British Journal of PLAY THERAPY

Volume 1 l Number 1 l May 2004

Published by the British Association of Play Therapists British Journal of Play Therapy An official publication of the British Association of Play Therapists (BAPT)

SUBSCRIPTIONS SCOPE The British Journal of Play Therapy is published The British Journal of Play Therapy is a twice a year in Summer and Winter. Two issues national journal with a focus on the theoretical form a volume. The journal is published on behalf and research aspects of Play Therapy practice. of the British Association of Play Therapists. Its aim is to bring together the different theoretical and professional disciplines involved Subscription rates include delivery (but not VAT in Play Therapy and this will be reflected in the or Sales Tax where this is payable). composition of the Editorial Board. Nevertheless we welcome submission from all The annual subscription rates for volume 1 relevant professional backgrounds. The journal (2004) are as follows: thus aims to promote theoretical and research developments in the fields of Play Therapy prac- Britain (England, Scotland and Wales) tice. Submission of reviews, systematic reviews Institutions £50 and research papers which support Individual £30 evidence-based practice are also welcomed. Papers may assume any of the following forms: Europe Institutions £60 (a) Papers reporting original research findings. Individual £35 (b) Theoretical papers. (c) Review papers, which need not be North America (USA, Canada and Mexico) exhaustive, but which should give an Institutions £70 interpretation of the state of research or practice Individual £40 in a given field and, where appropriate, identify its clinical implications. Orders, which must be accompanied by (d) Systematic reviews. payment, may be sent to: Journal Department, (e) Brief reports and comments. The British Association of Play Therapists, 31 Cedar Drive, Keynsham, Bristol, England, BS31 2TY. CORRESPONDENCE Correspondence to the Editor should be sent to COPYING BAPT, 31 Cedar Drive, Keynsham, Bristol, No part of this publication may be reproduced, England, BS31 2TY. stored or distributed by any means without [email protected] permission in writing from the British Association of Play Therapists.

Organisations authorised by the UK Copyright Licensing Agency may also photocopy material Copyright © 2004 British Association of Play subject to the usual conditions. Therapists (BAPT). All rights reserved. BRITISH JOURNAL OF PLAY THERAPY

Volume 1 Number 1 May 2004

Editor ROBERT DIGHTON School of Psychology and Therapeutic Studies, Roehampton University of Surrey, London, England

Correspondence to the Editor should be sent to BAPT, 31 Cedar Drive, Keynsham, Bristol, England, BS31 2TY. [email protected] BRITISH JOURNAL OF PLAY THERAPY 2004 VOLUME 1 NUMBER 1 MAY

EDITORIAL Robert Dighton 4

PAPERS D. Hutton 5 Storytelling and its application in non directive play therapy

K. Robson and A. Tooby 16 Play Therapy with Looked After Children: An Attachment Perspective

J. Carroll 26 Play Therapists and the Children's Rights Movement

V. Ryan 35 'My new mum'. How drawing can help children rework their internal models of attachment relationships in non-directive play therapy

C. Daniel-McKeigue 47 Transforming Therapy into Research. Is it possible to conduct research that investigates the process of play therapy without affecting the delicate balance of the relationship between the child and therapist, which is central to the therapy?

A. S. Naylor 56 Non-Directive Play Therapy: Should we and can we attempt to measure its effectiveness?

Notes for Contributors 66

Table of Contents

3 Bri. J. Play Therapy, Vol. 1, No. 1, pp. 4, 2004 British Association of Play Therapists Editorial - to Sue Sowerbutts - The publication of the British Journal of Play spectives on the 'child'. Various questions emerge: Therapy heralds the beginning of a new era in the pro- Are client's having significantly different experiences fession. It represents not only a synergy of theory, to that of adults in the play therapy process? How, as practice and research, but also a particular maturation play therapists, can we better understand the client's of the play therapy profession. In its infancy, play experience? Is it possible to meet the client's needs, as therapy focussed predominantly upon its mode of well as conforming to the ever increasing laws, regu- delivery. Over the last twelve to fifteen years, its the- lations and guidance for play therapy practice? oretical basis has rapidly evolved. This Journal pro- That our attachment experiences are internally rep- vides an academic context for play therapists and resented is not disputed, but in circumstances where related professionals to develop, explore and elucidate such representations are associated with difficulties theory, practice and research. The profession retains and complexity, how can we enable the client to distinct and diverse theoretical orientations. An adapt and transform such representations? This ques- essential function of the Journal is to provide a rigor- tion is central to Ryan's paper. Through case materi- ous and atheoretical forum for the presentation of al, Ryan details the process and function of play ther- papers. It is noteworthy that many tensions exist apy as context and method for enabling clients to between the theoretical perspectives in play therapy, adapt internal models of attachment. The theme of and whilst exploration of similarities is important, it attachment informed play therapy practice again is the tension between theories that invoke provoca- emerges. Such enquiry also offers potentially new and tion, challenge and creativity. Thus, the Journal is a fruitful research into children's representations of context that must tolerate theoretical difference. attachment, as well as the assessment and outcome Hutton's paper details the use of storytelling within measurement of play therapy practice. play therapy practice, highlighting its theoretical basis The final two papers both explore play therapy as a commonly used therapeutic method and explain- research. First, Daniel-McKeigue reviews the current ing its application in case material. Hutton utilises research base for play therapy and then elaborates the the use of storytelling as a psychological container for complexity of undertaking research within the thera- the client, thus facilitating symbolic expression and peutic relationship. Whilst further research is exploration. Linked to this symbolic method, the required, there exist clear and present dangers for therapist integrates a dyadic therapy mode to allow both therapist and client. The second, by Naylor, also the changes, understandings and shifts to translate questions the methodologies commonly used to into the parent-child relationship. investigate therapy with children. Taking a social Robson and Tooby's paper illustrates the complex constructionist perspective, Naylor illustrates the needs of looked after children; this client group often complexities implicit in play therapy research. expressing multiple, diverse needs with a significant Quantitative measures are commonly used, but can co-morbidity of mental health difficulties. Rather they adequately reflect the client's experience? Both than utilising the clients' familial attachments within Daniel-McKeigue and Naylor conclude that a the play therapy, Robson and Tooby suggest that the research methodology that involves the client, allow- therapists themselves serve as secure base figures. ing the client an active voice, is an essential goal for Since this client group exhibits diverse and complex play therapy research. need, the authors use an attachment informed Finally, I wish to note that the development of this approach to play therapy. Journal is the culmination of the fruitful and dynam- Carroll's paper elucidates the tensions surrounding ic dialogues with my first and primary clinical super- law, ethics, children's needs and play therapy practice. visor, Sue Sowerbutts. It is her wisdom, sensitivity Carroll describes the real-world conflicts for play and rigour that has long been the foundation stone of therapists, who practice in contradictory and poten- my play therapy career. It is to Sue that I wish to tially paradoxical national, international law, as well dedicate the very first editorial of the British Journal as ethical principles that underlie such laws. At the of Play Therapy. heart of this paper exist Carroll's doctoral thesis data. Robert Dighton The client's voice offers stark contrast to adults per- Bri. J. Play Therapy, Vol. 1, No. 1, pp. 5 - 15, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. Storytelling and its application in non directive play therapy Deborah Hutton Child and Adolescent Mental Health Service, Peterborough, Cambridgeshire, England

This article aims to address the use of storytelling within the practice of non-directive play therapy. Much of the literature currently published on the therapeutic use of sto- rytelling heralds from psychoanalytic child psychotherapy, structured ('problem focussed') play therapy or narrative therapy. By contrast to these therapies the non directive approach does not attempt to guide or alter the child's narrative but rather allows them to script their own story and experience the emotions associated with it's expression.

The article focuses in particular on the shared storytelling process of a mother and her daughter as part of a longer non-directive play therapy intervention. In this context the benefits of shared storytelling usually ascribed to the therapist/child relationship were experienced by family members and their affectional attunement altered as a result. Although the changes which occurred within the mother/child relationship were short lived such was the complexity of their attachment behaviour the stories they told were, in the opinion of the author, highly symbolic of their emotional difficulties. As a case example one such story is examined in detail in terms of how both the pro- cess of its telling and its symbolic content related to its creators.

In the author's experience many of the children article, have lively, active imaginations that bid referred for play therapy, almost regardless of an immediate response from the listener or play- their difficulties, will spontaneously create sto- mate. The telling of stories within play therapy ries from, or give narratives to, their doll play, can thus be seen as both a means of expressive puppetry, sandplay, drawings or role-play. communication for the storyteller and as an Some of these stories will remain as silent inter- activity which helps form a relationship with the nal dialogue, some will be spoken aloud but to listener. the self and others will be shared directly with This article aims to highlight how, if given the the therapist. How the child shares his or her opportunity within a therapeutic environment stories with the therapist varies from the thera- children can spontaneously create stories which pist being required by the child to be the 'audi- are relevant symbolically to their emotional dif- ence', to the therapist being the co constructor ficulties. The case example described to illus- or co author of the child's story. Some children trate the process of storytelling within a non need time to develop the fantasy or symbolic directive play therapy intervention is not how- play which gives rise to stories and helps expres- ever typical of traditional individual play thera- sion of their thoughts and feelings. Other chil- py for it involves the child's mother directly in dren, such as the child later described in this the play process in place of the therapist. The therapist took on the role of observer and sup- porter of the shared play that occurred between Correspondence to: Deborah Hutton, Cedars, 16 the mother and daughter. The joint session dis- Aldermans Drive, Peterborough, England, PE3 6DA cussed occurred following a series of initial indi-

5 STORYTELLING 6 vidual sessions with the child who was therefore to express their emotional issues. Bettleheim familiar with the process of non directive play (1976), writing from the Freudian tradition, has therapy, the therapist and the play room prior to been most influential in persuading therapists of the commencement of the joint sessions. At the the symbolic content of fairy tales and their rel- end of the joint sessions the child was offered a evance to children's unconscious desires, second series of individual sessions. Occasional thoughts and feelings. More recently and from progress review meetings were also held between a developmental perspective Harris (2000) the mother and the therapist in order to main- argues that a child's imaginative life does not tain a collaborative approach in meeting the provide a glimpse of their unconscious desires, child's emotional needs in readiness for dis- which if unsatisfied drive their imaginative play charge from the child and adolescent mental but rather that their imagination is activated by health service. external input, by fictional characters (in stories Before the case example is examined in more or on television) which arouse emotion. Harris detail a theoretical context for the provision of asserts that in normally developing young chil- storytelling in play therapy will be provided by dren, it is the imagination which arouses emo- reviewing the use of the storytelling techniques tion rather than emotions which stimulate the widely applied in the field of child psychothera- imagination. py and the theories which underpin their prac- The seemingly opposing views of Harris tice. (2000) and Bettleheim (1976) do however con- verge in the area of the function of the imagina- Storytelling Theory tion. Both theories agree that the ability to pre- tend or imagine allows for children to contem- For the past thirty years storytelling has been a plate events and encounters they themselves popular therapeutic technique within the field may not have experienced and that these imag- of child psychotherapy (Brandell 1998) with key inings can evoke feelings of satisfaction or dis- texts arising from the psychoanalysts in the early appointment, relief, fear or excitement associat- 1970's (Bettleheim 1976; Gardner 1971) to the ed with the events represented in their play. evolving narrative therapies (White 1998; Imaginative play is the cornerstone of play ther- White and Epston 1990) of the 1990's. apy and much of the play therapy literature Storytelling as a mode of metaphorical com- argues strongly for the needs of troubled chil- munication has been used within a broad range dren to have the opportunity to assimilate their of settings which include the creative/expressive emotionally difficult/abusive experiences arts therapies (Gersie 1997; Dwivedi 1997; through the process of play (Cattanach 1993; O’Toole 2002; Pettle 2001; Parkinson 2001), Gil 1991; Ryan 1999; Ryan & Wilson 1996) . psychodrama and dramatherapy (Hoey 1997; Jennings 1992; Lahad 1992), sandplay (Miller Play Therapy: Within child psychotherapy and and Boe 1990; Newson 1992) and play therapy play therapy in particular the stories children tell (Cattanach 1993; Jennings 1999; Oaklander are often elicited along with other projective 1988) as well as a tool in education and training tests/activities such as puppetry, painting, cos- (Gersie and King 1990; Robinson 1986; tume play and doll play (Barker 1985; Brandell Whitehead 2001). 1986; Cattanach 1997; Claman 1980; Despite the popularity of storytelling as a ther- Daigneault 1999; Carlson & Arthur 1999; apeutic intervention there are conflicting views Freeman et al 1997; Frey 1993; Oaklander as to it's validity as a means of helping children 1988). Many of the storytelling techniques used in 7 D. HUTTON child psychotherapy are derivatives and adapta- ly accepting therapeutic environment within tions of Gardner's (1971) classic Mutual Story which a child can freely explore these issues Telling Technique (MSTT). The process of the without fear of judgement or experiencing the MSTT involves the child being invited by the pressure to change (Wilson et al 1992). therapist onto a make-believe television show and to tell a 'good' story, one which is not based Narrative Therapy: The emergence of narrative on things they have read or seen on television or therapy has rekindled interest in storytelling as a that has happened to them in 'real life'. After process of externalising problems. The process it's telling the child is asked to identify what was of 'externalisation' creates a way for the identi- the moral of their story and the meaning of the fied problem to be seen as outside of the person story is elicited from a subtle 'post story enquiry' or family with whom it resides. Externalising by the therapist. The therapist then uses the the problem helps give rise to 'alternative stories' child's metaphor as the basis of their own story, and can create within an individual or family a one which includes solutions to the problems sense of 'personal agency' over the problem identified or holds alternative views to those (White 1988; White and Epston 1990). held within the child's story and concludes with Narrative therapists Freeman et al (1997) an alternative moral (Gardner 1971). Like believe there is a link between the process of nar- Bettleheim (1976), Gardner did not believe that rative therapy's 'externalisation' and the theories children needed stories to be interpreted in behind the use of expressive arts; they feel that order for them to understand their metaphorical for children, externalisation is like playing a meaning but rather that the child would feel the game of 'pretend'. It is argued that the process 'fit' of the story with their own inner conflicts as of drawing or dramatising 'the problem' appeals appropriate. to children who prefer to communicate about problems obliquely, in metaphor or play (Axline Non Directive Play Therapy: Unlike non direc- 1969; Bettleheim 1976; Brandell 1986; tive play therapy, 'structured' (Wilson et al Gardner 1971; Frey 1993; Freeman et al 1997; 1992) or 'focussed' play therapy (Carroll 1998) Schlozman 2000) It is also argued that children has a 'problem focus' which the therapist experience a sense of relief when they express an attempts to address in a variety of ways and as externalised problem in a symbolic yet physical- such Gardner's MSTT fits well into this ly experienced way (Freeman et al 1997) their paradigm. The strict practice of non-directive feelings 'displaced' or 'projected' onto the play play therapy however prohibits the therapist materials (Wilson et al 1992) and thus exter- from using the MSTT in either its original or nalised. adapted forms. Based on Rogerian client cen- tered counselling, Axline's eight principles Summary: In sum there seems to be justification (Axline 1969, Carroll 1998; Wilson et al 1992;) for the use of storytelling as a therapeutic inter- outline the aim of a non directive therapist in vention from a variety of sources. The authors working within the child's emotional defences, of the psychodynamic literature write of the allowing the child rather than the therapist to internal or intra personal benefits of creating lead the process (Axline 1969; Dorfman 1951; stories as symbolic expressions of unconscious or Guerney 1983a) according to the issues they preverbal thoughts and feelings. Authors from a themselves identify. The non directive therapist developmental perspective as well as the narra- uses the core skills of reflective listening, empa- tive therapists emphasise the value of a story as thy and congruence to create an unconditional- being related to the interpersonal context in STORYTELLING 8 which it was told. tration at Karen's need for control, describing The following case example illustrates the use her as "obsessive" in her need for order with of storytelling specifically within a non-directive regards the personal effects in her bedroom and play therapy intervention and speculates on its rejecting of her mothers help with her personal value as a therapeutic tool. care. Elaine openly expressed her view that Karen was "mental" and that there was "some- Case Example thing wrong with her".

