reacting to the child’s verbal behaviours consistently and adaptively, (4) devel-
oping and assisting numerous opportunities for play routines, and (5) providing a running
verbal commentary, which reflects the focus of attention and awareness (Cogher, 1999).
Non-directive play therapy can be used with individual or group sessions. The sessions
can be held in a multitude of places, such as the child’s play room or home (Cogher, 1999).
The approach has varying intensities; the parents may use it briefly during everyday activ-
ities or it can take place in specific settings with a play therapist. The therapist provides a
safe and welcoming environment with numerous toys that may be randomly chosen or
picked for a specific purpose (e.g. dress-up clothes or costumes to develop the child’s
dramatic play). While the child is playing, the therapist may imitate and provide verbalisa-
tion about what the child is doing in very simple language (e.g. ‘jump’, ‘you are jumping
around’). This link between the child’s present activity and the therapist’s verbalisation
provides an opportunity for the child to listen and learn language in association with
activities (Cogher, 1999).
 Early Child Development and Care 1029

Non-directive play therapy may be implemented at any phase of an assessment and inter-
vention process. It is especially effective for children with communication difficulties,
including specific developmental speech and language disorders, learning difficulties,
attention deficit disorder and autistic spectrum disorder (Cogher, 1999). This approach may
help children gain confidence and supports positive interactions for children with attention
and/or behaviour problems.
Cognitive-behavioural play therapy is a popular intervention pioneered by Aaron
Beck in the 1960s (Beck 1964, 1976). This form of play treatment is most effective for
children between the ages of two-and-half and six years and focuses on verbal communi-
cation (Knell, 1998). Puppets or stuffed animals are often used to model cognitive strate-
gies and for making positive self-statements. The goal is to use a coping model approach
to help express analytical skills or solutions to problems that may parallel the child’s
difficulties. One aspect of this approach emphasises concentrating on the child’s strengths
by utilising play and downplaying complex cognitive and verbal interventions. This
approach allows the child to recreate problem situations and challenge them.
Cognitive-behavioural play therapy has been effective for treating young children with
separation anxiety. For example, through puppet play a therapist may help a child with
separation anxiety to voice feelings about parting from the parent. In re-enacting the sepa-
ration, the child is encouraged to discuss the puppet’s fears, and through discussions the
therapist creates a list of the puppet’s fears as well as a list of positive coping statements the
puppet could use to console itself. The therapist often becomes the puppet’s voice and
expresses the child’s fears while also modelling adaptive coping skills for the child. As
sessions progress, the child incorporates the modelled skills into coping behaviours to use
when separated from a parent. This approach is an excellent way to facilitate cognitive
change, in addition to teaching new behaviour skills at a developmentally appropriate level
(Knell, 1998).

Training play therapists

To become a registered play therapist (RPT) or a registered play therapist-supervisor (RPT-
S) a Master’s Degree or higher Mental Health Degree is required from an accredited univer-
sity, in addition to accruing greater than 150 hours of specialised play therapy training,
having extensive clinical experience and adequate supervised training. RPTs are required
to earn 36 continuing education hours every three years in order to maintain their certification
(Association for Play Therapy, 2007).
Effective play therapy supervision requires teaching, modelling and the encouragement
of basic and responsive skills, with a focus on the professional growth of the play therapist.
The focus on growth is meant to facilitate a play therapist’s self-awareness in order to
ensure that the relationship between therapist and child is continuously improving (Ray,
2004).
Basic skills therapists learn during play therapy include non-verbal communication,
such as leaning forward to appear interested, seeming comfortable and using appropriate
tone of voice as well as using short responses so that the child’s interest is not lost (Ray,
2004). Basic verbal skills’ training includes: (1) Learning to respond to the child, and
remembering that children have limited language ability and tracking behaviours by using
words to state the behaviour of the child. Examples of tracking behaviour include (when a
child is drawing a circle) ‘You’re drawing’ or (as a child is dancing) ‘You’re dancing’. (2)
Reflecting content or restating what the child is saying, for example (when a child
expresses a detailed story of playing with his/her friend on the playground) the therapist
1030 M.L. Porter et al.

