Tag Archives: play therapy

Exploring the ties that bind

By Bethany Bray April 24, 2020

Family therapy pioneer Virginia Satir famously said, “If we can heal the family, we can heal the world.”

Satir believed the family to be the “factory” where all people are made. She was among the first to champion an idea now commonly acknowledged among counselors: A person’s family of origin and family relationships influence that individual’s health, personality and life patterns — and, when explored in therapy, provide a fuller picture from which to help the client. That understanding can be expanded even further when the individual consents to involving family members in counseling sessions.

When considering whether it is appropriate to involve a client’s family in counseling sessions, “I look at what the primary focus of our work will be,” says Esther Benoit, a licensed professional counselor (LPC) with a private practice in Newport News, Virginia. “If the primary focus is on relational [issues], I want to bring in as many people as can possibly show up to sessions.”

Regardless of whether professional clinical counselors work with family groups, couples or individuals, an exploration of family issues can provide a more holistic picture of clients and what is contributing to their presenting issues.

Heather Ehinger, a licensed marriage and family therapist in Connecticut, urges practitioners to ask questions that dig into the traditions, boundaries and roles in the family systems in which clients operate. For example, perhaps clients perceive their role within their family to be that of the troublemaker or the placater. How did they arrive at that role? Is it a role that they desire
to inhabit?

“Using a family systems lens to treat anyone is very important,” Ehinger says. “Even if all you do is treat individuals … [using] a holistic lens, a family systems lens, in their assessment … will enrich any counseling that did not include that already.”

Trauma and transitions

Although discussing a client’s family background or involving family members in counseling sessions can enhance work with clients regardless of what brought them to counseling, there are a number of issues for which family work can be particularly helpful. The counselors interviewed for this article report that issues related to trauma and transitions — such as blending two families after a second marriage — come up repeatedly in their work with families.

Trauma, including past sexual, physical or emotional abuse, can often lead to problems with attachment in families, notes James Robert Bitter, a counselor educator who supervises graduate students at East Tennessee State University’s (ETSU’s) on-campus community counseling clinic. There is also the trauma of separation. Bitter says several students he supervises are counseling young clients who are in foster care or being raised by grandparents because their parents are incarcerated or struggling with addiction.

“[In] family therapy these days, in our area, we’re not working so much with children and families because they are structurally misaligned or have difficulty with psychiatric disorders. We are much more working with trauma and working with families to be more effective in how they raise children,” says Bitter, a professor of counseling and human services who specializes in family counseling and the Adlerian method. “When there’s been a rupture in attachment issues, helping clients [relearn attachment] in a compassionate way is hard. The people who have been traumatized are way outside the natural bond.”

Kristy A. Brumfield, an LPC at a group practice in Philadelphia, finds that working with families in groups can often help those who are struggling with transitions such as the arrival of a new baby, a move, or the particulars of co-parenting after a divorce.

Transition challenges can also crop up naturally as families grow and age, Benoit adds. For example, families may find that formerly established patterns that used to work well around the areas of discipline and boundaries begin to cause friction as children turn into teenagers. Professional counselors can serve as valuable sources of support and guidance as families take a step back and examine the patterns within their systems, says Benoit, who specializes in relational work with individuals, couples and families across the life span.

“Working through developmental things is huge [with families], as well as attachment and focusing on relationship patterns,” Benoit says. “Also transition points. Anytime there’s an expansion or contraction of a family system, that’s when people often seek help. It can be a birth, a death, a divorce or a blending of a family. Sometimes, what was working before is no longer working.”

Getting together

The term “family counseling” may invoke thoughts of the traditional nuclear family, with juvenile children and parents sitting together and talking with a clinician. This arrangement can and does happen, but family counseling also encompasses groupings beyond the immediate or traditional family unit. It can involve any constellation of family members willing to participate who are relevant to or involved in the family’s presenting issue and who could benefit from work on communication patterns and relationship issues.

When involving multiple people in counseling sessions, counselors must first identify who the client is and what that entails, including privacy issues. In some cases, the individual who first sought counseling will be the client; in others, a couple or the entire family group will be the client. (Find out more about this essential conversation in the 2014 ACA Code of Ethics, including Standards A.8. and B.4.b., at counseling.org/knowledge-center/ethics/code-of-ethics-resources.)

Benoit says she always begins counseling with family groups by fully explaining and defining the therapy relationship and letting the family decide if they would be comfortable with a group format. “I like to put the ball in the client’s court and give them a chance to decide if this modality feels right and will address what they want it to in counseling,” says Benoit, a member of the American Counseling Association.

Recently, Benoit received a call from a couple seeking counseling for their twin teenagers struggling with stress related to being in high school. The twins were both gifted and very bright. Benoit first met with the parents, without the twins, to learn more about the situation and to explore the family dynamics. She quickly saw that the family’s relationship was strong and healthy, which meant that wasn’t the issue of concern. Instead, the twins needed space to process some complicated emotions — feeling close and supportive of each other and yet sometimes simultaneously competitive with each other in academics, sports and extracurricular activities.

When Benoit had her first session with the twins, she talked over several options with them: individual work with different counselors, seeing her together for sessions, or having the entire family involved in counseling. Benoit stressed that if the twins decided to come to her together for therapy, they would need to stay together for sessions. She gave the twins time between their first and second sessions to think it over.

“Because of the uniqueness [of their situation] and how connected they were to each other, they felt it was most appropriate to be seen together,” Benoit recalls. “Ultimately, they decided that this felt like the best option [for them].”

Benoit emphasizes that this process will look different for each client and must be tailored to fit each client’s needs and presenting issues. For example, she has another set of juvenile siblings on her caseload who see her separately as individual clients. Their presenting issues are very different, and their counseling work does not overlap, so individual sessions work best for them, she explains.

The symptom carrier

Ehinger owns a group family counseling practice with two locations in Connecticut. Her staff of therapists is able to collaborate and co-treat family groupings and individuals within families who need counseling on separate issues simultaneously.

Frequently, in families, there is one identified person who is symptomatic and causes the family to seek counseling, such as a teenager with an eating disorder or a child with attention-deficit/hyperactivity disorder. Even so, the problem often runs deeper and affects the entire family. “The idea is that one person is holding the symptoms, but it’s not the only problem within the family system,” says Ehinger, an ACA member with a doctorate in counseling education and supervision.

This is especially common when couples have an unhealthy relationship or are going through a divorce, she says. Their child may be the one who is symptomatic, but the issue is rooted in the parents. “The child may be afraid to go to elementary school and has a lot of anxiety. The parents have talked with the school and find that it’s not anything academic, and the child is not being bullied,” Ehinger says. “Then we might find out from the parents that the father moved out two months ago, there’s a lot of fighting and there are lawyers involved. They may say, ‘We’re not fighting in front of the kids.’ [But] whether they’re fighting in front of the kids or not, this child is absorbing the energy and knows there’s something going on.”

Ehinger and a colleague at her practice co-treated a family in which a teenage son was identified as symptomatic. The parents initially sought counseling for the 16-year-old because they said he was grumpy and defiant, staying out past curfew, skipping classes and experimenting with substance use.

The teenage son started individual counseling with a male clinician at Ehinger’s practice. Because the practice specializes in family systems issues, the clinician viewed the teen’s troubles from a systems perspective and soon uncovered a larger challenge. The answers the teen gave to questions about his family life indicated there was tension in the home and that his parents were having trouble.

The family also had a daughter who was a freshman in college. When she came home for holiday break, she refused to return to school and started displaying defiant behavior and some of the other symptoms her brother had shown. As these challenges unfolded, Ehinger began working with the parents, while her colleague worked with their children. Sometimes they would all convene for sessions together, with four family members and two clinicians in the same room.

Ehinger’s conversations with the parents in counseling revealed that the couple had experienced an issue with infertility and that both of their children were adopted. The couple hadn’t resolved their grief over their infertility, and that contributed to them struggling with their adopted children gaining their independence and beginning to “launch” from home, Ehinger says.

Within a few months, the symptomatic teenager was no longer “the problem” — the couple’s marriage was, Ehinger says. The son’s symptoms dissipated as counseling helped him find autonomy, and he subsequently stopped acting out as often.

This family’s presenting issue was due to problems with attachment, Ehinger explains. “The parents hadn’t really grieved the loss of having the ability to have their own children. They were extremely sensitive to being ‘perfect’ parents. They felt they would be failures if they weren’t perfect parents to these adopted kids and were pointing fingers at each other out of frustration.”

The issue was exacerbated, Ehinger recalls, because the parents had large extended families with lots of children, so they felt inadequate and insufficient compared with their relatives.

Ehinger worked with the mother to boost her self-esteem and process her infertility grief in individual sessions. With the couple, Ehinger also focused on grief processing, as well as finding safety within their relationship. They talked about “how to be intentional with each other, how to relate to each other, what their idea of marriage is, and how they [could] be more intentional to get to that,” she says. She also provided psychoeducation on why transitions, including child development during the teenage years, are so hard for families.

Ehinger often uses narrative therapy with families, and in this case, it was particularly helpful. In this family, the narrative was that the husband and wife felt like “bad parents,” the son was the “troublemaker,” and the daughter had always been the “good one,” although she later struggled when she came home from college.

“We worked to change that story: The parents were not bad but hypervigilant. We taught them about attachment, normal teenage rebellion and helped them recreate the narrative of their family,” Ehinger says. “We talked about roles: How did [the son] get the role of the troublemaker? Did he want to keep it? Did he ask for it? Who would resist him shedding that role? What other role could he [and other family members] become?”

Uncovering patterns

Benoit finds structural family therapy and experiential family therapy helpful in her work with family clients. Both modalities focus on interaction patterns within family groups.

“A family’s whole systemic interaction pattern can be shifted by changing small behaviors. That’s why it’s so important to identify those patterns,” says Benoit, a full-time faculty member teaching online at Southern New Hampshire University.