Family Composition and History: Karen, aged Initial Therapy: Although Elaine wanted Karen nine, lives with her mother and younger sister. to have individual therapy immediately she was Karen's parents separated when she was a few persuaded by the therapist to have a few prelim- weeks old; she has contact with her father at inary sessions with Karen in order to agree a weekends. behavioural programme whereby Karen's efforts Elaine, Karen's mother, has suffered from to control her temper would be recognised (and physical and mental health problems since her rewarded) by her mother. The programme adolescence. Elaine has found it difficult to achieved some success and was continued whilst cope Karen's long standing history of temper Karen's individual work began. tantrums; their relationship is characterised by anger, rejection and negativity. Karen's insecure Individual Play Therapy Sessions attachment pattern of behaviour towards her mother is complex and could be further cate- Karen attended an initial series of eight indi- gorised as being of the disorganised subtype vidual non directive play therapy sessions on a with her experiencing high levels of anxiety and weekly basis. Karen remained tense, keen to low self esteem (Howe et al 1999). please both the therapist and her mother with whom she discussed her play sessions both Reason for referral: Elaine has received help from before and immediately after each session. Each various agencies with parenting skills on a num- week Karen worried about what she should do ber of occasions during Karen's life. The re in the play room, struggling to make decisions referral to CAMHS was made by Elaine's thera- about which activity to undertake but once pist who had noted how within the family sys- engaged in play, settled and worked with con- tem hostility, discouragement and criticism centrated energy. Karen preferred to stay with- were a feature of daily family interactions and he in the metaphor of her play rather than talk wondered whether Karen would benefit from about her 'real life' and for the majority of her the unconditional environment of play therapy. sessions chose to work with the sandtray and the associated World materials (Lowenfeld 1979) Presenting Problems: A bright, articulate child, expressing her internal conflict in symbolic Karen had done well at school where she was rather than verbal form. As Karen's confidence socially popular and academically able. Karen grew she began to relax enough to start to use was however a tense, restless and alert child, her role-play and puppetry to enact stories of her low self esteem evidenced by a lack of self belief own making. and an inability to internalise her achievements. On meeting Karen and Elaine in the waiting Attending the initial appointment with her room for her penultimate individual session mother and sister, Karen occupied herself with Elaine appeared unwell; she explained that she drawing whilst her mother expressed her frus- had been given a prescription to which she was 9 D. HUTTON having an adverse reaction and she planned to The relief experienced by Karen following the go to the hospital pharmacy for advice whilst telling of her story was soon replaced by further Karen had her play session. anxiety when she met Elaine at the end of the On entering the playroom the therapist session. Her speech now slurred Elaine observed an increase in Karen's tense state and explained she had been advised to return home empathised with her anxiety concerning Elaine's and sleep off the effects of the medication she health. Karen volunteered her hypothesis that had taken. The following week Elaine appeared there had been a mix up at the pharmacy and recovered and Karen did her puppet show as she that instead of being given tablets that 'were had planned. supposed to make you happy', her mother had been given ones which had made her depressed; Discussion: If evidence of the value of the non- Karen said that she wanted to 'do a play' about directive approach were needed this session, in this. the author's opinion, clearly demonstrates how Karen acted out a brief play scenario whereby children can use play therapy sessions to address she took the role of the doctor who had mud- feelings which are relevant to their current situ- dled up two prescriptions as he was in a hurry. ations. The story Karen created appeared repre- Karen wrote out the prescriptions on paper sentative of her thoughts and feelings concern- from the 'doctor's bag' and used a baby doll in ing her mother's difficulties of that morning and role as the patient to bring the matter to the her dramatisation of this 'story' allowed her to doctors attention. Having addressed and achieve some momentary mastery over and resolved the issue in this first enactment Karen therefore temporary relief from her anxieties. then set up a row of soft toys and invited the therapist to join them in being part of the audi- Joint Play Sessions ence. Karen developed the role-play, enthusias- tically embellishing it's narration by introducing Following Karen's individual sessions the ther- more characters and further drama. At the end apist held a progress review meeting with her of the performance Karen stopped abruptly. In mother. It was apparent that the relationship response to the therapist's appreciative applause between Elaine and Karen remained conflictual Karen bowed and flopped onto a beanbag with despite the success of the behavioural pro- a proud and relieved smile on her face. The gramme (which had eventually fallen by the therapist reflected on how Karen had seemed to wayside) and the provision of individual work enjoy her play and she confirmed that she had, for Karen. The previously recommended plan noting that next time she'd like to do a puppet of Karen having designated one to one time to show. Karen added that at first she hadn't been play at home with Elaine had also failed as sure if she 'could do it' i.e. the play, but now felt Elaine observed that when together, Karen did- "okay about it". The therapist wondered with- n't "seem to know what to do" with her. Aware in herself whether this was not only a comment of their ongoing relationship difficulties Elaine on Karen's confidence in terms of her acting was offered the opportunity of some joint play skills but also a statement of how she felt about sessions with Karen in the hope that these the subject matter of the play. The therapist would facilitate their shared play skills and in shared with Karen her experience of the play by turn their relationship; having been asked sepa- indicating her relief that after the initial anxiety rately both Elaine and Karen agreed to this plan the mix up over the prescriptions had been sort- and a series of five joint sessions with an addi- ed out. tional progress review meeting was arranged. STORYTELLING 10 Shared Storytelling: The first joint session ran make a pig farm and Elaine accepted the pro- smoothly despite Elaine's' initial wariness being posal, moved silently towards the sandtray and less familiar with the playroom than Karen. began to place into it a few pigs and cows. Karen and Elaine had undertaken some sand- Karen followed her mother's example but sensi- play and the pair had co-created a maze, set tive to the angry way Elaine placed the animals within the walls of a castle; a story had arisen into the sand, began to mimic her movements, which involved various characters attempting to expressing her anger in the same way and in find the centre of the maze in order to win the doing so knocked over the standing animals. prize of the right to live in the 'beautiful land' of Bemused, Elaine noticed Karen's non-verbal the imagined kingdom beyond the castle communication and the play stopped once grounds. again. The second session started with more difficul- Elaine and Karen continued to struggle with ty however with Karen and Elaine arriving late. deciding who should lead the play for some Still angry, Elaine explained they had just had a time. In an attempt to persuade her mother to row because despite having been involved in take the lead Karen stated she felt her ideas were choosing the time of the appointment, Karen inferior to Elaine's but Elaine failed to respond was concerned about missing school and had to this statement, one which had seemed to the not wanted to attend. Given the time lost and therapist to reveal both Karen's low opinion of the angry feelings that clearly remained Elaine herself and her admiration of her mother's cre- and Karen were asked if they still wanted to go ativity. The therapist again considered inter- ahead with session as planned. Elaine decided rupting the play in order to reflect upon what that having battled to get to the session they she thought was a significant statement but should make use of the time and undertake fur- decided against this so that the storytellers ther sandplay; Karen cautiously agreed with her would continue with their struggle to negotiate mother's decision. and develop the play. Eventually, Elaine and There was a tense atmosphere as Karen walked Karen agreed a farm would be built and as over to the sandtray and asked her mother what Elaine added classrooms the farm became a she wanted to do. Although calmer, Elaine's 'farm school'; the tension in the room seemed to anger was still evident and she insisted Karen reduce and the play began to move forward. choose what they should do; they struggled with As Elaine became engaged in the play she start- this for a while, volleying back and forth defen- ed to add structure and give instructions to sive comments. Karen tried to engage her Karen which she eagerly followed. In turn mother's attention by identifying figures that Karen began to offer ideas which were support- could be used in the play but Elaine was unre- ed by her mother's responses and gradually sponsive and sat watching her daughter from started to take the lead herself in developing the her chair. Karen began nervously 'singing' to story. Karen decided that the farm school was a herself as she placed a few trees and walls in the place where animals learnt to behave like other sandtray. animals and then this evolved into a school In the hope that the players would find a way where animals learnt "to behave" (i.e. to behave to resolve the impasse they had reached the ther- better). Karen nominated the King and Queen apist decided to maintain her role as observer figures as "Masters" who were to reside on a hill rather attempt to mediate and therefore rescue over looking the school. Karen from the tension of the situation. Now more settled into the play Karen nomi- Eventually Karen suggested that they should nated herself to 'be the horses' and her mother 11 D. HUTTON 'the pigs'. Karen decided that when the animals the experience of doing the sandtray in the hope had 'learnt to behave' they should be allowed to of sharing some of her observations. Elaine's go out of the school and created a forest for only comment was that everyone was out of the them at one end of the sandtray as a place where school but Karen was quick to point out that the they were "free to go wild and everything". lone black horse was still there. Karen contin- Karen giggled as her mother made a mud bath ued with the play alone, caring for the horse by for the pigs to wallow in as their reward for good giving him some flowers to eat and 'tucking him behaviour. up' under a blanket of sand. Karen and Elaine then 'played out' their story. When asked how she had found the session Elaine introduced teachers and parent animals Elaine was unforthcoming. The therapist into the story, the teachers taking an authoritar- noticed how Karen continued to play quietly ian role in deciding which pupils had been good with the lone black horse in the sandtray and enough to be allowed home for the weekend; staying within the story's metaphor reflected the parents were to arrive on Friday to collect that perhaps Karen was unhappy about the horse their successful offspring. Karen assumed the being on his own and wondered whether she role of teacher to the horses and identified one wanted a different end to the story. Visibly of her pupils as having been naughty all week. relieved by the offer Karen immediately intro- In role, Karen asked Elaine, as teacher to the duced into the sandtray a new brown horse, pigs, if she would stay in school over the week- identifying him as the younger brother of the end in order to look after the horse pupil who black horse. Karen continued the story by con- would not be going home. Wanting the week- cluding the little brown horse wanted his broth- end off herself Elaine declined. Not wanting er to be allowed out of the school for the week- her pupil to stay at school on his own Karen end and making him ask the Masters if they sought advice from the Masters to see if they would release him. Watching, Elaine recognised would look out for him; Karen narrated the a family dynamic portrayed by Karen's extension Masters also decline her request on the basis that of the story and looking directly at Karen com- the pupil had not been good enough and besides mented, with a hint of sarcasm in her tone, "the which, they "hated" him. older one is always the scared one and the Karen lowered her voice and appeared deeply younger one is always the braver one". Non ver- emotionally involved in the play. Elaine sat qui- bally Karen's gave the impression of having etly by the side of the sandtray out of the play as understood her mother's meaning but she said her character in the story had gone to the pub nothing as she played on, granting the little with the Masters for a drink on his way home. horse his wish and making the two brothers gal- As the session neared it's end Karen still had the lop happily off into the forest. Once the black unresolved problem of the "bad" black horse horse was freed Karen seemed to relax and con- staying alone in the classroom over the weekend. firmed the story was finished. When the therapist gave Karen notice that the session was almost finished and she immediate- Discussion: Using a non directive approach ly and abruptly ended the play. meant that as an observer of the play the thera- Even though Karen had confirmed she was fin- pist did not make verbal comments which could ished she looked tense and restless, fiddling with have interrupted the flow of Elaine and Karen's the loose sand around the edges of the sandtray. interactions nor intervene to help resolve or As was the usual format to the sessions the ther- address their difficulties. With hindsight the apist tried to initiate a reflective discussion on therapist could have made more use of empath- STORYTELLING 12 ic reflections during the play in order to bring to school where animals had to 'learn to behave' Elaine and Karen a conscious awareness of the Karen introduced the idea of a feelings underlying their behaviour and verbal punishment/reward system into the story which statements, although it could be argued that this was reminiscent of the behavioural strategies she too would have affected the course of their herself had experienced earlier on in the inter- interactions and the storytelling process. vention. Equally Elaine introduced to the story It is usual within non directive play therapy for the adult roles of teacher and parent, reflective the therapist to provide children with a time of the roles she fulfils in responding to Karen's warning towards the end of a session so as to oppositional behaviour. The story's metaphor help them prepare themselves for the conclusion seemed to perfectly mirror their daily 'real life' of their play (Ryan and Wilson 1996). In the struggles. session described Karen chose to end her play as The spontaneously co created story also soon the end of the session being near was men- allowed for the first time representation of wider tioned. Whilst the therapist accepted Karen's family dynamics. Karen was able to represent decision to end she was sufficiently attuned to through the story's metaphor a 'good /bad split' her emotional state to recognise her unease at between the animals at the school who were the story concluding with the black horse alone 'good enough' to go home and also between sib- in the classroom and what this may have repre- lings, the 'good' little brown horse succeeding sented symbolically for her in terms of feelings where the 'bad' black horse had failed. Karen of rejection and isolation. Unlike with the chose the role of as the black horse for herself Mutual Storytelling Technique (Gardner 1971) and in so doing experienced the feelings associ- the therapist did not offer Karen an alternative ated with failing to be either good enough to be ending to her story but rather allowed for her to allowed home or to be as good as her sibling. create for herself her own alternative ending, to It became apparent from her comment towards find her own solution to her problem, a key the end of the session that Elaine recognised for concept of client centred practice (Axline 1969; herself the link (or the 'fit', Bettleheim 1976) Dorfman 1951). between the ending of Karen's story and her Like the individual session previously described 'real life' sibling relationship; she did not need this example of a shared play session illustrates the therapists interpretation in order to become how current emotional difficulties are presented conscious of this. As co author of the story in the playroom and affect the course of therapy Elaine had within her power the opportunity to thereafter. Initially Elaine appeared to be a address Karen's feelings of not being 'good resistant playmate, perhaps because of her resid- enough' but did not do so despite Karen's ual angry feelings from the conflict before the expressed wishes. It appeared therefore that in session. Once Elaine had become engaged in this instance Elaine's lack of affectional attune- the process of setting up the sandtray however a ment (Stern 1985) with respect to Karen was co constructed story evolved which seemed to portrayed both symbolically through the story allow each player an expression of their difficul- and observably through her behaviour within ties both currently and more generally. In the session. choosing a school as the landscape for their story both Karen and Elaine unconsciously created a Conclusion: By the end of the series of joint ses- context in which they could address some of the sions, all of which followed this style of story- dynamics which had lead to the argument telling, Karen and Elaine's shared play became which preceded their session. By creating a observably more collaborative, trusting and 13 D. HUTTON pleasurable to them both. At the end of each that the process of storytelling itself has thera- session there were further opportunities to peutic value for the storyteller even without the reflect upon Karen's emotional needs within the symbolic meaning of the stories being made con- story telling process and these discussions scious through the use of interpretative reflec- seemed to facilitate changes in their shared play tions by the therapist. and the level of emotional attunement they Most often in the course of play therapy the lis- achieved. The spontaneously co-created story- tener to a child's story is the therapist. The ben- telling process had allowed for both Karen and efits of storytelling in terms of helping form Elaine to tell the tale of their relationship in an trusting collaborative relationships between a externalised form, through the metaphor of a child and therapist is well documented (Brooks story. The complexity of their attachment style, 1985; Cattanach 1997; Carlson and Arthur the ambivalence of Elaine as a new player and 1999; Carlson and Sperry 1998; Gardner 1971; the emotional defensiveness of both players Gersie and King 1990). In the case example dis- required a non directive approach to story- cussed in this article however substituting the telling, one which would allow them to set the child's mother in place of the therapist as play pace and find their own way to tell their story. mate to the child meant that it was the moth- At the follow up appointment with Elaine, one er/daughter relationship which benefited most month after the joint sessions had ended, she from the process of shared or co constructed sto- reported that after a brief period of improve- rytelling. ment conflict had returned to the household Currently, the two main models for working and once again Karen's behaviour was deemed with carers and children to effect change in the it's source. Elaine asked for Karen to have some levels of attunement within their relationships more individual sessions, convinced there was are Filial Therapy (Guerney 1983b; Vanfleet still 'something wrong with her'. Karen's story 1994; 2000) which is based on child centred or is therefore not one which ends with a 'happy non directive play therapy principles and ever after'. Howe et al (1999) notes how fre- Theraplay (Hughes 1997; Jernberg & Booth quently children and parents with insecure dis- 1999) a structured intervention which involves organised attachment relationships seek the help the therapist teaching the carer how to respond of professionals and yet how difficult it is to to/play with their child. The methods described affect long lasting change in their attachment in Family Play Therapy (Schaefer & Carey behaviour patterns. 1994) encourage carers to join in with their chil- dren's play and have the therapists facilitate this Conclusion process in roles that vary in their degree of direc- tiveness. The case example described here can be Karen's story was selected as a case example to considered as a type of family play therapy as illustrate how spontaneous storytelling can arise unlike with the practice of filial therapy, the and be worked with in non directive play thera- mother, Elaine, was not trained in core non py. For highly defended, anxious but imagina- directive play therapy skills prior to the joint ses- tive children such as Karen the telling of stories sions but rather given the opportunity for free in a mode of their choosing, be it verbally or play with her daughter under the supervision of through sandplay, role play or puppetry, can a therapist using a non directive approach. bring about relief from the indirect expression The use of storytelling within non directive or externalisation (Freeman et al 1997; Wilson play therapy presents children with the unique et al 1992) of their feelings. The author argues opportunity to express themselves freely without STORYTELLING 14 the therapist aiming to alter, correct or add to Psychotherapy, 34, 3, 414-425. the development of the stories they create. Daigneault, S D (1999) Narrative Means to Adlerian Further more the inclusion of family members Ends: An Illustrated Comparison of Narrative within play therapy suggests a direction for the Therapy and Adlerian Play Therapy. The Journal of future use of storytelling as a therapeutic tool, a Individual Psychology, 55, (3) 298-315. Dorfman, E (1951) Play Therapy. Chapter 6 in process which can both benefit the individual as Rogers, C (Ed) Client-Centered Therapy, London; a means of metaphorical communication whilst Constable. simultaneously developing the relationship Dwivedi, K, N (1997) The Therapeutic Use of Stories. between the teller and the listener. London: Routledge. Freeman, J, Epston, D and Lobovits, D (1997) Playful References Approaches to Serious Problems: Narrative Therapy with Children and Their Problems. New York: W W Norton & Company. Axline, V (1969) Play Therapy. New York: Ballentine. 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HUTTON Jennings, S (1999) Introduction to Developmental Rogers, C (1961) On Becoming a Person. London, Playtherapy. London: Jessica Kingsley. Houghton Mifflin. Jernberg, A. M & Booth, P. B (1999) Theraplay; Rogers (1989) A Client-centered/Person-centered Helping Parents and Children Build Better Approach to Therapy. Chapter 10 in Kischenbaum, Relationships Through Attachment-Based Play. Second H & Henderson, V. L (Eds.) The Carl Rogers Reader, Edition. San Francisco Jossey-Bass. London, Constable. Kestenbaum, C. J. (1985) The Creative Process in Ryan, V (1999) Developmental Delay, Symbolic Play Child Psychotherapy. American Journal of and Non Directive Play Therapy. Clinical Child Psychotherapy, Vol 39, No.4, 479- 489. Psychology and Psychiatry, 4, 2, 167-185. Kottman, T and Stiles (1990) Mutual Storytelling Ryan, V and K, Wilson (1995) Non Directive Play Technique; An Adlerian Application in Child Therapy as a means of recreating Optimal Infant Therapy. Journal of Individual Psychology, 46, 2, 42- Socialisation Patterns. Early Development and 51. Parenting, Vol. 4 (1) 29-38 (1995). Lahad, M (1992) 'Story-making in assessment Ryan, V and Wilson, K (1996) Case Studies in Non method for coping with stress' In Sue Jennings (Ed.) Directive Play Therapy. London: Jessica Kingsley. Dramatherapy Theory and practice 2, 150-163, Schaefer, C, E & Carey, L, J (1994) Family Play London, Routledge. Therapy. London, Jason Aronson. Lewis, P & Kavanagh, C (1995) Play as Dialogue; Schlozman, S C (2000) Vampires and Those Who Giving Voice to the Child in Family Therapy. Slay Them: Using the Television Programme 'Buffy Journal of Systemic Consultation & Management, Vol the Vampire Slayer' in Adolescent Therapy and 6, 227-239. Psychodynamic Education. Academic Psychiatry, 24, Lowenfeld, M (1935,1991) Play In Childhood. I, Spring. Oxford: Mac Keith Press. Stern, D (1985) The Interpersonal World of the Infant. 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New Therapy: A Non Directive Approach for Children and York; Gestalt Journal Press. Adolescents. London: Bailliere Tindall. O’Toole, D. (2002) Storytelling with Bereaved Wilson, K & Ryan, V (2001) Helping Parents by Children. Chapter 14 in Boyd Webb, N(Ed.) Working with their Children in Individual Child Helping Bereaved Children: A Handbook for Therapy. Child and Family Social Work, 6, 209-217. Practitioners (Second Edition. New York: Guildford White, M (1988) The Externalising of the Problem Press. and the Re Authoring of Lives and Relationships. Parkinson, R (2001) Ely, Enoch, the Fisherman and Dulwich Centre Newsletter, Summer 1988/89, 3-21. the Genie (2001). Context, 55, June, 2-4. White, M and Epston, D (1990) Narrative Means to Pettle, S (2001) Smaller than an Ants leg and the Therapeutic Ends. New York: W. W. Norton & Most Amazing Tummy Ache. Context, 57, October. Company. 13-14 Whitehead, T (2001) Discovering the Magic of Robinson, J. G (1986) Fairy Tales and Teaching Stories. Professional Social Work, August, 16-17. Family Therapy. Journal of Family Therapy, 8, 4, 383-393. Bri. J. Play Therapy, Vol. 1, No. 1, pp. 16 - 25, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. Play Therapy with Looked After Children: An Attachment Perspective Katrina Robson and Alison Tooby NSPCC South Cumbria Team, Cumbria, England The authors consider the use of play therapy interventions with looked after children within a framework of attachment theory. The point is made that children who are looked after have frequently experienced multiple traumas and abuse which has result- ed in separation from birth families and subsequently changes in significant attach- ment figures. Attachment theory is applied to the carer/child dyad and the thera- pist/child relationship and implications for practice are considered. This article emphasises that therapeutic responses to looked after children need to reflect the com- plexities of children's lives. The importance of involving carers in the play therapy intervention is discussed and the concept of a continuum is suggested. The authors consider the importance of ensuring any changes within play therapy are recognised and responded to within the child's attachment relationships at home. An acknowl- edgement of the dilemmas and challenges for play therapists is given and the value of involving carers is highlighted. As two play therapists working in an NSPCC Rothschild (2000) distinguishes between chil- therapeutic team, largely with children who are dren who already have the internal resources to looked after, we have become increasingly aware work directly with a traumatic event and those of the inherent complexities and dilemmas children who need help to build resources and which this work presents. The children with resilience through the therapeutic relationship. whom we work have often experienced multiple Many of the children with whom we work have traumas and abuse, which has resulted in sepa- attachment difficulties as a result of early ration from birth families and subsequently abuse/neglect often at the hands of a caregiver. changes in significant attachment figures. Thus their trust has been broken by someone We recognise that a play therapy intervention upon whom they also depend. In terms of any with these children therefore may not be as clear therapeutic relationship this means they require as with children who have experienced a more a therapist who can remain trusting and secure secure attachment. It is more likely then that the in themselves whilst working with strong feel- work will be longer term and will involve help- ings aroused through the transference relation- ing the child to begin to develop basic trust in ship and whilst also remaining aware of the the therapist in order to provide them with a power they hold in this relationship. As secure base from which to explore traumatic Casement (1985) highlights we need to be our experiences. Children who have more secure own "internal supervisor", constantly evaluating attachments already have this secure base in our own practice and reactions. place and can use this to explore and resolve Our knowledge of the child protection system feelings relating to trauma. and the impact of child abuse and trauma has been fundamental in informing our practice, Correspondence to: Katrina Robson, NSPCC South enabling us to understand and pick up on issues Cumbria Team, Dallington, Walney Road, Barrow- and themes within the work and feed back into in-Furness, Cumbria, England, LA14 5UT. the system when necessary. Respecting children's

