CALl FORNI A STATE UNI VERSITY, NORTHRIDGE
CRITIQUE OF LITERATURE
ON
PLAY THERAPY
A project submitted in partial satisfaction of the requirements for the degree of Master of Arts in
Educational Psychology
by
Pamela Ann Phillips
January 1986 The Project of Pamela Ann Phillips 1s approved:
- Stan Charnofsky, Plt!l:
EugenfiGig l io, P�.
r Bernard N1senholz, Ph.D., Chair (
California State University, Northridge
ii TABLE OF CONTENTS Page
ABSTRACT ...... iv
Chapter
I. INTRODUCTION ......
Statement of the Problem Purpose of the Study Definitions of Terms Questions Significance of the Study Sources of Materia 1s Procedures for Collection of Data
II. THEORISTS AND THEIR APPROACHES ...... 10
Psychoana 1yt i c Approach Structured Approach Re1 at i onsh i p Approach Nondirective Approach Limit-Setting Approach Summary
Ill. RESEARCH RELEVANT TO MAJORAPPR OACHES ...... 41
Studies Using Psychoanalytic Theory Studies Using Structured Theory Studies Using Relationship Theory Studies Using Nondirective Theory Studies Using Limit-Setting Theory Summary
IV. SUMMARY AND CONCLUSIONS ...... 60
Summary Cone 1 us ions
BIBLIOGRAPHY ...... 64
iii ABSTRACT
CRITIQUE OF LITERATURE
ON
PLAY THERAPY
by
Pamela Ann Phillips
Master of Arts in Educational Psychol ogy
Literature in the area of play therapy was surveyed, summar1zed, and organized. The h1storical approach was used in the collection of data for this study. Materials were gathered through library services and therapists in the field. The material found was divided into theory, approach, and research. Theory and approach were organized into Chapter
II. Material on research was organized into Chapter Ill.
After an extensive search of the literature, it was found that material
iv was scattered throughout books and journals. Much of the hterature dealt with either theory or practice or both, but did not include research. If research was presented, it was often not accompanied by theory.
This study provides a summary of the theory behind each of the major psychodynamic approaches, and discusses the theory and approach of the major theorists published in each area. A thorough review and summary of the research found relating to the major theories is presented.
A summary and conclusions, including research needs on outcome and process, are included in Chapter IV. An extensive bibliography is presented at the end to aide the professional, the student, and the researcher in using this study as an important reference source.
v Chapter 1
I NTROOUCT ION
Play therapy has been described as the opportunity by which a child can experience growth by using his most natural medium of expression, play
(Axllne, 1947b). Even as early as Aristotle, play was believed to have its beneficial uses. He belleved that play was an emotional outlet for anxieties (Mitchell, 1948). In the writings of Rousseau, it can be found that he believed play to be helpful in understanding and educating children.
He stressed that children were different from adults, and that they could be understood better by teachers if only the teachers would become children themselves (Lebo, 1955a).
In the early stages of child development, Piaget believed that the child must begin at the concrete level of experience before he could develop to the abstract level. Play is the medium by which the child can concretize
1 2
his emotions and then generalize them to the abstract (Piaget, 1962).
Piaget, along with Sigmund Freud, believed that the principle function of play was adaptive, in that it allowed the child to assimilate and master unique and unpleasant experiences (Schaefer, 1976). From these early bellefs, the beginnings of play as a therapeutic technique began to emerge.
The earliest uses were those of Anna Freud and Melanie Klein, who embraced the psychoanalytic approach.
From these discoveries of the therapeutic use of play, and the realization of the uniqueness of the therapeutic needs of children, professionals have adapted play into their own practices as a
learning-expressive modality (Axline, 1947b; Freud, 1954, 1951; Klein,
1955; Solomon, 1938). Adults verbalize, whereas children express themselves through feelings and explorations. Play therapy permits the child to release his feelings and to explore his environment and relationships (Allen, 1942; Axline, 1947b; Dorfman, 1965; Erikson, 1 963;
Freud, 1954; Ginott, 1 961 ).
Statement of the Problem . Although counsel ors of children will usually agree that play is an
acceptable form of therapy for children, the literature found on the 3
subject is scattered and time consuming to piece together. It is difficult to find material, especially on theory and practice. which is not outdated.
More recently, there has been more research conducted, but in the literature. it is usually isolated from theory and practice. The material deallng with theory. practice and research, ranging from books
(Allen. 1942; Axline. 1947b; Freud. 1954, 1951; Ginott, 1961) to articles
(Dorfman, 1965; Klein, 1955; Lebo. 1955a. 1953; Solomon. 1938) has been summarized and catagorized in this study.
Purpose of the Study
The purpose of this study is to summarize and complle the literature concerning the basic psychodynamic theories of play therapy, their practical applications in the field. and the research done, into a comprehensive summary.
Most material on play therapy deals with either theory, practice and recently more research. but there have not been any clearly organized studies done to present the major theories and to correlate these with their actual use by therapists in the field. Also. the current research has not been tied together to support these theories. or to produce evidence to support new findings related to these theories. The purpose of my study is 4
@ '
to organize the literature on playtherapy into useable material, that is,
material which is tied together in one study to be used by students, professors, professionals or others interested in the theory, practice and research of p 1 ay therapy.
My intent is to present a chapter which includes a discussion of the major psychodynamic theories, and the various practical approaches used by authorities in the field. I will cite references and major contributors in each field. The next chapter will deal with research. This will be organized into sections of research dealing with the different theories, and studies done to promote new findings in the area of play therapy. My
last chapter wil l provide a summary, conclusions, and a look at future uses of and developments in the field of play therapy. A thorough bibliography wil l be presented at the conclusion of the study.
Definitions of Terms
The term childtherapy 1s used to describe all therapeutic work done with children, no matter what theory or practice is used.
Play therapy is defined as the therapeutic use of play in an equipped play therapy room with a play therapist present.
The play room is defined as a room equipped with a variety of specially 5 selected apparatuses, toys and materials which the child can use as a medium of expression.
The term individual playt herapy is used to describe therapy which occurs in the play room with one child in the presence of a play therapist.
The term group playtherapy is used to describe therapy which occurs in the play room with more than one child in the presence of one or more play therapists.
Areas of emphasis are the facets of the play experience which influence process and outcome. The areas explored in this study are:
a. Theoretical position of the play therapist
b. Specific techniques used by each play therapist
c. Process
1. Stages of the play process
2. limits set during play
3. Key elements used (modeling, mirroring, etc.)
4. Equipment
5. Famfly interactions
6. Setting
d. Types of children treated
e. Duration of therapy
f. Termination and outcome 6
Questions
Similar areas of emphasis are generally used by therapists and writers
in addressing the field of play therapy. In analyzing the information gathered, the important questions considered were:
1. What are the major published theories and how do the major therapists tn each area differ in their own approaches to each of the areas of emphasis defined above?
2. What research has been done to substantiate each of these theories and support the practice of therapists in each area of emphasis?
Significance of the Study
Play therapy is recognized as a form of therapy for treating emotionally and /or socially malajusted children (Axline, 1947b), but little has been done to compile the diverse array of literature in this area.