One way counselors can encourage families to shift long-held and unhealthy patterns is to raise family members’ awareness of the roles they play within the system. “For example, sometimes one member will be the family’s harmonizer, smoothing over all conflict,” Benoit says. “Those roles often dictate how members interact in day-to-day interactions, but also during conflicts and transitions. Understanding the roles that are played and how those influence interactions can help challenge family members to explore alternatives and to try on new roles as their family systems grow and change over time.”

Benoit’s focus on patterns involves careful listening and close observation of the ways that family members talk and interact, both verbally and nonverbally, in sessions. This includes body language as well as the tone and subtext of what is said verbally. “I’m taking it all in,” she says.

Perhaps the family members always sit in the same order for each session, for example, or one child always sits with one parent and distances themselves from the other, or the children always look at their mother before saying anything. Often, families don’t even realize that these patterns are happening or that there might be deeper meaning behind them, Benoit says.

Her method is to gently point these patterns out to the family, framed by curiosity. Her approach doesn’t paint the behaviors necessarily as being bad, but rather just as something to ask about and gather more information on.

“With family counseling, families are coming to us to get information and feedback, so pointing out patterns can help,” Benoit says. “Over time, I might point [a pattern] out to the family and say, ‘This is what I’m seeing. Help me understand where this comes from, and how it helps in your relationship. … Tell me about what this behavior means to your family.’”

For example, a child may always sit between his mother and stepfather in session. What might this symbolize? Is it a physical representation of the bridge-building role the child plays in the family? Benoit would bring up this observation, framing it as a question or a “tell me more” prompt.

“It’s something to explore. It doesn’t always mean something, but it’s worth asking,” she says. “And I get it wrong all the time. Sometimes the family will say, ‘Gosh, no!’ and then it just helps me to learn more information” about the family system.

Behavior patterns within families can also be rooted in culture or context, Benoit adds. For example, a young child who always defers to his or her parents or waits to speak in counseling sessions can be exhibiting a sign of respect taught within the family or culture.

Uncovering patterns and the meanings behind them demands that practitioners be present and focused on each moment in session. It also requires keeping a curious mindset, Benoit says. “One of the reasons I love relationship counseling so much is that instead of working with one person, you’re working with multiple people. But more importantly, you’re working on the space between people,” she says. “It’s really dynamic and powerful work.”

Processing trauma

Bitter counsels clients with the internship and practicum students he supervises at ETSU’s on-campus counseling clinic, which offers free services to members of the community, many of whom have minimal or no health insurance coverage. Bitter says he starts thinking about other family members who could be involved in counseling work within the first session with a client. From his perspective, all issues that bring clients to counseling are family issues in one way or another.

“Everything is a family issue,” says Bitter, who will be publishing a third edition of his book, Theory and Practice of Couples and Family Counseling, with ACA this fall. “Instead of family or couples [counseling], a broader term might be relational counseling. From the moment we are born, we are in a relationship. We can’t survive without them.”

Bitter recalls one client whom he has counseled for multiple years (beginning when the client was 14), with various counseling interns also being involved in one-semester intervals. Initially, the client’s aunt contacted ETSU’s counseling center to request help for her nephew.

The client’s mother struggled with addiction and had been married four times, in addition to having multiple other relationships, all of which had been immersed in drug culture. The youth — the second of his mother’s five sons — had seen “a constant stream in his young life of drug dealers and men with whom his mother was having relationships,” Bitter says. By the time the boy was 5 or 6, he had taken on the role of unofficial parent and caretaker for his younger brothers. He would get them up and dressed in the mornings and make sure they had food to eat, and he would clean the house.

When he was 9, the boy and his older brother went to live with their father, who had alcoholism. There, the client also took on caretaking tasks for his brother and, to an extent, his father. Bitter notes that the boy would have to ask his father repeatedly for money to buy food for the household.

At one point, the youth called his aunt and asked if he could stay with her. The aunt took him in and called the ETSU counseling center for help. Initially, Bitter saw the teen as an individual client (at the teen’s request). But in sessions, the youth would claim that he was “fine” and never bring up anything to talk about.

“The trauma and neglect in this boy’s life led him to be depressed but also led him to be very secretive. He had a very, very hard time telling me what was going on in his life,” recalls Bitter, an ACA member. “When you grow up being a little boy who has to take care of everyone else, you have to present a really good face to the rest of the world and learn to act as if everything is fine, until it is not.”

Eventually, Bitter worked with the youth to involve his aunt and grandmother — the most supportive family members in the client’s life — in counseling sessions. In their work together, Bitter focused on ways to rebuild the teen’s broken family while removing the caretaking role he had shouldered for so many years. “I asked the adults to be a family, and the aunt and grandmother were willing to do that,” Bitter says.

A year and a half later, counseling began to include a focus on the teenager transitioning from living with his aunt to moving back in with his father, who had worked to get sober and secured a job as a landscaper. “The counseling center helped with that transition and rekindled relationship and also reversed the pattern of trauma [in the family],” Bitter says. “We helped him to live as a child again and rely on the adults in his life. Now he has an aunt, grandmother and father who are functionally caring for him.”

The teen will soon turn 17. He’s doing well but is “still careful and cautious in relationships,” Bitter says. “He has two good friends and can’t really handle more than that.”

The teen and family’s recovery came “after two years of [counselors] constantly seeing this family, encouraging them and literally teaching them how to talk to each other, helping them with how to respond to each other,” Bitter says.

Effective parenting

In addition to working through unresolved trauma, much of what Bitter focuses on with families in counseling is changing unhealthy parenting patterns. Parents often come to the counseling clinic at their wits’ end because of behavior problems with their children.

The world has changed dramatically over the past century, but parenting styles, on the whole, have not, Bitter contends. With what counselors know about attachment and the benefits of using boundaries rather than punishment with children, practitioners are well-equipped to offer psychoeducation to parents who are struggling, he says.

“The majority of people parenting today, when we’re at our best, we sometimes parent better than our parents did, but when we’re at our worst, we all parent at about the same level our parents did — and we have to assume they did the same thing,” Bitter says. “Most of parenting is teaching [clients] how to form really good bonds with children and help them grow and develop.”

Bitter says a counselor’s role is to offer guidance rather than explicit instructions or commands to parents. “I wait for the client to say what they did and then ask, ‘Did that work for you? How did it go?’ If you had to spank your child [multiple] times per week, then it’s not working. Let’s talk about what might work [instead].”

Counseling can also normalize parents’ challenges, sending the message that they aren’t alone in their struggles. “They get to see that they’re like every other family — if you have children, you’re going to make a mistake every day,” Bitter says. “Often, parents are doing a pretty good job but just need [extra] help. But those who are dealing with trauma, or dealing with a bond between a child and parent that has to be reconnected, that takes some time and patience.”

Bitter draws on a number of methods to help parents, including Jane Nelsen’s positive discipline approach, Michael Popkin’s active parenting system, the Systematic Training for Effective Parenting (STEP) program, and James Lehman’s Total Transformation trainings for parents. However, Bitter emphasizes the “natural consequences” concept when it comes to child discipline.

As a child, Bitter says he hated Brussels sprouts, but his father loved them, so the pungent vegetable often appeared on the family dinner table. This circumstance frequently escalated into verbal battles, with his father insisting that Bitter was going to eat Brussels sprouts and Bitter insisting otherwise. Use of the natural consequences philosophy can circumvent such parent-child power struggles.

“Now we know that if parents serve a variety of things and a balanced diet, over time a child will make good choices,” Bitter says. “If you make [healthy] food available, a child will eat it. I recommend that parents model good eating habits but not get into fights over what the child is or isn’t eating. [When a child refuses to eat something], say ‘OK, don’t eat that.’ The natural consequence is that the child will get hungry. If they say, ‘I’m not eating breakfast’ [with the rest of the family], a parent should say, ‘OK.’ The child will come back at 10 a.m. and say, ‘I’m hungry.’ The parent can respond [by saying], ‘OK, lunch is served at noon, and you’ll make it until then.’”

If these types of patterns are repeated often enough, children will learn from their experiences and realize the natural consequences of their choices, Bitter points out.

He gives another example: Perhaps a mother who is struggling with a defiant adolescent finds that the child pushes back on her instructions to come out of the mall to be picked up at 3 p.m., despite having been dropped off for shopping with friends hours earlier. Bitter says he would ask the client, “What would happen if at 3 p.m. [when the child isn’t there], you just pressed on the gas in your car and drove away?” When the child calls to ask why Mom isn’t there to pick him or her up, she can calmly explain that she was there at 3 p.m. but the child wasn’t. Now, Mom has other things to do but will return to get the child when she can, Bitter says.

The crux of this method is for parents to learn to control themselves, Bitter says. Once they learn and find control, their child (or children) will follow.

“This is not difficult stuff. It’s hard to put into practice but easy to understand. Part of this is just helping couples and families get there,” Bitter says. “It takes patience on the part of the parent. The parents we are seeing are extremely frustrated because what they’re doing isn’t working. … If you put these [concepts] into practice, [parents] will have a more harmonious life with their children. It’s just a question of getting started.”

Playing together

Brumfield is a registered play therapy supervisor and has used play therapy not only with children, but with adults and families, for 18 years. While play therapy with children is mostly unguided, Brumfield provides prompts and gentle guidance for the adults and families on her caseload, often in the form of games and activities. This can include asking a family to create a puppet show or to play out a story using puppets in session. Among the many benefits of this approach, Brumfield says, is helping adults “reconnect to the playful parts of themselves.”

Brumfield, a member of ACA, also uses music and art in her work with families. For instance, she might ask family members to draw their answer to a counseling prompt. Or she’ll pass out rhythm instruments and have the young children beat a pattern, while the parents are encouraged to add to it or to repeat it back to the children on their own instruments.