16 17 K. ROBSON and A. TOOBY strategies or coping mechanisms is critical and it affected by experiences such as loss or abuse, tak- is clear that if a child's placement is in a state of ing into account age and consequent stage of crisis then that child's energies will be going into development. We believe that an awareness of simply coping. In these circumstances play ther- basic child development such as Erikson's apy is not appropriate and should not be under- (1995) stages provides a useful guide which we taken. Rothschild (2000) states that therapists can use as a way of comparing or measuring should "Regard defenses as resources". Similarly where a particular child should be on the con- Bannister (2003) highlights that it is only when tinuum of child development. Having the these strategies are not needed or have become opportunity to work with more securely limiting that therapy should be considered. attached children during our play therapy train- We feel our work as experienced play therapists ing has been invaluable, providing insight and needs to reflect the complex issues in these chil- knowledge into the differences and presenting dren's lives by utilising an open minded an opportunity to experience how a secure child approach to other relevant theories and integrat- is able to use the therapeutic relationship to ing this into our practice. The different theoret- work through trauma. This has then actively ical perspectives provided by our respective play informed our assessments. therapy courses have given us an opportunity to Seeing child development as a continuum learn from each other and influence each others means we recognise that all children have to practice. Having a broad knowledge base, along- make many developmental transitions through- side an acknowledgement of the use of the self out childhood e.g. moving from the early stage in the therapeutic relationship allows us, as play of dependence or trust (Erikson 1995), to then therapists, to adapt our practice to the needs of using the parent/carer as a "secure base" (Bowlby particular children and be prepared at times to 1998:11) from which they can explore with con- not have any answers and to stay with and fidence, moving towards increased indepen- accept the child's feelings. dence and autonomy (Erikson 1995). Given that we are both committed to play ther- The formation of trust or a secure base is a cru- apy as a valuable intervention for looked after cial first step in enabling a child to learn, explore children this article will explore how play thera- and reach developmental milestones (Bowlby py can contribute towards meeting the complex 1966, Erikson 1995, George 1996). It therefore needs of looked after children. This will include goes without saying that children who do not some consideration of the current debate have this good beginning to their lives will con- regarding the appropriate method of treatment sequently have significant difficulties with later for children with attachment difficulties. developmental tasks, such as achieving a sense of Alongside this we will outline our understand- autonomy, self-reliance, confidence and the abil- ing of the play therapy approach and the appli- ity to make and sustain relationships outside of cation of attachment theory to our practice. the family (Archer 2003, Crittenden 1992, 1997d, Groze 1992, Hughes 1999). A Starting Point Our goal then in play therapy is to assist a child in approximating patterns of thinking which Our view is that having an understanding of typify the securely attached child so that he or basic child development is crucial in all of our she can begin to move along the appropriate work, enabling ourselves as play therapists to developmental trajectory. Our understanding of assess how individual children may have been child development is also then a much needed useful tool in evaluating change throughout the PLAY THERAPY WITH LOOKED AFTER CHILDREN 18 course of the work. central difficulties. Holding or other more intru- There has been a growth of interest in attach- sive methods are advocated as an alternative. ment over recent years and the work of Bowlby Keys Childcare Consultancy (1998:7) explain (1966, 1998) and Ainsworth (1978) has been their view: developed by many, including theorists with a neurological background such as Schore (2001) "Since most of these children have been in tra- and Glaser (2000). Much more is now known ditional talk or play therapy for years with a about the link between brain development, variety of therapists, they often view holding as attachment and subsequent developmental tasks a new challenge. They think it might turn out e.g. self regulation. For example it is now to be more fun than playing cards for another two years". accepted that the routine interactions between a secure caregiver/infant dyad result in neurones A further issue for us is the emphasis in much of within the brain connecting and thriving. As the this literature upon the child rather than the relationship progresses from birth, the caregiver child within their unique system and family. has the task of regulating their babies affect, Crittenden's work looking at attachment pat- enabling them to remain in an alert, relaxed terns throughout the life cycle has been a major state for increasingly longer periods of time until influence for us (Robson 2001), highlighting the they eventually become able to do this for them- complexities involved in treating children within selves. In terms of play therapy, the learning this substitute families and emphasising the dyadic provides with regard to the attachment relation- nature of the attachment relationship and the ship can also be seen to apply to the therapeutic influence of wider systems and issues. relationship. The play therapist/child relation- ship relies on the ability of the play therapist to Play Therapy and Looked attune to the child in the same way as a carer in After Children early childhood and the play therapist then per- haps providing some of the same functions e.g. One of the key questions for us then is whether facilitating the development of self regulation. changes seen in individual play therapy can suc- Programmes such as Brain Gym (2002) are cessfully be transferred into the child's signifi- being developed and used with children who cant attachment relationships and become part have difficulties self regulating, linking learning, of the "dance" (Sroufe & Erikson 2002:4) movement and child development. between child and carer. Thus the small changes There is currently some debate about whether in the child's pattern of behaviour initially seen play therapy with children with attachment dif- in the playroom, are then recognised by the carer ficulties is an appropriate intervention and there at home and influence the responses they give. are many who question it. Having read a wealth These are then catalysts for change within the of literature relating to this subject we are aware dyad, beginning a process which flourishes as that it may be a much more complicated issue confidence grows that things can be different. than it would seem. Firstly it is not always clear A single case study was used to explore this how many of these writers understand play ther- question as part of Katrina's MA at York apy and many seem to make an assumption that University (Robson 2001). The findings indicat- play therapist's are easily "seduced" by children ed that in this particular case the child's carers and that rather than challenging the child they were sufficiently sensitive/attuned to their child, are lulled into repetitive play which avoids the that they were able to recognise and respond to 19 K. ROBSON and A. TOOBY the changes the child made through the play ment process (Stern, 1985) which occurs therapy intervention. The therapeutic alliance between infant and carer and which forms the between play therapist and carers proved to be basis of trust and self regulation. Thus we believe vital, reflecting the child's ultimate need to that play therapy can adapt to the individual attach more securely to her carers as a primary child and provide an environment which both aim of the work. Donaldson (2003) emphasises the avoidant and the preoccupied child can this eloquently, making the point that whilst make use of, the play therapist having the task of confidentiality is important it is also essential remaining sensitive and attuned to that particu- that carers feel included rather than excluded. lar child in the same way as a carer with their The notion that the child applies his or her unique infant. internal working model to other relationships The therapeutic relationship, utilising the use (Bowlby, cited in Pearce & Pezzot-Pearce 1997) of symbolic play and play as communication, means that the abused or neglected child will provides the opportunity for the reworking and often have a negative view of the self and of oth- mastery of previous experiences (Frazier & ers and will consequently have developed not Levine 1983, Pearce & Pezzott-Pearce 1997, only a tendency to interpret the actions of oth- Wilson & Ryan 1994). The availability and sen- ers as hostile but also a pattern of increasingly sitivity of the therapist thus provides a safe base sophisticated behaviours designed to get needs for the child and a different experience in terms met and cope with overwhelming experiences of accepting and trying to understand the child's and feelings. Likely behaviours include avoid- behaviours rather than rejecting them or getting ance, ambivalence, compulsive compliance, caught up in the day to day impact of caring for helplessness and preoccupation with others such a child. (Crittenden 1992, George 1996, Howe 1999, Play and symbolism become a way of expressing Howe & Fearnley 1999). feelings and perceptions of the world, self and In terms of child therapy then this means that others and this is worked with in such a way that the child, as with other important relationships, the experience of being responded to differently is highly likely to repeat these patterns with a and developing insight and awareness means the therapist much in the same way as an adult in child is then able to take the risk to try out new psychotherapy (Holmes 1993, Heard & Lake behaviours and ways of being (Wilson et al 1997). Pearce and Pezzot-Pearce (1994:428) 1992). Thus therapy is a co-constructed process, highlight "This notion of the child's tendency to the child and the therapist working together impose an earlier model of relationships upon a towards meaningful change (Cattanach 1992). therapist is consistent with Freud's conceptuali- sation of the psychoanalytic phenomenon of Meeting the need:How Can transference". The therapist then works with Attachment Theory Help? what happens between herself and the child in the playroom, accepting the child as they are, Being aware of the dyadic nature of attachment empathising and reflecting back important feel- relationships and the influences of wider systems ings and using her own congruent feelings to and issues is central to the assessment process enable the child to begin to have some insight which informs any treatment plan. Ryan and into their own behaviour and also experience Wilson (1995) highlight the similarities between something different through the therapeutic the role of the play therapist and that of the pri- relationship (Wilson et al 1992). As previously mary carer putting forward the view that play highlighted this is very similar to the attune- PLAY THERAPY WITH LOOKED AFTER CHILDREN 20 therapy provides an experience of attunement approach is in fact a coercive one which means it and sensitivity which echo's the early infant - is not comparable to the early holding which mother relationship and socialisation process. occurs as part of a reciprocal loving relationship An awareness of the dyadic nature of the thera- between carer and infant. Eminent attachment peutic relationship is also fundamental. theorists such as Crittenden (2002) and Crittenden (2002:3) highlights the similarities Erickson (2002) make the link between parental between the parent - child relationship and the sensitivity and secure attachment, Erickson link- therapist - client relationship, stating that thera- ing this also to treatment of children with attach- py "carries the potential for both a corrective ment difficulties. process that could free clients from the misper- "Everything I've learned about attach- ception of threat and also a distorting process ment indicates that sensitivity is the path- that could exacerbate the problems of clients". way to a secure attachment, so I'm uneasy about approaches that are intrusive" She discusses how children will mold themselves (Sroufe & Erickson 2002:5). to fit the therapist in the same way as with a We would subscribe to this view and whilst we carer, and notes to function effectively during accept that there are issues particular to children an attached persons process of change, both par- with attachment difficulties we would advocate ents and psychotherapists need self awareness, that it is possible as a play therapist to intervene confidence with the process of personal change, effectively, keeping in mind both the child and and willingness to continue this process in carer as a dyad. themselves. This is particularly pertinent when As we know from our experiences there are no working with children who have severe attach- short routes and no absolutes. Often a combina- ment difficulties, the danger of acting on strong tion approach is needed, the play therapist hav- feelings evoked through the transference, poten- ing a central role in really hearing and under- tially leading to the therapist unintentionally standing the child's world and influencing the colluding with the child thus isolating the carer. systems working together to support the child. This point about carers feeling isolated or Partnership with carers and other agencies is par- blamed has been raised within the current ticularly beneficial for children who have attach- debate which challenges whether play therapy ment difficulties and need consistent responses should be used individually with children whose from adults around them. When children, as early experiences have led to the development of infants have missed out on the day to day, insecure attachment patterns. Theories have minute to minute repeated routine interactions been put forward which suggest that interven- with a sensitive carer, then as they become older tions should be adult led, always include carers and are increasingly subjected to outside influ- (Hart &Thomas 2000, Howe & Fearnley, ences the task of replicating this process becomes 1999, Hughes 1997, 1999; James 1994) and more difficult. The child is therefore more likely focus specifically on certain areas of develop- to require a team of adults around them who are ment e.g. shame (Hughes 1997). Holding is all working consistently together to support advocated as a form of appropriate treatment for them e.g. schoolteacher, social worker, fostercar- these children, the argument being made that er/adoptive parent, play therapist. "Holding therapy replicates the early nurturing Furthermore if the aim of the work is to enable care and security these children have missed" a child to develop a more secure attachment pat- (Wertheimer 2002:2). tern with their carer then we need to think about We would put forward the view that this the specific dyad and plan how best to include 21 K. ROBSON and A. TOOBY the carers in the work. When a child has a carer ence and working with the child's communica- who is able to be sensitive and attuned enough tion and symbolism presented through the play, to recognise small changes and also be secure in the presence of the carer, thus providing a safe enough in themselves to trust and work in part- base for both carer and child. Additionally nership with the play therapist then individual enabling the carer to develop understanding of play therapy may be an appropriate interven- and insight into the child's emotional world and tion. We therefore recognise the importance of consequently increase sensitivity and ability to the play therapist paying attention to the carers recognise and respond to the signals given by the ability to be emotionally available to their child child. Crane (in Landreth 2001:93) refers to as part of a holistic assessment. Adopters and conjoint sessions where " both the parents and fostercarers of older children have missed out on the child are changing at the same time and the creation of a dyadic attachment pattern and therefore, a new equilibrium is reached". Child may therefore need to work very hard to attune and carer are enabled to risk trying out different to their particular children. Crane (in Landreth ways of relating to each other, perhaps also revis- 2001) discusses the value of observing parent iting the child's earlier stages of development and child playing together as part of the thera- which have been impeded and enabling them to peutic assessment. have an alternative, more satisfactory experience. The carers attachment pattern will also influ- As these small mutually satisfying interactions ence how they respond to their particular child's develop and increase, they form a foundation attachment behaviours and therefore the rela- which can be built upon, increasing trust and tionship which they co-construct. Hart & confidence and thus becoming part of the rela- Thomas (2000:321) suggest that "…as the chil- tionship. Also then echoing the attachment pat- dren become more enmeshed in a relationship tern which develops in that of a secure with the adoptive parents, the adoptive parents carer/infant dyad. As the child experiences more become more embedded in the production of sensitive responses this may in turn lead to a their feelings and behaviour". We believe it is more balanced and less distorted internal work- the combination of these two factors which ing model. mean that as time goes on some carers may The debate regarding children with attachment understandably become increasingly worn out difficulties highlights the dilemma when individ- and experience a sense of hopelessness. ual play therapy does not produce change in rela- Additionally there may be some carers who have tionships at home. Sometimes, it seems to us unresolved issues resulting from their own that raising the possibility that some of the diffi- childhood which have a direct impact upon culties may lie with the adult caregiver as part of their behaviour as an attachment figure to their the dyad, is frowned upon or seen as blaming. child. This poses the question of how the play Whilst it is apparent that many of the children therapist can use her/his skills to influence not with whom we work do indeed have attachment only the child's attachment behaviours but also difficulties is it not more helpful to both adult the carer responses and the dyadic relationship. and child to take a more complex and open The concept of working with the child and pri- minded view about both the carer and child's mary carer together, having the carer present in behaviours as a unique dyad? Is it not more help- the playroom may need to be considered. The ful to be non-judgmental and yet congruent play therapist then utilises the core skills to pro- enough in our relationships with carers to help vide unconditional regard/acceptance, empathy them to recognise when there are issues which and genuiness, reflecting feelings, using congru- they can take responsibility for and empower PLAY THERAPY WITH LOOKED AFTER CHILDREN 22 them to do something about it? Crittenden parent/infant attachment relationship. Filial (2002) discussed the fact that a child who has play therapy can be adapted to individual family been sexually abused will often raise the issue circumstances and socio-economic backgrounds, that they feel responsible for the abuse and the having wide cross-cultural applicability, includ- professionals response is then often to dismiss ing where there are attachment difficulties. In this too quickly in order to make the child (and order to undertake filial play sessions themselves) feel better. In reality however there parents/carers need to have the ability to be may well be aspects of the child's behaviour emotionally available to their child for at least a which may have increased their vulnerability. short period of time (Vanfleet 1994). Where She makes the point that the child themselves is carers are unable to do this another approach already aware of this and needs the professional may need to be considered and thought given to to help them identify those aspects thus provid- identifying support for the carer to help them to ing an opportunity for them to take back some regain enough emotional energy to help their power and control over their lives. Thus in this child. Berlin (2002) discusses the advantages of example there is no element of blame but rather “tripartite psychotherapy” in older children an honest exploration of the complexity of the when the projection of the mother's own unre- situation. We would put forward the view that solved issues is contributing to the child's symp- this same non-judgmental, holistic approach toms. Similarly Crane (in Landreth 2001:92) can be used with adoptive/fostercarers, helping highlights "sometimes parents may have person- them to explore the unique dynamics of their al problems that interfere with their ability to relationship. interact appropriately with their child. Support Our work as play therapists involves respecting for the carers such as individual/couple coun- and unconditionally accepting both the carer selling may need to be considered as part of a and the child, using congruence to inform package of work and provided by another thera- empathic reflections. Our view is that children pist. deserve this right in the same way as adults and we would therefore disagree with the argument Conclusion that more intrusive approaches including hold- ing therapy should be employed. Children in We are aware that we have not discussed in any our society are often relatively powerless and depth the more directive interventions with this is compounded for children who are in care carer and child recommended by others and who often feel they have no control over (Fearnley & Howe 1999, Hughes 1997, 1999, what happens to them. James 1994). Although this is an interesting One way of helping carers to attune to their debate it is beyond the scope of this article where child is through using filial play therapy (Van our focus has been on working with children Fleet1994). This technique is well researched with attachment difficulties utilising play thera- and involves the play therapist training and sup- py as a core intervention. Our view is that many porting the carer so that it is they who under- of these professionals raise important questions take therapeutic play sessions with the child. which we as play therapists can learn from and Carers learn how to listen empathically, convey perhaps integrate into our work at an appropri- the use of reassuring limits and focus on their ate time. Occasionally the focus of our work child's feelings and actions. Much of the focus is may need to shift to adapt to circumstances, upon the carer being emotionally available and reflecting the needs of the unique dyad at that attuned to their child, thus reflecting the early particular point in time. 23 K. ROBSON and A. TOOBY In writing this article our aim has been to high- relationships with children. Acknowledging the light that the therapeutic responses to children dyadic nature of attachment when working with who are looked after need to reflect the com- children who are looked after requires a shift in plexities of their lives. Our experience has been thinking. There is a continuum of involvement that in working with these children we need to which may mean, for example in one situation make efforts to influence and work as part of the undertaking individual play therapy with a child team supporting the child so that the play ther- involving planned progress/feedback meetings apy intervention is recognised and incorporated with carers or, at the other end of the scale work- into the overall planning. ing directly with the child and carer together in the playroom. However working in this way can be particular- As play therapists we therefore remain very ly demanding and sometimes fraught with ten- committed to play therapy as a method of work- sions, presenting many challenges for us as play ing with children who are looked after. therapists. The impact of working with chil- We are aware that we have made many points dren who are looked after and who have experi- which could usefully have been expanded upon. enced trauma and abuse needs to be considered The scope of this article has not allowed us to do at the point of allocation, taking into account this but we hope that raising these points will that play therapists undertaking this work need add to the ongoing debate. experience, skills, knowledge plus the support of We have put forward the view that we need to good supervision, to ensure that feelings are remain open minded to other approaches which contained, rather than responded to/acted upon may enhance our practice but we believe that we too quickly. It is vital that play therapists work- can do this whilst also remaining confident in ing with looked after children are supported, our trust in play therapy and in ourselves as have a safe supervision space where their own change agents. The use of ourselves in the thera- feelings and responses can be explored and peutic relationship can be extremely difficult and where issues can be identified which need to be challenging at times whilst also being a very taken to personal therapy. If this is not provid- powerful tool and we can use an attachment ed then we believe that there is the potential for framework to help us to make sense of the ther- the therapist to become overwhelmed and for apeutic relationship and to understand and this to be played out either within the actual influence the child's relationship with carers. play therapy or the professional network. Our view is therefore that acknowledging the We need to recognise that children with attach- dyadic nature of relationships is key and this can ment difficulties can present superficially within be achieved in ways which are accepting and the relationship with the therapist and that non-judgmental of both child and caregiver. developing a therapeutic alliance with carers is Play therapists can then work in genuine part- essential. The carers role is critical to these chil- nership with carers and children, using their dren and our view is that we need to acknowl- skills to adapt to the needs of the dyad within the edge that adults as well as children bring their system at that point in time. own patterns of attachment influenced by their “Including parents in the play therapy process own experiences and this is reflected in the can be exciting since both the parents and the "dance" (Sroufe & Erikson 2002:4) between children benefit. Involving parents does carer and child. As play therapists we also need require extra effort, but the positive results to be mindful of this issue in our professional make it all worthwhile” (Crane in Landreth, 2001:94). PLAY THERAPY WITH LOOKED AFTER CHILDREN 24 References Vol 23, 2, 19-30. Frazier, D. & Levine, E. (1983) Reattachment Ainsworth, M. D. S, Blehar, M, Waters, E & Wall, S Therapy:Intervention with a very young physically (1978) Patterns of Attachment Hillsdale abused child. Psychotherapy: Theory, Research and NJ:Erlbaum. Practice, Vol 20 (1). Archer, C & Brunel, A (eds) Trauma, Attachment and George, C. (1996) A Representational Perspective of Family Permanence Fear Can Stop You Loving. Child Abuse and Prevention:Internal Working London: Jessica Kingsley. Models of Attachment and Caregiving. Child Abuse & Bannister, A (2003) NSPCC Therapeutic Neglect, Vol. 20 (5) 411-424. Conference Seminar Presentation Birmingham. Glaser, D. (2000) Child Abuse and Neglect and the Bee, H. (1995) The Growing Child. New York: Brain- A Review. Journal of Child Psychology and HarperCollins. Psychiatry, Vol 41, (1). Berlin, N. G. (2002) Parent-Child Therapy and Groze, V. (1992) Adoption, Attachment and Self- Maternal Projections:Tripartite Psychotherapy-A Concept. Child and Adolescent Social Work Journal, New Look. American Journal of Orthopsychiatry, Vol Vol 9(2). 72, 2, 204-216. Hart, A. & Thomas, H. (2000) Controversial attach- Bowlby, J. (1966) Child Care and the Growth of Love ments: the indirect treatment of fostered and adopted (2nd ed). Middlesex:Harmondsworth. children via Parent Co-Therapy. Attachment & Bowlby, J. (1988) A Secure Base:Clinical applications Human Development, Vol. 2 (3), 306-327. of attachment theory. London: Routledge. Heard, D & Lake, B. (1997) The Challenge of Casement, P. (1985) On Learning from the Patient. Attachment for Caregiving London: Routledge London:Tavistock Routledge. Holmes, J (1993) Attachment Theory: A Biological Cattanach, A. (1992) Play Therapy with Abused Basis for Psychotherapy. British Journal of Psychiatry, Children. London:Jessica Kingsley. Vol 163, 430-43. Crittenden, P. M. (1992b) "Treatment of anxious Howe, D, Brandon, M, Hinings, D & Scholfield, G. attachment in infancy and early childhood". (1999) Attachment Theory, Child Maltreatment and Development and Psychopathology, Vol 4, 575-602. Family Support:A Practice and Assessment Model. Crittenden, P. M. (1997d) "Truth, Error, Omission, London: Macmillan Press Ltd. Distortion and deception: The Application of Attachment Theory to the Assessment and Treatment Howe, D & Fearnley, S. (1999) Disorders of of Psychological Disorder" in Dollinger S M C & Attachment and Attachment Therapy. Adoption & Dilalla L F (eds) (1997) Assessment and Intervention Fostering, Vol. 23 (2). Across the Lifespan. Hillsdale NJ: Lawrence Erlbaum Hughes, D. A. (1997) Facilitating Developmental Associates. Attachment: The Road to Emotional Recovery and Crittenden, P. M. (2000) Molding Clay: The Process Behavioural Change in Foster and Adopted Children. of constructing the Self and Its Relation to USA: Jason Aronson Inc. Psychotherapy. Revista de Psicoterapia, Vol 41, 67-82, Hughes, D. A. (1999) Adopting Children with dedicated to Vittorio Guidano. Attachment Problems. Child Welfare, Vol. LXXVII, Crittenden, P. M. (2002) Attachment & (5), 541-561. Psychopathology. Seminar Presentation Kent. James, B. (1994) Handbook for Treatment of Donaldson, K. (2003) To Share or not to Share. Attachment-Trauma Problems in Children. New York: Newsletter of The British Association of Play Therapists. The Free Press. Issue 33 5-6. Landreth, G. (2001) Innovations in Play Therapy Educational Kinesiology (UK) Foundation (2002) Issues, Process and Special Populations. Sussex: Educational Kinesiology-Brain Gym Information Brunner-Routledge. Pack London. Pearce, J. W. & Pezzot-Pearce, T. D. (1994) Erikson, E. (1995) Childhood and Society. 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Sroufe, A. L. & Erickson, M. F. (2002) Attachment Theory and 'Attachment Therapy.' The APSAC Advisor, Fall, 4-5. Stern, D. (1985) The interpersonal World of the Infant. New York: Basic Books. Van Fleet, R. (1994) Filial Therapy: Strengthening Parent-Child relationships Through Play. USA: Professional Resource Press. Wertheimer, F. (2002) Healing Touch. The Guardian, 27.7.02. Wilson, K, Kendrick, P. & Ryan, V. (1992) Play Therapy:A Non-directive Approach for Children and Adolescents. London: Bailliere Tindall. Wilson, K. & Ryan, V. (1994) Working with the sex- ually abused child:the use of non-directive play ther- apy and family therapy. Journal of Social Work Practice, Vol. 8 (1). Bri. J. Play Therapy, Vol. 1, No. 1, pp. 26 - 34, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. Play Therapists and the Children's Rights Movement Jo Carroll Malborough, England Principles underpinning the Children's Rights movement, now enshrined in national and international laws, assume that many children are competent to provide opinions in matters which concern them, are able to be truthful when expressing those opin- ions, and may be empowered by joining decision-making processes even if the out- come challenges their own views. These principles have also been part of play thera- py theory for many years.

