Counseling Today, Member Insights

Play (in) therapy: Approaches to working with young children

By Maureen Bissen Neuville December 3, 2021

I do play therapy, but I am not certified nor am I a registered play therapist — although I wanted to be! 

My early counselor training and mentorship was mostly behavioral, but early on I moved to a less didactic and more interactive approach. That, combined with my interest in working with children, drew me to explore play therapy. 

After earning my master’s degree in counseling, I entered a play therapy certificate program. I’d completed most of the classroom credits when the university decided to end the program. I felt such disappointment. This was in the years well before virtual coursework, and it was not possible for me to travel to get internship or supervision elsewhere. Thus, my goal of attaining certification in play therapy was squelched. Instead, I worked for years as a general counselor and developed an expertise in serving youth and families.

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Cultivating skills with youth

Given the lack of opportunity to complete my formal education and certification in play therapy, I moved forward with developing more intentional activities (e.g., drawings, games with therapeutic content) in my counseling work. My sessions with youth of all ages affirmed the value of interactive play and hands-on exercises. Keeping their hands busy and minds engaged enhanced the therapy experience for them. Yet I realized the importance of making sure I was not just offering fun tasks or gimmicks but rather genuine and intentional therapeutic purpose and process. 

For example, playing Uno with school-age clients can help with building rapport, but to make it therapeutic, one could have certain cards associated with directives to share an experience or emotion that is relevant to their treatment goals. There is an abundance of workbooks to use with youth of varying ages to supplement and engage them directly in their therapeutic work. I used many of these workbooks, often adapting tasks and visuals to my therapeutic style and my clients’ needs and preferences, and I also designed my own visuals and interactive work. To make the work more their own, I began having the youth draw or make their own charts and scaling graphs (“Show me however you want to”) rather than doing it for them and just filling in their answers. 

These techniques were certainly not play therapy, but they were part of my evolution as a counselor of youth. Throughout the years, I independently reviewed my earlier play therapy coursework and read additional materials, primarily by Terry Kottman and Garry Landreth, building my sense of professional self within their theoretical constructs.

‘Play in therapy’ or play therapy?

In my years teaching Counseling Children and Adolescents courses in a local CACREP-accredited master’s in mental health counseling program, I encouraged my students to include playful and hand-on activities in their sessions with youth — even with teens. Somewhere along the way, I felt a need to delineate the difference between this approach and true play therapy, so I coined the phrase “play in therapy.”

When the few play therapists in our small city retired, they, familiar with my work, began to send their referrals to me. I took on these young clients, informing their caregivers of my partial training in play therapy (although at the time, almost no other options existed nearby). I added more representational tools (e.g., puppets, a dollhouse) to my work with youth. To provide more continuity for these youth and to deepen my own work, I intentionally moved to a fuller play therapy mindset and approach. 

At that time, I had opportunity to work independently within a certified mental health clinic, and I made the decision to create a separate play therapy room. The importance of having a sizable array of figures became clear to me, as too few tended to limit the children’s expressions. I had read that a minimum of 100 figures was needed and that a few hundred would offer fuller opportunity for expression. This initially surprised me, but I found it to be true. Almost never has a child been overwhelmed by the volume of figures in my room; in those rare instances when they were, I would guide them in a more focused, yet still varied, selection. 

As I expanded my therapy office, I became nearly obsessed with scouring secondhand stores and rummage sales to find miniature figures — a common malady for aspiring play therapists. Miniature figures, when carefully chosen and made easily accessible, offer a world of expression for children, who often create their own metaphors and meaning with them.

I continued to immerse myself in play therapy, reading professional articles and books by both traditional and contemporary authors. My goal was to put play therapy theory and skills fully into practice. One of the big changing points for me was when I consciously began to play less with the child and instead sat with clients while they played. I’m naturally a talker and somewhat directive, but I learned to watch, to listen, to be silent. I observed, reflected and encouraged my young clients. 

More and more, I allowed the child to be in charge, enhancing Eriksonian tasks of autonomy, initiative and industry. I learned to curb my inclination to speak to, move toward and invite the child; instead, I let them come to me. 

Certainly there are times when we as counselors need to be in charge, to have rules and boundaries, and to take the lead to move therapy forward, but I emphasize here Kottman’s Adlerian value (also recommended by Landreth and others) of returning responsibility to the child and empowering them. This helps build a secure relationship in which children can choose to play (or not to play), be themselves and know that you will accept them and meet their needs.

Counseling young children 

Research for my Guided Drawing technique (published in the Journal of Creativity in Mental Health in December 2019) led me to a deeper understanding of early child development and approaches for that population. Familiarizing myself with DC:0-5 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood and reviewing literature on developmental tasks and trajectories were helpful in assessing, diagnosing and treating my youngest clients. I strongly recommend that child therapists at least view the DC:0-5. Its biopsychosocial focus, which highlights early caregiving, informs us of early developmental inclinations and experiences that affect youth who eventually present to us for counseling.  

While Landreth does not endorse posing questions to children in sessions, many counselors do query their young clients. Adaptations to standard counseling microskills have proved helpful and become central to my work with youngsters. I now reframe my questions into curious statements. For example, rather than asking, “What were you feeling when that happened?” I might say, “I wonder what you felt” (with an emphasis on “wonder” and a clear closure at the end.) This subtle change helps youngsters feel less intimidated, less forced to answer in a prescribed way and gives implicit permission not to answer at all. This question-as-statement approach can also be helpful when wanting to gather information from older youth. 