may say ‘It sounds as if you had a great time playing with your friend on the playground’.
Reflecting content validates a child’s perception of their experiences and clarifies the way
that the child views him/herself. (3) Reflecting feeling or responding verbally to a child’s
expression of emotions. Reflecting feeling helps children become aware of and recognise
their feelings. Examples of reflecting feeling include (a child hugs her doll and kisses it)
‘You really love your dolly’, or (a child tries to tie his/her shoe, but cannot so he/she takes
his/her shoe off and throws it) ‘You seem really angry with having to tie your shoes’. (4)
Facilitating decision-making, such as providing choices and allowing children to make
decisions on their own. For example, a child might point to a ball that has fallen under the
table in an effort to have the therapist retrieve the ball. The therapist may respond by
saying, ‘What do you think we should do about the ball that rolled under the table?’ Foster-
ing creativity and acceptance of the child’s decision is emphasised (e.g. the child might
choose to crawl under the table to find the ball and motion to the therapist to join him/her).
(5) Enhancing patients–therapists relationships by building self-esteem and self-worth, as
well as encouraging children to love themselves. For example, the therapist might remind
the child of a previous session in which the child effectively overcame a fear of separating
from a parent.

Interpretating children’s play

During training, supervisors model for beginning play therapists how to show acceptance
and interpret children’s play behaviours. Interpretation is vital in play therapy because it
connects the way that children behave during therapy sessions to the way that they behave
out of them. There are three major issues that can keep a play session from being interpreted
properly (O’Connor, 2002). One is viewing the session as overly directive. Second is not
having a well-organised model of interpretation, which may lead to inconsistent interpreta-
tion. Third is not having a solid understanding of how interpretation is important to the play
therapy process. Interpretation reinforces the therapy process by keeping each session
problem-focused, which can shorten the length of treatment. The following six steps are
recommended by O’Connor (2002) for efficient interpretation:

(1) Build a preliminary case that includes hypotheses about the primary causes of the
presenting problem/issue and those factors that may be maintaining the child’s
symptoms and/or behaviours.
(2) Develop a treatment agreement with the child by stating the way(s) in which the
child’s life will be enriched over the course of treatment. At the same time, a ther-
apist needs to explain that such advancements will take effort, including sometimes
talking about feelings that may make the child uncomfortable, angry, frightened,
etc. Therapists should emphasise their belief that the long-term improvements
children make far outweigh discomfort they may feel at first.
(3) Develop a list of interpretations that will be used to show the child a different way
of viewing his/her problems.
(4) Begin showing and implementing the planned interpretations during the play and/
or verbal discussions while noting the child’s reaction so as to evaluate the precision
of the hypotheses. If the child repeatedly rejects the interpretations or does not show
a change in behaviour, the therapist should return to the preliminary case formula-
tion and consider revising the underlying hypotheses.
(5) Help the child learn to use new techniques to solve problem, while developing
different reactions and behaviours.
 Early Child Development and Care 1031

(6) Reiterate interpretive matter as it applies to a variety of different conditions. This

will help the child to implement his/her new knowledge and skill, not only in the
therapy session but in everyday situations as well.

Proper interpretation may greatly enhance the therapy session. Interpretation builds up
the child’s use of language as well as promotes positive problem-solving and coping behav-
iours. Interpretations also help children take the ideas and concepts that they learn in the
therapy session out into the real world.