However, the application of Children's Rights principles is not straightforward. Drawing from a research project which studied children's opinions of play therapy, I illustrate the complexity of adhering to these principles; and propose that, while it is ethically sound to include children in decision-making whenever possible, some chil- dren may also welcome occasions when adults take responsibility for them. Introduction1 their opinions considered in all matters which concern them. Two years before signing the In this paper I shall review current political United Nations Convention on the Rights of the thinking and principles regarding the rights of Child (1983) the British Parliament placed a children, designed to ensure that children's commitment to taking account of children's views are taken into account when decisions are feelings by placing it first on the welfare check- made which concern them. I shall propose that list (Department of Health, 1989), thus placing play therapy theory and practice anticipated significantly greater emphasis on children's views these principles, and consider their application that in previous legislation. This has led to within the playroom and when supporting chil- active (if problematic) efforts to involve children dren in their efforts to relate in the external in decision-making (Thomas, 1998) and the world. I shall draw on current literature and on development of children's advocacy projects my own research (Carroll, 2002, 2003), to illus- (Boylan & Wyllie, 1999). trate complexities in this field. Social work has not been alone in responding to changes in social and political thought. Research Children's rights in education (McLaughlin et al, 1999), medicine (Focus, 1999); and divorce proceedings National and international laws embrace prin- (Marshall et al, 2002) demonstrate the move- ciples promoting the rights of children to have ment towards increased attention to children's views. However, in this discussion I shall con- centrate on children's involvement in child pro- tection and looked-after systems, as many who 1 Ideas developed in this paper were first explored in my doctoral thesis (Carroll, 2002). attend play therapy have such experiences. I shall use the generic term 'children' to include all Correspondence to: Dr Jo Carroll, 38 St Martins, young people; space also prohibits a discussion of Marlborough, England, SN8 1A. the specific difficulties facing black or disabled (Email: [email protected]) children (Russell, 1996; Thomas, 1999). 26 27 J. CARROLL In practice, involving children in the child pro- tions and opinions took precedence over their tection arena is problematic (Schofield & own. In a comparable study Thomas (1998) Thoburn, 1996). It raises three complex issues: found that older children (aged 10 and over) how can the competence of children to con- were more likely to be included in meetings, tribute to the decision-making process be with the views of other children communicated assessed? How honest are they? Is it possible to through social workers or carers. However, all balance the wishes of children with the respon- the children felt that their views should be taken sibility of adults to act in their best interests? into account, and some social workers struggled to represent the views of children if they The competence of children diverged from their own. In addition, in spite of directives to assume children's competence and The concept of competence has become provide them a platform, there are wide varia- embroiled in the 'Gillick principle' (Smith, tions in practice. 1996), established by the House of Lords in 1986, when it was agreed that a child under six- The honesty of children teen could receive medical treatment without parental consent if it could be shown that he or The concept of competence includes not only she was competent to make that decision. The an ability to understand and participate in dia- tenets of the Children Act (Department of logue; the veracity of children's testimony is also Health, 1989) actively gave children a, presum- questioned. Concern falls into two categories: ing their competence unless it can be shown that the possibility that they may lie, and their abili- they are unable to develop opinions of their ty to recall events accurately. own. Hall (1996) reviewed studies of children truth- However, in spite of this presumption, collec- telling in the research context, and found that tion of evidence in child protection is dominat- deliberate lying is rare. The issue is most perti- ed by adults, who dictate the areas of concern nent when children are questioned about abuse; and the nature of data being considered (Boylan research in this area has shown that, with mean- & Wyllie, 1999). The issue becomes critical ingful prompts, children's free recall of events is when Court processes are activated; although sound (Fundudis, 1998). However, children children have a right to separate representation with attachment difficulties or post-traumatic if it can be shown that they are able to instruct a symptoms may display evidence of conflictual solicitor and the Guardian ad Litem does not memory systems (Crittenden, 1995). adequately reflect their views, it remains an Questions of accuracy also raise epistemological adult decision to provide children with appro- issues: if a child's narrative differs from an priate information (Munro, 2001) and an adult adult's, it may simply represent an alternative responsibility to develop skills which enable perspective. It can be argued that, since opin- children to express themselves freely (Young & ions and fundamentally subjective, the construct King, 1989). of objective truth is irrelevant (Brandell, 1988). Planning for looked-after children is complex. Bell (2002) studied children's participation in Balancing the wishes of the child with child protection and looked-after systems: his or her best interests although social workers provided information, most children's comprehension of that informa- The promotion of children's participation in tion was poor and they felt that adult percep- PLAY THERAPISTS AND THE CHILDREN'S RIGHTS MOVEMENT 28 matters that actively concern them does not Oaklander (1969) proposed structured exercis- imply that their wishes are always granted. es to help children understand and express Adults retain the responsibility to ensure the themselves openly, stressing that interventions safety of the child, and to ensure his or her well- should be relevant and children consent freely to being. Yet the experience of the Children's joining with them. Moustakas (1973) stressed Society Advocacy Project indicates that when the value of reflection and empathy for chil- children, parents and social workers are able to dren's feelings, reinforcing the validity of each work together it is possible to reach solutions child's unique perspective. that are meaningful to the child, even if his or In 1983 Guerney explored notions of accep- her wishes are not met entirely (Boylan & tance and permissiveness in the playroom, giving Wyllie, 1999). The study also showed that such children space to be themselves and initiate participation is empowering for children, change when and if they choose. All views are enabling them to feel greater influence in the valid and can be thought about. There must be shaping of their own lives. limits, but these are meaningful and explored For decisions about children's welfare is rarely when necessary. In such a context children are as clear-cut as a juxtaposition of the child's wish- able to be honest with themselves and their ther- es and his or her welfare would suggest. Active apists, and their views of the world are accepted engagement with children may help them and understood. Allen (1982) developed the understand actions taken by adults, and to feel concept of integrity in the therapeutic relation- part of processes that may have significant reper- ship, in which children can be deeply themselves cussions in their own lives. When adults seek to and be accepted as they are. protect children from the consequences of More recently, Wilson et al. (1992) describe unfortunate choices and join with other profes- the value of congruence with children's feeling, sionals making decision for children but not and its role in helping to understand and vali- with them, opportunities may also be lost to date children's perceptions. Cattanach (1992) help children develop essential problem-solving explores children's relationship within the skills and feelings of self-efficacy. 'imaginary space' of story-telling and play, enabling children to distance themselves from Children's rights in the playroom the real world and express feelings safely. Thus issues of honesty, central to the context of chil- Principles embracing the competence of chil- dren's rights, have no relevance: subjective feel- dren, their fundamental honesty and a right to ings and real and valid, and drive children's view self-determination have been familiar to play of the external world. Once defused in play, it therapists since long before the Children Act. becomes possible to engage cognitive processes Axline (1969 - but first written in 1949) devel- and assist in realistic decision-making. oped her non-directive play therapy method in These principles recur throughout the play the mid-twentieth century. Her fifth principle therapy literature (for instance Copley & directs that: Forryan, 1997; Gil, 1991; Moustakas, 1997; The therapists maintains a deep respect for the Schaefer, 2002; West, 1996). If principles of child's ability to solve his [sic] own problems if children's rights are so familiar to play therapist, given an opportunity to do so. The responsi- why have I felt it necessary to discuss them at bility to make choices and institute change is such length at the outset of this paper? the child's. (ibid:73) 29 J. CARROLL Children's rights and the play therapist Some felt that there were 'no rules', while others felt boundaries were realistic and not inhibiting. I have recently completed a research study Within these boundaries, children revelled in (Carroll 2002, 2003) that sought the opinions the opportunity offered to make choices for of children regarding their play therapy experi- themselves: ences. This project, while not without ethical TL. [In play therapy] you're not told what dilemmas, assumes that children are able to pro- to do all the time. You're not told to do vide such opinions if given the opportunity to this and do that, you can do it freely. do so, that they are likely to be honest with me, I. So you have, more choices? Or . . . and that opinions which differ from their thera- L. More choices. Cos like I say you can pick games out and fun things that you pists' have equal validity. The eighteen children really like doing. So that's very different eventually interviewed were selected by their from . . doing maths. play therapists, who also gave their accounts of Lewis, 11. the play therapy process. This was a qualitative Therapists who employed focused methods study (Silverman, 1997), and data analysis ensured that children were happy with opportu- developed from grounded theory principles nities offered; the children were able to tell me (Glaser & Strauss, 1967). that they had felt able to refuse to comply with Details of my methodology are explored else- suggestions made by therapists without concern where (Carroll, 2002), and I shall not use pre- that they would be censured. The children in cious space outlining that here. Verbatim this sample experienced the full potential of extracts from children's interviews are also used exploring their own needs and wishes within the sparsely; readers looking for original evidence limits of the playroom; their competence and are directed to my Thesis. I propose to use data honesty was not questioned. collected in the course of that study to illustrate However, the picture becomes more complex the form taken by children's rights principles, as when children began to talk about endings - of discussed above, in the play therapy process. I sessions, and when play therapy came to a close. shall begin by looking at activities within the Evidence from therapists demonstrates the care playroom, and then discuss the external context. with which they approach the ends of sessions. Throughout the following extracts, the inter- All the children were told, a few minutes before viewer (myself) is signified by and 'I', and the it was time to leave, that the end was approach- children by their initial. The therapists are 'T'. ing. Nevertheless, six children talked about finding the ends of sessions difficult: Children's rights in the playroom I. Was there anything you really didn't Play therapy principles suggest that children like? are offered an opportunity to explore issues that B. Going home. I wanted to stay there. concern them, at their own pace, and in their I. What did you do, when it was time to go home, if you didn't want to go? own time. This occurs in the environment of B. The way I started to act, like (grumpily) the therapeutic relationship, which contains and 'Bye'. I didn't like going home, cos I want- sustains the child throughout the process. ed to stay there some more. Inevitably, this includes limits, generally imple- Britney, 10 mented by the adult. However, for many chil- dren, these were not experienced as restricting. PLAY THERAPISTS AND THE CHILDREN'S RIGHTS MOVEMENT 30 No child willingly leaves playing with a loved therapy to a close. Those children who felt they adult. In addition, separation has complex had made a joint decision with their therapist meanings for many children, as it replays inter- were also more likely to access mixed feelings nal representations of loss (Edwards, 2000). about ending. Evidence from my sample sug- Play therapists operate with external realities, gests that feeling in control of the process of ter- and are unable to allow every child to play for as minating may significantly reinforce self-effica- long as he or she would choose; they also under- cy. While I cannot generalise from my small stand that endings may mirror other significant sample, this echoes the findings of child advo- losses, and thus require sensitivity and under- cates: children may not always like adult deci- standing. sions (such as bringing therapy to a close), but This challenges the Children's Rights perspec- they are more likely to accept such decisions if tive, in which children are enabled to engage they feel part of the process of making them. with decisions that concern them. Children in I do not expect such thinking to come as a sur- my research showed some understanding of prise to play therapists. What may be less pre- practicalities, but only the oldest children could dictable is children's lack of recollection of the begin to think about the possibility of the thoughtful preparations for termination made unconscious processes in play therapy. In such by therapists. In every case, therapists sought to circumstances, there seems little alternative to prepare children gently, over several weeks, therapists being responsible for ending sessions using the time to review progress and allow free thoughtfully, with limited room for negotiation expression of feeling about the loss of therapy with children. and of the relationship. None of the children I This process is replayed with even greater sig- interviewed could recall these preparations; nificance when play therapy comes to and end. Gemma's comments were common: Some children in my sample talked of their dis- I. Do you know how long it was between tress when therapy ended: deciding it was time to stop and you actually S. Well, it felt like someone special was going stopping? away from me. Like was leaving, leaving my G. Um, a week, I think. life, or something like that. Gemma, 11 Stephanie, 9 It may be that children found recalling these Others had more mixed feelings, regretting the processes too painful to discuss with me; internal loss of the therapeutic relationship but enjoying processes, restored by play therapy, may have new-found skills and confidence: disintegrated temporarily as therapy ended, dis- torting memory systems (van der Kolk, 1996). K. Before play therapy I used to be really scared of fireworks. And balloons, but now I'm play- My experience as a play therapist, reinforced by ing with balloons and one firework night I discussions with colleagues, leads me to believe actually uncovered my ears and counted a load that careful, reflective and sensitive preparations of fireworks. for ending therapy occurs almost universally. Kelly, 10 However, observations from this sample indicate that these preparations are not stored in retriev- The crucial difference between those children able memory, thus reinforcing the practice of still grieving for the loss of therapy when com- including children in decision-making processes pared with those whose feelings were openly as therapy ends; if excluded, children may expe- mixed was the latter group telling me that they rience the loss of their therapists as abandon- had made the decision themselves to bring play ment. 31 J. CARROLL Play therapists and the external system The children saw no contradiction between the confidentiality of the playroom, and efforts Most child advocates work at the interface of made by play therapists on their behalf. Two the child and the system containing him or her. siblings had experienced several moves in the They seek to help children find their voices. looked-after system, and saw their play therapist While the focus of play therapy often lies in pro- as crucial in helping them achieve stability: cesses within the playroom, therapists also inter- J. Sometimes it (moving from one placement act with the external system, seeking to support to another) got annoying. Cos you'd like those caring for the child and ensuring that the unpack your stuff, then pack it up again, then child's needs remain central in adult thinking. unpacked it, then packed it up again. There was only one instance in my study where I. How do you think T stopped that happen- a child was unaware of efforts made on his ing? behalf by his play therapist: she felt that teachers J. Cos she told Social Services our feelings, and were being unjustly punitive, and engaged in what sort of place we would like to go to. I. Right, and that was part of the play therapy, helping them to see that this child was held do you reckon? That was part of what her job? responsible for every misdemeanour, even when Or was it something extra that she did? he was elsewhere. I can find nothing in the J. I think it was just a little bit extra, I think it child advocacy literature that would suggest was a bit extra and part of her job. involving the child in discussions such as this. Jamie, 12 In every other instant, children were fully aware of their therapists engaging with those looking after them, and were unperturbed by it. It seemed that children were accustomed the were private. adults talking about them that they did not One child was adopted during her course of question it. At the same time, they knew that play therapy; her therapist provided advice for therapist would not disclose confidential infor- the Court, along the guidelines offered by Ryan mation, and that interactions in the playroom & Wilson (2000). This child did not talk to me about her play therapist's activities in Court; L. On day there was this teacher in year three however, she valued the opportunity to ask ques- that I really didn't like, and I bottled it up for tions about her adoption, and the freedom to about a year until I was talking to T6 I could express her mixed feelings about it. The play sort of like say 'Oh, I don't like so-and-so teacher.' Cos it was like she wouldn't say any- therapist played the dual role of expert witness thing. and container of private feelings; the child's tes- I. So did that help? Knowing she wasn't going timony indicates that she did not feel burdened to tell anybody? by legal issues, and valued the provision of rele- L. Cos if you told one of your friends; I know vant information sensitively provided. they're really good friends, but sometimes you This mirrors Jamie's experience: both therapists can't trust friends that much; because I went to negotiated with the external system on behalf of tell someone something I didn't like about their children. Child advocacy literature would someone, and they went and told them. suggest that such children should be given a Lewis, 11 voice of their own, and that therapists should not speak for them (Boylan & Wyllie, 1996). I did not ask their therapists if they had consid- PLAY THERAPISTS AND THE CHILDREN'S RIGHTS MOVEMENT 32 ered involving these children more directly in Conclusions systemic processes, nor seek criteria for making such decisions. Nevertheless, for these children, In this paper I have reviewed the principles knowing that a caring adult was acting on their underpinning the Children's Right movement, behalf was sufficient. assuming the competence and honesty of chil- One therapist in my sample automatically dren, and discussing the value of children join- includes all the children she works with in six- ing in decision-making processes. I briefly weekly reviews of progress, including the child's recalled the familiarity of these principles in play carers in this discussion. She feels that this therapy theory. I then turned to my own ensures that all those involved in the therapy in research for evidence of the application of these working together towards the same goals. She principles in the playroom. admitted that Simon found it difficult to engage However, my study indicates that the issue is in this discussion, but persisted in her efforts to less straightforward than it first appears. involve him. All Simon could tell me was that: Freedom to choose in the playroom is experi- S. T thought we would talk every now and enced as liberating; at the same time the lack of then after a session or before a session. choice about the length of sessions, while realis- Simon, 11. tic, was a struggle for some. This difficulty was heightened when therapy came to an end; my He could not tell me the purpose of these dis- study confirms the importance of therapists cussions; however he had vivid recollections of including children in decision-making during his play. Playing was far more memorable that the termination phase of therapy, ensuring that reviews! His therapist's efforts to include Simon they feel empowered by play therapy and not in discussion about the goals and progress of abandoned at its ending. Nevertheless thought- therapy would be applauded by the Children's ful preparations for endings are often lost in Rights movement, yet his testimony indicates children's complex memory systems. that processes in the playroom held far greater Play therapists also interact with the external significance for him. system. Children in my sample showed no anx- Evidence from this small sample suggests that iety or distress about this activity, and generally the practice of involving children in decision- welcomed efforts made on their behalf. making is a complex process. The Children's Children's Advocates would suggest that chil- Rights literature demonstrates that for some dren should be more actively involved than children it is empowering (Boylan & Wyllie, those in my sample; yet the child whose thera- 1996); yet Jamie was clearly delighted that the pist made the greatest efforts to involve him in play therapist acted as advocate on his behalf, decision-making saw these discussion as far less and succeeded (where he had perceived himself memorable than his activities in the playroom. as having failed) in procuring a permanent A small sample such as this can only raise ques- placement for him. This would imply that there tions for future study; however, I suggest that a continue to be times when some children need principle of involving children, while ethically adults to take decisions on their behalf; howev- admirable, needs also to be sensitive to the devel- er, greater flexibility within the system would opmental, emotional and psychological needs of help those children who have found their voice the child. Some children may find involvement to have it heard, and to differentiate those chil- empowering; others may be intimidated, con- dren able to speak for themselves from those not fused, or bored. yet empowered to do so. Finally, my project reaffirms that many chil- 33 J. CARROLL dren can, if given the opportunity, provide evi- Copley, B., & Forryan, B. (1997). Therapeutic Work dence of their opinions and talk about matters with Children and Young People. London, Cassell. that concern them in research interviews. I Crittenden, P. M. (1995). Attachment and psy- assumed the children would be competent; chopathology. Attachment Theory: Social, developmen- tal and clinical perspectives. S. Goldberg, Muir, R., & those I interviewed engaged with me willingly, Kerr, J. Hillsdale, New Jersey, The Analytic Press. and the richness of date gathered (only a fraction Department of Health (1989). An Introduction to the of which appears in this paper) demonstrates the Children Act 1989. London, HMSO. importance of continuing to seek children's per- Edwards, J. (2000). "On being dropped and picked spectives where possible. up: adopted children and their internal objects." At the same time, I found no solutions to com- Journal of Child Psychotherapy 26(3): 349-367. plexities implicit in the Children's Rights move- Focus (1999). Treatment Decisions of Young People. ment. Play therapists, alongside child advocates, London, Royal College of Psychiatrists Research seek to empower children. Nevertheless, there Unit. Fundudis, T. (1998). "Young children's memory: are occasions when adults have to make deci- how good it is? How much do we know about it?". sions for children; it continues to be vital that Child Psychology and Psychiatry Review, 2(4): 150-158. adults, rightly retaining responsibility to protect Gil, E. (1991). The Healing Power of Play: Working children and thus ultimately wield power, with Abused Children. London, Guilford Press. remain open to the needs, wishes and fantasies Glaser, B. G., & Strauss, A.L. (1967). The Discovery of children, however these may be expressed. of Grounded Theory: Strategies for Qualitative Research. New York, Aldine de Gruyter. References Guerney, L. F. (1983). Client-centred (nondirective) play therapy. Handbook of Play Therapy. K. Schaefer C.E. & O'Connor. New York, Wiley: ch.2. Allen, F. H. (1982). Therapeutic relationship with Hall, N. (1996). Eliciting children's views: the contri- children. 'Play Therapy: Dynamics of the Process of bution of psychologists. The Voice of the Child: A Counselling with Children. G. I. Landreth. Illinois, Handbook for Professionals. R. Davie, Upton, G. & Charles C. Thomas: ch.19. Varma, V. London, Falmer Press: 61-77. Axline, V. (1969). Play Therapy. New York, Marshall, K., Kisdall, E.A.M., Cleland, A. (2002). Ballantine Books. 'Voice of the Child' under the Children (Scotland) Act, Bell, M. (2002). "Promoting children's rights 1995: giving due regard to children in all matters that through the use of the relationship." Child and Family affect them. Volume 2 - Feasibility Study. Edinburgh, Social Work, 7(1-11). Scottish Executive Central Research Unit. Boylan, J., & Wyllie, J. (1996). Advocacy and child McLaughlin, C., Carnell, M., & Blount, L. (1999). protection. The Voice of the Child: A Handbook for Children as teachers, listening to children in education. Professionals. R. Davie, Upton, G. & Varma, V. Time to Listen to Children: personal and professional London, Falmer Press: 56-70. communication. P. Milner, & Carolin, B. London, Brandell, J. R. (1988). "Narrative and historical truth Routledge.: 97-111. in child psychotherapy." Psychoanalytic Psychotherapy, Moustakas, C. (1973). Children in Play Therapy. New 5(3): 241-257. York, Aronson. Carroll, J. (2002). It Makes You Feel Better: children Moustakas, C. (1997). Relationship Play Therapy. talk about play therapy, Unpublished thesis: New Jersey, Aronson. University of Reading. Munro, E. (2001). "Empowering look-after chil- Carroll, J. (2003). Children talk about play therapy. dren." Child and Family Social Work, 6(129-137). International Handbook of Play Therapy. C. E. Oaklander, V. (1969). Windows to our Children. Schaefer. New York, Wiley: (in print). Utah, Real People Press. Cattanach, A. (1992). Play Therapy with Abused Russell, P. (1996). Learning to listen to children with Children. London, Jessica Kingsley Publishers. disabilities and special educational needs. The Voice of PLAY THERAPISTS AND THE CHILDREN'S RIGHTS MOVEMENT 34 the Child: A Handbook for Professionals. R. Davie, Upton, G. & Varma, V. London, Falmer Press: 107- 119. Ryan, V., & Wilson, K. (2000). "Conducting child assessments for Court proceedings: the use of non- directive play therapy." Clinical Child Psychology and Psychiatry, 5(2): 267-279. Schaefer, S. C. (2002). Foundations of play therapy: theory and practice. Nineteenth Association for Play Therapy International Conference, St Louis, USA., Association for Play Therapy. Schofield, G., & Thoburn, J. (1996). Child Protection: The Voice of the Child in Decision-Making. London, Institute for Public Policy Research. Silverman, D., Ed. (1997). Qualitative Research: Theory, Method and Practice. London, Sage. Smith, P. M. (1996). A social work perspective. The Voice of the Child: A Handbook for Professionals. R. Davie, Upton, G. & Varma, V. London, Falmer Press: 49-60. Thomas, L. K. (1999). Communicating with a black child: overcoming obstacles of difference. Time to Listen to Children: personal and professional communi- cation. P. Milner, & Carolin, B. London, Routledge.: 65-78. Thomas, N. (1998). The reality of participation in decisions for 'looked after' children. Exchanging Visions: Papers of Best Practice In Europe for Children Separated from their Birth Parents. BAAF. London, BAAF: 71- 77. United Nations (1983). Convention on the Rights of the Child. van der Kolk, B. A. (1996). Trauma and memory. Traumatic Stress: the overwhelming experience on mind, body and society. B. A. van der Kolk, McFarlane, A.C. & Weisaeth, L. New York, Guilford Press: 279-302. West, J. (1996). Child-Centred Play Therapy. London, Edward Arnold. Wilson, K., Kendrick, P. & Ryan, V. (1992). Play Therapy: A Non-Directive Approach for Children. London, Balliere Tindall. Young, I., & King, P. (1989). "The child as client." Childright, 62(6-7). Bri. J. Play Therapy, Vol. 1, No. 1, pp. 35 - 46, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. 'My new mum' How drawing can help children rework their internal models of attachment relationships in non-directive play therapy Virginia Ryan University of York, England The ways in which two different maltreated children seemed to use spontaneous draw- ing to change their internal working models of attachment relationships during their non-directive play therapy sessions are discussed in this article. As background to understanding the importance of their drawings, attachment theory and research are briefly reviewed, along with the place of drawing in developmental research and child therapy. Particular attention is given to the role of spontaneous drawing and non- directive play therapy practice. After presenting the vignettes from the two children's play therapy sessions, practice implications for play therapy practice are explored. Finally, suggestions are made regarding contributions play therapy practitioners are able to make in play therapy research. Towards this end, specific research questions of interest to play therapy and to developmentalists more generally are derived from the case vignettes presented in this article. Introduction theory and case studies have examined child maltreatment from various perspectives; howev- Attachment concepts and research are used er, there have been relatively few detailed extensively by play therapists in their clinical accounts of specific processes children use in work, informing the way they collect referral therapy to help them with this task. information, form their initial hypotheses, and In this article the way two different children conduct their ongoing work. An attachment reworked their current ideas of primary attach- framework is applied to understand children ment relationships in non-directive play therapy and their family relationships, and more broad- will be described.1 Interestingly, both of these ly to understand children's wider social world, children used drawing as a way to make this in particular their school life and friendships. attachment process more visible and concrete for For some children their interpersonal world themselves. Drawing also enabled them to share includes professional relationships with social their internal world intimately with their thera- workers, medical staff, and play therapists too pist. Excerpts from their play therapy will illus- (see Ryan and Needham, 2001; Ryan, 2004, for trate this process. First the scene will be set with examples). background information on attachment theory This article will explore a very difficult attach- and research and on drawing and play therapy ment task for some children, that of changing practice. The practice suggestions that emerge their primary attachments during childhood fol- lowing maltreatment by their parents. Research, 1All identifying details have been changed for both of these children. Verbal consent to write up my work Correspondence to: Dr Virginia Ryan, Department was not given by the children themselves due to their of Social Policy and Social Work, University of York, young age or developmental delay. Written consent York, England, YO10 5DD. was given by the local authority for the use of case (Email: [email protected]) material. 35 'MY NEW MUM' 36 from these children's clinical illustrations, along atypical populations, including maltreated chil- with the research potential of this type of clini- dren and late adopted children (Steele et al, cal material for the field of play therapy, will be 1999). Other methods to assess children's discussed in the last part of this article. attachment status and the ways they may have changed their internal working models of Historical overview attachment relationships from before to after therapy also were devised, using for example, It is well known that Bowlby's theory of attach- photos of attachment-inducing experiences such ment relationships became a rich source of as leaving a parent (Clarke et al, 2002; Wright empirical research with Ainsworth's ground- and Binney, 1998). These assessment methods breaking study of children's attachment and the expansion in attachment theory and behaviours in the Strange Situation. This led to research to study internal experiences of attach- the development of four main attachment clas- ment relationships in turn influenced and sifications of securely attached, and the three informed clinical practice, including play thera- insecurely attached categories of avoidant, py practice. Play therapists increased their ambivalent and, later, disorganised. These cate- understanding of types of play and behaviour gories were based on infants' and young chil- children displayed during therapy in more dren's movements towards and away from their informed and more empathic ways. carers after separations and reunions and in the presence of a stranger while placed in an unfa- Background to Play Therapy miliar situation. Attachment theory and Illustrations research expanded to include studying older children's attachments, and their non-visible, This article is written with this backdrop of mental means of staying close to carers. attachment-informed practice. Vignettes have Children were assumed to develop internal been chosen from two different children's non- working models of attachment experiences and directive play therapy sessions. relationships to help sustain themselves in diffi- Developmentally, both children were at a cult and unfamiliar experiences away from car- preschool level of emotional functioning, even ers. Research correspondingly attempted to find though their chronological ages differed. One means to study these internal working models of child, Matthew, was aged four and a half, and experiences and relationships, especially as the the other child, Scott, was aged seven. Both clinical importance of attachment relationships children were seriously maltreated within their became more commonly realised (Ryan, 2004). birth families and had been removed perma- In adults the Adult Attachment Interview nently.2 (AAI) became a powerful research and clinical They each had relatively recently changed fos- tool (Steele, 2002). The ways children's internal ter carers when their therapeutic work began. models of attachment experiences were Their local authorities intended that these new expressed began to be devised and researched placements would be their long term, perma- also. One important research area has been analysing children's play and talk in completing 2The particular difficulties maltreated and looked standardised story stems (known as the after children have in reworking their attachment rela- McArthur story stems technique). This method tionships have been discussed more fully elsewhere. has been used with pre-school and younger See for example Ryan, 2004, 2001, 1999; Ryan and school aged children, from both typical and Wilson, 2000a. 37 V. RYAN nent placements in foster care. Interestingly, it. For example, it is unclear from research on both boys chose similar methods to rework their young children's spontaneous drawings why internal experiences of attachment relationships they often change what they say their drawing with their new carers in play therapy by using represents as they draw. Does this mean that drawing. Matthew's role plays during sessions their drawings do not depict symbolic contents also seemed to be important part of this rework- and instead they give 'labels of convenience' to ing, as was Scott's rudimentary symbolic play in adults when asked for an answer? (Gross and the sand and water. Before presenting these Hayne, 1999) And/or could it mean that chil- vignettes from the children's sessions, drawing dren themselves change their thoughts and ideas and its importance as a therapeutic and assess- as they draw? ment tool will be explored, highlighting how it Significantly, in studies of children's event is used by non-directive play therapists. memories and accuracy as eye witnesses for testi- mony purposes, drawing was found to offer less Using Drawing and Art Work in Non- support for memory than concrete props, prob- directive Play Therapy ably because children had to generate their own retrieval cues from their drawings. Salmon Drawing often has been used for a range of speculated that drawing "may be more effective purposes with young children in both clinical when the event is highly salient or distinctive and research contexts. In clinical work it is and when the structure of the event can serve to often directive in nature, focussing on asking cue memory." (2001, 289). Several factors were children to draw in order to help them commu- identified by researchers that may underlie the nicate and express themselves more fully (e g effectiveness of drawing for aiding recall in chil- drawing 'worst moments' to trigger specific dren. These may also provide clues about the memories of traumatic events. See Bentovim et way children consolidate their internal working al, 1995; Pynoos and Eth, 1986). models and memories of attachment figures. Developmental research on children's drawings One factor seems to be that when children's fits into this adult-led literature and often con- drawings are of higher quality in representing centrates on how drawing facilitates both verbal objects, they seem to recall more information communication with interviewers and aids recall about a past event (Pipe et al, 2002). This may for previous events (e g Pipe, Salmon and hold true of their drawings of attachment figures Priestley, 2002). Research on children's eyewit- also, and is of interest in considering the case ness testimony gives one type of developmental material below. context for understanding children's drawings. Another area of both developmental research It demonstrates that even young 3- to 4-year old and clinical interest has been understanding and children understand the symbolic potential of classifying children's drawings as symbolic repre- drawing. When they are instructed to draw sentations of inner events. Malchiodi (1998) objects, even though the results are not easily gives a succinct summary of the varied means recognisable as objects to adults, children them- that have been employed in assessment and selves can remember what these objects were on research on children's drawing, such as projec- recall. However the means children use to rep- tive drawing tests and pyshodynamic interpreta- resent inner and outer experiences spontaneous- tions of drawings' symbolic contents. Malchoidi ly in their drawings, and without detailed adult argues that in addition to looking at the similar- instructions, has more controversy surrounding ities of structure and contents in children's drawings, a child-centred framework is essential. 'MY NEW MUM' 38 This framework should respect the 'richness, Case Illustrations uniqueness, complexity and spontaneity' of children's drawings. To understand the signifi- Matthew cance of drawings, they also need to be placed within children's individual and developmental The vignettes below seemed to show Matthew's contexts, along with their emotional, social and emotional struggles with his internal working cultural experiences. model of his attachment relationship with his This respect for children's unique ability to cre- mother and with his new carer, who had strong ate the means of expression most suitable to physical similarities, by coincidence, with one their particular personality, competencies and another. Matthew's play therapy gave glimpses emotional life is at the heart of non-directive of how he appeared to generate meaningful sym- play therapy practice. Art activities selected for bols of these internal working models of his pri- their developmental appropriateness are made mary attachment relationships based on real life available to children and young people in the experiences, along with fantasy elements. playroom. Children may choose to use art Matthew's weekly play therapy sessions began materials to uniquely express their inner and when he was four and one half years old and outer experiences, and they may in the process continued for nine months. The sessions had learn new ways to master materials, to help two phases: they first were undertaken as part of themselves and to form close relationships with a Court assessment in Care proceedings, then other people. Drawing is one important way they were continued for therapeutic purposes during play therapy sessions that some children after this initial assessment. (See Ryan and and young people choose to make visible and Wilson, 2000b for a fuller discussion of play manageable very troubling current experiences assessment sessions for Court purposes.) and memories, as well as more nebulous, yet Matthew, along with his brother, was referred to potent emotions attached to these experiences. me by the Court after both children alleged that Drawing may be used over a period of time as a their father had seriously sexual abused them. preferred expressive medium. When this occurs There also were issues of neglect; they appeared both the children and their play therapists have to have spent long periods of time in their cots an accessible medium to use to assess progress as babies and young children before being placed and explore a range of old and new feelings. in foster care. Matthew's brother had fared Other times, however, children choose to use worse than Matthew, who seemed to have been an impermanent medium for their drawings or treated as a favoured child by his mother, at least to take their drawings home immediately. In some of the time, while his brother was routine- the cases discussed below, this ongoing process- ly scapegoated. es of adding, subtracting, taking home and eras- During the course of their therapy both ing were important parts of the therapeutic pro- Matthew and his brother continued to make cess itself. The white board in the playroom allegations of abuse by their parents and close was used and drawings were erased during or relatives. They sometimes shouted obscenities after sessions, and one child, Scott, took his to one another before these allegations, includ- paintings home immediately. Thus there was ing shouting 'You son of a witch' to one anoth- no permanent record of their drawings. The er. On one occasion Matthew heard his broth- illustrations in this article therefore are taken er allege to their foster carer that both their par- from play therapy case notes, rather than being ents had dressed him in black during his abuse true reproductions of these children's drawings. by them. He had shouted out very graphic 39 V. RYAN details of the torment he had suffered to his carer in Matthew's presence. (Investigative interviews were held at two points during Matthew's and his brother's play therapy because of these further allegations.) The sessions to be highlighted here are Sessions 17, 20 and 25 of his weekly therapy sessions. Session 17 was the session held immediately after his brother's allegations of abuse by his mother and father in Matthew's presence, men- tioned above. For several sessions prior to Session 17, Matthew appeared to have been addressing his relationship with his mother using role play. He had spent long period of time in the sturdy baby cot in the playroom and I had been directed to be a loving, kind mother who spoiled him with presents, but who was Figure 1: Session 17, 'Naughty Meg' and 'Naughty nasty and shouting out to everyone else around Mog' me. I had reflected (as therapeutic asides) that it the cat was naughty too, and made angry cat felt good to him to have his mum being kind to noises as he drew. After these drawings, him and that he was glad not to be in trouble Matthew again involved me in his role play, this with her. I also used my own feelings congru- time with me in the child role. He became a ently, saying that I was playing the way he want- witch, alternating the witch's role with one of ed me to, but if I were really taking care of a lit- being a nasty father figure. Matthew acted out a tle boy, I'd get him out of the cot to play with story in which a child was very naughty during him. I added at another point that I would try an abusive incident and made to wear a black to be kind to others around us too, if I was being coat. Based on this role play and other a real mum and not pretending. behaviour during our sessions, and in keeping When I went to the waiting room to bring with non-directive play therapy practice of Matthew to the playroom for Session 17, he had working systemically with carers, at the next play just finished reading an available book, Meg and therapy progress meeting with the foster carer Mog, with his foster carer. (This book is a and social worker I discussed the direct help brightly coloured one and appeals to many Matthew was likely to need from them. This young children because of its simple yet adven- direct work would help him to understand that turous storyline. Meg is a kind and somewhat his brother had not been naughty many times childlike witch who lives with her benign pets, a but had been abused by their parents. black cat, or 'moggie', and an owl.) After arriv- During Session 20, three weeks later, Matthew ing in the playroom Matthew immediately again pretended that he was a baby playing in his decided to draw at the white board, and drew cot; this time he became frightened by large what he labelled 'Naughty Meg'. (See Figure 1, insects nearby. (He had instructed me to bring Session 17 for these reproduced drawings.) He him a box of large plastic insects and he had compared Meg to his foster carer, saying that placed them around his cot himself.) I respond- the hair was the same, but the foster carer's hair ed by trying to keep him 'safe', after checking was nicer. Matthew then drew Mog, saying that with Matthew that this was the response he 'MY NEW MUM' 40