Observing how the family interacts during these activities tells Brumfield a lot about the relationships, patterns and roles within the family. For example, is one person dominant and leading the entire plan for the family puppet show? Or does everyone work on drawing on their own, almost as if no one else were in the room? “While watching them interact, I see the gaps and places where the family might grow,” explains Brumfield, who is also a counselor educator at Immaculata University in Pennsylvania.

In addition to in-session activities, Brumfield encourages families to make time for activities together at home. These can run the gamut from a game of hide-and-seek or a family bike ride to board games and puzzles. She recommends games that encourage conversation and that are cooperative rather than competitive. One of her personal favorites is the Ungame, a board game that directs players to answer various questions to encourage conversation but has no winner. Similarly, families can use a conversational card deck — a number of which are available online — to spark healthy discussion at mealtimes.

When it comes to “assigning” families activities to do outside of session, Brumfield likes to have each family member think of three things they would like to do together. “Children often have ideas readily, and the children are really the ones teaching the parents. I ask the parents to think of their own childhood and what they enjoyed or things they wished they were able to do when they were a child,” Brumfield says. “The primary goal is connection and helping them be more cohesive and work together.”

Boosting family connection typically involves taking a break from technology, Brumfield adds. She often requests that clients try to unplug during family activities. An exception is when technology prompts bonding, such as when a teenager invites his or her parent to play a nonviolent video game together.

Playful activity — inside and outside of counseling sessions — helps families to be less guarded with one another, Brumfield notes. It also boosts communication, joy and vulnerability. Parents might feel silly at first, and that’s a good thing, Brumfield asserts. She reassures parents that letting their guard down to play does not lessen their authority or diminish boundaries.

“When family members are more vulnerable, they’re more able to be seen. It can increase [the family’s] understanding of one another,” Brumfield says. “The children can see their parents differently — as more human. The parents are able to feel reconnected and able to have fun with their children, which can help balance more challenging times for families. … For younger children, mastery can be learned. It can be a confidence boost to be able to participate and learn to be a part of their family. For parents, they’re able to see the things that their children are capable of. Parents often want to do everything for a child, [and play] helps them discover what they can do for themselves.”

Brumfield encourages counselor practitioners to remember the power of play, regardless of whether they specialize in play therapy. “We all — counselors and clients alike — need to be connected with the playful parts of ourselves,” she says. “Remember the importance of humor in our work. It can even be a form of self-care. Think of play as a way to release, stay centered and help in other facets of life.”

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Families and technology

Heather Ehinger, a licensed marriage and family therapist in Connecticut, says conflict over technology use comes up over and over again in her work with families.

This includes fighting between parents and children (and among couples) about which technology is being used and how often. In addition, a couple may have differing views over the age at which their children should have access to technology (such as their own cellphone) or whether they should be allowed to have a computer or video game system in their bedroom.

The conflict that arises over one or more family members’ use — or abuse — of technology can be a flashpoint or an indicator of deeper issues. Technology isn’t necessarily what brings a family in to counseling, Ehinger says, but it’s often a contributor to their presenting issue.

“Technology is not the problem exactly, but it is part of the problem. It feeds into authority issues and discipline,” Ehinger says. “Technology is like a thorn in the family’s side, but it actually turns into the lens through which we see whether the family is functioning or not.”

Ehinger worked with one family who had a son in fourth grade. He was acting out at home, having tantrums and pushing back against boundaries with his mother, who was a stay-at-home mom. He wanted to play Fortnite all the time and would sneak his mother’s cell phone away from her to do so. She would find her son upstairs, still in his pajamas, playing the online video game when it was time to leave for school in the mornings.

This was partly a problem of overstimulation and obsession on the son’s part, but there was also a disconnect on the part of the mother, Ehinger says. Sometimes, disagreements over technology use are generational. In this case, the mother didn’t realize that her son was using the game as a way to socialize and communicate with peers. Adding to her frustration was the fact that she had previously worked in a corporate environment and was used to people listening to her, Ehinger observes. Now, as a stay-at-home mom, she was locked in a battle of wits with her young son.

When it comes to addressing issues of technology use, Ehinger says that psychoeducation about family roles and setting boundaries can be particularly helpful for families in counseling. She often talks with parents about setting limits, taking televisions out of children’s bedrooms, and establishing regular “no tech” nights, when the home’s Wi-Fi is switched off for the evening, to spend time together as a family.

Ehinger also moderates conversations with couples in counseling to get them on the same page regarding their family’s technology use.

“Often, it turns out to be a couple’s problem,” Ehinger says. “They need to define roles when it comes to discipline and boundary-setting — which is all affected by their family of origin. They have to create an ‘our way’ [instead of ‘my way’] and stop bickering and fighting with each other.”

 

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Contact the counselors interviewed for this article:

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Find out more about family counseling from the International Association of Marriage and Family Counselors, a division of ACA, at iamfconline.org.

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What’s left unsaid

By Lindsey Phillips January 3, 2019

A child discloses that her grandfather has been sexually abusing her, and the mother’s response is shock that his abuse didn’t stop with her when she was a child. This scene is not uncommon for Molly VanDuser, the president and clinical director of Peace of Mind, an outpatient counseling and trauma treatment center in North Carolina. As she explains, adult survivors of child sexual abuse often assume that the offender has changed or is too old to engage in such actions again. So, the abuse persists.

Concetta Holmes, the clinical director of the Child Protection Center in Sarasota, Florida, has treated clients with similar intergenerational abuse stories. “In that unresolved trauma … what has happened is now a culture of silence around sexual violence that is ingrained in the family,” she says. “That [affects] things like your feelings of safety, security [and] trustworthiness, and it reinforces that you should stay with people who hurt you.”

Kimberly Frazier, an associate professor in the Department of Clinical Rehabilitation and Counseling at Louisiana State University’s Health Sciences Center, acknowledges that people often don’t want to think or talk about child sexual abuse, but that doesn’t stop it from happening. The nonprofit Darkness to Light reported in 2013 that approximately 1 in 10 children will be sexually abused before they turn 18.

Because of the culture of silence that surrounds child sexual abuse, it is safe to assume that the true number is even higher. Cases of child sexual abuse often continue for years because the abuse is built on a foundation of secrets and fear, Frazier points out. Survivors frequently fear what will happen to them (or to others) if they tell, or the shame they feel about the abuse deters them from disclosing.

Societal norms can also diminish a survivor’s likelihood of disclosing. For example, society has for decades implicitly sanctioned sexual interactions between boys who are minors and adult woman, but it is still abuse, says Anna Viviani, an associate professor of counseling and director of the clinical mental health counseling and counselor education programs at Indiana State University. Holmes adds that gender stereotypes such as this can cause boys to feel as though they shouldn’t be or weren’t affected by sexual abuse, which is not the case.

“I think the biggest fallacy [counselors have] is that [child sexual abuse] is going to impact people from a particular demographic more than another,” Viviani says. “Childhood sexual abuse cuts across every demographic. I think the sooner we can accept that, the sooner we’re going to be better at identifying clients when they have this issue in their history.”

Putting on a detective hat

Identifying signs of child sexual abuse is neither easy nor straightforward. Part of the difficulty lies in the fact that the signs are not clear-cut, says VanDuser, a licensed professional counselor (LPC) and an American Counseling Association member. Regressive behaviors such as bed-wetting can indicate abuse, but they might also be the result of other changes such as a recent move, a new baby in the family or a military parent deploying, she explains.

VanDuser also warns that child sexual abuse is insidious because a lot goes on before the offender actually touches the child. “Childhood sexual abuse sometimes leaves no physical wounds to identify,” she says. Some examples of noncontact abuse include peeping in the window at the child, making a child watch pornography or encouraging a child to sit on one’s lap and play the “tickle game.” Such activities are part of the grooming process — the way that offenders build trust and gain access to the child.

In addition to physical signs such as bladder and vaginal infections, changes in eating habits, and stomachaches, survivors of child sexual abuse also demonstrate behavioral and emotional changes. One major warning sign is if the child displays a more advanced knowledge of sex than one would expect at the child’s developmental stage, VanDuser says.

Other possible behavioral signs include not wanting to be alone with a certain person (e.g., stepfather, babysitter), becoming clingy with a nonoffending caregiver, not wanting to remove clothing to change or bathe, being afraid of being alone at night, having nightmares or having difficulty concentrating. In general, counselors should look for behaviors that are out of character for that particular child, VanDuser advises.

Viviani, a licensed clinical professional counselor and an ACA member, also finds that people who have experienced child sexual abuse have higher rates of depression, anxiety, panic disorders and posttraumatic stress disorders.

Because the signs of child sexual abuse are rarely clear-cut, counselors must be good investigators, Viviani argues. In her experience, adult survivors present with an array of symptoms, including health concerns, relationship problems and gaps in memory, so counselors have to look for patterns to discover the underlying issue.

If counselors notice any of these signs, VanDuser recommends asking the client, “When did this problem (e.g., bed-wetting, cutting, nightmares, acting out in school) begin?” Counselors can then follow up and ask, “What else was going on at that time?” The answers to these questions often reveal the underlying issue, she notes. For example, if the client responds that his or her depression or vigilance to the environment began around age 12, VanDuser says she will dig deeper into the client’s family relationships.

Frazier, an LPC and a member of ACA, suggests that counselors can also look for patterns in a child’s drawing — for example, what colors they use, how intensely they draw with certain colors, or if they scratch out certain people or choose not to include someone — or in the choices children make with activities such as feeling faces cards (cards that depict different emotional facial expressions). When Frazier asked one of her clients who had come to counseling because of suspected sexual abuse to select from the feeling face cards, she noticed the client consistently picked cards with people wearing glasses. Frazier later discovered that the child’s abuser wore glasses.

For Frazier, becoming a detective also involves going outside of the office to observe the child in different spaces, such as in school, in day care or at the park. Frazier includes the possibility of outside observations in her consent form, so the child’s parent or guardian agrees to it beforehand. She advises that counselors should take note of whether the child’s behavior is consistent across all of these spaces or whether there are changes from home to school, for example. In addition, she suggests asking the parents or guardians follow-up questions about how the child’s behavior has changed (e.g., Has the child lost the joy of playing his or her favorite sport? Is the child withdrawn? Is the child fighting?).

