Play is the language of children. In play therapy, children are given the opportunity to play out their feelings, experiences and problems using toys and expressive arts. All the toys in the playroom have a therapeutic purpose. Some of the toys in playrooms are a sandtray with miniatures, water or water table, medical kits, puppets, paints and other art supplies, clay and doll houses among others. Play therapy helps children to express how they feel about an event, situation or problem, understand their feelings and learn to express their feelings in new ways (Riedel-Bowers).
The outcomes of play therapy depend on the goal of the child and/or parent(s)/caregiver(s). Children are able to build internal resilience and the family can learn new ways of understanding and interacting with their child to meet their child’s needs. Some outcomes may include the child being able to understand and express their emotions, play out their feelings of loneliness, anger or fear, learn coping skills when confronted with a situation where they are worried or scared, reprocess an experience or trauma or to overcome a specific fear. Play therapy can also be used to help children learn how to develop better interpersonal relationships, process the grief associated with the death or loss of a loved one, the onset of a childhood illness or disability or learn about a recent diagnosis. Outcomes can include having better relationships, doing better in school, resolving behavioural issues, learning how to regulate emotions and/or connecting more with the family.
Play therapy helps children and teens living with anxiety. Often Cognitive-Behavioral Therapy (CBT) will be used as a model for treating children or teens living with anxiety. Play therapy differs from conventional CBT approaches only in that it uses play and expressive arts to engage and assess, provide psychoeducation and treat children and teens. Play therapy is used to help children and teens learn about relaxation and mindfulness techniques, learn and understand their feelings, and how feelings are connected to thoughts and behaviour. Children can learn coping skills, develop a plan and implement exposure therapy. Parents will learn how to coach children in implementing their new skills at home and how to help their children learn these new ways of being in fun and creative ways.
There are many different types of play therapy approaches. These are based on different theories or models and are applied by the therapist to meet the needs of the child. Therapists may specialize in one or two different kinds of play therapy and others may use different approaches based on the child’s needs and goals. There is non-directive and directive play therapy. Child-centered play therapy is an example of non-directive play therapy where the child leads and decides the direction of play. An example of directive play therapy includes Cognitive-Behavioural. In this case, the therapist would guide the play based on the child’s goals and needs. Other types of play therapy include Psychoanalytic, Jungian, Gestalt and Adlerian among others. There are also family play therapy approaches including Filial and Family Theraplay.
Play therapy can be used for children as young as two years old. For this age, child- centered play therapy would most likely be used by the therapist. Despite the belief that play therapy is for young children, teens, adults and older adults all benefit from play therapy.
Play therapy techniques vary depending on the type of play therapy. One of the most widely used play therapy techniques is Sandtray-Worldplay (De Domenico), which involves sand, a sandtray, water and miniatures that the child and/or family/caregivers use to reflect, express and communicate their experiences (Fraser, 2013). Sandtray can be both directive with the therapist providing direction or non-directive with the child directing the play. Sandtray can be used in all phases of therapy. Another technique includes puppetry which can be used with a narrative model of play therapy. Puppet shows can be used in all phases of therapy and can also be used for the child to show the family what they have learned in therapy. Other techniques include the use of clay, doll houses, painting or drawing, dance and movement, writing, music and games, among others.
Therapists often start by telling the child about the playroom. In a child-centered playroom, the therapist will explain to the child that the playroom is a special playroom because the child can do whatever they want in the playroom, they do not clean up and the only rules are “no hurts for the therapist and no hurts for the child.” The therapist often explains play therapy and confidentiality with the use of books. The therapist will frequently ask the child if they know why they have come to play therapy and if the child has any questions. The therapist will often ask the child if they have any goals. Often the questions the therapist will ask has to do with the play or is part of a game. The questions therefore vary depending on the type of play therapy and the goals of the child and/or parent(s)/caregiver(s).