Figure 2: Session 20, 'Nice Mog' and 'The Witch' Figure 3: Session 25, Matthew's foster carer wanted from me. Matthew seemed satisfied explore the way the white paint made the black with my responses and climbed out of the cot, a bit lighter if he used a lot of it. saying firmly that he was drawing a witch on the Five weeks later (Session 25) Matthew struc- board again. Matthew drew Mog the cat first, tured his play therapy session in a similar way: who was now 'not naughty' but 'nice', and who first he drew, then he role played a very young was very frightened of the witch. (See Figure 2, child after he drew. Matthew had been busy Session 20 for these reproduced drawings.) making a construction in the playroom. Mog had claws and would scratch the witch, Finishing this, he told me he was drawing his Matthew stated, as he drew large claws on the foster carer on the board. (See Figure 3, Session cat's paws. He then said that Mog couldn't get 25 for the reproduced drawing.) Matthew away from the witch, even with these claws, and admired the drawing he had made and decided that the witch hurt Mog instead. (This drawing to rub it off the board to practice his writing. sequence coincided, according to his foster (Matthew was in his first term in primary carer, with Matthew worriedly telling her that school, and just beginning to learn to write.) He he had had a cat when at home. He remem- worked for several minutes on his writing, then bered that his mother had hurt the cat after she appeared tired and collapsed into the baby cot. was scratched and after that, the cat was gone.) Similarly to earlier sessions, Matthew told me to Matthew proceeded to black out the witch's collect toys for him to play with in the cot, but eyes, so she couldn't see any more, then the then changed his mind and played a hiding mouth, so she couldn't shout. He began slowly game with me. First he hid balls inside the cot rubbing out Mog because 'the witch had made for me to find, but acted mistrustful of me and him go away'. Matthew finished his drawing, worried that I would peek. Deciding in a short saying in a definite tone to me that the witch time to trust me to play out his script, he first was horrible. Then he looked around the room hid the balls playfully, then hid himself under for another activity and decided to use the the cot and played 'peep-o' with me, as a very paints. Matthew started enjoying all the paint young child would do. I responded as the play- colours, especially the black paint, and began to ful and 'nice' mum he said he wanted me to be. 41 V. RYAN