Speaking a child’s language

Young children may not have the words or cognitive development to tell counselors about the abuse they have been subjected to. Instead, these children may engage in traumatic play, such as having monsters in the sand tray eat each other or being in a frenzied state and drawing aggressive pictures, VanDuser says.

“One of the most important things for clinicians to remember when they’re working with kids and abuse is that it’s really critical to be working within the languages that children speak,” says Holmes, a licensed clinical social worker and a nationally credentialed advocate through the National Organization for Victim Assistance. “Children speak through a variety of different languages that aren’t just verbal. They speak through play. They speak through art, through writing [and] through movement, so it becomes really important that clinicians get creative in using evidence-based practices and different modalities to talk with children through their language. … Talking in a child’s language allows them to feel like the topic at hand is less overwhelming and less scary.”

For example, children can use Legos to build a wall of their emotions, Holmes says, with counselors instructing clients to pick colors to represent different emotions. If orange represents sadness and red represents frustration and 90 percent of the child’s wall contains orange and red Legos, then the counselor gets a better visualization of what emotions are inside the child, she says.

Next, counselors could ask clients what it would take to remove a red brick of frustration or what their ideal wall would look like, such as one that contains more bricks representing happiness or peace. Counselors can also ask these clients to rebuild their Lego walls throughout therapy to see how their emotions are changing, Holmes says. This method is easier than asking children if their anger has decreased and by how much, she adds.

Frazier, past president of the Association for Multicultural Counseling and Development, a division of ACA, also finds that working with children keeps counselors on their toes. Children are honest and will admit if they do not like an intervention, so counselors have to be ready to shift strategies quickly, she says. For this reason, counselors need to have a wide range of creative approaches in their counseling bag. She recommends drawing supplies, play school or kitchen sets, play dough and sand trays.

With sand trays, Frazier likes to provide dinosaurs and other nonhuman figurines for children to play with because it helps them not to feel constrained or limited. This allows them to freely let a dinosaur or car represent a particular person or idea, she explains.

Frazier also recommends the “Popsicle family” intervention, in which children decorate Popsicle sticks to represent their family members and support systems. This exercise provides insight into family dynamics (who is included in the family and who isn’t) and allows children to describe and interact with these “people” like they would with Barbie dolls, she says.

Frazier advises counselors to keep culturally and developmentally appropriate materials on hand. For example, they should have big crayons for young children with limited fine motor skills, and they should have various shades of crayons, markers, pencils and construction paper so children can easily create what they want.

Being multiculturally competent goes beyond ethnicity, Frazier points out. Counselors should understand the culture the child grew up in and the culture of the child’s current locality because what is considered “normal” in one city or area might differ from another, she says. For example, in New Orleans, where she lives, people regularly have “adopted” family members. So, if a child from New Orleans were creating his or her Popsicle family, it wouldn’t be strange to see the child include several people outside of his or her immediate family and refer to them as “cousin” or “aunt,” even if they aren’t blood relatives.

Thus, Frazier stresses the importance of counselors immersing themselves in the worldview of their child clients. “You can’t be a person who works with kids and not know all the shows and the stuff that’s happening with that particular age group, the music, the things that are on trend and the things they’re talking about,” Frazier says. “Otherwise, you’ll always be behind trying to ask them, ‘What does that mean?’”

With adolescents, Holmes finds narrative therapy to be particularly effective, and she often incorporates art and interview techniques into the process. For example, the counselor could ask the client to draw a picture of an emotion that he or she feels, such as anger. Next, the client would give this emotion a name and create a short biography about it. For example, how was anger born? How did it grow up to be who it is? What fuels it? Why does it hang around?

Next, Holmes says, the counselor and client could discuss the questions the client would ask this emotion if it had its own voice. Then, the client could interview the initial picture of the emotion and use his or her own voice to answer the questions as the emotion would. The answers provide insight into the emotional distress the client is feeling, Holmes explains.

Frazier will do ad-lib word games with older children, who are often more verbal. While clients fill in the blanks to create their own stories, she looks for themes (e.g., gloomy story) or the child’s response to the word game (e.g., eager, withdrawn). 

Long-lasting effects

Unfortunately, the effects of child sexual abuse don’t end with childhood or even with counseling. “Children revisit their trauma at almost every age and stage of development, which is every two to three years,” Holmes notes. “That might not mean they need counseling each and every time, but they find new meaning in it or they find they have new questions … or new emotions about it.”

Viviani, VanDuser and Frazier agree that recovery is a lifelong process. As survivors age, they will have sexual encounters, get married, become pregnant or have their child reach the age they were when the abuse occurred. These events can all become trigger points for a flood of new physical and emotional symptoms related to the child sexual abuse, Viviani says.

Often, an issue separate from the abuse causes adult survivors to seek counseling. In fact, VanDuser says she rarely gets an adult who discloses child sexual abuse as the presenting issue. Instead, she finds adult clients are more likely to come in because their own child is having behavioral problems or because they’re feeling depressed or anxious, they’re having nightmares or they’re married and have no interest in sex.

Adults survivors often experience long-term physical ailments. According to Viviani, who presented on this topic at the ACA 2018 Conference & Expo in Atlanta, some of the ailments include diabetes, fibromyalgia and chronic pain syndromes, pelvic pain, sexual difficulties, headaches, substance use disorders, eating disorders, cardiovascular problems, hypertension and gastrointestinal problems.

Another long-term issue for survivors is difficulty forming healthy relationships. Because child sexual abuse alters boundaries, survivors may not realize when something is odd or abusive in a relationship, VanDuser says. For example, if an adult survivor is in a relationship with someone who is overly jealous and possessive, he or she may mistakenly translate that jealously into a sign of love.

Child sexual abuse can also affect decision-making as an adult around careers, housing, personal activities and sexual intimacy, Viviani notes. For example, one of her clients wanted to attend a Bible study group but didn’t feel safe being in a smaller group where a man might pay attention to her. In addition, Viviani finds that adult survivors sometimes choose careers they are not interested in just because those careers provide a safe environment with no triggers.

To help adult clients make sense of the abuse they suffered as children and move forward, Viviani often uses meaning-making activities and mindfulness techniques. She suggests that counselors help these clients find a way to do something purposeful with their history of abuse, whether that involves sharing their story with a testimony at church, volunteering for a mental health association or participating in a walk/run to raise awareness of suicide prevention.

Finding self-compassion

Survivors of child sexual abuse often blame themselves for the abuse or the aftermath once the abuse is revealed, especially if it results in the offender leaving the family, the family losing its home or the family’s income dropping, VanDuser says. One of her clients even confessed to thinking that she somehow triggered her child sexual abuse from her stepfather.

“Sometimes the worst part is the dread [when the child knows the sexual abuse is] coming eventually. So, sometimes a teenager will actually initiate it to get it over with because the only time they feel relief is after it’s done,” VanDuser explains. “Then they know for a while that they won’t be bothered again.”

Counselors often need to shine a light on survivors’ cognitive distortions to help them work through their guilt and shame, VanDuser says. She tries to help clients understand that the sexual abuse was not their fault by changing their perspective. For example, she will take a client to a park where there are children close to the age the survivor was when the abuse happened. She’ll point to one of the children playing and ask, “What could the child really do?” This simple question often helps clients realize that they couldn’t have done anything to prevent the abuse, VanDuser says.

Viviani takes a similar approach by talking with clients in the third person about their expectations of what a child would developmentally be able to do in a similar situation. She asks clients if they would blame another child (their grandchild or niece, for example) for being sexually abused. Then she asks why they blame themselves for what happened to them because they were also just children at the time.

“As you frame it that way, they begin to have a little bit more compassion for themselves, and self-compassion is something that’s so important for survivors to develop,” Viviani says. In her experience, survivors are hard on themselves, often exercising magical thinking about what they should or should not have been able to do as a child. “As we help them develop self-compassion and self-awareness, we see the guilt begin to dissipate,” she adds.

Regaining a sense of safety

Safety — in emotions, relationships and touches — is a critical component of treatment for a child who has been sexually abused, Holmes stresses.

Counselors should teach clients about safe and unsafe touches, personal boundaries and age-appropriate sexual behavior rules, adds Amanda Jans, a registered mental health counseling intern and mental health therapist for the Child Protection Center in Sarasota. Counselors can also help clients “understand that they are in charge of their bodies, so even if a touch is safe, it doesn’t mean they have to accept it,” she says.

Hula hoops provide a creative way to discuss personal space boundaries with clients, Holmes notes. Counselors can use hula hoops of different sizes to illustrate safe and unsafe boundaries with a parent, sibling, friend or stranger, she explains.

VanDuser helps clients engage in safety planning by having them draw their hand on a piece of paper. For each finger, they figure out a corresponding person they can tell if something happens to them in the future.

Counselors can also take steps to ensure that their offices are safe settings. Jans, an ACA member who presented on the treatment of child sexual abuse at the ACA 2018 Conference, uses noise machines to ensure privacy and aromatherapy machines to make the environment more comfortable. She also has a collection of kid-friendly materials, so if a child starts to feel dysregulated during a session, he or she can take a break and play basketball or color.

Likewise, if clients are hesitant to discuss the topic, Jans allows them to take a step back. For instance, she has clients read someone else’s experience (either real or fictional) rather than having them write their own story, or she has clients role-play with someone else serving as the main character, not themselves. This distance helps clients move to a place where they eventually can discuss their own stories, she says.

Another technique Jans uses to ease clients into writing and processing their own stories is a word web. Together, Jans and a client will brainstorm words related to the client’s experience and put the words on a web (a set of circles drawn on a paper in a weblike pattern). Jans finds this exercise helps clients get comfortable talking about the subject and, eventually, these words become part of their narrative.