Limit setting and inappropriate/unproductive behaviours

During play therapy, therapists often face the problem of children acting out inappropriately,
such as displaying violent, irate or destructive/self-injurious behaviours. Also problematic
are children who become withdrawn or uncooperative during sessions. Gary Landreth (2002)
suggests that therapists consistently set limits and use manipulative toys to facilitate more
appropriate behaviours and help children learn coping skills during play therapy sessions.
Landreth (2002) suggests the following manipulative toys for achieving specific goals: (1)
Realistic toys: puppets, bottles, dishes, cups, telephones, dolls, doll houses, cash register,
dress-up clothes and cars. These toys allow timid, apprehensive, resistant or introverted
children to play and warm up to the session. (2) Aggressive-release toys: rope, toy soldiers
and aggressive puppets (e.g. tiger, lion or shark), pounding bench and a bop bag. These items
aid in the expression of rage, hostility and irritation. Play therapy rooms should also have
items that are meant for breaking and throwing. These can include inexpensive things such
as popsicle sticks to break, play dough to smash, egg cartons to throw or stack and knock
down. (3) Creative toys for emotional release: newspapers, magazines, scissors, crayons,
markers, paint, clay, masks, puppets, beads, sand and tape or glue. These resources allow
the child to convey an ample range of feelings and to be imaginative. Having appropriate
manipulative toys for children to access is critical for facilitating progress in play therapy
sessions.
Limit setting is vital to the facilitation of the therapeutic process (Axline, 1969; Bixler,
1949; Guerney, 1983; Landreth, 2002). It can be difficult for therapists to keep an accepting
attitude while trying to shield others, themselves and the play materials from an aggressive
or destructive child (Landreth, 2002). Limits in play therapy have both helpful and practical
benefits in that they preserve the patient–therapist relationship, foster self-responsibility
and self-control, and provide a sense of comfort and emotional security within the session
or room. Limit setting helps tie the therapy session into the world of reality and promotes
the development of self-control and socially appropriate ways of expressing the feelings
behind undesirable behaviours.
The diverse reasons for setting limits can be summarised as follows: (1) define bound-
aries, (2) provide feeling of safety and security, (3) demonstrate the therapist’s intent to
keep a child safe, (4) tie session to reality, (5) protect therapist and allow therapist to keep
positive attitude towards child, (6) allow child to express negative emotions without harm-
ing self or others, (7) provide consistency, (8) promote and enhance responsibility and self-
control, (9) promote emotional and physical release, (10) protect materials and room, and
(11) maintain legal, moral and professional standards (Axline, 1969; Bixler, 1949; Ginott,
1959, 1994; Landreth, 2002).
The therapeutic limit setting process consists of the three basic steps to help children
understand the limits, and to provide alternative actions and behaviours they may express.
Step 1: the therapist recognises the child’s emotions, desires and needs. This shows the
1032 M.L. Porter et al.

child that he/she is understood and accepted. Step 2: communicating the limit. Limits
should be clear, simple and understandable. There should be no doubt in the child’s mind
as to what is acceptable or unacceptable. Step 3: pinpoints acceptable alternatives. Since the
child may not be aware of another way to express his/her feelings, the therapist’s job is to
provide acceptable alternatives.
The limit setting process can be one of the most important variables in the play therapy
relationship. The purpose in limit setting is not to impede the behaviour but rather to provide
an appropriate and acceptable way in which the child can act out or convey emotions and
desires. If appropriate limits are not set into place, a therapy session may become very disor-
dered and chaotic. On the other hand, an extreme amount of limits restricts the child’s
creative, exploratory and emotional release. Limits have to be well thought out and consistent
in order to provide emotional and physical security and promote inner development and
growth in the children (Landreth, 2002).