Theory, practice and research are rarely tied together to form a comprehensive, indepth look at the significance of the field. Usually, theory and practice are tied together, but research is not included to support it, or research will be disclosed and tied in with practice without attempting to integrate this with theory. More and more literature is 7
being produced and research conducted without any attempt to provide a clear, comprehensive picture of this vast, expanding field. The professional or student attempting to do research, or any party interested in the field, has to do an extensive amount of searching and reading of literature to find the material pertinent to their area of research or interest.
This study contains an organized approach to the theory, practice and research of play therapy. It will provide an important reference source for the professional, the student and the researcher. It will assist those new to the field with an overall look at basic theories. It will provide an excellent reference source for the professional seeking rel ated information in a specific area of interest or concern which may relate to his practice. It will also provide the researcher with background information necessary for the implementation of studies conducted in the future.
Sources of Materials
Materials gathered for this study are limited to those I was able to locate through Education Resource Information Center (ERIC), Education
Index, Psychological Abstracts, Dissertation Abstracts, Child Development 8
Abstracts and Bibliography, bibliographies, journals, textbooks, and
suggestions by selected therapists in the field of play therapy. Data were
gathered from the libraries at the University of California at Santa
Barbara, Callfornia State University at Northridge and through the
inter-llbrary loan system. In addition, materials were collected through
Ventura County Library Services, and from local therapists in the field. It
is assumed that the above named sources have provided access to a comprehensive amount of data on the subject.
Procedures for Collection of Data
The historical approach was used for the collection of data. Materials were gathered through library systems as well as therapists currently working in the field of play therapy. Bibllographies were collected from books and articles on play therapy as well as from the therapists
contacted. These bibliographical entries were collected from an ERIC search of Current Index to Journals in Education and Resources in
Education, Psychological Abstracts, Dissertation Abstracts, Child
Development Abstracts and Bibliography, Education Index, and Government pub licat ions. 9
The combined bibliographies were taken to the library for further research. Books and articles were read, and pertinent information was summarized on index cards. Many articles were partially or entirely xeroxed for future reference. The material was then organized into three major areas: theory, practice and research. Theory and practice developed into Chapter II, while research was separated into Chapter Ill. Chapter II
THEORISTS AND THEIR APPROACHES
This chapter wi11 deal with the llterature concerning five major areas of psychodynam ic theory development: psychoanalytic, structured, relationship, nondirective, and limit-setting.
The various approaches of play therapy have been focused on different functions. Psychoanalytic, structured and relationship theories all center around play as a form of communication. Children expose their inner selves through play and are assisted by the therapist in resolving conflicts and disturbed emotions. Nondirective therapies center on the child with no direction by the therapist, in the belief that the child has the inner desire
to be healthy, and given the right environment, will naturally resolve any
imbalances. Then, the limit-setting therapies focus on play as a medium through which other techniques, such as catharsis through symbolism, can
10 ll
(l ' be applted.
Psychoanalytic Approach
Sigmund Freud appears to have been the first to apply psychotherapy to chlldren. He believed that child's play should be decoded, and stressed the use of objects as a way of understanding feelings. He did not however work directly with chtldren. His interest was directed more toward observation as a means of explaining personality dynamics and development (Freud, 1938). An example of this can be found in his work
Analysis of a Phobja in a Five-Year-Old Boy ( 1932), where he provides the boy's father with ways of helping Utt1e Hans work through his conflicts and fears which are reflected in his phobic reactions. This case is considered the foundation from which interventions with children through their parents and play were developed. Further indepth study on this theory can be found in The Basjc Writings of Sigmund Freud (freud, 1938).
A brief summary, found in the work of Kessler ( 1966), is presented here:
1. Psychic determinism is the sine qua non of all theories of
personality development. Every thought, feeling, or action has a couse,
and can be understood in terms of antecedent conditions.
2. The same principles of behavior operate, under different 12
conditions and to a different extent, in both normal and disturbed
individuals. The difference between the mentally il l and the normal is
a difference in degree, not of kind.
3. Psychoanalysis established the tremendous power of repressed
thoughts and feelings. Children have an unconscious storehouse of
memories and feelings.
4. Anxiety and the mechanism of defense against it are a major
cause of repression to unconsciousness and account for much of what
seems irrational and unrealistic. This anxiety can arise from inner
conflict as well as from conflict with the outside world. This concept
is necessary in the understanding of neurosis.
5. There is abundant evidence of the importance of past events in
present behavior, but psychoanalytic investigations demonstrated the
long arm of unconscious memory, reaching back to the first five years
of life.
6. Sexual feelings and conflicts in early childhood are particular
sources of difficulty, whether the reasons for these are biological,
environmental, or a conbination of both. (pp. 9-1 0)
The work of von Hug-Hellmuth, in 1919, is believed to be the first use of play in the therapeutic setting. Though her use of play was not 13
considered a play technique, she used play as a substitute for free association by arranging the play rather than waiting for spontaneous situations to develop. She also tried to become familiar with the child's natural surroundings and view him in his own environment (Hug-He11muth,
1929).
Anna Freud and Melanie Klein later used Sigmund Freud's analytical be11efs in developing their own distinct theories. They basically differed in their bellefs regarding the development of the ego, superego, and in their methods of analysis. They also put their theories to practical use in varying ways. In the 1920's, Anna Freud began her work with children, and moved to Vienna in 1938 to develop her practice and teaching into the
"Vienna School of Child Psychoanalysis" (Freud, 1951 ). Melanie Klein began her work in Berlin, but five years later, in 1926, moved to London to develop her techniques into the "English School of Psychoanalysis" (Klein,
1932).
AnnaFreud
Theory
The roots of Anna Freud's work with children stem from basic psychoanalytic beHefs, but she did not focus on theory or techniques as much as she centered on the child. She believed that modifications and 14
adjustments of analytic methods were necessary. Her reasoning for this came from her realization of the differences in the needs of adults as apposed to the needs of children (Freud, 1928).
She stressed the need for wooing the child, and establishing a strong rapport, almost a dependence on the therapist. She saw this as a pretherapeutic stage, which allowed the ch11d to develop confidence in the therapist, to gain insight into the trouble, and to own the decision for analysis rather than letting the decision lie with the adults. This would allow the child to be analyzed on much the same grounds as an adult. In adult analysts, the client allys himself with the therapist against the troublesome part of his being, and thus the child, in much the same way, should develop this strong dependence on the therapist in order that analysis might be carried out in the presence of this strong transference
(Freud, 1928, 1954).
Practice
In the practice of her theory, she used three basic techniques derived from the school of psychoanalysis: history taking, dream interpretation, and free association. A history of the child was taken from the parents instead of directly from the cllent's memory, as would be done with adults. This was done because of the child's focus on the present, and the 15
limited amount of time the child could derive a memory from. Dream interpretation and free association were also adapted for use with children. She stated that a child dreams no less than nor more than an adult, and by becoming fully involved with the child, she pursued the dream to its origins. In free association, she encouraged the child to verbalize daydreams or fantasies, and suggested that the child try to visualize, or see pictures. Toys were also used to help the child express himself, and allowed her to observe various reactions in relationship to things and people represented by the toys (Freud, 1951; Murphy, 1960; Schaefer,
1983).
Anna Freud's abtlity to adapt psychoanalytic theory to her practice with children provided major contributions to the area of child therapy. The use of play in her interactions with children allowed this adaptation to create a positive, successful means for working with troubled children.