VanDuser also suggests getting out of the office. Sometimes she takes child and adolescent clients to a store to get a candy bar. On the way, she will ask them what they are feeling or noticing. If clients say that someone walking by makes them feel strange, VanDuser asks how they would address this feeling or what they would do if someone approached them. Then they will talk through strategies that would make the client feel safe in this situation.

Taking back control

Survivors of child sexual abuse often feel they can’t control what happens around them or to them, Frazier says. So, counselors can get creative using interventions that return control to these survivors and make them feel safe.

Viviani helps clients regain some sense of control in their lives by teaching grounding and coping skills. “Coping skills are so important to helping them begin to trust in themselves again so that they have the skills to really uncover and deal with the abuse,” she explains.

In sessions, counselors can help clients recognize what their bodies feel when they are triggered. Then they can help clients learn to deescalate through grounding skills such as noticing and naming things in their current surroundings or reminding themselves of where they are and the current date, Viviani says. Rather than reliving the incident — being back in their bedroom at age 5, for example — clients learn to ground themselves in the here and now: “This is Jan. 10, 2019, and I’m sitting in my office.”

VanDuser highly recommends trauma-focused cognitive behavior therapy (TF-CBT) for work with survivors of child sexual abuse. TF-CBT is a short-term treatment, typically 12-16 sessions, that incorporates psychoeducation on traumatic stress for both the child and nonoffending parent or caregiver, skills for identifying and regulating emotions, cognitive behavior therapy and a trauma narrative technique.

For a creative approach, VanDuser suggests letting children use crayons and a lunch bag to create a “garbage bag.” She first writes down all the bad feelings (e.g., fear, anger, shame) the client has about the abuse. As the child finishes working on one of the bad feelings, he or she puts the feeling in the garbage bag. When all the feelings are in the bag, VanDuser lets the client dispose of it however he or she wishes — by burning it, burying it, throwing it in the actual garbage or some other method.

Jans and Holmes suggest empowering clients by giving them some control in session. For example, if clients are feeling sad, the counselor can remind them of the coping strategies they have been working on (perhaps progressive muscle relaxation and grounding techniques) and ask which one they want to use to address this feeling. The counselor could also list the goals of therapy for that day and ask clients which one they want to work on first, Holmes says.

Holmes acknowledges that clients may never make sense of the abuse they suffered, but counselors can help them make sense of the abuse’s impact and aftermath. For Holmes, this meaning making involves clients being empowered to reclaim their lives after abuse rather than being held hostage by it, realizing that trauma doesn’t have to define them and learning to be compassionate with themselves.

The hero who told

Holmes encourages counselors not to shy away from discussing child sexual abuse. “If clinicians hesitate, clients will hesitate. If the clinician avoids it, the client will avoid it,” Holmes says. “It’s the clinician’s responsibility to take the lead on this topic. Sexual abuse is so widespread in our society that we do our clients a disservice when we don’t incorporate sexual abuse histories into our [client] assessments.”

Typically, however, counselors are not the first person a child will tell about the abuse. Often, children first disclose the abuse to a teacher or other school personnel, and their reaction is crucial in ensuring that the child gets help, Viviani says.

Thus, she advises counselors to partner with schools and child advocacy organizations to educate them on what they should do if a child discloses sexual abuse. “They need to know what to do,” Viviani emphasizes. “They need to know what to say to support that child because we may not get another chance, at least until they hit college age when they’re not under that roof anymore, or we may never get that chance again.”

Counselors must also empower survivors of child sexual abuse. “They shouldn’t be waiting for the therapist … or their best friend to ride in and save them. We want them to be the hero of their own story,” Holmes says. “And how we do that is through finding ways they can start to recognize and make safe and healthy decisions about different pieces of their life, and we want to model that even within the therapy environment.”

The end result of TF-CBT is the child writing his or her own narrative of the sexual abuse. VanDuser emphasizes that no matter how the child’s sexual abuse story begins, it always has the same ending: the hero — the child — who told.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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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.

The therapy behind play therapy

By Bethany Bray August 24, 2018

Ashley Wroton, a licensed professional counselor (LPC), says parents of her young clients have told her that pediatricians sometimes make comments suggesting that they try “real” therapy with their child rather than play therapy.

“Play therapy is real therapy,” says Wroton, a registered play therapist who works with clients ages 3-12 at a group outpatient practice in Hampton, Virginia. “Play is the medium through which the therapy occurs. … The play helps them open up to make better connections.”

The idea that play therapy isn’t a wholly serious or legitimate approach to therapy is a misconception with which play therapists often contend — including among other helping professionals, says Jeff Cochran, a professor of counselor education and head of the Department of Educational Psychology and Counseling at the University of Tennessee. Perhaps understandably, those not trained in the theory might be skeptical of the effectiveness of allowing a child to explore a room full of art supplies, stuffed animals and toys for the length of the therapy session. However, Cochran explains, under the watchful eyes of a play therapist, the toys are a medium through which the child communicates, learns, self-discovers, shares experiences and forms a trusting therapeutic relationship. The play, he asserts, serves simply as a bridge to therapy.

“Because we refer to it as play, [people assume] it’s supposed to be all light and easy for the child. But, no, it’s work,” says Cochran, a member of the American Counseling Association.

Defining play therapy

The fourth edition of The Counseling Dictionary, published by ACA, defines play therapy as the “use of play as a means of establishing rapport, uncovering what is troubling a person (often a child), and bringing about a resolution.”

Under the broad umbrella of play therapy are a number of focused methods and approaches, ranging from child-centered, filial and dyadic to animal-assisted play therapy. Although most often associated with children, play therapy can also be used in varying forms with teenagers and adults, as well as with children and their parents or their caretakers together. It can also be used in conjunction with more traditional therapy methods such as cognitive behavioral, Adlerian, Gestalt and narrative therapies.

However, simply having some toys in a therapy office or encouraging clients to draw or play with blocks as they talk with a counselor is not play therapy, stresses Dee Ray, an LPC and director of the Center for Play Therapy at the University of North Texas. The 2014 ACA Code of Ethics emphasizes that practitioners should undergo “appropriate education, training and supervised experience” to become fully competent in a specialty area such as play therapy before using it in practice. Practitioners can also obtain special play therapy credentials (such as the registered play therapist credential) through training, supervision and other requirements. These credentials provide practitioners additional credibility and may be preferred by certain employers or clients, Ray explains.

The process

Play therapy generally begins with a period of observation and assessment by the counselor, followed by work to process and focus on challenges the practitioner has identified based on cues the client exhibits during play.

Wroton starts therapy by talking with her child client’s parents or caregivers to hear what they believe the presenting issue is. After first watching the child play on his or her own, Wroton conducts a session in which the child and adult caregivers (or other family members living in the home with the child) play together so she can observe how they interact. Afterward, she talks with the parents or caregivers about what she noticed.

Play therapists learn much through observation, including how the child handles separation from the caregiver when the child is brought into the therapy room, Wroton says. Some children are clingy or start crying when the parent leaves, whereas others don’t seem to mind at all. This provides play therapists cues about the child’s level of attachment.

Other cues can be found in how clients play with objects in the playroom. For example, clients with anxiety, obsessive-compulsive behaviors or control issues are often very structured in their play, Wroton says. They might engage in organizing behaviors rather than playful play. She remembers one young boy who gravitated toward arranging the stuffed animals by category: jungle animals, farm animals, aquatic animals and so on.

At the same time, Wroton says, practitioners need to watch from session to session to see if clients’ play behaviors change at all. At first, organizing behaviors might be a way for clients to soothe themselves or to create order because they’re nervous. But if those same behaviors continue across sessions, they could be an indication of anxiety, autism, past trauma or other issues.

Most important, each client in play therapy will need a tailored approach and a different degree of involvement from the counselor, Wroton says. She notes that some of her clients are very independent while playing, hardly making eye contact with her as she makes observations and asks questions, whereas others invite her to play with them.

Play can run the gamut from imaginative to soothing or sensory, such as child clients painting or placing their hands in water or sand elements. As clients explore and play, Wroton narrates with questions such as “I wonder why this toy is doing that?” or “I notice that you don’t invite me to play. Do you invite other friends to play?”

In imaginative and role-play scenarios, Wroton might ask her child clients, “What could have gone differently?” or “What do you wish had gone differently?” Their answers, along with the scene they have acted out previously, can provide clues about the issues troubling these children. For example, repeatedly arranging toy figures with a “bad guy” in the scene might indicate that a child is struggling with trauma or violence from his or her past.

Wroton says she determines the course of sessions “once I learn how they [the children] do the work and how engaged they are. … I use the dynamic I see in session with them. I use my narration to challenge their thought process, make observations and ask questions. [I] guide and tease at those threads I see coming out.”

The power of play

A quote from play therapy researcher and author Garry Landreth is often used to explain the method’s effectiveness: “In the play therapy experience, toys are like the child’s words, and play is the child’s language.”

In addition to speaking a child’s language, play therapy provides a supportive, therapeutic environment and, therefore, an incubator for learning and healing, Cochran says. “When a therapist is reaching out to the child in kindness, [the child] will gradually open up. It makes all the rest of the pieces work from that therapeutic relationship core,” he says. “They cherish the undivided attention that for some adults might be too intense.”

Cochran and his wife, Nancy, both specialize in child-centered play therapy and together present trainings and workshops on the topic. They co-led an education session titled “Growing play therapy up for older children, adolescents and adults” at the ACA 2018 Conference & Expo in Atlanta this past spring.

“Once the child knows that the therapy hour is a place where they are safe, a spark is lit,” says Nancy, an ACA member and a trainer and consultant in child-centered play therapy with the National Institute for Relationship Enhancement. “With children, that’s the purity of it. The child has the ability to … take the lead and work through to mastery.”