Cultural issues in play therapy

Therapists will be exposed to and interact with diverse populations, and need to become
culturally competent, including recognising the cultural issues that may become barriers in
therapy. Cultural awareness helps therapists develop the skills and knowledge to ensure that
their methods are culturally sensitive (O’Connor, 2005).
Therapists should be careful not to assimilate the client into the dominant culture
(O’Connor, 2005). A major problem faced by play therapists is the difference between the
assumptions of some play therapy models and the values of particular cultural groups. The
following are five such differences: (1) The tendency to believe that play behaviour is
alike across cultures. (2) Play therapists support children in expressing their feelings
through play and verbalisation. However, many cultures place limitations on directly
expressing their emotions through indirect or subtle means. (3) Most play therapy sessions
practiced in the USA are unstructured and based on a relaxed relationship between the
patient and the therapist. Many parents have difficulty understanding that a therapist is
‘playing’ with their child, and find it hard to understand how this will help their child
resolve problems. (4) Play therapy focuses on children and parents willingly communicat-
ing with the therapist, including discussing their life experiences. However, in some
cultures discussing the private matters of family life is inappropriate and against the values
and customs. (5) Most Western thinking leans towards logical and methodological
problem-solving. On the other hand, many non-European cultures would rather use a
holistic approach (O’Connor, 2005).
There are three very common cultural errors that a play therapist may make while work-
ing. First, play therapists tend to overestimate or underestimate the significance of one or
more cultural factors in their clients’ lives. For example, some play therapists may try to
avoid cultural biases all together and see children as all the same. This takes away a child’s
cultural identity. On the opposite end, a therapist may assume that a particular cultural
generalisation fits all children in that culture. Second, therapists may fail to adequately
discriminate among cultural subgroups. The last error is when a therapist only becomes
familiar with the culture only as they see it through their clients (O’Connor, 2005).
There are several ways that a therapist can minimise errors and enhance their cultural
sensitivity. A major step towards becoming culturally competent is developing an under-
standing of one’s own culture and identification. A therapist must understand their own
culture in order to understand others. Also, it is important for play therapists to develop
culture specific knowledge. This means studying play in several cultures, and researching
 Early Child Development and Care 1033

what play materials are most familiar and suitable to children and families of diverse
culture groups. Therapists must practice and work on their cultural awareness and knowl-
edge to become culturally competent (O’Connor, 2005).
The following are the guidelines that are designed to help play therapists practice
competently: (1) respect psychological, historical and political dimensions of each culture
and provide the family with a sense of acceptance; (2) demonstrate a positive reception for
the strengths of different cultures; (3) when a therapist is working with children of a differ-
ent ethnic or cultural group than their own, acknowledge the difference and ask the parents
and the child if they have any questions or problems concerning this issue; (4) do not gener-
alise about all clients that belong to a specific racial or cultural group; (5) understand that
prejudice is a real problem in the USA so a child may have trouble trusting; (6) Eurocentric
counselling approaches might not always be suitable; (7) a blend of approaches that accept
diverse cultural perspectives may be best for children from multicultural backgrounds; (8)
interpretation is important, and the therapist must take the child’s background into count;
(9) children may have to be taught the rules of therapy; (10) the therapist must examine the
role of play for multicultural populations; and (11) therapists should seek interaction with
cultures outside of the therapy process (O’Connor, 2005).

Techniques and games to use in play therapy

For 60 years, play therapy has been a popular clinical tool for use with children mostly
because many children do not possess the abstract reasoning and verbal skills required to
verbalise their feelings, thoughts and views (Hall et al., 2002). Play is also more familiar
and less threatening to children, and through play young children may relive traumatic
issues and learn coping strategies in a safe environment. Hall et al. (2002) have described
15 fun and inexpensive techniques that effectively help children express their feelings,
manage anger, master self-control and reduce depression, fear and anxiety while supporting
the growth of problem-solving skills. These techniques are briefly described below and
readers are referred to Hall et al.’s (2002) paper for additional details.