Discussion of Matthew's Play symbols, similarly to other maltreated children's Therapy Sessions symbolic representations, was due to attachment experiences that seemed intertwined with basic These illustrations from Matthew's sessions fear of survival. Desperate emotional struggles seem to show several important aspects of how arise in children attempting to continue to children rework their internal working models maintain their fear-laden primary attachment of attachment relationships in non-directive relationships. play therapy. First, Matthew appeared to draw Matthew's symbol of a witch was a highly per- on both his important experiences from his past sonal one and was very different from the benign and current life, as well as on fantasy and his witch 'Meg' in the book he had been read. own imagination in developing his personal Matthew transformed Meg into a malevolent symbols to represent his primary attachment and darkly disturbing witch. This witch seemed relationships. It is likely that the woman figure to fit his highly negative experiences of his in Sessions 17 and 20 was Matthew's personal mother based on his own deep fears and dis- symbolic representation of his mother, although turbing experiences with her. The witch was a he did not label it as such directly, nor did I, in way to represent the emotional turmoil he expe- keeping with non-directive play therapy prac- rienced when hearing the details of his brother's tice. (See Wilson, Kendrick and Ryan, 1992 for abuse and seeing his brother's strong distress. discussion of non-directive practice skills.) The cat 'Mog' also was transformed by Matthew We have discussed elsewhere (Ryan and into a potent personal symbol. The 'Mog' in the Wilson, 2000a, 2000b) ways children's real life book was little and benign, but also referred to experiences map onto their perceived and inter- as 'naughty'. This seemed to reverberate with nal worlds, and the importance for play thera- Matthew's own experiences with his birth par- pists of considering the objective evidence they ents and their care of him. Unlike the Mog in have available to support the hypotheses they the book, Matthew's cat became fierce and generate in their practice. For Matthew, his ses- frightening. This depiction seemed similar to sions had understandable internal consistency his real life experience with the cat at his birth and underlying dynamics as they unfolded over parents' house; when the cat became aggressive, time. The theoretical/research literatures on rel- it was hurt and made to 'disappear' by powerful evant issues and the psychological and develop- parents. Matthew may have identified with the mental context of Matthew's drawings were cat himself, and included his brother in this considered in arriving at a likely interpretation identification too, since some of their experi- of his drawings, as was the direct information ences with their parents were similar to those of available from files, court papers and conversa- the cat. tions with carers and professionals. Given all of these overlapping and consistent Scott's Play Therapy Sessions sources of information, it seems likely that the timely reading of the Meg and Mog book dur- Scott's life before being looked after, similarly ing the period in which Matthew's brother was to Matthew and his brother, also was very diffi- recalling abusive experiences with their parents cult and damaging; he had been seriously helped Matthew to bring all his disparate and neglected and physically abused by his mother. highly emotive experiences together into two In addition Scott had been sexually and emo- graphic symbols. The emotional potency of his tionally abused for several years by his mother's 'MY NEW MUM' 42 partner, who was the father of his two younger half brothers. After removal from his mother's care, Scott had been placed with his brothers in a shorter term foster placement. Because of his learning difficulties, developmental delay and emotional/behavioural problems, the care plan for Scott was long term fostering; sadly, his brothers had been placed separately from him in a pre-adoptive placement. Scott's play therapy began when he was seven years old. He had just moved from his foster placement of eighteen months' duration to his new, long term, specialised foster placement. His behaviour was challenging for his carers: he seemed very angry and mistrustful of them, refusing to eat meals with the family and becom- Figure 4: Scott's Former Carer 'Mary' and his ing particularly disruptive at bedtime. During 'New Mum' his first month of weekly therapy sessions Scott's foster carer). "This is my new mum." (See play was chaotic, with most of the contents of Figure 4 for these reproduced drawings.) one shelf unit regularly ending up in a heap in In his sessions over the next several weeks Scott the corner of the room. (I limited the mess, and stopped ritually throwing items into the corner Scott began to accept these limits, allowing me of the room. Instead, he began to play hesitant- to contain his 'mess' to some extent.) In his fifth ly with a few toys and use them in the sand and session Scott began to recognise my presence on water. Scott played at a rudimentary level, and a deeper level for the first time, after he had seemed to be listening carefully to my basic unintentionally thrown sand in my eyes. He reflections of his activities and feelings.3 This became upset and then less anxious as I play began to be part of the routine he developed acknowledged his feelings. Instead of his usual for the last part of his play therapy hour, as did frantic physical activity, Scott approached the his directing me to play in parallel with him, whiteboard and hesitantly drew a round shape. drawing and painting like he did, during the first He then asked me to draw with him. part of the hour. One painting we did was a We drew in parallel, with Scott intent on hav- reproduction of the one he had done on the ing me help him draw his figure and then hav- white board in his earlier session of his 'new ing me reproduce it for myself 'just the same' on mum'. He reproduced this image with some my section of the whiteboard. The figure had difficulty and with very close concentration, to have curly hair-Scott told me what it had to leaving me to follow his painting for myself. look like and we each tried drawing the hair on When he finished, Scott excitedly decided to our figures, getting it to look 'right' after several bring his painting out to his carer, so that she tries. Then the eyes, mouth and body, with sev- could keep it, and Scott wanted his carer to hold eral attempts before Scott was satisfied with the onto the other painting too. Scott said emphat- results. Scott decided to change the hair himself ically, 'It's for me to keep!' on my figure to straight hair, and added specta- 3See Ryan, 1999 and Ryan and Wilson, 1995 for a fuller dis- cles. He stood back, looked at both figures and cussion of the beginnings of symbolic play for developmen- said quietly to me-"You did Mary." (his former tally delayed children. 43 V. RYAN Discussion of Scott's Play Therapy his memory storage in the playroom and may Session have aided his recall after taking them home. It is of note that his potential use of the paintings Scott's drawing of his foster carer was less com- as aids for recall seemed more important for him plex than Matthew's, but seemed to serve a sim- than retaining a common therapeutic rule of ilar function. Both children appeared to use having his paintings remain in the playroom drawing to help themselves develop internal during his intervention. His need for paintings mental images of their new attachment figures as aids for recall was in keeping with his limited and to separate these images from their previous ability to think abstractly and project himself ones. As stated above, maltreated children may into the future within his play therapy sessions have more difficulty creating stable internal generally. working models of their primary attachment relationships. And children who are looked after Further Practice Implications for Play have more attachment figures than usual to Therapists assimilate and accommodate to in their mental representations. It seems likely then that these One of the tenets of non-directive play therapy, children will need more intensive help for this that children are able to find their own chosen reworking process. Both Matthew and Scott medium of expression for their emotional issues showed how this process can be aided in play given a facilitative play therapy environment, therapy, it helped them transform their internal seems well illustrated in both Matthew's and models into new, more integrated and meaning- Scott's sessions. Both children developed their ful ones. own symbols, showing that even young and In his spontaneous drawing and painting, Scott developmentally delayed children can be adept at needed the therapist to reinforce the concrete creating highly meaningful symbols for them- and specific features of his carer that he appeared selves which fit their own experiences. Indeed, to be developing as retrieval cues for each of child therapists who direct children to draw par- these figures separately (e g glasses, hair style). ticular symbols to represent their experiences are Scott's attempts to represent his attachment fig- unlikely to be able to capture the potency, cre- ures accurately also may fit into the research lit- ativity and personal meaning that spontaneously erature discussed earlier, where accurate draw- created drawings have for children who chose ings of objects seemed to aid young children's this medium of expression. ability to recall past events. Scott's develop- Additionally, symbolic representations in them- mental delay and learning difficulties probably selves seem to have curative potential; this quali- made it necessary for him to have concrete rep- ty of symbolic play can be more readily under- resentations of both of these attachment figures. stood within an attachment and memory related He creatively used painting to develop his rela- framework. By giving concrete representation to tionship with his carer and to develop his rela- inner reality, children can manipulate and make tionship with his play therapist as a substitute more objective (i e 'keep at arm's length') their attachment figure. Scott began to allow his ther- most potent emotional experiences. They also apist to contain his anxiety and distress and to can share these with adults within trusting rela- serve as his safe base as he explored new ways of tionships more readily because they are concrete- playing in his therapy sessions. And his paint- ly represented, as Scott did with the paintings for ings seemed to be used as concrete objects to aid his foster carer and himself. 'MY NEW MUM' 44 One of the benefits of non-directive play ther- drawing to work through their experiences with apy for children is that by having the therapist primary attachment figures, more detailed witness their drawing and take part in his enact- research is possible. For research purposes play ments of earlier or developmentally more therapists could pool their information; this advanced experiences, children are able to have could take several different forms. Using the integrated emotional experiences of their own phenomenon discussed above, a comparison choosing. With younger and emotionally could be made between maltreated and bereaved immature children, they often seem able to rep- children's drawings and paintings during play resent their experiences symbolically, but their therapy. Or children of different ages and/or symbols are highly likely to be fragmented and abilities, such as the above two children, may be confused for complex emotional events and sit- compared. Another interesting possibility uations (Slade, 1994). For Matthew, non-direc- could be comparing children's drawings with tive play therapy allowed him to remember and play therapists who are directive with those who develop a narrative about his earlier experiences are non-directive, or comparing children who through drawing and role plays. As Slade have stable attachment experiences with carers cogently states: "Children learn to represent (selected, say, from a primary school population) internal experiences because these experiences with children who are referred to a bereavement are first made real by another's recognition of service for children. Play therapists then may be them." (1994, 95) The role of non-directive able to have more insights into whether chil- play therapists then is to help children and dren's personal symbols/drawings emerging in young people 'tell their story', along with help- play therapy were the same as those of children ing children separate reality from their internal without emotional problems and difficult expe- emotions and fantasy. This process seems to riences of care. occur most usefully as the story itself unfolds, Other more detailed research questions may be with the child directing the action. of more interest to other play therapists. Using the above example, some questions that may be Researching Internal Working Models of interest are: of Attachment Relationship in Play Therapy n For children who choose drawing as their preferred medium of expression of attach- ment figures, do these drawings change over The field of play therapy is in need of both pro- time and in keeping with other developments in cess and outcome research, yet play therapy gen- their attachment relationships within therapy erally attracts practitioners who wish to help and within their home life? children directly, rather than take time from When adults ask children to draw their their clinical work for research. One of the ways n attachment figures, what are the differences in forward for play therapy research suggested by their drawings from their spontaneously pro- the case illustrations above is to exploit the duced drawings? What are the implications for wealth of information play therapists have avail- assessment of children and assessment of their able in their clinical notes. By examining their progress in play therapy? own detailed records of play therapy sessions and collecting information from other play ther- In conclusion, hopefully, play therapists will apists who have similar illustrations of well create more opportunities to examine such defined phenomena, such as children using important questions in the future. This will 45 V. RYAN result in deeper understanding of play therapy assessments for court proceedings: the use of non- practice and increase our overall understanding directive play therapy. Clinical Child Psychology and of children. Psychiatry, 5(2), 267-279. Ryan V and Wilson, K (1995) Non-directive play therapy as a means of recreating optimal infant social- isation patterns. Early Development and Parenting, References 4,29-38. Salmon, K (2001) Remembering and reporting by Bentovim, A, Bentovim, M, Vizard, E and Wiseman, children: the influence of cues and props. Clinical M (1995) Facilitating interviews with children who Psychology Review, 21(2), 267-300. may have been sexually abused. Child Abuse Review, Slade, A (1994) Making meaning and making believe: 4, 246-62. their role in the clinical process. In A Slade and D P Clarke, L, Ungerger, J, Chahoud, K, Johnson, S and Wolf (Eds) Children at play. Oxford: Oxford Stiefel, I (2002) Attention deficit hyperactivity disor- University Press, 81-107. der is associated with attachment insecurity. Clinical Steele, H (2002) State of the art: attachment. The Child Psychology and Psychiatry, 7(2), 179-198. Psychologist, 15(10), 518-522. Gross, J and Hayne H (1999) Young children's Steele, M, Hodges, J, Kaniuk, J, Henderson, K, recognition and description of their own and others' Hillman, S and Bennett, P (1999) The use of story drawings. Developmental Science, 2(4), 476-489. stem narratives in assessing the inner world of the Malchiodi, C A (1998) Understanding children's child: implications for adoptive placements. In J drawings. London: Jessica Kingsley Shatter and R Phillips (Eds) Assessment, preparation Pipe, M, Salmon, K and Priestley, G K (2002) and support. London: British Association of Adoption Enhancing children's accounts: how useful are non- and Fostering. verbal techniques? In H L Westcott, G M Davies, and Wilson, K, Kendrick, P and Ryan, V (1992) Play RHC Bull (Eds) Children's testimony. Chichester: Therapy: a non-directive approach for children and ado- Wiley lescents. London: Bailliere Tindall. Pynoos, R and Eth, S (1986) Witness to violence: the Wright, J C and Binney, V (1998) The (modified) child interview. Journal of the American Academy of Separation Anxiety Test (age 8-12) Unpublished Child Psychiatry, 25(3), 306-319. manuscript. Ryan, V (2004) Adapting non-directive play therapy for children with attachment disorders. Clincial Child Psychology and Psychiatry, 9(1), 75-87. Ryan, V (2001) Non-directive play therapy with abused children and adolescents. In Wilson, K and James, A (Eds) The child protection handbook, 2nd Edition. London: Harcourt Brace (Originally pub- lished 1995, pp 354-371). Ryan, V (1999) Developmental delay, symbolic play and non-directive play therapy: essentials in atypical and normal development'. Clinical Child Psychology and Psychiatry, 4(2), 167-185. Ryan, V and Needham, C (2001) Non-directive play therapy with children experiencing psychic trauma. Clinical Child Psychology and Psychiatry, 6(3), 437- 453. Ryan, V and Wilson, K (2000a) Case studies in non- directive play therapy. London: Jessica Kingsley, pp 251. (Previously published 1996, Bailliere Tindall.) Ryan, V and Wilson, K (2000b) Conducting child 'MY NEW MUM' 46

Figure 1: Session 17, 'Naughty Meg' and 'Naughty Figure 3: Session 25, Matthew's foster carer Mog'

Figure 2: Session 20, 'Nice Mog' and 'The Witch' Figure 4: Scott's Former Carer 'Mary' and his 'New Mum' Bri. J. Play Therapy, Vol. 1, No. 1, pp. 47 - 55, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. Transforming Therapy into Research. Is it possible to conduct research that investigates the process of play therapy without affecting the delicate balance of the relationship between the child and therapist, which is central to the therapy? Chris Daniel-McKeigue Liverpool Hope University, Merseyside, England There is a growing concern that therapeutic practice should be supported by research evidence. Whilst play therapists would undoubtedly support the underpinning of their approach with a reputable study there is likely to be a concern that an investigation conducted whilst therapy is in progress may influence the therapeutic process itself.

I begin by outlining the impetus for research within the general field of therapy as utilised with children. The extent of research within the specific area of play therapy is discussed and com- pared with the value of innovative practice and the integral process of evaluation. It is estab- lished that play therapy is not alone in being under researched. Some of the factors that limit the parameters of a research study in this area are highlighted. I continue by considering the sensitivity of the therapeutic dynamic particularly with respect to therapy with children that is rarely instigated by children themselves. The problems of conducting research whilst the therapy is in progress are explored and the resultant implications for the choice of research methodology. The question is raised of whether it is possible for a therapist to combine their role with that of a researcher whilst still maintaining their integrity as a practitioner. The image from chaos theory of the butterfly effect is used to illustrate how light the touch of research needs to be upon play therapy. Finally the metaphor of alchemy is used to illustrate how it may be possible to transform one medium into another.

In the spirit of heuristic research the author invites readers to respond to the ideas within this paper and would welcome correspondence via letter or Email: [email protected]

The Need for Research to Underpin clinical services for this age group, can be Therapy with Children and Play rigorously assessed.” Therapy (Target & Fonagy, 1996) “Research on the effectiveness of therapies The Precedent for Research for children has lagged far behind that on the treatment of adults...It is very important that research studies reflect the balance of The government White Paper 'The Health of clinical provision more closely, so that the the Nation' (Department of Health, 1992) effectiveness of psychodynamic and family emphasised that the planning of health services therapies, both very widely practiced in should be based on research evidence. Mental health was one of five key areas that were identi- Correspondence to: Chris Daniel-McKeigue, fied as needing to be addressed. With specific Liverpool Hope University College, Liverpool, regard to child and adolescent mental health it England, L16 9JD. was recognised that childhood disorders can 47 TRANSFORMING THERAPY INTO RESEARCH 48 'have serious implications for adult life' (ibid: Braverman, 1997; O'Connor & Schaeffer, 83) if not treated. Furthermore, a subsequent 1994), which is augmented with references to review of psychotherapy provision in England research into the use of play therapy in short commissioned by the Department of Health term interventions, for example in filial therapy found that 'psychological disorders in children where parents are taught to use the basic play are very common, and children are less likely to therapy principles (Landreth, 1991). recover spontaneously than has traditionally Carrol (2000) conducts a review of the litera- been supposed' (Department of Health, 1996; ture pertaining to the evaluation of therapeutic DOH, 1996). Given the pervasive nature of play, a wide net that includes play therapy. childhood problems it is surprising that this Apart from narrative case studies only three review also found that 'research on the effective- studies are referenced that relate to play therapy. ness of therapies for children has lagged behind The findings are not judged by Carrol to be par- that on the treatment of adults' (ibid:51). ticularly helpful: the first example, Reams & The necessity to conduct specific research on Friedrich (1994) is conducted by students who treatments with children was justified because of were neither experienced nor qualified in play the significant differences in comparison with therapy. A study by Nicol et al (1988) uses approaches used with adults. These key differ- insufficient measures to effectively assess ences were outlined as being the involvement of whether change had occurred. The final study, parents/guardians in the decisions and support Wilson and Ryan (1999) is reported to have pos- of treatment, actual involvement of parents and itive results but is only an introductory investi- siblings in treatment and also that the 'range of gation conducted by trainee play therapists. techniques used is broader and will include the Carrol (2001) recommends that the text by use of play, art and other creative activities and Gitlin-Weiner et al (2000) contributes to the place less reliance on talking, especially with research base, however whilst the studies cited younger children' (ibid:35). are directly related to play they are not specifi- cally connected to the practice of play therapy by Play Therapy Research qualified therapists. I conclude that research conducted by qualified It is clear that there is a need for research to and experienced play therapists is rare and insuf- underpin the practice of therapy with children. ficient to provide an adequate evidence base to However research within the creative arts thera- the play therapy approach. Records of case stud- pies as a whole, is scarce (McNiff, 1998; Payne, ies are more readily available and contribute to 1993). This is especially true of play therapy. the foundation of the therapy but they do not The seminal British texts (Cattanach, 1992; have the same objectivity as data collected from McMahon, 1992; West, 1992; Wilson, a research study which influences their validity. Kendrick, & Ryan, 1992) largely rely on anec- dotal evidence and case studies to underpin Research and Innovative Practice practice. Subsequent publications that explore the therapeutic dynamic in more detail are illus- The Royal College of Physicians make a useful trated with detailed narrative case studies distinction between the data gained from (Cattanach, 2002; Ryan & Wilson, 2000). research and practice that heralds from the Looking to our American counterparts we find a intent of the intervention. similar trend (Axline, 1989; Landreth, 1991, 2001; O'Connor, 2000; O'Connor & 49 C. DANIEL-MCKEIGUE

"The distinction between medical research and “Research can serve as a basis for informing innovative medical practice derives from the practice by testing theoretical propositions intent. In medical practice the predominant about the processes underlying clinical prob- intent is to benefit the individual patient con- lems and their modification and, more directly, sulting the clinician, not to gain knowledge of by testing the effects of treatment on clinical general benefit, though such knowledge may outcomes. Central features of research (e.g. emerge from the clinical experience gained. In explicitness of procedures and methods, repli- medical research the primary intention is to cation across researchers and sites) overcome advance knowledge so that patients in general some of the frailties of judgment, even though may benefit: the individual patient may or may research itself has its own frailties.” (Kazdin, not benefit directly" (1996:6,4). 1996:v).