In fact, the crux of what makes play therapy so effective — and different from most other counseling methods — is that it is directed by the client, the Cochrans assert. Play therapists don’t suggest that clients play with a certain toy or work on a presenting problem. Instead, play therapists offer warmth, empathy and a gentle structure for clients to make their own meaning through the exploration and play they chose to engage in.

In play therapy, Jeff explains, the counselor sets up the process that leads to self-discovery on the part of the client. “You let the process teach them,” he says.

“It’s really the child that directs,” Nancy says. “They’ve got a unique voice in here [the play therapy room] which doesn’t always include words. When children are given the chance to go on a journey of self-discovery, they come in and they find a unique voice within that room. Once they find their individual voice, they become more accepting of self. Not only that, but they embrace self.”

Play therapy gives clients a safe space to explore what it feels like to be in control, she adds, with learning opportunities presenting themselves at every turn. As young clients try out the various toys in the playroom, they are learning what they do and don’t like, explains Nancy, an adjunct assistant professor in the Department of Educational Psychology and Counseling at the University of Tennessee. They can also push against preconceived ideas — whether of their own making or instilled in them by others — of what they are and aren’t good at.

In the process, Jeff adds, these clients are learning not only that they can play the xylophone, for example, but that they can take on a challenge and master it.

“They can try and fail and put themselves at risk in sessions [in ways] that they wouldn’t otherwise,” Nancy says. “The process and the therapist’s unconditional positive regard allow the child to make choices and be their own guide. They can be surprised by what is discovered.”

Giving clients control

One of the Cochrans’ graduate students worked with a child referred to play therapy because he was exhibiting obstinate behavior at preschool and not connecting with classmates. The 4-year-old had experienced abuse in his past, and his fear of taking risks discouraged him from trying new things or learning at school. Nancy says that the boy was nonverbal until the 10th session of play therapy.

In his first appointment, the boy was withdrawn and anxious, alternately slouching against the wall, crawling underneath a rug and hiding behind a shelf of toy bins for much of the session. Throughout the session, the Cochrans’ graduate counseling student offered gentle narration, such as “You’re not too sure about this” and “This is difficult for you.” She stayed with him, talking him through the process, which showed that she was committed to allowing him to choose how to proceed in his playtime, Nancy says.

Afterward, the graduate student confided to Nancy that she thought she had failed and had just made the young boy miserable. When they went back and watched video footage of the session together, however, Nancy pointed out something that the counseling student had missed. The boy had repeatedly tossed toys out from behind the shelf where he was hiding, but in the very last minute of the session, he found a pair of toy binoculars and had looked through them directly at the counseling student.

“It showed that he was curious, reaching out and was open to an eventual relationship,” Nancy says. “[I told the student], ‘Think of all the things he expressed and you helped him express. It was so beautiful that you stayed warmly right there with him.’”

Over the course of therapy, the young client opened up more and more. At the second and following sessions, he went behind the shelf and dumped toys out, both to explore and to see how the student counselor would react. He later gravitated to self-expressive work in a sand tray and used the counselor as an ally as he fought with a punching bag and engaged in imaginative role-play and rescue schemes. Eventually, the boy and the counselor played together, with the boy proudly setting up challenges and showing off his skills tossing balls into a toy bin.

The client was in foster care, and over the course of therapy, his play evolved from symbolic to direct expression as he drew pictures of what he wanted his family to look like, Nancy adds.

At one point early on in therapy, the counselor moved in to sit next to the client as he was working at the sand tray. He responded during the next session by putting objects in all the chairs to let her know that he wasn’t quite ready for that, Nancy recalls with a chuckle. “He was in control to let her in, little by little. But from the start, he wanted to know her and wanted her to know him. That connection was made from the very first session by giving him control of when and how — even though that first session wasn’t very playful.”

Watching video footage of the difference between when the client first came to play therapy and later sessions is remarkable, according to Nancy. “When you look across the sessions we did with him, his whole physical presence in the room changes, from looking downcast, to playing, laughing and making eye contact.”

In play therapy, clients learn to shed the defensive behaviors they have established to hide a vulnerable core, Nancy says. “They grow up — or down — to the age they’re supposed to be. You can have a child in play therapy who is 7 years going on 40, or 7 years going on 2. They develop the skills [in play therapy] to be a good, solid 7 years old,” she says. “They try on roles, explore what it feels like to be in control, integrate what is useful and let go of what they don’t need.”

Jeff acknowledges that play therapy’s power of self-discovery “sounds deceptively simple. … It’s hard to believe it can be so impactful.” However, through play, clients are able to examine themselves and push limits to discover patterns of repeated mistakes and blind spots.

For example, a play therapist might see young clients use a doll to act out, fluctuating between caring and nurturing behaviors and hurtful behaviors. Jeff says the counselor can narrate with empathy, accepting all play behaviors and attending to the child’s process as the child makes choices of how she or he wants to be in life.

“Being with a child while she tries on hurtful ways of being can be like allowing a child to have all chocolate for lunch to find out that it’s not actually good,” Jeff says. “They’re playing out what they’re thinking about: ‘How does it feel? What does it mean to me?’ They can fluctuate between what they’ve seen in their life versus what they want.”

Testing limits and making connections

Ray, an ACA fellow and a professor in the counseling program at the University of North Texas, is a registered play therapist and a certified supervisor in both child-centered play therapy and child-parent relationship therapy. She estimates that roughly 70 percent of a play therapist’s work is nonverbal and 30 percent is verbal. When play therapy practitioners do speak, it is typically to offer reflection and encouragement on the play they are observing or to offer guidance such as setting limits, she says.

“If [the child client] is depending on an adult to make decisions, I would respond, ‘In here, it’s up to you.’ If they’re asking, ‘How do I spell this?’ or ‘How do I draw this?’ the answer would be, ‘In here, you can draw or spell it any way you want to,’” Ray says.

When a young client becomes angry or tests limits, the counselor can recognize how the client is feeling and redirect the behavior. For example, when the child gets agitated, the play therapist can suggest that rather than drawing on the wall, they draw together on paper, rip the paper or punch a punching bag, Ray says.

“The child learns that every decision they make has consequences,” she says. “Acknowledge that they do have that feeling, and the feeling is OK. But never say, ‘You can’t.’ Say, ‘This [behavior] is not for doing.’”

This type of limit setting emphasizes that the child’s feelings are valid, Ray explains. It also sends the message that the child’s behavior — not the child himself or herself — is the problem and that there are always other ways of expressing strong feelings through an acceptable behavior. If a counselor presents the limit as “You can’t,” it implies that something about the child is not OK, Ray says. This type of response also might engage the child in a power struggle with the counselor by personalizing the expression of the feeling, she explains.

Children will naturally bump up against limits as a form of exploration, so play therapists will often see young clients who want to climb on things, break toys or exhibit other destructive behaviors, Jeff Cochran says. As with so many aspects of play therapy, the manner in which the counselor diffuses these urges can be an opportunity for self-discovery.

“We start with a simple opening message: ‘In this room, you can say anything you want and do almost anything you want, and if there’s something that’s not OK to do, I will tell you,’” Cochran says.

When the child does bump into a limit, the play therapist responds with empathy to the child’s experience in that moment and limits as little of the child’s behavior as possible — just enough to keep the child and therapist safe and the therapy room functional. “That in itself becomes therapeutic,” Cochran says. “They learn that there are ways to express themselves other than pushing boundaries. The therapist doesn’t have to make that happen; it’s a naturally occurring thing. They learn themselves who they are and what they want. Is what you are doing going to get you what you want?”

The growth and learning that begin in play therapy naturally carry over and are applied elsewhere in clients’ lives, Wroton says. In other words, the “work” of play therapy continues, even if the play therapist doesn’t observe a direct cause and effect in sessions, she says.

Wroton remembers one client, a 9-year-old boy, who had been adopted after going through the foster care system. Before being removed from his birth home, he had been exposed to graphic sexual content, anger, violence and alcohol abuse. In play therapy, he responded well and gravitated to making scenes in a sand tray.

Wroton told the boy, “I want to know what it’s like to be in your world.” Repeatedly, he would respond to this prompt by creating a scene that involved a king figure and several blue Smurfs. He would bury and uncover the Smurfs, and then rebury them. When he was finally finished making his scene, the Smurfs would always remain buried beneath the sand. They weren’t uncovered until it was time to clean up, Wroton says. The boy didn’t identify who or what these figures might represent, simply referring to them as “Smurfs,” she adds.

Then, one day, something changed for the client: He buried and reburied the Smurfs like usual, but he also buried the king and left him beneath the sand. Afterward, Wroton received a call from the client’s adoptive mother. Her son, who previously had never talked much about his past, was suddenly opening up and connecting more with her.

Wroton thinks the Smurfs and king figure in the boy’s sand tray scenes represented experiences and feelings that the young client had tucked away — including family members who were abusive yet for whom he also held some positive memories. Through the sand tray, he was processing these feelings and coming to terms with what the memories meant to him.

“Typically, a change in play means a change in processing,” Wroton says. “What motivated him that day, I’m not sure. For a month and a half, he had played out that scene over and over with the same characters. We might do the work here, but the application of it, and the completion of the work, is done [outside of session]. And that’s the end goal.”

What lies beneath

Ray thinks there is no better method than play therapy for reaching children who have behavioral or mental health challenges. “So many of our interventions are about telling, doing and suggesting. But in play therapy, we trust the client to know where they need to go,” says Ray, a past president of the Association for Child and Adolescent Counseling, a division of ACA. “It’s an intervention that trusts the child — they know where to go to solve their own problems and move toward self-enhancing solutions. If you offer a relationship that facilitates growth, the child is able to make the change through the developmentally appropriate language of play.”

“It’s something that is very, very different than most mental health interventions,” Ray continues. “It’s not acting upon the child; it’s acting with the child.”

The self-directive aspect of play therapy reached one of Ray’s clients in ways that other more direct methods might have failed to do. The 8-year-old girl was referred to Ray by her school because of aggressive behavior, which included being suspended after trying to hit her teacher. However, in play therapy, the girl never mentioned any anger regarding school, her teacher or her classmates. Instead, she played out scenes from her family and home life, where, it turns out, she was being abused.