When I do ask questions, especially of the very young, I typically use cued invitations with a three-choice format: “Were you really scared, kind of scared or not scared?” “Are you worried more, less or the same as you were when Papa was here?” Numerous professional articles support this cued invitation approach as being better than either forced-choice or open-ended questions for young children still in the concrete thinking stage. I suggest this as a starting point at least, with deeper or more specific inquiries coming only after rapport has been established or a need for more specific information becomes evident. These cued invitations, if presented conversationally, generally do not disrupt the flow in a free-play environment.

Play speaks, and we are to listen

My academic preparation included awareness of how patterns and themes emerge and are revealed in children’s play. Patterns of play might include (but are not limited to) orderly, tentative, chaotic or focused (maybe on a certain category of figures) or the acting out of scenes over and over. 

Likewise, the identification of themes can be essential in understanding child clients. Some common themes revealed in ongoing play sessions include family-oriented expressions, nurturing, loss and aggression. Fantasy and make-believe are also common. The counselor’s task is to consider whether this is typical child’s play (for this child at this time) or symbolic of wishful thinking connected to distress in the child’s life situation. Patterns and themes are critical factors to watch and listen for in child’s play because this is the way that children reveal what is in their hearts and minds.

As sessions proceed, it is important to note if there are changes in a child’s play and to consider what those changes might indicate. I have learned to recognize some common themes and to form hypotheses about what those might mean to or about the child (e.g., the child is experiencing anxiety or fear of abandonment). Yet I’ve also learned to give the child time to reveal whether my hypothesis is a fit for them. 

I have been surprised at what children reveal as they engage in representational or metaphoric play. Sometimes their play serves as a disclosure of abuse or distressing events; other times it provides a picture of their worldview and self-concept. 

There is a danger in interpreting every action as projective, however. Sometimes the child’s play is just that — play. Knowing the difference can be challenging. My advice is to keep your hypotheses in mind and to see if patterns support them, while remaining very open to what else might surface in sessions. 

As is the case with all counselor development, skills will improve with experience, especially when we engage in supervision or peer review and as we self-reflect and recalibrate our approaches.

Play therapy

The play therapy space is both literal (the room, child-sized furniture, sand tray, miniatures, etc.) and figurative (the emotional and verbal space created by the counselor). Such a space offers opportunity for children to establish and express their own dominant and recurring ideas. It no longer surprises me, but it still amazes me how children (consciously or not) express their inner selves and make meaning of their life as they process through their play.

Although a counselor can be culturally sensitive while engaging a child with “play in therapy,” I believe that play therapy has the added advantage of being more culturally open because the child sets the stage, selects the figures and, thus, tells their own story. During “play in therapy,” a counselor might choose a particular worksheet or set of figures to demonstrate a concept, but these visuals might not fit a world that is familiar or preferred by the child. 

From the start, I was intentional about including miniature human figures of varying skin tones, but I later added numerous other items to give children the opportunity to represent their own religious, cultural and family traditions and values in their play. Offering myriad toys and miniatures from which children may choose diminishes the inferred bias (even if unintentional) that may occur when a counselor chooses the visual or hands-on tools. 

I have learned to scaffold and support, to delight with clients’ successes, yet also allow them to struggle. I empathize with, even normalize, what they might perceive as failures. Here’s a simple example: A few children have had trouble opening the cover to my sand tray. Resisting the urge to bail them out, I sit and wait, saying, “You are trying to figure out how to open that.” Even as the children’s eyes plead for help, they keep on trying and eventually get it open. I delight aloud in their competence. (I could remove the cover completely, but what opportunity for discovery and mastery.)

I learn much from my young clients by being watchful and responsive. Mirroring can be a powerful technique and happens naturally when the counselor is fully attentive and responsive to the child. I’ve come to realize the value of simple reflections, tracking and restating children’s phrases word for word. 

I also learn from my interns. One amazed and delighted me in her very first play therapy setting. A child arranging animal figures said, “I’m playing a zoo.” The intern responded, “You are playing a zoo.” This literal tracking — word for word, even when not grammatically correct — can sound and feel awkward for many professionals, but this intern got it right away. 

I often explain to parents why I respond in this curious-sounding, almost mechanical way. It’s so the child will know I am listening carefully and that I accept their telling and their verbiage. Children are generally comforted by this. Even so, one child asked me, “Why do you talk that way?” 

My response to the child’s question was, “So you know I’m listening.”

Grasping the difference

Despite play seeming inconsequential, it is an important developmental task and thus highly facilitative when included in a child’s counseling. “Play in therapy” is a valid and effective way to work with youth. Yet true play therapy is not a technique but an integrated way of being with and for the child and has particular purpose. 

Many counselors do not realize the difference between “play in therapy” and play therapy, nor do they know that the latter is systematic and grounded in theory, whether client-centered, Adlerian or other. I encourage all counselor educators to enlighten students about this, even if only to highlight that adding a playful manner or activity to a session does not in itself constitute play therapy. In either approach, as with all therapy modalities, the client-counselor relationship is central to the work. In play therapy especially, the child’s growth comes from the counselor being fully present.

Seeing young children might be within any licensed professional counselor’s scope of practice, but it is not a competency for most. I remind my supervisees, and here my readers, to honestly know and ethically reveal their level of competence. “I use play in therapy” is, I believe, accurate for most counselors who work with youth. 

For me, “I use play in therapy” has evolved into “While I am not certified, I do play therapy.”

 

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Maureen Bissen Neuville is a licensed professional counselor. She has been a therapist, counselor educator and clinical supervisor in La Crosse, Wisconsin, for more than 20 years. She is grateful to be able to continue in the counseling field even as she moves toward retirement. Maureen envies and respects those who have completed play therapy certification or achieved registered play therapist status. Contact her at mneuville@pomcounselingllc.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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