No parallel distinction is made between the The Challenge of Research usefulness of the information from either source. Does the knowledge gained from inno- It is over ten years since the government direc- vative practice with an individual have equal tive to underpin therapy practice with research validity to knowledge gained from research evidence. Play therapy has yet to respond by where the intent was to benefit clients in conducting and publishing an investigation. It is general? interesting to note that in contrast to individual The play therapy approach is underpinned by psychotherapies, behavioural and cognitive innovative practice in the same way as the roots behavioural therapists have been found to con- of adult psychotherapy in the 19th century were duct more systematic studies with children to from interventions with clients recorded princi- evaluate the effectiveness of their approach pally by practitioners such as Freud and Jung: (Target & Fonagy, 1996:318). There is a simi- 'the case study approach set a standard for lar trend within adult treatments for depression reporting treatment, evaluating its effects, and and eating disorders (Roth & Fonagy, making decisions of what to apply to whom' 1996:100:182). Is it the nature of the thera- (Kazdin, 1996:v). Play therapy may not be peutic approach that lends itself to investigation? clearly evidenced by research studies but evalua- tion is key to the process. This is conducted “Behavioural and cognitive psychotherapies are both by the therapist and in partnership with psychological approaches which are based on another professional with a clinical understand- scientific principles …clients and therapists ing of the nature of the work through the pro- work together to identify and understand prob- cess of supervision. This model of consultation lems in terms of the relationship between is acknowledged without exception by the thoughts, feelings and behaviour…this then British authors cited earlier as pivotal to the leads to the identification of personalised, time- limited therapy goals and strategies which are approach. Indeed it is recognised by the British continually monitored and evaluated.” (British Association of Play Therapists as central in their Association for Behavioural and Cognitive code of ethics and practice (2002). The super- Psychotherapies, accessed on line April 2003) vision dynamic contributes to the strength of the approach and adds an objective perspective to the therapy. However it does not claim to The play therapy and cognitive behavioural fully address the affect of personal bias and can- therapy (CBT) approach differ from each other not equal the way that: in a number of ways that may affect the likeli- TRANSFORMING THERAPY INTO RESEARCH 50 hood of instigating research. Rather than focus The Child as Central to the Therapy on how the client thinks and creates meaning, the play therapy approach concentrates on feel- When dealing with unconscious material ings and acknowledges the impact of the uncon- through the process of therapy it is important to scious, in a way that the relationship between be aware of the sensitivity of the dynamic. child and therapist is central. Instead of plan- Particularly so when dealing with children as: ning and structuring the therapy a play therapist 'unlike the adult, the child rarely refers himself allows the child to direct the sessions by their for therapy' (Dorfman, 1951:263). A parent or choice of play that may not necessarily directly professional may consider it to be in the child's focus on the specific reason for referral. In both best interests and make a referral for a therapeu- therapies weekly sessions of an hour are usually tic intervention; it is conceivable that this may employed but a CBT intervention is generally happen without consultation with the child. A more short term and may take between 12-15 therapist would attempt to engage a child, gain sessions (British Association for Behavioural and rapport and give them an opportunity to choose Cognitive Psychotherapies) whereas play thera- whether to participate. As Dorfman (ibid) sug- py is usually conducted on an open-ended basis gests children 'seldom come with the desire for and is more likely to be conducted over a longer self-exploration which characterises many adult term. It is difficult to predict how long a play clients who seek help'. However whilst a child therapy intervention will be whereas a CBT may initially attend therapy at an adult's behest, therapist will establish time limits. the therapy relies on the child's natural capacity Edwards (1993) suggests that anxiety deters for self-exploration, summarised by Axline arts therapists from undertaking research but I (1989) in the eight basic principles of play ther- would suggest that it is more likely to be that the apy: therapeutic method does not easily lend itself to the rigours of scientific investigation without “The therapist maintains a deep respect incurring significant methodological changes. for the child's ability to solve his own problems if given an opportunity to do so. The child-centred therapeutic approach means The responsibility to make choices and to that it does not follow a predictable structure, institute change is the child's” (69). the focus is on feelings and unconscious materi- al that makes it difficult to quantify progress I conclude that it is the child, not the therapist with any accuracy. The fact that sessions are not who holds the key to the process. The therapy time limited but generally conducted on an does not aim to find a solution to a problem but open-ended long-term basis makes it difficult to rather to resolve issues as far as is possible. I pro- conduct a comparison between interventions. pose that this is a process of elucidation, recon- Of primary concern to a therapist would be the ciliation and harmonisation. It is not possible to impact of introducing a research dynamic to change the events that have happened in a therapy that would be in opposition to the cen- child's life, but what can be affected is their tral tenet that the therapy is child-centred. understanding of what has happened, their responses to it and their resultant behaviour. The Sensitivity of the Therapeutic Dynamic: The child may not always initiate the process of attending therapy but the therapy will only "I have spread my dreams beneath your feet, occur if they engage in the process. The thera- tread softly because you tread on my dreams" pist facilitates exploration and change by provid- William Butler Yeats, Aedh wishes for the cloths of Heaven. ing the conditions necessary by offering a sup- 51 C. DANIEL-MCKEIGUE portive relationship and a consistent environ- working to nurture a child within therapy then ment. It is vital to the process that the therapist it would seem to be a conflict of interests to respects the sensitivity of the material that the introduce a dynamic which is not strictly of ben- child brings to the session, honours the child's efit to the individual. If the aim of research is to capacity to realise change and respects the study a phenomenon with a view to finding out dynamic of the child/therapist relationship. more about current practice as a means of informing future practice, then the argument Trust in the Therapeutic Relationship could be made that this would primarily benefit subsequent clients rather than the client that is The central core of the child/therapist relation- participating in the research. The research could ship has to be trust. This must be established also be construed as of benefit to the therapist, for a client to feel free to fully express their self developing their skills, knowledge, career etc. within a session. The therapist may need to Since therapy should prioritise the client's needs compensate for the imbalance of power that has I would propose that research conducted whilst been suggested may exist between the therapist therapy is in progress is likely to represent a con- and child. Consideration also needs to be given flict of interests and may repeat the pattern of to the fact that the therapist is ultimately imbalanced power relationships that the child responsible for the child's well being within the has previously experienced. session. Additionally the therapist has a duty of care and must take into account the child's safe- Therapy and Research Ethics ty in their other environments. The focus of the therapy should be based on the child's needs; If a research project were conducted whilst this is demonstrated by the child directed nature therapy was in progress then there would be of sessions, the reflection of feelings by the ther- safeguards to ensure that the research is con- apist and the emphasis on the establishment of ducted in an ethical manner. Before a child or rapport (Axline, 1989; West, 1992; Wilson et other participant was consulted about participat- al., 1992). However to achieve this the therapist ing in a study it would be good practice to con- must balance their role as a responsible adult sult an ethics committee that would oversee an and the persona of trustworthy therapist. What investigation and ensure its authenticity. The may complicate this further is to introduce a issue of requesting consent from a minor would research element. be a hurdle and depending on the age of the I would suggest that in a circumstance where a individual a parent/guardian would be likely to therapist must be aware that it may be necessary be involved in a decision. The implications of to compensate for a power imbalance it would who is competent to give consent is only one of be difficult to introduce a research dynamic that the issues that would be crucial to resolve when involves the child without compromising the dealing with the matter of researching children relationship. Many of the children referred for in therapy. play therapy have a history of neglect, abuse or A further dilemma is how a therapist can gain trauma; they have experienced abusive relation- verbal or written consent from a child who has ships with adults in the past. It is essential that been referred for a therapy that is not based on the therapy does not repeat the previous dynam- verbal communication. The process of play ics but works to empower the child and demon- therapy does not depend on the spoken word strate that they have the capacity to form posi- but uses the language of play to facilitate clients. tive, productive relationships. If the therapist is This raises the question of how truly informed TRANSFORMING THERAPY INTO RESEARCH 52 written or verbal consent could be from a minor to suggest that the child was at risk. Introducing who has been identified as needing a nonverbal a study would inevitably challenge this boundary based therapy intervention. It would be expect- and though anonymity would be assured the ed that research participants whose language was child would not have the same level of confiden- not English would be offered a translated con- tiality. It is difficult to predict to what degree sent form. Perhaps the same entitlement could this would influence the course of the therapy be given to children, who may not be fluent and how it would affect the child's freedom to with communicating via language. Methods divulge secrets or to fully participate in the ses- could be devised of explaining and gaining con- sions. sent through the process of play. However this The balance of power is a sensitive issue with- creative approach would not fit the parameters in therapy, particularly in sessions conducted of consent forms normally approved by ethical with children. The request for consent to con- committees, which may prove to be an impedi- duct research is charged with concern regarding ment to the process. the boundaries of confidentiality, the level of In addition to the problems that communica- understanding of the child, the freedom of the tion difficulties raise in gaining consent are the child to refuse permission and the conflict of emotive aspects of the request. I would suggest interests of the therapist. Is it truly possible for that one of the major issues that children explore a therapist to adopt the role of researcher, to in therapy is self-esteem. The therapist is 'tread softly' and to leave no impression on the engaged as a neutral facilitator of the child, therapy? someone who is not involved in the child's life. To request consent to research the therapy Choosing a Methodology That Can introduces the therapist's needs and could affect Generate Robust Research Without the relationship. Some children have learned Influencing the Therapeutic Process from experience to please or pacify adults regardless of their own needs, the therapy pro- “'The 'butterfly effect': the idea that the mere cess helps to redress the balance. This equilibri- flap of a butterfly's wing can make the differ- um would undoubtedly be affected by the ther- ence between a hurricane occurring and not apist's introduction of a request for consent. occurring.” The Oxford Companion to Philosophy 1995 Not only is the therapy likely to be affected but also considering the child's reason for referral To conduct ethical research with a child client there may be doubts as to whether the child has whilst the play therapy was in progress it would the capability to refuse the request of an adult be necessary to use a study that was designed to regardless of how well they were facilitated. have the touch as light as a butterfly on the ther- apeutic process. The risk is that any intrusion Reconciling the Roles of Therapist and on the dynamic could cause a significant affect: 1 Researcher a hurricane rather than a zephyr . A play thera- py researcher would need to be sure that an investigation was planned in a way that priori- The therapeutic relationship is based on a tised the needs of the child client. Perhaps the foundation of trust. One of the parameters of dearth of research in this area of child therapy the sessions that is established from the outset is reflects the complexity of this issue. There is a that the content is confidential and that this pri- danger that a study that was designed to be sen- vacy would only be broken if there was anything sitive to all the issues may not significantly add 53 C. DANIEL-MCKEIGUE to the body of knowledge. Alternatively the therapy baselines using questionnaires as part of therapeutic method may be dissected in such a a longitudinal investigation. However to truly way that the results pertain to therapy that has comment on the practice of play therapy with been researched, rather than the natural process. regard to process it would be helpful to view the Target and Fonagy (1999) contradict this and therapy as it is in action. What seems clear is state that conducting research with children in that the integrity of the therapy is highly signif- therapy is a challenge but that the research only icant; a methodology would need to be sympa- affects a small number of clients and suggest that thetic to the therapeutic process and be consid- 'monitored treatments have superior out- ered the least invasive. It would be difficult to comes…it seems that perhaps we are more rig- consider the individual needs of clients if a large orous, motivated and effective when we know sample size is used, or if any attempt to stan- our work is scrutinised'. I am concerned that dardise the therapy is made. Since the context this argument suggests that therapists' work is and integrity of the material are central to the more effective when they are under the analysis enquiry then a qualitative approach could be of a research study. For a play therapist regular considered (Parker, 1994). Such a methodology supervision should fulfil the role of regular usually focuses on a relatively small sample size, scrutiny. Perhaps also the positive outcomes of the researcher would be central to the study and monitored treatment could also be attributed to the search is for a greater understanding of the the fact that clients too are affected by participa- phenomenon and the nuances rather than a tion when part of an investigation. fixed truth. An action research approach (McNiff, Lomax, In aiming to find a research methodology that & Whitehead, 1996) to a study would purport has little impact on the therapy and is compati- to serve the interests of the client that was ble with the play therapy approach I conclude involved in the study as any findings could lead that a qualitative perspective may be congruent. to the instigation of changes that would benefit Rather than rely on large numbers of clients the client involved in the research. Technically where the individual case is lost in numbers the this method is intended to benefit the profes- data is generally derived from a relatively small sional practice that it investigates. However it sample. The exception is not dismissed as an would be difficult to measure the affect that the anomaly, but included and examined as signifi- intervention itself had on the therapy. A study cant. It is important that the methodology of conducted retrospectively could engage child choice has the least influence on the process. In clients following the completion of therapy; this the same way that the needs of the client must be would not interfere with the natural therapeutic the priority for the therapist, the needs of the process but comment on it following termina- client could be a priority within a qualitative tion. There are other research approaches that methodology. It would not be necessary to could be engaged that would not include the implement standardised methods for the sake of child whilst the therapy is in progress but that the research. In conjunction with the safe- would comment on the therapeutic process. guards to ensure ethical research it could be jus- Unobtrusive measures as described by Robson tified to engage in research that does not intrude (1993) that rely on documentary evidence and on the therapeutic relationship but would effec- data archives could be employed, for example tively comment on the process. using available literature in a meta-analytic review of case studies. If time was not an issue then it could be possible to conduct pre and post TRANSFORMING THERAPY INTO RESEARCH 54 Transforming Therapeutic Process to the rigours of investigation using methodolo- Into Research - The Search for gies that have the gentle touch of a butterfly's wing and the affect of a zephyr. Alchemy “You are an alchemist; make gold of that”. Notes William Shakespeare, Timon of Athens 1Zephyr was the Greek god of the west wind. ActV Scene i. The gentlest wind, Zephyr was known to have a sweet breath that caused flowers to grow. In The early alchemists attempted to convert lead common parlance a zephyr describes a refreshing into gold, trying to achieve the metamorphosis light breeze. of one medium into another. Their unsuccess- ful efforts seem to mirror the dilemmas faced by Acknowledgements play therapy researchers whose aim is to trans- Thanks are due to Dr Sam Warner for her help- form the therapeutic process into a research ful comments on an earlier draft of this paper. dynamic. The additional quandary for thera- pists is to achieve this transformation without compromising the integrity of the therapist or References unduly affecting the therapy. The practition- er/researcher's dilemma is to transform one Axline, V. (1989). Play Therapy. Edinburgh: medium into another without causing an undue Churchill Livingstone. affect. British Association for Behavioural and Cognitive It is interesting to note that as the science of Psychotherapies. A Guide to Understanding Cognitive and Behavioural Psychotherapies. Retrieved 20th April, alchemy developed the process became con- 2003, from the World Wide Web: cerned with bringing about a mysterious inner http://www.babcp.com/ transformation process within the human psy- British Association of Play Therapists. (2002, June che rather than a quest to turn base metal into 2002). British Association of Play Therapists Ethical riches. It was the work of later alchemists that Basis for Good Practice in Play Therapy. BAPT. guided Jung to understand a recurring dream Retrieved April, 2003, from the World Wide Web: (Jung, 1978:40) and led him to continue to http://www.bapt.uk.com/ethicsandpractice.htm develop his ideas regarding symbols and to deep- Carroll, J. (2000). Evaluation of therapeutic play: a en his understanding of the collective uncon- challenge for research. Child and Family Social Work, 5, 11-22. scious and archetypes. Alchemists believed in Carroll, J. (2001). Play Therapy. London: National the unity of all existence. Perhaps in the same Children's Bureau. way it could be possible to unify the role of prac- Cattanach, A. (1992). Play Therapy with Abused titioner and researcher. If the core values of Children. London: Jessica Kingsley Press. therapy remain constant and the codes of ethics Cattanach, A. (Ed.). (2002). The Story So Far: Play are adhered to, then the introduction of a Therapy Narratives. London: Jessica Kingsley Press. research dynamic need not necessarily unduly Department of Health. (1992). The Health of the affect the therapy. Nation: a strategy for health in England: HMSO. In the spirit of alchemy we need to release 'the Department of Health. (1996). NHS Psychotherapy Services in England: Review of Strategic Policy: HMSO. spirit of things from their leaden literalism' DOH. (1996). NHS Psychotherapy Services in (Romanyshan, 2000). We must liberate play England: Review of Strategic Policy: HMSO. therapy from its reputation of not being ade- Dorfman, E. (1951). Play Therapy. In C. R. Rogers quately underpinned by research and submit it (Ed.), Client-centered therapy: its current practice, 55 C. DANIEL-MCKEIGUE implications and theory. Boston: Houghton Mifflin. Blackwell. Edwards, D. (1993). Why Don't Arts Therapists Do Romanyshan. (2000). Alchemy and the subtle body Research? In H. Payne (Ed.), Handbook of Inquiry in of metaphor: soul and cosmos. In R. Brooks (Ed.), the Arts Therapies. London: Jessica Kingsley. Pathways into the Jungian World. London: Routledge. Gitlin-Weiner, K., Sandgrund, A., & Schaefer, C. Roth, A., & Fonagy, P. (1996). What Works for (Eds.). (2000). Play Diagnosis and Assessment (Second Whom: A Critical Review of Psychotherapy Research. ed.). New York: John Wiley and Sons, Inc. New York: The Guilford Press. Jung, C. (1978). Approaching the Unconscious. In Royal College of Physicians. (1996). Guidelines on the C. Jung (Ed.), Man and his Symbols (Second ed.). Practice of Ethics Committees in Medical Research London: Pan Books. Involving Human Subjects (3rd ed.). London: Royal Kazdin, A. E. (1996). Foreword. In A. a. F. P. Roth College of Physicians. (Ed.), What Works for Whom: A Critical Review of Ryan, V., & Wilson, K. (2000). Case Studies in Non- Psychotherapy Research. New York: The Guilford directive Play Therapy. London: Jessica Kingsley Press. Press. Target, M., & Fonagy, P. (1996). The Psychological Landreth, G. L. (1991). Play Therapy: The Art of the Treatment of Child and Adolescent Psychiatric Relationship. Florence, USA.: Accelerated Disorders. In A. Roth & P. Fonagy (Eds.), What Development. Works for Whom: A Critical Review of Psychotherapy Landreth, G. L. (2001). Innovations in Play Therapy: Research. New York: The Guilford Press. Issues Process and Special Populations. Philadelphia: Target, M. P., Fonagy, P., & et al. (1999). Research Brunner- Routledge. Summary: The effectiveness of Psychodynamic and McMahon, L. (1992). The Handbook of Play Therapy. Cognitive-Behavioural Therapies for Children with London: Routledge. Severe, Complex Emotional Disorders. [Internet]. Anna McNiff, J., Lomax, P., & Whitehead, J. (1996). You Freud Centre. Retrieved 20.11.02, from the World and your action research project. London: Routledge. Wide Web: http://www.annafreudcentre.org McNiff, S. (1998). Art-Based Research. London: West, J. (1992). Child-centred Play Therapy. London: Jessica Kingsley Press. Edward Arnold. Nicol, A. R., Smith, J., Kay, B., Barlow, J., & Wilson, K., Kendrick, P., & Ryan, V. (1992). Play Williams, B. (1988). A focussed approach to the Therapy: A non-directive approach for child. London: treatment of child abuse: a controlled comparison. Balliere Tindall. Journal of Child Psychology and Psychiatry, 29, 703- Wilson, K., & Ryan, V. (1999). Evaluation of the 711. effectivenes of non-directive play therapy:developing O'Connor, K. J. (2000). The Play Therapy Primer a methodology for evaluating the process and out- (Second ed.). New York: John Wiley and Sons Inc. comes of time-limited interventions with troubled O'Connor, K. J., & Braverman, L. M. (Eds.). (1997). children. International Journal of Play Therapy. Play Therapy: Theory and Practice. A Comparitive Presentation. New York: John Wiley and Sons Inc. O'Connor, K. J., & Schaeffer, C. (Eds.). (1994). Handbook of Play Therapy. Volume Two Advances and Innovations. New York: John Wiley and Sons Inc. Parker, I. (1994). Qualitative Research. In P Banister et al (Ed.), Qualitative Methods in Psychology. Buckingham: Open University Press. Payne, H. (Ed.). (1993). Handbook of Inquiry in the Arts Therapies. One River, Many Currents. London: Jessica Kingsley Press. Reams, R., & Friedrich, W. (1994). The efficacy of time-limited play therapy with maltreated preschool- ers. Journal of Clinical Psychology., 50, 889-899. Robson, C. (1993). Real World Research. Oxford: Bri. J. Play Therapy, Vol. 1, No. 1, pp. 56 - 65, 2004. © 2004 British Association of Play Therapists (BAPT). Printed in Great Britain. All rights reserved. Non-Directive Play Therapy: Should we and can we attempt to measure its effectiveness? Angie Naylor Edge Hill University College, Lancashire, England This theoretical paper explores and discusses the ways in which the effectiveness of non- directive play therapy should or can be measured. Non-directive play therapy is often used as an intervention for children presenting a variety of concerns, but it has long been criticised for a lack of adequate research to prove its efficacy. The need for a mea- surement of the outcomes of play therapy is questioned. Contemporary discourses of childhood and child abuse are discussed in relation to research with children. The arti- cle considers whether scales and measurements are reliable, ethical and viable options within play therapy research. The subjectivity and interpretative issues around mea- surements and the difficulty of being able to obtain significantly large enough sample sizes to draw general conclusions are highlighted. The author concludes that there is a need for a different approach to measuring the outcomes of play therapy.