Melanie Klein
Theory
Whereas Anna Freud advocated play as mainly a medium through which she could build an alliance with her young client, Melanie Klein used play as a direct substitute for verbalization. She believed that the young child's verbal skills were not fully developed enough to express the 16
complex thoughts and feelings that the child was possible of experiencing,
and considered play to be the child's natural form of expression (Klein,
1932).
Klein believed that analysis was beneficial for all children. Her basis for this came from her ·be 1ief that the ch i1 d experiences comp 11cated psychological conflicts (Kessler, 1966). She stressed that the Oedipal complex exists in the first year of life, and that a harsh, cruel superego develops in the second quarter of the first year before the resolution of the Oedipal complex. Thus, a complicated psychic system develops, and the child is capable of highly sophisticated fantasies.
Klein based her studies on the mother-child fantasies, and the strong
love drive accompanied by destructive tension. These studies included an emphasis on the use of the play of opposites in the understanding of the object relationship. She believed that the child divides the world into good and bad objects which represent the protective and aggressive tendencies. During states of crisis, the presence of an aggressive tendency causes the chlld to unconsciously strive to repair any imaginary
injury he thinks he has caused his mother. Klein believed that to maintain good mental health, it was necessary for the child to undergo early analysis (Klein, 1932, 1955). 17
Practice
Melanie Klein, unlike Anna Freud and her need to develop a close bond with the child , had no introductory stage. She began her sessions with direct interpretations of the child's behavior. During her sessions, she used three key elements from the psychoanalytic approach: free association, exploration of the unconsious, and analysis of the fransf erence.
Her use of free association consisted of interpreting the preconscious and unconscious meaning of each of the child's play activities. She stressed both the use of toys and dramatics in discovering the fantasies, anxieties, and defenses of the chlld. Klein's method of interpretation of the child's behavior through actions and words would compare with the psychoanalytic technique of free association used with adults who would express themselves in a predominantly verbal manner.
In her exploration of the unconscious, Klein would observe a play situation, then conclude and interpret what the child's use of certain toys and movements meant to the child. She would express this to the child who would then realize that the toys stood for people and that the actions he created stood for his feelings toward those people. She believed that the chi 1d would gain insight into the idea that part of his mind was 18
unknown to him, and would begin to reahze the nature of the work that the analyst was doing with him. This was her way of establ ishing the analytic situation.
Klein, in keeping with the beliefs of Sigmund Freud, believed that the child tranferred his early experiences, feellngs, and thoughts onto his parents, then onto others. In this case, the analyst would be the object of the transference, and would be able to analyze the past as we11 as the unconscious part of the mind. Through reexperiencing early fantasies and emotions, and being able to connect these to his parents, the child would be able to rework these relations and diminish his anxieties (Klein, 1932,
1 955).
Structured Approach
Though they differ sltghtly in their approaches, the four major theorists in this area include Gove Hambridge, David Levy, J. C. Solomon, and Jacob Conn. Hambridge defined 1t as a technique used w1thin the playroom in which the therapist was responsible for developing a series of specific stimulus situations which the ch11d would carry out
(Hambridge, 1955). Levy called this type of therapy "release therapy"
(Levy, 1938), Solomon referred to it as "active play therapy" 19
(Solomon,1938), and Conn saw it as the "play interview" (Conn, 1939). The
basic theories behind each man's approach are so similiar, that they are combined in the next section. Each theorist's approach is then explored under a separate heading.
Theory
Structured therapy was derived from the psychoanalytic school of thought. The main similarity is the therapist's responsibility for a major part of the therapeutic experience. The belief here is that the therapist knows more about the needs of the child and is capable of determining what is best in the way of running the therapeutic sessions. The sessions
are controlled, and the chi ld plays out situations which will bring about
the best opportunity for catharsis and abreaction of certain feelings.
Their belief is that through catharsis and relearning, the child can
reconstruct the areas which have deterred development.
Solomon stands out as having made one very important addition of his own to this theory. Ego development was a primary concern of Solomon's.
He believed that if the ego had developed properly before the onset of a
traumatic situation, then the prognosis would be positive (Solomon, 1955). 20
Approach
David Levy
Levy developed a technique ca11ed "release therapy" to deal with ch11dren who had experienced a traumatic situation (Levy, 1938, 1939).
His emphasis was on recreating the incident through play, using materials and toys he provided. He usua11y provided only the toys which he thought would help in the recreation, but the child was not forced into any specific play events. Levy wanted the child to recreate the situation over and over again until he could assimilate the negative thoughts and feelings associated with the event. This type of therapy was derived from Sigmund
Freud's idea of repetition compulsion.
Levy divided release therapy into two kinds: specific release therapy and general release therapy. Specific release therapy was used when three very definite conditions existed: the child had had the symptom for a short duration, the child was under ten years of age, and the problem was not complicated by family interactions. The sessions would begin with free play, where the child could become familiar with the new surroundings and the therapist. When he felt it was appropriate he would begin to ask questions and introduce play materials for the reenactment of the specific situation. ------
21
General re lease therapy was used when the child's problems had
stemmed from too many demands made at too early an age. Levy would not
use structured events, but would use it to modify social behavior or to
release aggression.
J, C. Solomon
Around the same time that Levy was developing release therapy,
Solomon was developing a technique called "active play therapy" for use
with acting-out, impulsive children (Solomon, 1938, 1940}. He felt that if
the chlld could act out the rage or fear he was experiencing, it would have
an abreactive effect, because the child would be in a safe environment
where the negative consequences expected would not material lze. He not
only used this technique for direct therapy, but he also used it as a
diagnostic tool and a research device.
Solomon bel ieved that the child could also redirect the previously used
negative energy into more socially acceptable behaviors. He stressed the
necesslty for the child to differentiate between present situations and
concern over past anxieties and future consequences.
He saw the first stage of therapy as one where fantasies were traced
back to the actual history of the child. This permitted a base from which
the chlld could experience pleasures along with negative aspects of the 22
event. It allowed the child to realistically face the problem with new, more positive solutions.
Solomon used dolls to represent significant others, including one for himself. He be lieved that the child might verbalize more easily through the dolls rather than face-to-face with the therapist. He also thought that practicing verbalization with the dolls would be helpful in the transferance of verbalizations to others.
Goye Hambrjdge
Hambridge·s techniques were very similar to those of Levy, but
Hambridge used a much more structured approach. He set up a very specific play setting, in which the actual traumatic event was reenacted
(Hambridge, 1955).
In the first stage of the play process, Hambridge established a positive relationship wlth the child, and he made sure that the child had developed sufficient ego resourses before continuing on with the reenactment. This would help prevent the child from experiencing flooding, and the regression and scattered emotions which accompany it.
During the sessions of reenactment, he allowed the child to choose materials which were additional to the ones he had chosen for it. He belleved that an adequately equipped playroom, with clinically acceptable 23
materials, was very important. This would allow the child to make selections which were significant elements of the play session.
After the reenactment had been worked through, Hambridge would make sure that the child was allowed free time. This would give the child time to come together before leaving the playroom, and entering a less safe environment.
Hambridge stressed the importance of involving the parents in the play process in order to assist treatment. He informed the parents of the increase of aggressiveness which would occur because of treatment, and helped them prepare for this, and other changes in behavior which would appear at home.