(1) Feeling word game: In this game, the therapist asks the child to name ‘feelings’.
The therapist writes the feelings on individual index cards and uses them to tell a
story. This approach helps children through story-telling learn about emotions
they have difficulty verbalising. The feeling word game is appropriate for children
aged four and older, and may be used with children who have conduct problems,
attention-deficit/hyperactivity disorder (ADHD) and anxiety problems.
(2) Colour-your-life: In this game, the therapist associates colours with emotions and
has the child draw them out and talk about them. Colour-your-life is a good
technique to help children develop an understanding and awareness of affective
states so that they are able to verbalise their feelings in an appropriate way. This
technique is best used with children between the ages of 6 and 12. The only
requirement is that the children possess a basic understanding of emotions and
recognise colours and colour names.
(3) Pick-up-sticks game: In this game the therapist uses the original pick-up-sticks
game and adds a twist as each coloured stick is used to represent an emotion.
Once the child or therapist picks up a stick they have to tell about a time they felt
the emotion that the colour of the stick represents. This is a fun and inventive way
for children to express their feelings. This game is best with children between the
ages of 6 and 12, and may be played individually or with a group of children. This
1034 M.L. Porter et al.

technique is also helpful for children who are competitive because their desire to
win may influence them to pick up sticks with colours that represent emotions that
they may not normally express.
(4) Balloons of anger: For this technique, the therapist helps the child blow up a
balloon and tie it; the therapist then examines the balloon and tells the child that
it represents the body and the air inside the balloon is anger. The therapist then
lets the child stomp the balloon and explains that if this were a person, the
popping of the balloon would be an angry act such as hitting a friend. This tech-
nique gives children a good visual image of anger, and works well with children
who have difficultly controlling their anger. The technique may be used for
individual or small-group therapy.
(5) Mad game: Wooden blocks are used to build a tower in this game. When a block
is placed on top of another one the child is asked to express something that would
make him/her angry or something that is unfair. Every statement is acceptable and
it can be serious or silly. Once all of the blocks are stacked in a tower, the therapist
asks the child to make a statement of ‘what makes you angry’; the child is then
asked to make a mad face and knock the block tower down. This game allows a
child to physically and verbally show anger. This technique may be used with
children of all ages, and the emotion can be adapted to suit the situation.
(6) Beat the clock: This game was designed to enhance a child’s self-control. The
therapist tells the child he/she will receive five chips if a certain task can be
preformed in the allotted time. If the child completes the task within the time
limits, the chips can be turned in for prizes. This game strengthens a child’s
impulse control and provides children with a sense of accomplishment. Beat the
clock is useful with children with impulse control issues and ADHD.
(7) Slow motion game: This game is also designed to exercise and enhance self-
control. At the beginning of the game, the therapist introduces the concept of self-
control and explains that maintaining self-control is difficult when things are
going fast. The child is given a stop watch and asked to act out various activities
in slow motion. This slow motion re-enactment helps the child gradually increase
self-control.
(8) Bubble breaths: This is a relaxation technique that is designed to teach children
deep and controlled breathing so that they are aware of the control they have over
their own bodies. In bubble breaths, bubbles are used to teach children how to
breathe. With each bubble, they are asked to explain how they are feeling. This
game is effective for individual or group formats, and has been shown to reduce
feelings of anger, fear and/or anxiety.
(9) Worry can: Children, like adults, worry about various things in their lives. These
feelings may be the root of some of their deeper issues, fears and anxieties. In this
game, the therapist cuts a large piece of paper and covers a can (e.g. a large empty
coffee can). The therapist then asks the child to draw or write scary things on the
piece of paper. The paper is then glued onto the can. The child has the option of
writing down or drawing worries and placing them in the can anytime during the
session. This game allows the child to express worries and discuss them. This
technique is useful with both individuals and groups and may be used with older
children.
(10) Party hats on monsters: This game is designed to allow children to gradually face
and conquer fears. The therapist asks the child to draw something that feels happy
or safe, and this is followed by a discussion. The therapist then asks the child to draw
 Early Child Development and Care 1035