Introduction toys and play to communicate. Play has the power not only to facilitate normal child devel- This theoretical paper aims to explore and dis- opment, but also to alleviate abnormal cuss the ways in which the effectiveness of non- behaviour. Play can help overcome resistance; directive play therapy should or can be mea- build competence; enhance self-expression, sured. There is increased pressure on play thera- problem solving, role taking, and creativity; and pists to provide evidence of the process and out- provide an opportunity for abreaction, catharsis, comes of play therapy (Carroll, 2000). This arti- attachment formation, and alleviation of fears. cle attempts to initially question and address In addition, the positive emotions that occur some of the issues around the need for a defini- during play can help to build resiliency in chil- tion of 'success', 'child abuse' and 'childhood' as dren (Reynolds & Stanley, 2001). social constructions. It seeks to highlight the Recovery from difficult life experiences can be qualitative versus quantitative debate in ques- facilitated by a play therapist allowing a child tioning the use of scales and measurements as freedom of expression in a safe and trusting envi- reliable, ethical and viable options in assessing ronment. Play therapy is commonly used for the outcomes of non-directive play therapy. children who have been referred for therapy due Play therapy is based on the rationale that play to difficult life events, which may include some is a naturally occurring phenomenon in children form of 'child abuse'. It can offer such children a (Reynolds & Stanley, 2001). Because children space in which the feelings the experiences gen- under 10 have less well-developed expressive erated can be expressed and contained. Although language, they are more accustomed to using appropriate for children of all ages, it is usually used with children between 3 and 12 years of age (British Association of Play Therapists (BAPT), Correspondence to: Angie Naylor, Department of 2002). Social & Psychological Sciences, Edge Hill University In directive form, the play therapist assumes College, St Helens Road, Ormskirk, Lancashire, responsibility for guidance and interpretation, England, L39 4QP. (Email: [email protected]) 56 57 A. S. NAYLOR whereas in non-directive play therapy the thera- in such a way that it moves the process forward. pist may leave the responsibility and direction to Certain therapist responses were found to the child (Axline, 1989). Supporters of non- enhance the therapeutic nature of the relation- directive play therapy state that the approach ship. allows the child to be him or herself without fac- ing evaluation or pressure to change. The child Should we attempt to measure the is the source of his or her own growth and ther- effectiveness of non-directive apeutic change (Dasgupta, 1999 In Milner & play therapy? Carolin (eds)). But can play therapy ever be truly non-directive in its approach? Are we attempting to measure the same process? Although non-directive play therapy is often Particular factors in the non-directive process used as an intervention for children presenting a are certainly dictated such as the time slot, variety of concerns, it has long been criticised for length of session, and the room in which the a lack of adequate research to demonstrate its therapy takes place and equipment available. efficacy (Carroll, 2000). Indeed, there is In non-directive play therapy, it is argued that increased pressure on practitioners offering ther- therapists emphasise the child's ability to select apy to troubled children to provide evidence of materials that make the most sense to him or efficacy of their interventions but current her, using them to work through and resolve dif- research has not yet provided the necessary evi- ficulties in their own way and in their own time dence (Carroll, 2000). (Axline, 1989). The sessions are very much There is increasing pressure on child-welfare child-led. Wilson, Kendrick & Ryan (1992) services to be accountable for the outcomes of comment that non-directive play therapy their practices. Studies by the Department of requires the lowest degree of therapist directive- Health (1991d) indicated that all professionals ness. The main skill that is used and developed involved in child care decisions would benefit in non-directive play therapy is that of reflec- from training in the collection and use of evi- tion. dence and hence should be challenged to exam- Axline (1989) comments that the non-directive ine the values on which their views are based. play therapist must be completely accepting of Evidence-based practice seeks to ensure individ- the child, fully able to understand the implica- uals base decisions on individual children and tions of this term, be permissive so that the child families on clear, sufficient and well-recorded can be themselves and accept the child without evidence about past and present functioning passing judgement. (Department of Health, 1991d). However, it could be considered the extent to In the United Kingdom, the evaluation of prac- which the therapeutic process relies on the indi- tice has broad implications for clinical services. vidual personality of the play therapist. Darr Indeed, it could be argued that the failure to (1996) investigated the development of the ther- conduct evaluation resulted in accusations of a apeutic relationship in a non-directive play ther- lack of accountability for much of the social ser- apy setting through the use of three case studies. vices arena in the 1960s (Herbert & Harper- The evidence demonstrated that the activity of Dorton, 2002). Research and evaluation of prac- the therapist has a significant impact on the tice is necessary to inform good practice. The development of the relationship; with activity question of 'Did my client improve because of referring to the therapist's ability to be alert to my work?' is a question that must be asked sys- the messages the child is sending and to respond tematically, empirically and consistently NON-DIRECTIVE PLAY THERAPY 58 (Herbert & Harper-Dorton, 2002). be further traumatised by having to describe the Play therapists have traditionally conducted circumstances of the abuse many times to many small research studies, which have demonstrated different investigators (Colton, Sanders & the effectiveness of play therapy across modality, Williams, 2001). age, gender, clinical vs. non-clinical popula- It can also be highlighted that limited research tions, setting, and theoretical schools of thought includes the opinions and experiences of chil- (Ray; Bratton; Rhine & Jones (2001). However dren (Carroll, 2000). The UN Convention on this lack of comparability between such small- the Rights of the Child (1989) emphasise that scale studies meant that critics could challenge children have the right to freedom of speech and the utility and efficacy of play therapy as a viable opinion, to be consulted and taken account of psychotherapy intervention (Ray et al, 2001). and to challenge decisions on made on their It is often hoped that play therapy will uncov- behalf. Thus, in order to appropriately attempt er information that can used to diagnose the to assess the effectiveness of play therapy, the children's problems (Jennings, 1993). This world from the child's perspective must be could be due to the need for evidence that will addressed. Carroll (2000) reports methodologi- stand up in a court of law, such as in child abuse cal challenges in attempting to include chil- cases. Ryan & Wilson (1995) found that non- dren's opinions about the play therapy experi- directive play is particularly effective in giving ence. Evidence is contradictory in that most the court clear indications of the child's wishes, children see playing as just fun, whereas others feelings and developmental needs, with or with- were able to recognise the value of having diffi- out an explicit verbal statement. This is may be cult feelings thought about and understood. due to the fact the non-directive play therapy, Nevertheless 'having fun' may be an important by its very nature, is non-coercive and largely part of the therapeutic process. free from therapist suggestion. Turner (2000) Such advocacy for children has only seriously feels that with proper focus and professional dis- begun since the implementation of the Children cipline, play therapy has a useful and vital role to Act 1989 (Colton et al, 2001). The role of the play within court assessments. advocate, as with the play therapist, is to express However, Ryan & Wilson (2000) subsequent- the voice of the child, both to the child and ly acknowledge some disadvantages of the use of those who have the responsibility of making non-directive play therapy as an approach to decisions for the child. It may well be that rea- assessing children and young people in the care sons for working with a child are to assess, system for use in court proceedings, including enable the child to express a view, be therapeu- issues around the correct clarity and interpreta- tic or a mixture of these (Colton et al, 2001). tion of the child's communication within the metaphor of play. The guidance 'Working Can we measure the effectiveness of Together to Safeguard Children' (Department non-directive play therapy? of Health, Home Office, Department for Education and Employment, 1999) seeks to Primarily, the focus of the intervention must be ensure that everybody who works with children questioned. The most significant impact for is aware of indicators that a child's welfare is at young children on their psychosocial develop- risk. Whilst the rights of the child (United ment is often said to be the caregiving relation- Nations Convention on the Rights of the Child ship provided by their parents (Howe; Brandon, (UNCRC), 1989) mean that a child has a right Hinnings & Schofield, 1999). The quality and to testify and may in fact want to, a child may 59 A. S. NAYLOR character of the relationship may be influenced group conferences (Howe et al, 1999). Howe et by several factors, including the parents' own al (1999) maintains that psychologically, the attachment needs; parents' own relationship his- child needs to develop a strategy that gets them tory and experiences of care as a child; parents' into proximity and psychological engagement response to attachment-related issues; parents' with their attachment figure, which is the goal internal working model and mental representa- of attachment behaviour. tion of the self and others (particularly the child) Children referred for play therapy have com- and defensive strategies (Howe et al, 1999). monly experienced some form of 'abuse' Perhaps the most important focus of interven- (BAPT, 2002). The definition of 'child abuse' tion should be the parent or parents, since inse- has caused much debate in recent years. Child cure caregiving poses a major developmental abuse can be said to be socially constructed with risk to the child. its meaning arising from the value structure of a Attachment theory maintains that, within close social group and the ways in which these values relationships, young children acquire mental are interpreted and negotiated in real situations representations of their own worthiness based (Taylor, 1989 in Stainton-Rogers, Hevers & on other people's availability and their ability Ash, 1992). The difficulty for those concerned and willingness to provide care and protection with reporting child abuse can be to differenti- (Ainsworth, 1978 in Howe et al, 1999). The ate between child abuse and reasonable disci- most important relationship for the child can be pline (Colton et al, 2001). argued to be the main caregiver, who usually The National Commission of Inquiry into the becomes the child's selective attachment figure. Prevention of Child Abuse (1996, p.1) acknowl- Parents who are insensitive, rejecting, interfer- edged that technical definitions of child abuse ing or emotionally unavailable present their are need for statutory, legal, statistical, procedu- children with a psychological problem (Howe et ral and research purposes. The report of the al, 1999). National Commission of Inquiry into the Therefore in attempting to measure non-direc- Prevention of Child Abuse (1996, p.4) suggest- tive play therapy, are we measuring the child's ed less tolerance of child abuse in general, based responses to a poor attachment relationship? on a broader understanding and definition of What changes, if any, will occur in the parents? what constitutes such abuse. A broad definition Is it the child's responsibility to adapt to his or of child abuse was adopted, her environment or should the environment and the people in the child's life change in some "Child Abuse consists of anything which indi- way? Play therapy is very much a child-focussed viduals, institutions or processes do or fail to do intervention with the aim of improving chil- which directly or indirectly harms children or dren's social, emotional and behavioural compe- damages their prospects of safe and healthy tence. Social workers may work indirectly on the development into adulthood. " children's psychosocial development by offering (National Commission of Inquiry into the parents, emotional and material support; com- Prevention of Child Abuse, 1996, p.2) munity and self-help groups; improved reflec- The Department of Health (Dartington Social tive functioning via ad hoc conversational Research Unit, 1995 in Parton, Thorpe & opportunities, counselling, psychotherapy and Wattam, 1997) suggests that understanding the self-help groups; advocacy and advice and prob- importance of context helps to define abuse. lem-solving and planning skills using task-cen- The ecological model (Jack, 2001 In Foley, tred, solution-focused approaches and family NON-DIRECTIVE PLAY THERAPY 60 Roche & Tucker (eds)) emphasises that child representations of childhood must surely play a abuse is the product of the various stresses and part in the therapeutic process at all levels, from supports, or risk and protective factors that exist referral, the therapy process and the 'success' of in the child's environment. If the risk factors outcomes. outweigh the protective factors, the likelihood The representation of the sexually abused child that the child will experience some form of can be highlighted by the charity advertisement abuse is increased. But the definition of 'child by a National Children's home in the early abuse' will depend on who is doing the defining 1990s which showed a picture of an abject little and for what purpose (Jack, 2001 In Foley et al boy sitting on a bed with the message 'Kevin's (eds)). Conversely, despite these efforts, the con- Eight, but for him childhood's over.' (Gittins, cept of child abuse remains very much open to 1998, p. 9). This representation suggested that interpretation by the individual (Colton et al, contact with adult sexuality disqualifies a child 2001). from childhood. Key constructs of childhood may play a part in Thus, in attempting to assess the effectiveness, defining 'abused children'. (Parton, Thorpe & outcomes or 'success' of play therapy, forms of Wattam, 1997). Historian Philippe Aries (Aries, measurements must be considered. The quanti- 1960, 1986 in Gittins, 1998) originally drew tative versus qualitative debate has long existed attention to the idea that childhood is socially between academics and researchers in general. and historically constructed rather than innate, The quantitative position commonly disregards and that attitudes to children change over time qualitative approaches as lacking in objectivity, (Aries, 1960 in Gittins, 1998). reliability and validity (Coolican, 1999). The common ideology of the child as innocent, However, qualitative data may be more likely to hopeful and angelic ('romanticization') can be reflect human thought and action in a natural, argued to be problematic. Kitzinger (1990) (in cultural context (Coolican, 1999). Parton et al, 1997) states that innocence is a Currently, in the field of play therapy, qualita- source of 'titillation' for abusers, that notions of tive research mainly takes the form of narrative innocence 'stigmatise' the knowing child, and case studies. Narrative case studies do overcome that it presents an ideology of childhood which such problems, but there is then the issue of is used to deny children power. Such representa- attempting to make generalisations. These do tions are contradicted by discourses of 'evil' or provide ample anecdotal evidence, but there is 'corrupt' children ('original sin'); children who not, as yet, a comprehensive review of this data are violent or kill (Gittins, 1998). 'The child' nor any clear conclusions drawn (Carroll, 2000). and 'childhood' can be said to be a myth and an Narrative case studies can also be criticised for adult construction (Gittins, 1998). not being objective or providing a comparative The 'romanticization' of childhood discourse analysis of a given intervention. The difficulty suggests that we should protect children's inno- though is in producing a quantitative research cence, such as from sex or violence. In contrast design, which excludes all relevant variables and the 'puritan discourse of childhood' suggests produces unequivocal data (Carroll, 2000). that children should be carefully controlled, reg- Bratton & Ray (2000) in a review of eighty-two ulated and disciplined. Therefore adults should research studies demonstrated evidence of sever- have authority over children and should use this al researchers using traditional scales used in psy- to act in the child's long-term interests, even if it chological and educational settings, with signifi- makes the child unhappy or causes distress cant results, in attempting to measure the effec- (Stainton-Rogers, 2001). Such ideologies and tiveness of play therapy. However it must be 61 A. S. NAYLOR questioned whether these scales measuring what apy sessions. they are designed to measure. Numerous other Such studies indicate positive evidence for the (possibly unmeasurable) factors are unaccount- efficacy of play therapy intervention but the ed for such as the child's background, home life extent of these changes must be considered. and previous learning. Indeed, the majority of Indeed, contributing factors for any tick-box research findings seem to derive from studies scale could include age and general improve- carried out on children from the general popu- ment from time between completing the scales; lation rather than children who have been improvement due to the extra attention received referred by the social services for play therapy during the sessions; time in the academic year; due to presenting a range of problems. individual frame of mind on the day; investiga- The Piers-Harris Children's Self-Concept Scale tor effects; and it is not known whether these (1964) measures self-concept, which can be effects were sustained over a longer period of argued to be an important factor in how chil- time. dren feel about themselves. Significant findings The Boxall Profile Assessment Tool have been found on self-concept ratings after (Bennathan & Boxall, 2002) commonly used in exposing children to a short (10 / 12 sessions) the field of education and play therapy covers non-directive play therapy intervention (Crow, both developmental and diagnostic strands for 1990; Gould, 1980). the researcher to complete about the child. The Child Behaviour Checklist demonstrated Examples of statements include, 'Maintains significant findings when used as a measure- acceptable behaviour', 'Makes and accepts nor- ment in play therapy. Brandt (1999) found that mal physical contact with others', 'Takes appro- young children with behavioural adjustment priate care'. It can be concluded that there are difficulties who participated in 7 to 10 play serious subjectivity and interpretative issues therapy sessions improved significantly on inter- around this measurement. nalising behaviours (withdrawn behaviour, Indeed, there are difficulties and limitations of somatic complaints, anxiety / depression) as employing quantitative measurements in non- measured by the Child Behaviour Checklist. directive play therapy. These include problems Springer, Phillips, Phillips, Cannady & Kerst- with aiming to make a direct connection Harris (1992) found that children identified as between any change in skills and therapy ses- having at least one parent suffering from alcohol sions due to the contribution of other unmea- or drug dependency that participated in an surable factors. There is the difficulty of being experimental group of play activity groups expe- able to obtain significantly large enough sample rienced significant changes on depression and sizes (from the play therapy population) to draw hyperactivity as measured by the Child general conclusions (Carroll, 2002). Behaviour Checklist. Ethical considerations can often make research Several checklists were utilised in the evalua- with children, essentially in a clinical setting, tion of play therapy in emotionally disturbed difficult. Issues of confidentiality, anonymity children (Shashi; Kapur & Subbakrishna, and protection from harm (British Psychological 1999). Significant reductions of symptons were Society Ethical Guidelines, 2002) can make it reported on a child's Behaviour questionnaire, a difficult for researchers who are outside of the developmental psychopathology checklist for playroom and play therapy process. parents, a child's Behaviour checklist and a Nevertheless, a process that is essentially non- symptom-rating checklist administered before directive and free from therapist intervention and after a course of 10 non-directive play ther- NON-DIRECTIVE PLAY THERAPY 62 may find it difficult to justify 'intrusive' research The Convention on the Rights of the Child i.e. in the form of administering scales or mea- (1989) injects two fundamental challenges to surements within the playroom setting. traditional practices in respect of children Morrow (1999 In Milner & Carolin (eds)) (Lansdown, 2001 In Foley et al (eds)). Firstly, states that as well as the usual ethical guidelines, the means by which the best interests of the there are four key considerations in research child are assessed must primarily consider the with children. Firstly, children's competencies, extent to which all of their human rights are perceptions and frameworks of reference may be respected. Secondly, children must have the different at different ages, having implications opportunity to be heard. Listening to children for the consent process, data collection methods through research can be argued to be an essential and interpretations. Children are vulnerable to element in their protection. Children have expe- exploitation in interactions with adults, so adult rience and views that are relevant to the devel- responsibilities to children must be considered. opment of public policy, improving and allow- The differential power relationships between ing decision making to be more accountable adult researcher and child participant can (Lansdown, 2001 In Foley et al (eds)). become problematic at the point of interpreta- Can we attempt to measure the effectiveness of tion and presentation of research findings. And non-directive play therapy? There are potential finally that access to children has to be mediat- difficulties with employing traditional scales and ed via adult gate-keepers, and this has implica- measurements to this research due to their limi- tions for the consent process. tations. It has to be questioned whether the rea- son play therapy's effectiveness as a therapeutic Conclusions tool can be criticised is because an adequate way has not been found of measuring it. Perhaps Should we attempt to measure the effectiveness there is a need for a more holistic, child-centred of non-directive play therapy? As previously dis- approach to assessing the outcomes of play ther- cussed, there are problems and issues in apy. attempting to link a measurement to a process The concept of the child at the centre of the that is essentially non-directive and free from research process is one that is supported by the therapist intervention. Nevertheless, there is a Children Act 1989 and the UN Convention on need for play therapy to provide adequate the Rights of the Child (1989). Such legislative research to demonstrate its efficacy (Carroll, measures encourage children's voices to be heard 2000). and their opinions sought on matters that affect Children's human rights (UNCRC, 1989, them. (Morrow, 1999 In Milner & Carolin Article 3) mean that a child has a right to be (eds)). In UK social policy research, relatively examined and researched. Children have valu- few studies have been based on children's able contribution to make in respect of individ- accounts of their experiences (Morrow, 1999 In ual decisions that affect their lives and as a body Milner & Carolin (eds)). Contemporary chil- in the broader public policy arena (Alderson, dren are increasingly likely to experience a vari- 1993; John, 1996; Marshall, 1997). Lansdown ety of family settings as they pass through child- (2001 In Foley et al (eds)) adds that the welfare hood, but there is little social policy research model of childcare has perpetuated the view that into how children make sense of family life children lack the capacity to contribute to their (O'Brien, Alldred & Jones, 1996). own well-being or do not have a valid contribu- Theories of the social construction of child- tion to make. hood and postmodernist discourses of childhood 63 A. S. NAYLOR play a significant part in work with children. By that any tick-box scale would struggle to adopting particular discourses or images of chil- achieve. dren influences the way we act toward children. The competing discourses of child concern References mean that there is no moral consensus about what child abuse is and what action should be Ainsworth, M; Blehar, M; Aters, E; & Wall, S. taken (Parton et al, 1997). Such difficulties will (1978). Patterns of Attachment: A psychological not be solved by finding better checklists or new Study of the Strange Situation. Hillsdale, NJ: models of psychopathology (Dingwall, Eekelaar Lawrence Erlbaum. In Howe, D; Brandon, M; & Murray, 1983 In Parton et al, 1997). Hinnings, D & Schofield, G. (1999). Attachment A more ecological model of child abuse (Jack Theory, Child Maltreatment and Family Support. A Practice and Assessment Model. Basingstoke, UK: in Foley et al (eds), 2001), takes into account Palgrave. the child, the child's family and the environ- Alderson, P. (1993). Children's Consent to Surgery. ment in which they live as a constant process of Buckingham: Open University Press. reciprocal interaction. The behaviour of indi- Aries, Phillippe (1960) 1986). Centuries of viduals can only be fully understood by taking Childhood. Hammondsworth: Penguin. In Gittins, into account the environment in which they D. (1998). The Child in Question. Basingstoke: live. Although an ecological approach has been Macmillan Press Ltd. incorporated into the social worker's assessment Axline, V. (1989). Play Therapy. Edinburgh: framework, there is still generally a limited Churchill Livingstone. Bennathan & Boxall (2002). The Boxall Profile understanding of the impact of environments Assessment Tool. A Guide to Effective Intervention in on children and families (Jack in Foley et al the Education of Pupils with Emotional and (eds), 2001). Behavioural Difficulties: Handbook for Teachers. Research with children will undoubtedly raise (AWCEBD, Charlton Court, East Sussex, ME17 methodological and ethical issues. James (1995) 3DQ. suggests using the model of the 'social child'. Brandt, M. (1999). Investigation of play therapy with The model views children as research partici- young children. Doctoral Dissertation, University of pants comparable with adults but takes into North Texas, 1999. 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Carroll, J. (2000). Evaluation of therapeutic play: a ticipant (James, 1995). Consequently, the child- challenge for research. Child & Family Social Work. centred research should centre on the child, Vol. 5, No. 1, pp.11-22(12). allowing the child to inform, make decisions on Carroll, J. (2002). Play therapy: the children's views. and shape the research. A holistic, flexible Child & Family Social Work. Vol. 7(3), Aug. 2002, approach to research in play therapy should 177-187. determine a more accurate picture of the child NON-DIRECTIVE PLAY THERAPY 64 Colton, M; Sanders, R & Williams, W. (2001). An Children in Society. Contemporary Theory, Policy & Introduction to Working with Children. A Guide for Practice. Basingstoke, UK: Palgrave. Social Workers. Basingstoke: Palgrave. James, A. (1995). Methodologies of competence for a Coolican, H. (1999). Research Methods and Statistics competent methodology? Paper prepared for Children in Psychology. 3rd Edition. 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Scope of the Journal including references) and reports (1000 - 2,500 The British Journal of Play Therapy is a words, including references). Papers of more national journal with a focus on the theoretical than 5000 words are unlikely to be published, and research aspects of Play Therapy practice. although in some instances authors may be Its aim is to bring together the different invited to divide a longer original submission theoretical and professional disciplines involved into two or more shorter pieces. in Play Therapy and this will be reflected in the composition of the Editorial Board. 2) Refereeing: The journal will operate a policy Nevertheless we welcome submission from all of anonymous peer review. Papers will normally relevant professional backgrounds. The journal be scrutinised and commented on by at least thus aims to promote theoretical and research two independent referees (in addition to the developments in the fields of Play Therapy prac- Editor/Associate Editors) although the Editor tice. Submission of reviews, systematic reviews may process a paper at his or her discretion. The and research papers which support referees will not be made aware of the identity of evidence-based practice are also welcomed. the author(s).

The following types of paper are invited: 3) Brief reports: These should be limited to 1. Papers reporting original research findings. 2500 words and may include research studies 2. Theoretical papers. and theoretical, critical or review comments 3. Review papers, which need not be exhaustive, whose essential contribution can be made but which should give an interpretation of the briefly. A summary of not more than 50 words state of research or practice in a given field and, should be provided. where appropriate, identify its clinical implica- tions. 4) Ethical considerations: The Ethical Basis for 4. Systematic reviews. Good Practice in Play Therapy requires all Play 5. Brief reports and comments. Therapists to act in an ethical, respectful and sensitive manner. The British Association of Submitting to the Journal Play Therapists resolves to avoid all links with The British Journal of Play Therapy publishes individuals and organisations and their formal papers which make an impact on the theory and representatives that do not affirm and adhere to practice of Play Therapy. In the British Journal the principles in the Ethical Basis for Good of Play Therapy, papers are written for Practice in Play Therapy. practitioners, related practitioners and those whose work shapes practice (e.g. policy-makers, Submission Deadlines supervisors, managers etc). The British Journal Winter 2004 Issue: 15th October 2004 of Play Therapy is concerned to develop a Summer 2005 Issue: 18th March 2005 specific genre of research writing that encompasses the validity, plausibility, ethics and clarity espoused by existing research journals, but which also emphasises practical relevance.

1) Length of articles: Contributions of different For more detailed notes for contributors, please lengths are invited, including both standard comtact the BAPT Administrator or visit research/theoretical papers (3000-5000 words, www.bapt.info/journal. BRITISH JOURNAL OF PLAY THERAPY 2004VOLUME 1 NUMBER 1 MAY

Editorial Robert Dighton 4

Papers Storytelling and its application in non directive play therapy 5 D. Hutton

Play Therapy with Looked After Children: An Attachment Perspective 16 K. Robson and A. Tooby Play Therapists and the Children's Rights Movement 26 J. Carroll 'My new mum'. How drawing can help children rework their internal models of attach- 35 ment relationships in non-directive play therapy V. Ryan

Transforming Therapy into Research. Is it possible to conduct research that 47 investigates the process of play BESTtherapy without affectingPRACTICE the delicate balance of the relaGUIDELINES- tionship between the child and therapist, which is central to the therapy? C. Daniel-McKeigue FOR BAR CODING AND ISSUE Non-Directive Play Therapy: Should we and can we attempt to measure its 56 effectiveness? NUMBERING OF MAGAZINES A. S. Naylor

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