Jacob Coon
Conn used his technique, known as the "play interview," to restore in the child what was already there (Conn, 1948). He made extensive use of dolls to represent specific people in the sessions. Planned life situations were used, and the each successive interview was based on the way the chi ld used the toys and dolls.
He was very strict about the fact that the sessions were not for entertainment, but for therapeutic use. He conveyed this to the child, who quickly realized that there was a definite focus to each session. Coon 24
geared his sessions to the individual chi ld by making use of the child's interactions with the materials, and he used his technique with children who had varying problems: fearfulness, timid and dependent behavior, castration fears, and anxiety.
Conn also worked with the parents in the play sessions. He usually saw the parents before the first session, and let them tell their story. Then, he would invite them into the sessions while their child reviewed what had been 1earned during the sessions.
Relationship. Approach
A number of play techniques developed in the 1930's were grouped together, and called "relationship therapies." The basis for these therapies was derived from the work of Otto Rank ( 1936). He stressed the importance of birth trauma in the development of the individual. His belief was that the stress experienced at birth caused a fear of individualization, and lead the person to cling to past experiences. When viewing the clfent, transference and past events were not as important to him as were the reali ties of the client-therapist relationship and the client's existence in the here and now.
Jessie Taft, Frederick Allen, and Clark Moustakas all adapted his 25
\1 • viewpoints to work with children in therapy. They believed that the negative effects of the trauma of birth created a Jack of ability in children to form positive relationships. The children who were affected by this usua1ly became very dependent, often c1 inging chi 1dren, and developed strong attachments to their immediate significant other, and were unable to successfully relate to others.
Despite the tendency to place less importance on transference and on the past experiences of the child, the fo11owers of relationship therapies still maintained close ties with the psychoanalytic approach. They just placed less emphasis on these areas, and more emphasis on the child-therapist relationship.
Jessie Taft
Theory
Taft's emphasis was existential. She concentrated on the relationship between the child and the therapist, and the child's abi Hty to use this relationship in an effective way (Taft. 1933). She believed that the process produced a union between the child and the therapist that the child had not experienced since weaning or birth, and that this union held the curative power of the therapeutic process. 26
Approach
During the sessons, Taft concentrated on the relationship that was developing, not the materials used. Her main emphasis was on the termination of each session and the termination of treatment. She believed that these separations were reenactments of the trauma at birth.
If the ch11d could successfully reexperience the separation from the womb at birth, then he could learn to survive future separations. She viewed the termination of the therapy process as an integral part of the process because the length of the process and the termination date were predetermined.
Erederi ck Allen
Theory
Allen belleved that the trauma experienced by the ch11d was more physiological. He emphasized this because of the extreme physical and biological changes that the ch11d went through during the time of birth
(Allen, 1942). Birth, according to Allen, was the final point of separation, and began a time of differentiation for the ch11d.
The relationship established between the therapist and the ch11d was determined by Allen to be the most important aspect in the successful 27
outcome of treatment. He felt that this would help the child develop a sense of value in an ever changing world.
Approach
Allen believed that therapy began when the therapist entered into a caring and supportive relationship with the ch1Jd, which allowed the child to gain confidence and a sense of self-worth. During the sessions, he did not believe in the chlld becoming dependent on him, nor did he take over responsibility for the growth of the chfld. He accepted the chi1d as he was at this stage of development, and centered on the difficulties which concerned the child most.
Allen became involved with the child, and allowed the child to express himself freely. He did not, however, belleve that the child should be considered a friend. He set 11m its for the child when appropriate.
Parental involvement was stressed by Allen. He would bring the chlld and the parent to therapy at the same time. The child would be seen in therapy, wh1Je the parent would be seen by a case worker. Thus, they were being seen together for the same cause, but they w�re also differentiated.
Clark Moustakas
Theory
Moustakas worked on helping the child with developing his individual 28
self, and with exploring positive interrelationships. He used the secure atmosphere of the play therapy setting, and the safe relationship that was established with the chfld for carrying out his therapeutic goals
(Moustakas, 1959).
His theory centered around the belief that the birth process was a never-ending experience. He contended that all people go through this growing process of pain and happiness when involved in a relationship with another human being.
Moustakas used the strength of his relationship with the child to help the child cope with the struggle between accepting his needs of dependency and his need to develop his autonomy. He strongly believed in focusing on feelings in the here and now, and not on symptoms and causes.
Approach
Moustakas bel ieved the role of the therapist was one of openness and self-awareness. He always started his work with the child by beginning where the child was, and by eminating a feeling of unqualified acceptance, respect, and faith.
He showed his respect by always allowing the child to make his own decisions. The play sessions were not structured, and the child was allowed to lead the way, choosing his own toys and materials. Moustakas 29
always listened to the child, and encouraged him to explore his own thoughts and feelings.
Even though the child was allowed to lead the way, Moustakas did not believe in being passive. He be11eved in setting lim its when necessary, and in taking an active part in the activities of the child. He would also take part in the planning of activities If the child wished.
Nondirective Approach
The roots for nondirective play therapy came from the work of Carl
Rogers. He developed the client-centere·d (nondirective) approach to therapy with adults. His approach grew out of his therapy with individuals, and his theory on personality change. A thorough summary of this approach can be found in Theories of Personality (Hall and
Undzey, 1957). The part of Roger's theory from which Virginia Axline developed her nondirective play therapy is very important. The following is a summary of this part of Roger's theory:
1. Characteristics of the infant: An infant perceives his experience
as reality and has predisposition toward activation in reality
perceived. He behaves who1istica11y and engages in a valuing
process, moving toward those things positively valued. 30
2. Development of the self: Part of the actualizing tendency in the
child becomes differentiated and symbollzed in awareness, which is
described as sel f-experience. This awareness becomes elaborated,
through interaction with the environment into a concept of self.
3. Need for positive regard: This universal trait develops from
awareness of self. It is reciprocal in that when the person satisfies
another, it becomes self-satisfying. Thus the expression of positive regard by a significant other can be more compell ing than the
organismic valuing process.
4. Development of the need for self regard: This is a learned need
developing out of self experience and the need for positive regard.
5. Development of conditions of worth: In the event that the person
experiences only unconditional positive regard, no conditions of worth develop. Self regard should be unconditional--hypotheticaJJy fu11y
functioning.
6. Development of incongruence between self and experience:
Experiences are perceived selectively. Those in accord are accurately
symbolized to awareness; those not in accord are denied awareness.
7. Development of discrepancies in behavior: Some behaviors
maintain self concept so as to make congruence. Others are 31
unrecognized or distorted so as to be consistent.
8. Experience of threat and the process of defense: An incongruent
experience is perceived as threatening. This leads to the development
of anxiety. Rigidity, distortion, and inaccurate perception of reality
result due to omission of data and intensionality.
9. Process of breakdown and disorganization: When a person has a
large degree of incongruence between self and experience and the
defense is unsuccessful, disorganization results.
10. Process of reintegration: Because the person is able to
experience conditions of worth in an atmosphere of unconditional
acceptance an increase in unconditional self-regard occurs. (Rogers,
1959, pp. 1 84-256)
Virginia Axline
Theory
In interpreting Carl Roger's theory, Virginia Axline suggested that as the child separates from his environment, he begins to form a reciprocal relationship with that environment. She also believed that the child forms a sense of self because of the way he views the perceptions of significant others (Axline, 1947b).