The goal of play therapy is to help children to reprocess experiences, express their emotions, heal and grow. More specifically, for young children the goal of play therapy is often developed between the parent(s)/caregiver(s) and the therapist during parent/caregiver consultation. Young children, teens and adults also develop their own goals for therapy. Even if a parent has a goal for therapy, the therapist will also work with the child to establish their own goals for therapy. Goals may include, for example, going to bed alone, resolving separation anxiety or learning how to express feelings among others
We’ve seen so many families who were hesitant about teletherapy be surprised about their abilities to participate in teletherapy during the Covid19 pandemic. Depending on the age, we’ve worked to adapt therapy to make it achievable and approachable using teletherapy. For example, we’ve seen that younger kids, younger than eight, have a harder time tolerating participating in the normal length of a therapy session, particularly if they are struggling for attention. So I’ve adapted to doing more work with parents and helping adapt therapy skills to things they can be actively practicing with their child during the week. That often includes helping reframe language to talk about emotions or about the status of current events. And families have been very happy during this time to get extra support in parenting as new challenges continue to arise in the current climate.
For slightly older kids, we’ve seen that working to adopt to the way we connect to children is incredibly important. Although I’ve tried doing my own research on how to adopt games to video sessions, I’ve found that letting kids lead the way has been very helpful during this time. They know far more than I do about socializing through games and it helps build trust in the therapeutic relationship for them to take the lead! By building this trust, it helps us to address other fractures in their relationships as well as skill building to handle difficult emotions.
Children self harm for different reasons. Some do it as a form of self-stimulation while others use it as a form of coping with negative emotions and still others may be doing it as a means of expressing their emotion when they don’t have the language. Self-harm can be very scary for families and also can escalate to more serious behavior. A family who is seeing self-harm should first off consult with a mental health professional who can help assess patterns of behavior, function of the self harm, and triggers to the behavior. These are the factors that can help individualize plans and interventions to help a child who is self harming.
Parents who see their child self-harm often respond first to their own fears and emotions, and we often see that their first reaction can accidentally invalidate their child’s emotions. A parent might initially say “How can you do that to yourself?” or “You don’t have to feel that way.” While these are well intentioned statements meant to protect their child, a child in enough distress to self-harm might hear these statements as criticism. It’s possible to validate the emotion, without validating the behavior. It’s important for parents to validate that their child is in emotional pain while also not wanting them to harm their bodies.
When your child begins to work with a therapist, it is natural to wonder if it is working and how long it will take to work, if it works at all. At the same time, because the therapist is mainly spending time with your child, it is common to feel in the dark since you are not in the room most of the time. We know therapy works best when there is a strong therapeutic connection between the therapist and the client. All the specifics of what type of therapy and what it is for are important but unless that therapeutic connection is there, the most highly recommended and technically proficient therapist may not be the best therapist for your child. Ask your child how they are feeling about the sessions. Do they dread going and refuse to get out of the car before an appointment? Do they say the sessions are boring and pointless? What we hope to see as a therapeutic relationship forms over time is that your child will not mind attending and maybe even look forward to going once they get the hang of it and have built some trust with their therapist. For slightly older children you can ask them if they think their therapist “gets” them or if their therapist seems to get along great with you but really does not seem to be hitting it off with your child. Keep in mind it can take time to build trust in a relationship and develop into a nice rhythm in the sessions but by asking your child questions in a curious way and listening for any signs of authentic connection, you can get a decent sense of how it is going. Of course, over time you would also want to see improvement in whatever target behaviors or emotions brought your child to therapy in the first place. However, parents can often under-estimate how long it takes to see those changes so that is why focusing first on the therapeutic connection is crucial.
Ask a therapist about their orientation: therapists should be able to define how they think about a child and family and how that impacts their work! Orientations include psychodynamic, attachment-focused, mentalization-based, and cognitive behavioral. And these different orientations can influence how a therapist works with a family. Which you should also ask! Ask how frequently your child will be seen, the length of sessions, and what level of parent involvement will be expected. For younger children, you should expect higher levels of parent involvement and for slightly older, we see a reduction where parents may be informed but less actively involved. Ask about what the intake process will look like and when you will be able to talk to them about their treatment plan for your child and/or family. And also know that different styles and orientations will be better fits for different types of issues. A child with a specific phobia or obsessive symptoms will benefit most from a cognitive behavioral therapist specializing in anxiety, which is more focused and skill based. While a child struggling with difficult relationships or history of disrupted attachment will benefit from a mentalization-based treatment focusing on skills related to interpersonal functioning.