something that scares them a little, but to draw something on it that will make it less
scary, and again, this is followed by discussion. This technique is great for
preschool and school-age children, and it is especially beneficial for children who
suffer from anxiety disorders.
(11) Weights and balloons: In this technique, the therapist helps the child create a list
of negative and positive thoughts that the child has about a specific situation. The
therapist explains to the child how negative thoughts can weigh a person down
and make them feel sad and discusses how positive thoughts can lift our spirits
and make us feel good. The therapist demonstrates this with weights and helium
balloons. This shows a complex idea in a manner that is developmentally appro-
priate for children. This technique is especially effective for depressed children.
(12) The power animal technique: This technique is targeted at boosting a child’s self-
esteem and sense of self-worth. In this game, the therapist shows pictures of
animals and asks the child to pick the one that he/she likes the best. The child is
then asked to make a mask of a favourite animal, and through play use the mask
to imagine what that animal might do in problem situations.
(13) Using a puppet to create a symbolic client: Puppets are important in play therapy
because children feel comfortable projecting their feelings through inanimate
objects, such as puppets and dolls. This technique is for children who are afraid
of therapy and the therapist. The therapist may say that the puppet is scared, and
the talk to the puppet is about fears and what can be done to make the puppet feel
better. This technique is typically appropriate for children between the ages of
four and eight who are apprehensive about attending therapy and who may be
frightened.
(14) Broadcast news: In this technique, the therapist introduces the concept of a TV
station where the child and therapist take turns acting as the broadcaster. The ther-
apist tells the first story about feelings and the child goes next. As the game
progresses the child may become less fearful about discussing feelings and
stories. This game is good with verbal children six and older, and is a good
activity for children who are outgoing, but maybe a bit more difficult for children
who are shy or withdrawn.
(15) The spy and the sneak: This game was designed to take negative family interac-
tions and make them positive. The therapist discusses positive behaviours the
child can perform to surprise a parent. The child is told that their parent is a spy
and the child has to try to surprise the parent by doing something before the parent
catches them, like picking up their school clothes off the floor and putting them
in the hamper. Through this game, children learn that they will receive more
attention when they act positively instead of negatively. This technique is used to
bring parents and children together.
In summary, the techniques described above are relatively easy-to-use play therapy
techniques for treating young children of different ages and with varying issues/disorders.
A larger repertoire of techniques possessed by a play therapist increases the likelihood of
finding an appropriate technique for a special/particular child.

Play therapy for children with disabilities

When working with children who have profound multiple intellectual disabilities, play
therapy can help these children develop and may provide significant social interactions. To
understand what play means for children with severe disabilities, one needs to understand
1036 M.L. Porter et al.

what play means for children with different types of disabilities. Children with hearing
impairments often do not play on a cognitive level comparable to their developmental age.
Their play behaviours do not appear linked with their communicative ability, but rather
with the visual behaviour of the people around them and their play materials. Children with
hearing impairments compensate with visual impressions and build their views on reality
from those impressions (Brodin, 2005). In contrast, visually impaired children often do not
show interest in traditional toys, but play with objects that are not usually thought of as toys.
It can be difficult to find proper play materials for children with visual impairments because
these children typically rely on manipulative toys, play alone or withdraw from play all
together. Children with motor disabilities may have difficulties playing with playmates, if
they cannot move by themselves. These children may also be less active or creative
(Brodin, 2005).
Play therapy may assist children with physical disabilities in discovering what they
can achieve and who they are. Children with physical disabilities may have low self-
esteem and feelings of inadequacy. One of the greatest issues a child with a physical
disability faces is feelings of rejection from others. One way to boost a disabled child’s
sense of self-esteem and self-acceptance is through client-centred or person-centred play
therapy (refer to earlier sections of this article). As already reviewed in person-centred
play therapy, the therapist provides the play materials and safe environment, but the
child leads the play. The key is to focus on the child’s growth and to promote decision-
making. In person-centred play therapy, the therapist does not play with the child but
watches, encourages and reflects emotions. The goal when working with children with
disabilities is to promote independence and the development of coping skills
(Carmichael, 1994).
When working with a child with a physical disability, the play therapy process may be
modified to include the child’s support team. This may include anyone working with the
child, such as a physical therapist, doctor, parents and siblings (Carmichael, 1994). Another
modification is supporting and training the parents on play therapy techniques. The last
modification is that traditionally the play therapist does not touch or hold the child.
However, when working with a patient with a physical disability, the therapist may need to
hold or support the child, position toys, help the child hold the toys or even hold the child
in his/her lap (Carmichael, 1994).
Play therapy for children with disabilities may also require adaptation of toys. If a child
cannot hold a paintbrush, the therapist might tape or velcro them to the child’s elbow to
allow the child to participate in art therapy. Another adaptation may be to introduce one toy
at a time, especially if the child does not have the skills to fully explore the environment
(Carmichael, 1994).
In summary, play therapy should provide children with physical disabilities the oppor-
tunity to express themselves in a warm and caring environment, and help them develop
independent thinking and creativity, which in turn may lead to self-acceptance. Whenever
possible parents should be fully included in the process, and the play therapy session should
be adapted to each individual child’s needs and physical disability. Through play therapy
in a safe environment, children with disabilities may learn new coping skills and indepen-
dence as well as gain a boost in their self-esteem (Carmichael, 1994).