Axline had two basic beliefs about the nature of people. First, she said 32
that the child loves growing and constantly strives for it, and second, the individual has basic needs which he is constantly trying to satisfy. She felt that the individual's ultimate goal in life was one of complete realization.
She believed that the well-adjusted child was one who was able to meet his needs by directing his own behavior through evaluation, selectivity, and application. Of the malajusted child, Axllne said that the child had not met his needs, and that he used devious means in order to gain satisfaction of these needs. He then developed an inner struggle for growth as his efforts were blocked by his environment. This caused the child to lose his sense of realism in his perceptions and his experiences.
For the child to develop a sense of unconditional self worth, Axllne said that it was necessary for the chtld to experience conditions of worth within an atmosphere of unconditional acceptance. This would allow the child to move from disorganization to reorganization. The crucial point of her nondirective therapy was that she believed that the child had within himself all the necessary components for growing and changing. Because of this, she said that the child would move where he needed to when all the conditions were right, and that it was the responsibility of the therapist to provide these conditions. 33
Approach
Nondirective therapy is not a technique. The process in nondirective therapy occurs because the therapist has incorporated a certain set of values into his personality, and he believes that the individual has the inner capacity for growth, decision making, and motivation for moving forward. Axl ine ( 1947b) states that there are eight basic principles by which the therapist should conduct himself in the play therapy process:
1. The therapist must develop a warm, friendly relationship with
the child, in which good rapport is established as soon as possible.
2. The therapist accepts the child exactly as he is.
3. The therapist establishes a feeling of permissiveness in the
relationship so that the child feels free to express his feelings
completely.
4. The therapist is alert to recognize the feelings the child is
expressing and reflects those back to him in such a manner that he
gains insight into his behavior.
5. The therapist maintains a deep respect for the child's ability to
solve his own problems if given an opportunity to do so. The
responsibility to make choices and to institute change is the child's.
6. The therapist does not attempt to direct the child's actions or 34
conversation in any manner. The child leads the way; the therapist
follows.
7. The therapist does not attempt to hurry the therapy along. It is a
gradual process and is recognized as such by the therapist.
8. The therapist establishes only those limitations that are
necessary to anchor the therapy to the world of reality and to make the
child aware of his responsibil ity in the relationship. (pp.75-76)
Axline believed that the relationship established with the child would enable him to use the capacities from within to deal more constructively with his environment and with those around him. In establishing this relationship, she felt that the most natural language for the child was play, and that within the safe, accepting environment, the child would realize the power within himself. As the child was freed of anxiety and tension, he would have more energy for forward growth. As the child became more congruent and reallstic, then others in his environment would respond differently, and the circular destructive process would become a positive process.
Axllne suggested that therapy should take place in an equipped playroom, but in some cases a corner of a room would be adequate. The room should include: soundproofing, a sink with running water, protected 35
windows, walls and floors that could easily be cleaned, and accessible shelves for materials. She did not beHeve in the therapist choosing the materials that the child would interact with, but let the child do the choosing. She did, however, have a list of equipment which she felt would be suitable for the playroom. This Hst can be found in Play Therapy: The
Inner Dynamics of Childhood (Axline, 1947b, p. 57). She stressed that each session should be a new beginning, so an materials should be cleaned up, and repaired or replaced if damaged.
Axline worked with all different children with various ages and difficulties, including physical handicaps. She even concluded that a child's teacher could be both teacher and therapist to a chlld. Axline also expressed the belief in play therapy as a way to help children with above average intelHgence who were having difficulty in reading (Axline,
1947b, 1949a).
Famny involvement in the play therapy process was seen by Axline as beneficial in some instances, but not necessary for successful therapy to occur (Axline, 1955). She thought that it could help as a means of self-discovery for the parents and the child, and she suggested that the family join the child in the playroom setting. She fe lt that 36
self-disclosure could provide the child with an opportunity to see himself in ways within the family that he had not previously seen.
Limit-Setting Approach
In 1949, Ray Bixler wrote an article titled Limits Are Therapy, and brought about a new area in play therapy. Bixler, and later Haim Ginott
( 196 1), stressed that limits were an integral part of the play therapy process.
Other therapists believed in limits, but not as the primary part of the process. Axline ( 1947b) and Moustakas (1959) believed that the setting of limits allowed the process to occur and that it added unique dimensions to the process. Two therapists, Dorfman ( 1965) and Schiffer ( 1952), who did activity therapy more than play therapy, set very few limits.
Ray Bixler
Theory
Bixler suggested that the development and enforcement of limits in the therapy session was the primary vehicle of change. He stated that the therapist should set limits which he or she was comfortable with. Bixler
( 1949) outlined five limits which he thought were basic to the play therapy sessions: 37
1. The child should not be allowed to destroy any property or
facilities in the room other than play equipment.
2 The child should not be allowed to physically attack the
therapist.
3. The chlld should not be allowed to stay beyond the time lfmit of
·the interview.
4. The chlld should not be allowed to remove toys from the
playroom.
5. The ch11d should not be allowed to throw toys or other material
out of the window. (p.2)
Bixler believed that well -defined limits allowed the relationship between the therapist and the chlld to be more comfortable. He saw that unclear limits were misused by the poorly adjusted child, and caused insecurity to arise.
Approach
Bixler set limlts at the time of the act. He did this so that the child would learn what he was permitted to do while he explored his environment and his relationship. Bixler ( 1949) suggested the following steps in setting limits during the play sessions:
( 1) reflect the desire or attitude of the chlld 38
(2) verbally express the limit
(3) provide an acceptable alternative, and finally
(4) control by physical means if necessary. (p. 4)
Bixler would remove the chlld from the playroom if he needed to enforce the limit of aggression toward himself. He said that children would leave the playroom with a sense of relief because their aggression had been controlled. Setting these limits in the playroom also helped control behavior at home.
Haim Gjnott ·
Theory
Ginott followed the beliefs of Bixler, but had some varying 11m its to be set for the child in the play therapy setting. A complete discussion of these limits and his reasons for using them can be found in his book Group
Psychotherapy with Chi1dren· The Theory and Practice of Play Therapy
( 1961 ). The following is a summary of the limits Ginott suggests:
1. He sets a firm time lim it, usually about fifty minutes.
2. He does not advise that playroom equipment be taken home.
3. Limits are set in order to prevent distruction of property.
4. The child is not allowed to attack the therapist because it could
cause emotional distress for the child and interfere with the 39
therapist's relationship with him.
Ginott has also developed specific guidelines for his approach to setting 1 im its. G i nott ( 1959) states the four step sequence as fo 11ow s:
1. The therapist recognizes the child's feelings or wishes and helps
him to verbalize them as they are.
2. He states clearly the limit on a specific act.
3. He points out other channels through which the feeling or wishes
can be expressed (he provides alternatives).
4. He helps the chtld to br1ng out the feelings of resentment that
are bound to arise when restrictions are invoked. (p. 1 07)
Approach
Ginott ( 1961) believed that the relationship with the child should begin on a very structured basis. He did not believe in letting the child make the decision on whether or not to go to therapy. If the child did not want to come to the playroom, he would extend his hand and take the child or allow the mother to take him.