In play therapy sessions with Ray, the client gravitated toward drawing her family and setting up scenes with figures in a dollhouse. As the characters in the dollhouse would interact, the girl would exhibit what Ray calls a “play disruption.” In the middle of a dollhouse scene, the girl would become more active and move through the room, often throwing or trying to break things. After directing her energy and aggression in this way, she was able to finish her scene in the dollhouse.

The girl wasn’t willing to talk with anyone about her family issues at school. The style of her play in play therapy, however, was an outlet for her to communicate and process what was happening. The young client talked about specific abuses that were happening at home during the family scenes she played out in therapy, Ray says.

Once the root of the child’s struggles became clear, Ray took the necessary steps to report the suspected abuse, documenting what the client had verbalized in session. Through play, the client formed a therapeutic bond with Ray and was able to work through what was troubling her. As a result, the child’s aggressive behavior at school dissipated.

“If I had brought the child in and said, ‘Let’s talk about how you’re aggressive at school,’ she would have shut down and not talked,” Ray says. “Having a counselor who trusts a child is so different than what many children experience [from adults]. That message of, ‘I’m going to accept you no matter what and trust that you know where you need to go,’ that, to me, is the healing factor of play therapy. It’s predicated on this amazing factor that if you put a child in an environment where they have control, they will move toward change.”

Not just for kids

Missy Galica, an ACA member and LPC intern in Lubbock, Texas, uses sand tray therapy in her work with adult clients, including college students from Texas Tech University. The medium can be particularly helpful for clients of any age who are struggling to find the words to articulate how they are feeling, she says.

What brings many of Galica’s college-age clients to counseling are academic struggles. By creating scenes in a sand tray, the students are often able to work through nonacademic issues that are troubling them and spilling over into their behavior and schoolwork.

Sand tray work “is good for those who just aren’t good at [verbal] communication or for those whose brains work faster than their mouths,” Galica says. “The sand tray makes them slow down. You really have to think about what you’re doing. You have to think about the representation and object placement. It’s also good for those who get nervous or people who just don’t like getting grilled with questions [from a counselor.] It gives them time to explore what they want to say, and they don’t have to have answers right away.”

As is the case with child-centered play therapy, sand tray work is nondirective. The client chooses what gets made in the sand tray and the meaning attached to it. Counselors should be careful to prompt clients to describe and talk about the scenes they have made in the sand tray without interjecting their own observations, Galica emphasizes.

“If you don’t ‘get it’ at first, if you don’t see a meaning, it’s OK. It’s the client’s space to do what they need to do,” she says. “Anything you can think of that happens in life can be represented in a sand tray, [but] don’t make any assumptions. Ask the client what things represent. You may see something and assume, ‘Oh, this is XYZ,’ but it may be the opposite.”

As part of the meaning-making process, Galica takes photos of each scene after clients finish their sand trays. Later, they look at the photos together, talk about the progress the client has made and discuss how the person’s sand tray scenes have evolved. This is also a good way to track and prompt discussions of representations that come up repeatedly with clients, Galica says.

Clients often have to take some time to think it through before they can explain the scenes they have created in their sand trays. Many times, Galica says, issues and challenges that have been troubling clients don’t become clear to them until they see the issues played out in a sand tray. For example, a client who is feeling overwhelmed with school or home life might put figures all in a jumble on top of one another. Or a client may use one object to represent themselves and place another object or objects at a distance or facing away from them. In this case, the client may be struggling with loss, attachment issues or fear of letting loved ones down. Ultimately, however, it is up to the client — not the counselor — to discover and talk through the issue that has taken shape in the sand tray. At the same time, the counselor provides the prompting and support to help and encourage the client, Galica says.

“It can be tempting to ask, ‘What are you doing?’ or ‘What does that mean?’ But don’t stop them. Let it play out. Wait to the end and then say, ‘Talk to me about this. Describe it for me,’” Galica suggests. “Often, it will be something you [the counselor] never would have thought of. I learn something new every day.”

Galica recalls a particular client whose parents wanted him to become an engineer and were paying his way through college. He hated his engineering courses, however, and harbored a desire to become a jazz musician. This had manifested into academic and other struggles while he was away from home. When the client made sand tray scenes, he often placed a female figure at a distance from the figure he used to represent himself. After multiple sand trays and discussions, it became clear that the client was terrified to tell his mother he didn’t want to be an engineer.

Galica began to focus on that fear with the client, asking him to express his feelings in a draft letter to his parents. She also had him speak to an empty chair as if his mother were there, which is a technique often used in Gestalt therapy. It took the student the entire semester before he felt prepared to tell his parents about his own dreams for his future.

As clients play out situations in sand trays, Galica asks them to show her what they would want life to look like if they had a magic wand to fix everything they were struggling with. What would a resolution look like? What would it look like in five, 10 or 20 years? From there, Galica and her clients talk through the issues and consider options for arriving at realistic resolutions.

Galica says sand trays can easily be used in conjunction with any modality to which a counselor is loyal. She regularly uses them along with cognitive behavior therapy for her college-age clients. Another benefit, she notes, is that the materials are readily available and easily transportable. Practitioners can pick up a plastic tray, sand and small figurines at any big box or craft supply store.

Sand tray work is a method that many counselors might not consider for adult clients “because we’re culturally conditioned [to think] that we don’t play after a certain age,” Galica says. However, sand tray work is very accessible (for both counselor and client), creative and versatile, she asserts.

“Broadly, it’s a way for clients to communicate without having to use words, because they may not have the words,” Galica says. For the client, it means, “I don’t have to stare you in the eyes and tell you all my secrets; the sand tray will tell you. … The beautiful thing about this is that as a counselor, there is no [need to assign] meaning. The only meaning comes from the client.”

 

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To contact the counselors interviewed for this article, email:

 

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Additional resources

Books published by ACA (Available at counseling.org/publications/bookstore)

From Counseling Today (ct.counseling.org)

ACA divisions

  • The Association for Child and Adolescent Counseling: acachild.org

Search for podcasts, online courses and other ACA resources at aca.digitellinc.com/aca/

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her
at bbray@counseling.org.

Letters to the editorct@counseling.org

 

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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.

Superheroes and play therapy: The perfect imaginary combination

By Jetaun Bailey and Tonya Davis July 9, 2018

Superheroes have a profound influence on American culture. Recently, Marvel Comics’ Black Panther came to life on the movie screen. It appears the movie had a twofold impact.

First, it brought heroic life to a seemingly little-known character. Second, unlike most other big-screen superhero movies, Black Panther placed value on social consciousness, awareness, community, family and pride. It broke boundaries that went beyond simply box-office sales, introducing a male of presumably African descent as the superhero. During the movie’s opening weekend, many news outlets showed young African American children wearing their dashikis as a symbol of pride in the African ancestry depicted in the movie.

As a culture, we hold our superheroes in high esteem, even if they are fictional characters. Thanks to Black Panther, many African American boys can identify with a superhero for the first time. This experience has likely heightened the imaginations of many African American boys as they imitate characters from Black Panther in their play.

Escaping to the imaginary worlds of our superheroes seemingly has therapeutic powers. Author and blogger Remez Sasson describes imagination as the mental ability to formulate an image that is not tangible through our five senses. For young children, an even deeper escape possibly occurs when watching these types of movies. The imagination is a powerful tool for children, as reported by Patti Teel in Pathways to Family Wellness magazine. When children imagine, they can visualize their heart’s desire, thus welcoming it into their reality.

 

Reaching beyond traditional play therapy

The therapeutic power of imagination is also evident in various therapy practices, specifically play therapy. According to “Helping a Child Through Play Therapy” by Jane Framingham, adults mistakenly think that child’s play is solely for fun and games or to occupy time. Unbeknownst to these adults, through creative and imaginative play, children are developing cognitively and emotionally while improving their self-worth, positive self-image, and communication and coping skills. For those reasons, play can be therapeutic in helping children overcome challenges that might inhibit developmental growth.

To tap into children’s imaginations and gain deeper understanding of their problems, play therapists are reaching beyond traditional play therapy tools such as sand trays, crayons, paints, animals, toys and dolls. Technology appears to have revolutionized the art of play therapy, thus making it easily accessible to counselors. This can be especially important for school counselors, who work in settings in which the counseling process is often limited because of the other administrative duties assigned to them.

Technology-based programs such as Marvel’s Superhero Avatar Creator and DC Super Friends Super Hero Creator represent the infusion of electronic media into play therapy. Based on “The iPad Playroom: A Therapeutic Technique” by Marilyn Snow and colleagues, the infusion of technology increases the imagination and creativity of the child by allowing the child to create media, pictures and other artwork while the therapist is present, either in conjunction with or separate from the therapist. For example, many applications are available to aid children in fueling their imaginations to create family dynamics or events through drawing and colors that possibly hold symbolism to their presenting problems. This invites the opportunity for metaphors to help solve real-world problems.

 

An ideal therapeutic method

This method of integrating superheroes through a technology approach in play therapy potentially could be an ideal therapeutic method of working with children, especially African American males, in the school setting. It appears to offer a nonintrusive approach for getting students involved in counseling because it integrates technology and play without asking probing questions.

As former school counselors, we have been disturbed by the alarming rates of African American boys being suspended because of perceived aggressive behaviors. Through our lenses, we have seen many of these students struggling with low-self-esteem or low self-worth. Ironically, sometimes these issues are not apparent through traditional presentations such as withdrawing or isolating.

The adjustment between school and family cultures has proved problematic for African American males regarding understanding their importance and worth. This likely causes tension in the school setting, resulting in aggression. These adjustment issues, or inability to navigate from one situation to another, is better known as code-switching.