Post-traumatic stress disorder

Play therapy is also effective for traumatised children (Ogawa, 2004). Trauma may occur
in relation to a kidnapping, a natural disaster (tornado, hurricane, etc.), an accident or
 Early Child Development and Care 1037

having surgery. Psychological trauma in children is defined as an external event or events

that render a child helpless and break down coping skills and defences. There are two types
of trauma: (1) unexpected, single, public stressor, such as a school shooting or natural disas-
ter (e.g. a hurricane), and (2) long-standing ordeal, such as abuse over years. Post-traumatic
stress disorder (PTSD) in the Diagnostic and Statistical Manual of Mental Disorders (4th
ed., text revision) (DSM-IV-TR) is extensive and includes viewing the event or learning
about the death, death threats or severe harm of a family member or another person close
to the client (Ogawa, 2004).
The child’s age and the type of trauma experienced by the child will likely impact the
therapeutic and healing process. Through the medium of play, children may open up and
express emotions about the trauma. Positive outcomes through therapeutic play depend on
a secure environment for the child to work through the traumatic event. After a traumatic
event, children often lose their sense of safety and may feel scared of the world, weak or
defenceless. Therefore, it is critical for the therapist to (1) create a safe and nurturing
environment, (2) help the child build or regain self-control, (3) facilitate the occurrence of
the event so the child can cognitively rework it, and (4) help the child feel satisfied with the
play therapy process (Ogawa, 2004). Release play therapy and child-centred play therapy
are effective types of play therapy for traumatised children (Ogawa, 2004). In release play,
the therapist supports the child to re-enact the traumatic event or issues (Ogawa, 2004). The
therapist picks toys that appear to be associated with the traumatic event to promote the
child to play out the event (Ogawa, 2004). In this approach, the therapist directs the child
to focus on the issue rather than interpret the child’s play. In child-centred play therapy, the
therapist creates a warm and caring environment to promote self-actualisation (Ogawa,
2004).
Children who have experienced trauma usually lose their sense of security and
control, both of which are important to healthy mental and emotional development.
Understanding the trauma helps the therapist implement the right therapeutic play process
(Ogawa, 2004).