He stressed the importance of preparing the mother in advance of the first session so that she would understand what was expected of the child in the playroom, and so that she could help the child deal with the new situation. He made sure that the parents were fully aware that the 40
playroom was not a place to have fun, but a place where their child could learn to make decisions, to gain independence, and to express his thoughts and feelings in a constructive way.
Ginott felt that the therapist should project a feeling of empathy, respect, and acceptance. He wanted to convey to the child that this relationship would be like no other relationship he had experienced.
Summary
This chapter has presented five major psychodynamic theories of play therapy. The beliefs and approaches of the major theorists in each area were discussed. It is hoped that the sources cited will provide further, more indepth information concerning each theory or theorist involved.
Using the historical approach, a summary of the early theorists was given. The writings of Anna Freud and Melanie Klein were discussed and compared. Structured theory and the various techniques of David Levy, J.
C. Solomon, Gove Hambridge, and Jacob Conn were summarized. The work of the relationship theorists, Frederick Allen, Jessie Taft, and Clark
Moustakas, was looked at. Clfent-centered therapy, developed by Carl
Rogers, was described, and its adaptation by Virginia Axline into nondirective play therapy was explored. Chapter Ill
RESEARCH RELEVANT TO MAJOR APPROACHES
The history of research conducted in regard to play therapy has been one of controversy. In 1966, Masling made reference to research in play therapy as being nonexistent. While this was not true, research at the time was not producing much evidence to show positive outcome using play therapy techniques (Ginott, 1961, pp. 135-158; Levitt, 1957, 1963).
Much of the problem may be due to the belief that therapeutic work is analogous to art, rather than science, and cannot be tested using valid and reliable methods. In play therapy, the age of the child, and the emphasis on the use of play rather than words as the child's form of communication, have posed even further concerns.
Harter ( 1983) has written an article which describes the scientific hypothetico-deductive method in comparison with research conducted in
41 42
play therapy. She compares each stage of the scientific method with its counterpart in play therapy research. She associates the deductive method of a hypothesis followed by experimentation with the inductive method of observation culminating in an general belief or hypothesis. The next step of experimentation, she correlates with the interpretations made by the · therapist during therapy. She belleves that acceptance of the hypothesis, vehement deniel, or play disruption on the part of the child means confirmation of the hypothesis, and no reaction means that the hypothesis has been rejected. Her analogy could give insight into the use of observations and case studies as research.
In the last twenty years, possibly partially due to this controversy, greater interest has been expressed in the pursuit of conducting valid and reliab�e research in play therapy. As a result of this, more studies have appeared which attempt to make use of a more scientific method of research.
Observation and case studies are an accepted form of research, but this chapter will attempt to present research which fits a more scientific model. Some case studies and observations are included. Additional observations and case studies for each major theory can be found by referring to Chapter II. Citations of works done by theorists in each area 43 will lead the reader to this information.
Studies Using Psychoanalytic Theory
As discussed in Chapter II, the psychoanalytic approach to play therapy has roots which extend back to Sigmund Freud and his work with adults.
From his work, Anna Freud and Melanie Klein became the leaders in adapting his theory to play therapy for children. Many observations and case studies have been reported to document their work. In recent years, there have been some studies done which make use of the scientific method of research.
Two case studies, that were both documented, reported positive changes in behavior using play therapy based on psychoanalytic tenets.
The first, recorded by Fries ( 1937), reports success with a young child following the direct teachings of Anna Freud. The second was reported by
Fraiberg in 1962, and was conducted with a four-year-old boy. Fraiberg followed the teachings of Anna Freud, but believed that the therapist should not be responsible for the educative nature of the work, which
Freud describes as necessary.
In 1974, a study done by Feigelson, attempted to show the importance of the central role of play therapy in the psychoanalysis of children. Case 44
examples were used, along with comparisons of the differences in results of using play and not using play in the psychoanalysis of these children.
Results are reported that show the c�ses using play to be more effective.
In 1980, a case study was reported by Reinelt and Breiter, in which psychoanalytic-oriented play and behavior modifi cation techniques were combined to help a boy with trichotillomania. Even though a scientific model was not used, behavior was measured, and results were recorded.
This case involved an analytic diagnosis of the problem, and a clarification of the symptoms suffered by a three-year-old boy.
Analytic-oriented play was used to help the child verbalize his feelings, and to give the therapist an idea of the underlying problems causing this behavior. Behavior modifi cation techniques were then used to help the boy change his pattern of behavior.
The boy was determined to have trichotil lomania, which was defined as the elimination of tension, learned behavior, or a symptom of psychodynamic conflicts. The boy was observed as constantly pulling out his own hair. The analytic interpretation stated that the hair pulling served two purposes: self punishment for destructive aggression wishes against his parents, and a way to give himself a feeling of existence. To help the boy overcome this condition, the therapist used pieces of the 45
boy's own hair to caress his lips. The belief was that the caressing hair
would become a substitute for unsatisfied needs for love and tenderness.
The behavior of the boy was monitored, and the hair pulling was
determined to become progressively less as the hair was used to caress his lips. Eventually, the boy was determined to be cured through the use of
psychoanalytic play therapy and behavior therapy techniques.
Studies Using Structured Theory
Structured therapy is an offshoot of psychoanalytic theory. The main
similiarity is the belief in the development of the personality. The
difference lies in the structured therapists' belief that the therapist is
more knowledgeable about the needs of the client, and should therefor
structure the play session to meet the needs of the client.
In 1955, Conn reported a case using his technique of the play interview.
He worked with a thirteen-year-old boy who suffered from fears of
castration. The boy was passive and very dependent. The play interview
consisted of the use of dolls, through which Conn encouraged the boy to
discuss his fears. His report ends with a follow-up study done fifteen
years later, when the boy had reached twenty-nine. Conn reports that he
had assumed, and maintained a masculine identity. His report does not, 46
however, go into much detail regarding events in the boys life between therapy and the follow-up study. This leaves some question as to whether or not there could have been other intervening factors.
Homefield ( 1959) did a study involving the effect of role-playing, along with the use of masks, as a therapeutic technique for children who stuttered. His hypothesis basically followed the beliefs of Hambridge
( 1955), who said that reenactment of a specific traumatic situation could bring about catharsis. Homefleld used limited reexposure of the child to emotional events with which the child had been unable to cope.
His study involved eighteen boys of elementary school age who stuttered. He divided the boys into three even groups who met once weekly for one hour of role-playing. One group never used masks, one group used masks only in the first few weeks of therapy, and the other group used masks for the entire eight-week period. The boys were all shown the same pictures, and asked to tell what they thought was happening.
Homefield believed that the permissive atmosphere provided a comfortable place in which the role-playing could occur, and that through role-playing the child could speak more fluently than during regular speech. His conclusions reported that the children who wore the masks for the first sessions of the role-playing began to speak more fluently than 47
the ones who did not, and the ones who wore them for the entire time had a greater potential for speaking more fluently more quickly.
In 1981, a research study was conducted using brief intervention therapy for behaviorally disturbed pre-school children. Bidder, Gray, and
Pates used positive learning and structured play techniques in treating nine children aged 14 to 36 months. The chtldren were diagnosed as having poor concentration, sleep disturbances, and poor cooperation with parents.