Eric Deggans, in “Learning How to Code-Switch: Humbling, But Necessary,” describes code-switching as beyond the exchange of two languages in a conversation. But in today’s diverse society, the term’s deeper meaning is shifting between different cultures to move through life’s conversations. Deggans, an African American man, implies that code-switching is an essential tool for African Americans to adjust culturally. Therefore, African American males are expected to recognize one set of rules in one setting and understand another set of rules in another setting while maintaining their identity.

 

Uses with a student

We have sought to address these adjustment issues with our African American male clients through the use of play therapy methods. Using the power of imagination in play therapy allows them to foster development and problem-solve issues that have been hindering their overall academic and emotional growth. In one case, Marvel’s Superhero Avatar Creator  was used with an African American male student who was having adjustment issues at school that produced aggressive behaviors both at school and at home. Although the nature of the school setting did not permit long-term therapy, this short-term approach showed significant positive results.

This student created a superhero avatar over the course of four sessions. During the creating phase, the student used his imagination to create a creature that had similar features and skin color to his own, thus solidifying the importance of identity and connection to the creature. Allowing the student autonomy in creating his creature aided in establishing the therapeutic relationship.

The student was able to arrange the way therapy was directed as the therapeutic relationship was established. Through the various stages of play therapy, from gaining insight to reorientation or reeducation, the therapeutic process became a playground in which the student could live out his imagination through his superhero in a way that was vivid and emotionally alive. This experience paved the way for deeper understanding of how the student perceived his school family in relation to his peers, faculty and staff, and his actual family. Through incorporation of a client-centered approach to play therapy, this student showed significant growth in his overall development and was thus able to transfer those skills (i.e., code-switching) between school and family relationships.

Once significant progress was made with the student, his parents were incorporated in one play therapy session. The student’s father decided to create a superhero avatar to bring life to his perceived role as the family protector. In retrospect, through this play therapy family activity, the father could see how his family viewed his role and their individual roles within the family.

The play therapy sessions, infused with the technology of creating superheroes, helped the student use his imagination to bring to life his own unique story and identity. In superhero stories, superheroes conquer their adversaries while overcoming their adversities. The ending of this student’s story depicted similar results.

This form of play therapy is a nonintrusive method that renders promising results by not asking direct questions, but rather allowing students to self-express through play. As such, we do not believe that the traditional mode of counseling would have achieved the same impact on this child’s growth and development. This lends support to the importance of expressive therapy for children, particularly African American boys. Expressive therapies can help children find their voices, especially through play-based techniques using superhero avatars.

 

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Jetaun Bailey, a former school counselor, is a certified school counselor, a licensed professional counselor supervisor and an assistant professor at Alabama A&M University. Contact Jetaun at Jetaun.bailey@aamu.edu or baileyjetaun@hotmail.com.

 

Tonya Davis, a former school counselor, is a nationally certified school psychologist, a licensed professional counselor supervisor and an assistant professor at Alabama A&M University.

 

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Related reading: See the upcoming September issue of Counseling Today magazine for an in-depth cover article on play therapy.

 

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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.

Behind the Book: Partners in Play: An Adlerian Approach to Play Therapy

By Bethany Bray October 10, 2016

It’s often said that play therapy reaches young clients through their own natural “language” of play. When combined with tenets of the Adlerian method, play therapy becomes a tool for the therapist to build an egalitarian relationship with the client while focusing on the individual and photo-1473662711507-13345f9d447chis or her dynamics with others, according to Terry Kottman and Kristin Meany-Walen, co-authors of Partners in Play: An Adlerian Approach to Play Therapy.

“The Adlerian belief in the ability to make new choices and to reinterpret situations provides a vehicle for play therapists to work with children to get out of their boxes, change their lifestyle patterns, increase their social interest, make shifts in the goals of their behavior and a host of other forums for determining their paths,” write Meany-Walen and Kottman in the book’s second chapter. “One of your primary responsibilities as an Adlerian play therapist is to discover how each child expresses his or her special and wonderful self and to convey a sense of celebration in his or her uniqueness to the child, parents and other people who interact with him or her. Sometimes the child expresses uniqueness in a way that others do not appreciate.”

Meany-Walen, an assistant professor of counseling at the University of Northern Iowa, and Kottman, who runs a play therapy counseling, training and workshop center in Cedar Falls, Iowa, are both licensed mental health counselors and registered play therapists.

The third edition of Partners in Play was published earlier this year by the American Counseling Association.

 

Q+A: CT Online contacted Kottman and Meany-Walen recently to learn more about this unique approach. Their responses are co-written, except where noted.

 

Your book focuses on Adlerian play therapy, which combines play therapy techniques with the Adlerian method. Why do you think they are a good fit? Why does that combination work to help young clients?

Adlerian psychology has a clear and easy-to-follow way to conceptualize clients and figure out what is “underneath” the presenting problem. Before the development of Adlerian play therapy, there was no precedent for working with individual child clients, nor was there a precedent for using play as a treatment modality using Adlerian psychology. We believe that combining Adlerian psychology with play therapy was a logical way to capitalize on the Adlerian methodology for conceptualizing and developing a treatment plan [while] at the same time using play, the “natural” language of children, to communicate with them.

 

What are some key takeaways that you want counselors to know about this topic?

We want counselors to learn about the myriads of ways of using play, art techniques, sand tray, active games, movement and dance, bibliotherapy and therapeutic storytelling as a vehicle for helping children, adolescents, parents and family members to grow in positive directions. We believe that the four-phase model of Adlerian or Individual Psychology — building a relationship with the client, exploring the client’s lifestyle, helping the client gain insight into his or her lifestyle, and learning and practicing new skills — is an amazing vehicle for working with clients. We value the systematic way Adlerian counselors conceptualize clients — looking at assets and strengths, interpersonal dynamics, intrapersonal dynamics (like personality priorities, Crucial C’s*, goals of misbehavior, mastery of the life tasks), problem-solving skills, self-defeating thought patterns and so forth — as a way to determine the best way to decide on the direction and structure of the therapeutic process.

 

* The Crucial C’s are one method that Adlerians use to conceptualize clients. They were developed by Amy Lew and Betty Lou Bettner, who suggest that all people need to have courage (the willingness to try new things without a guarantee of success), connect (the desire and ability to build relationships with other people), be capable (the belief that they are able to master ideas and skills) and count (the belief that they are valuable and special without having to earn love or worthiness).

How does Adlerian play therapy fit with your personality and style as a counselor? What made you want to specialize in this area?

I (Terry) am a very encouraging and exuberant person. Adlerian play therapy reflects my personality by being positive and playful. I was drawn to Adlerian psychology because it is so focused on the strengths of the client, which is exactly what I wanted to do when I became a counselor. I love playing, have always loved playing and had spent my whole life working with children in some capacity. When I was in high school, I worked part time in a pediatrician’s office. When I was in college, I taught swimming lessons to young children and volunteered in an after-school program for children who came from low-income families. I got my first master’s degree in elementary teaching and my second master’s degree in special education. I loved working with children in schools. It was a natural transition for me to work as a school counselor and to become a play therapist.

Adlerian play therapy was also a natural fit for me (Kristin). I had often considered the experiences of my youth, and my perceptions of those experiences, as instrumental in shaping who I was as an adult. I explored many different counseling theories, and Adlerian psychology was most consistent with how I understand people and how I want to work with them. The systematic way of understanding people’s ways of belonging and operating in the world, from an Adlerian perspective, helps me to feel organized and productive, both of which are important parts of my lifestyle.

By happenstance, I took a class from (co-author) Terry Kottman where I began learning about the value and art of play therapy. I started to use some of the play therapy concepts with my own child, who was 8 years old at the time. I noticed drastic improvements in his mood, his behaviors and our relationship. I wanted to help other children and families in the same way.

 

One of the things that prompted you to write the first edition of this title (in 1995) was a rising interest in play therapy. Two decades later, is the field still growing?

Yes, it is. The field of play therapy continues to grow, with the Association for Play Therapy growing from 3,346 members in 1998 to 6,166 members in 2015, increasing at the rate of about 1.5 percent each year. There is a wider understanding of the importance of credentialing of play therapists (registered play therapists, or RPTs) among mental health professionals and with the public.

 

What is one thing you wish you knew about play therapy as a new counselor? What advice would you give to recent counseling graduates who are starting out and are interested in play therapy?

I (Terry) wish I had known that play therapy was not just for children — that teens, adults and members of families can also benefit from using play therapy skills and techniques (including art techniques, sand tray, active games, movement and dance, bibliotherapy and therapeutic storytelling) as a way to express themselves, explore their issues, gain insight, and learn and practice new ways of communicating, solving problems and interacting with others.

The advice I would give recent counseling grads who are starting a career in play therapy is to obtain really good training in play therapy. I believe it is essential to explore the different approaches to play therapy and find one that fits with your personality and what you believe about how personalities form and how people change. After that, find training that includes being observed with children and getting feedback about your skills and abilities.

 

What prompted you to create a third edition of this title? What new information will readers find?

The counseling field continues to evolve as we make discoveries and learn from our experiences. We wanted to provide updated information about play therapy, counseling and how the two merge. Since the last edition, we have seen an increase in the importance of evidence-based treatments and research. In the current edition, we include information about some of our ideas of researching Adlerian play therapy as well as published accounts of Adlerian play therapy. We also included various resources for readers such a list of activities to use with children and informal assessments to use with children, parents or teachers.

 

In addition to your book, what resources would you recommend for counselors who want to learn more about play therapy?

For beginning play therapists who want to know about play therapy skills, another book I (Terry) wrote that is published by ACA would be a good resource: Play Therapy: Basics and Beyond (second edition). Another excellent resource is the website of the Association for Play Therapy (www.a4pt.org).

 

 

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Branding-Box-Partners-in-PlayPartners in Play: An Adlerian Approach to Play Therapy is available both in print and as an e-book from the American Counseling Association bookstore at counseling.org/publications/bookstore or by calling 800-422-2648 x 222

 

 

 

 

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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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.