Future directions/implications
Play therapy has been used for a number of decades as a psychological intervention for
young children, especially those under the age of 10. Play provides an appropriate and safe
means for children to communicate, especially since many young children, as well as ill,
disabled and traumatised children, have difficulty with abstract thought, verbalisation and
discussion of complex issues and emotions.
A recent meta-analysis on 93 play therapy studies reveals that overall play therapy is an
effective intervention for children (Bratton et al., 2005). Meta-analysis is a statistical proce-
dure that combines the results of several studies that focus on a topic (e.g. play therapy) to
examine if there is sufficient support for a hypothesis (e.g. play therapy is an effective
intervention for treating children). Typically, effect sizes are reported in meta-analysis,
with small effect sizes suggesting that there is little support that the topic studied is effec-
tive, or that more research may be necessary to determine the effects, moderate effect sizes
suggesting that there is good support for the topic studied and large-to-very-large effect
sizes suggesting very strong support for the topic.
Interestingly, in the Bratton et al.’s (2005) meta-analysis, filial play therapy (i.e. play
therapy conducted by parents), was associated with a very large effect size, whereas play
therapy conducted by professional therapists was associated with a medium-to-large effect
sizes (Bratton et al., 2005). This is an encouraging finding as it suggests that both parents
1038 M.L. Porter et al.

and professionals can effectively deliver play therapy, although apparently parents may
achieve better outcomes than professionals.
Another interesting finding from the meta-analysis was that larger effects were
obtained for non-directive play therapy approaches than for non-humanistic directive
approaches, such as therapies that were not child-centred and/or focused on board games
(Bratton et al., 2005). This finding is perhaps not surprising, and is in line with the spirit of
play, which is meant to be child-oriented and child-directed rather than adult-oriented or
adult-directed. However, as Bratton et al. (2005) point out, the findings contradict adult
psychotherapy approaches, which are more therapist-directed, and other meta-analytical
studies on child psychotherapy. This is not to say that directive play therapy approaches
should not be used with children, as these types of approaches produced moderate effect
sizes. Directive play therapies may be required and appropriate for specific issues in child-
hood. However, in general, better outcomes appear to be associated with play therapy
approaches that are non-directive or have a child-oriented theme. Bratton et al. (2005) also
report that play therapy appears to be effective regardless of the setting or location where it
occurs, and that the number of play therapy sessions impacts treatment efficacy. Readers
are encouraged to review the Bratton et al.’s (2005) paper for an excellent discussion on
previous meta-analytical findings that contradict the current meta-analysis and the implica-
tions of these contradictory findings.
Although Bratton et al.’s (2005) meta-analysis informs that play therapy is a viable
intervention for children, the authors also acknowledge the need for additional well-
designed play therapy studies, especially those that use alternative treatments rather than no
interventions to assess what additional factors may contribute to the effectiveness of play
therapy. For example, little research has been conducted on appropriate play therapy
approaches for children with varying medical conditions versus psychiatric conditions
versus emotional conditions. The publication of a copious number of well-designed
controlled studies is needed before meta-analysis can be applied to examine play therapy
effects on specific conditions. For children, major cognitive and personality processes
happen during play, and play acts as an adaptive resource for children. By continuing to
research play as a therapeutic agent, much may be learned about the processes underlying
play for creative problem-solving, coping and adaptation. Research that provides continuity
across settings (e.g. home, school and therapist’s office) is also needed.
In summary, play therapy has a history in the literature spanning at least six decades and
approaches are still evolving. A recent research suggests that, overall, play therapy
conducted by parents and professionals benefit young children. Play therapy may help
modify children’s maladaptive behaviours, personality and social issues as well as help
them develop more optimal relations with parents. However, there is still much research
needed to better validate play therapy approaches.

Notes on contributors
Maggie L. Porter, University of Alabama, College of Human Environmental Sciences, Human Devel-
opment and Family Studies, Tuscaloosa, AL 35405. This paper partially fulfilled the requirements
for a Master’s Degree in child life for this author.
Maria Hernandez-Reif, PhD, is a Professor at the College of Human Environmental Sciences, Human
Development and Family Studies, Tuscaloosa, Alabama.
Peggy Jessee, PhD, is Professor Emeritus at the College of Human Environmental Sciences,
Human Development and Family Studies, Tuscaloosa, Alabama.
 Early Child Development and Care 1039

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