This group of children was compared with a no-treatment group of six normal age-matched chlldren.
The experiment began with a two-week observation period, followed by the experimental group receiving treatment in their homes for a seven-week period. Of the original nine families, two did not cooperate, and one child improved spontaneously. Videotapes were made of each group at play for fifteen minutes prior to the therapists' visits. Analysis of the videotapes showed significant preintervention between-group differences in concentration, cooperation, and positive comments made by the parents and children. A follow-up study showed no significant changes in behavior since the termination of the experiment.
In 1982, a research study was conducted by Bleck and Bleck to show the significance of structured play in improving behavior of disruptive 48
children. The subjects were selected by third grade teachers in thirteen
elementary schools, who each selected three boys and three girls in their
classes who represented disruptive behavior. One half of the students was
assigned to a seven-week structured play group, and the other half was
assigned to a no-treatment control condition.
The treatment began with early group sessions focusing on social
interaction and self-disclosure. This was designed to increase group trust
and cohesiveness, awareness of self and others, and an understanding of
feelings. The next set of sessions dea1t with disruptive school behavior,
its consequences, and alternatives to such behavior. The final sessions
focused on cooperation, sharing, and feedback.
The students in the intervention group showed significant improvement
on the Coopersmith Self-Esteem Inventory and on the Disrespect-Defiance
factor of the Devereux School Behavior Rating Scale. The results were determined to indicate that structured play can have a positive effect on attitudes of disruptive children.
In 1983, a study was reported by Glanzer in which toys were used as aides in treating a twelve-year-old paranoid child. The treatment consisted of twenty-two sessions in which the therapist employed
sceno-test methods and guided imagery. The parents were also given ten 49
training sessions. Glanzer reported positive outcomes, with a five-year follow-up study reporting permanent recovery.
Studies Using Relationship Theory
Relationship theory developed out of the work of Otto Rank ( 1936), who believed that the trauma of birth lead the child to a fear of individualization, and to a need for clinging to past experiences.
Therapists in this area made use of the relationship they established with the child to help the chlld learn to successfully relate to others.
In 1955, Moustakas conducted a study to help determine the process which the chlld goes through in relationship therapy. The study involved the frequency and intensity of expression of negative attitudes of nine well-adjusted and nine disturbed four-year-old children. The chlldren were matched on intelligence and sociometric background.
The treatment consisted of four play therapy sessions for each child with the same therapist. Verbatim records were kept for each child's statements. From the first and third sessions, a llst of 241 negative attitudes were selected and rated in terms of intensity of feelings expressed. 50
Results indicated that both groups of children were determined to have
expressed about the same types of negative attitudes, but the disturbed
group expressed a significantly greater amount of negative attitudes with
a more diffuse and persuasive manner. Moustakas concluded that disturbed
and well-adjusted children could be more clearly differentiated on the
basis of intensity of negative attitudes rather than on frequency. He
suggested that as the therapy progressed, the negative attitudes of the
disturbed child became simi1ar to those of the we11-adjusted child, and
that the negative attitudes were expressed more clearly and less
frequently.
Another study done in 1955 was conducted by Moustakas and Schalock.
The emphasis of the study was on the relationship established between the
therapist and the child, and its effect on the child. Two groups of
four-year-old nursery school children were used. Group A consisted of
three girls and two boys considered to be normal, and Group B consisted of
four boys and one girl with serious emotional problems.
Each child was seen individually by the same therapist for two
forty-minute play sessions. with a three-day interval between sessions.
A report of the conclusions included a summary of observations of
behavior and a summary of anxiety-hostility ratings for both the therapist 51
and the two groups of chlldren, an analysis of interaction sequences initiated by the therapist and the chlldren's responses to them, and an analysis of interaction sequences initiated by the ch ild. Moustakas and
Schalock concluded that the interaction on the part of the therapist was an important factor in the play therapy process.
In 1967, Pothier reported a case study of a child who was having difficulty establishing positive relationships with others. The goal of therapy for this eight-year-old boy was to provide the boy with a concerned, consistent relationship, which would then allow him to transfer this behavior onto other relationships. Pothier concluded that play therapy was valuable in helping this boy fulfi ll his own needs through estab11shing positive relationships.
Studies Using Nondirective Theory
Borrowing from the basic beliefs of Carl Rogers, Virginia Axline developed nondirective play therapy for children. Fundamental to her work, w�s her belief that the child had within himself all the necessary components for growing and changing. She believed that the child would move where he needed to when all the conditions where right, and that it was the sole responsiblity of the therapist to provide that environment. 52
il .
Many case studies reporting successful interventions using nondirective play therapy have been reported. Andriola ( 1944) reported excerpts from successful therapy with a timid ten-year-old boy.
Landisberg and Snyder ( 1946) examined therapeutic results of cases with four children, aged five to six, of which two were reported successful and one incomplete. They suggested that, for younger chiJdren, nondirective
play therapy might be cathartic rather than insightful or educative. Axline ·
( 1948)has described her successful work with a four-year-old girl, and a young boy. Axline ( 1964) also devoted an entire book to her successful work with a boy named Dibs.
Two case studies reported successful outcomes using nondirective play therapy to help children with speech problems. In 1946, Reynert reported the successful case of a seven-year-old child who overcame a speech problem of stuttering. In 1953, Dupent, Landsman and Valentine conducted a study of a child who was suffering from delayed speech, where emotional disturbance was considered to be a causative factor. The researchers held forty-one interviews with the two therapists involved, and discovered that the therapists had observed improvement in emotional adjustment and in intel ligibility of speech, without any speech therapy being provided. 53
In the treatment of reading problems, nondirective therapy has been reported as having successful results. In 1945, Bixler conducted a series of twenty interviews which reported successful outcomes in he I ping a child to read, when no reading instruction was given. Axline ( 1947a,
1949b) presented case studies with children of above average intelligence who had reading difficulties. One of the children substituted the fantasy world of reading for friends, and the other two had difficulty reading. She believed that the children's emotional problems were causing the reading difficulty, and that given the opportunity to help themselves, they would.
She believed that the nondirective play therapy experience gave them that opportunity.
Some research studies have also been conducted to show the positive' outcome of nondirective play therapy. Axline ( 1949a) researched the correlation of play therapy and intelligence. Fifteen six- and seven-year-old children diagnosed as having behavior and speech problems were seen for eight to twenty sessions. Pre- and posttest therapy scores were used to divide the children into three groups: cht1dren who showed no change in intelligence scores after therapy, cht1dren who showed significant changes in inteJJigence scores after therapy, and children with average intelligence scores before and after therapy. 54
Axline reported that the children who did not have a raise in
intelligence scores were the ones who did not complete therapy, and the
ones who had an increase had completed the therapy sessions. She stated
that the reason for the increase in intelligence was not due to the play
therapy itself, but to the emotional release that took place, and allowed
them to function at their true capacities. Axline included the third group
of average intelligence chi1dren to show that behavior problems stem more
from emotional deficiencies than from mental deficiencies.
In 1953, Cox researched the effects of nondirective play therapy on the
interpersonal relationships and individual adjustment of two groups of
orphanage chi1dren. Nine children who were matched for age, sex, residential placement, adjustment, Thematic Apperception Test scores,
and sociometric measures were placed in each group. The sample was representative of the orphanage population.
The experimental group was given ten weeks of play therapy. The
control group received no therapy. Both groups were retested at the end of
therapy, and again fifteen weeks later. The adjustment scores and peer ratings of about half of the children in the experimental group showed
improvement. The control group showed no gains.
In 1958, Dorfman researched the personality outcomes of nondirective 55
play therapy with children aged nine to twelve, who had average intelligence, and who were considered by their teachers to be maladjusteq.
Her primary hypotheses included: personality changes occurred during a therapy period, they did not occur in the same child during a no-therapy period, and they did not occur in the control group. Her secondary hypotheses included: effective therapy can be done in a school setting, and therapy improvements occur without parent counseling in spite of the emotional dependence of children upon parents.
The basic experimental design which she used was the pre-test and post-test. It involved observation during three time periods for the therapy group of twelve boys and five girls. They were tested over three time periods which were pre-therapy or control period, therapy period, and follow-up period. The experimental group was tested over four time periods: thirteen weeks before therapy, immediately prior to therapy, immediately after therapy, and a year to a year and a half after therapy.
She used psychological tests, therapist judgments, and follow-up letters in order to investigate the outcome.
Dorfman found that reliable test improvements occurred simultaneously with a series of therapy sessions. She also found that time alone did not produce reliable improvements on tests. Her secondary 56
hypotheses were also supported.
In 1978, a research study was conducted by Schmidtchen and HobrOcker to determine the efficiency of nondirective play therapy. Treatment consisted of nondirective play therapy conducted in a guidance clinic. Pre and posttest scores for eighteen children nine to thirteen years of age were compared to the scores of two control groups. The experimental group showed significant improvement in social and intellectual flexibility, as well as a decrease in anxiety and behavior disorders. In addition, social self-concept approximated the mother concept of the children.
The effect of play therapy was predicted on the basis of individual input data represented by test scores and behavior disorder assessments.
Analysis proved valid in 55% of the improvement prognosis (31% of the controls), and 2% of the deterioration prognosis ( 16% of the controls). It was also suggested that more experimental therapy and additional treatment of the parents might further improve the results.
Studies Using Limit-Setting Theory
Limit-setting as a therapeutic approach was first explored by Bixler
( 1949). The approach centered around the beliefs that 1 imits were 57 fundamental to the play therapy process, and that they were the primary vehicle of change. No research studies were found on the effects of limit-setting in play therapy, however, three studies were found which attempted to identify the types of limits to be set.
In 1961, Ginott and Lebo developed a questionnaire which was designed to find the correlation between the use of limits and the theoretical orientation of the professionals assessed. The questionnaire contained flfty-four discrete 1 imits, and the respondents consisted of 100 therapists who considered themselves to be psychoanalytic, forty-one nondirective, and eighty-six from other schools.
From the results of the questionnaire, Ginott and Lebo concluded that the therapists from the different approaches all employed a similar number of limtts in their work with children. Some differences were noted in the kinds of limits set.
Another study done by Ginott and Lebo ( 1 963), investigated the most used limits in play therapy. A questionnaire on limits was sent to 227 play therapists ( 100 psychoanalytic, forty-one nondirective, and eighty-six from other schools). The questionnaire asked them to identify from the list the limits that they most frequently used with children from the ages of three to ten. From the results of this questionnaire, they 58
established a list of the most used and least used limits in play therapy.
Rhoden, Krenz, and Lund ( 1981) conducted a study which replicated and extended the studies done by Ginott and Lebo. Their study consisted of 131 play therapists questioned. The results showed a notably simllar pattern of limit-setting among the therapists of different orientations, sex, and years of experience. Statistically significant differences were found between therapists of different orientations for only 7 out of the 54 limits surveyed. Relatively few limits were never used, and at least half were ordinarily used. They also reported a notable decrease in differences of limits used over the nineteen-year period since the first study was completed.
Summary
An introduction to the history of research in play therapy was discussed, which included a look at the lack of research produced in the past as evidence of positive outcome. The controversy over therapy being analogous to art and not science, lead to a discussion of case studies and observations as being valid and reliable forms of research. The young age of the child and his nonverbal form of communication were discussed as posing other various concerns in research being conducted. 59
The use of observation and case studies as a va11d form of research was discussed as being acceptable, but with an emphasis being placed on the desire for more research to be conducted using a scientific model. The controversy over the lack of research and the need for va11d research studies to be conducted was discussed as possibly having lead to a greater number of studies being produced in the last twenty years.
The historical approach was used in reporting case studies and observations, with a greater emphasis being placed on reporting research using a more scientific model. All this was then separated into major theory areas, and summarized. In some cases, studies were grouped together if they were based on a common area of emphasis under a major theory. The reader was also referred to citations of major theorists in
Chapter II for the bulk of case studies and observations under each major theory. ---- �
Chapter IV
SUMMARY AND CONCLUSIONS
Summary
In summary, literature dealing with play therapy was surveyed,
summarized, and organized. The historical approach was used for the
collection of data. Materials were collected through the sources provided
by library services as well as therapists in the field. The material found
was divided into theory, approach, and research. Theory and approach were
organized into Chapter II, while the material found on research was
organized into Chapter III.
After an extensive search of the literature, it was found that material
was scattered throughout books and journals. Much of the literature dealt
with either theory and/or practice, and had been written when play
therapy first became popular. This literature discussed play therapy for
60 61
children from the standpoint of past therapy done with adults. More recent literature tended to show more work being done specifically with children. The literature found on research was usually in case study form, which had not been tied in with either theory or practice, and seemed to begin with the theory level. Some research was found that made an attempt to provide studies done using the scientific model (movement from hypothesis to research to theory). This research apparently came out of a need for more accountab11ity on the part of the play therapists, but it still proved to show very inconclusive evidence.
Conclusions
Even though more recent literature has been written, and more reliable research attempted, there is still a need for more comprehensive works to be written in the major areas of theory development. It is important for some works to include theory, practice, and research. This would provide the reader with information to help develop a clearer picture of what has . been attempted, what has been done to achieve the specific goals, what has been accomplfshed, and what measures were taken to insure that the outcome was achieved through the specified means.
The following are recommendations for providing more valid and reliable research dealing with outcome in play therapy: behaviors and 62
personality traits need to be more specifically defined, changes in behaviors rather than in personality need to be more clearly defined, and devices used to measure specific behaviors need to be more carefully developed and used. The process in play therapy also needs to be looked at more carefully in relation to the outcome. Methods for evaluating the process, including assessment of activity involved and interactions taking place within the sessions, need to be developed.
Few scattered studies have been done in areas of emphasis within the play therapy process. More research is needed in the following areas: materials, including toys, the playroom setting, Hmits, therapist behaviors, parental involvement, training models for development of skills in professionals and others, including parents, duration of therapy, and the termination process. At this time, a thorough review and summarization of all the literature and research done in all these areas so far, would be a very helpful beginning.
From this beginning, an organized approach to theory development could begin to grow. More information could be comp1Jed as therapy and research are conducted, and this information could be placed on computers for organization, storage, and future reference. Here, research and theory could become an integral part of the therapy process. As more information 63
is added, it could be compared, analized, and used for further developments in the field of play therapy. Bl BL IOGRAPHY
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