Distance learning may be particularly challenging for children with ADHD because they are expected to pay attention in the midst of many distractions around the house and on their devices and their teachers are not as easily able to redirect them. There is much less structure to the days, so writing down a schedule or to-do list to follow visually on a whiteboard can help. The schedule should have built-in breaks for movement, relaxing and eating. Striking the right balance of scheduled time and more unstructured time depends on each child’s needs. Rewards for working hard and getting tasks done can also be built into the routine. It is important that children with ADHD who are prescribed medications for it continue to take the medications regularly at the same time each day, even though routines have changed drastically. During the school day, parents can turn off any distracting notifications on the computer and designate a specific area in the house for doing schoolwork. There are also apps that can help with controlling unwanted electronic distractions. While classrooms often limit what kind of fidget toys can be used, one benefit of distance learning is that kids can use whatever fidget toys they want while working, if these are helpful. When there is less structure, “sleep creep” can occur that leads to kids staying up later and later which can lead to more problems with paying attention during the day. Sticking to a regular bedtime each night despite temptations to stay up later will help with focus and lessen irritability the next day. Also keep in mind that child and adolescent psychiatrists and pediatricians are able to evaluate children remotely during the pandemic, so if your child is in need of treatment for ADHD or needs their existing ADHD medication regimen adjusted, consider scheduling an evaluation.
It is very common for children to be reluctant to participate in therapy, whether it is in the office or online. Rather than surprise your child with a therapy session, it is best to tell them in advance that a session will be happening, explain that it is to help with “big feelings” or whatever is a developmentally appropriate way to explain therapy, and that you will be very open to answering any questions about it. Some children will assume they are in trouble or defective in some way, so it is also helpful to normalize that therapy is a helpful tool for people of all ages to learn skills to cope with all the stressful things that can happen in life. If parents go to therapy themselves, they can set an example by saying they go to their own therapy too and find it helpful. Once your child does participate, praise them for doing so and remind them it is a brave and important thing to do that makes you feel proud. If your child had specific fears about going, debrief with them after to check if their anticipatory anxiety matched what ended up happening. Ask them how it went and how they feel about going again. Also keep in mind your child’s therapist is likely well-versed in working with children who are reluctant to participate. Explain to the therapist if there are issues with participating and problem-solve together how to make the process go a little smoother.
How much parents and siblings are involved in therapy can be very dependent! For some kids, the therapy relationship is important as a safe space that can be separate from other relationships. Other times, parents and siblings play an extremely important role as agents of change. It’s important to open the conversation with a child and therapist with a gently curiosity and openness about how they can be helpful. Parents can ask their children or the therapist for language to talk about the specific issues. For example, I often help kids with anxiety externalize their anxious thoughts by giving a name to the anxiety. Parents and siblings can start referring to their observations of the anxiety by using that name, creating coherence amongst the family. However, it’s very important to get permission from the child to share and use that language. Otherwise, it can feel infantilizing or dismissive.
Parents also often want to get their child to “want to change,” and feel that they need to make that happen. It’s important for a child to build their own motivation to change and for families to recognize when the motivation is lacking. In the first scenario, that may mean allowing the therapist and child to collaborate on building motivation and a parent pushing to hard can make the child more resistant. It’s also important to differentiate between opportunity to build motivation and a child not having motivation to change. In these cases, parents working with the therapist directly for parent management training instead of the child being seen directly can often be helpful. I often say that the person who wants the change should be in the therapy room (or zoom), because they are the most likely to take action.
Children are having new anxieties about safety, school, and sickness during Covid19 and the social distancing mandates. So are the adults. One thing I’ve seen is children being acutely aware of their parents’ anxieties. It’s important to model the difference between healthy coping with anxiety and panic. Having language to name the feeling, validating the feeling, and saying out loud how you’re planning to cope with it is really important to model managing anxiety. It might mean saying “I’m noticing that I’m feeling anxious right now about all my work. I think my anxiety is trying to tell me this work is really important, but it’s also making it hard to concentrate. I’m going to go splash my face with water and take some deep breaths so I can concentrate more.”
It’s important to both validate the feeling, offer strategies, and be open to the rejection of both. Even if you don’t agree with everything your child is thinking about (e.g., “I’ll never see my friends again” may not be an actual fact), you can validate how stressful the situation may be (“That is such a scary thought!”). Offer a strategy to cope with the anxiety or problem solve along with the validation with a gentle curiosity (e.g., “Would it be helpful for us to find ways for you to connect online?”) If your child protests or becomes more upset, continue to validate how scary it might be to be worried in this way. Remember that rejection of problem-solving strategies is not a rejection of you, it’s the anxiety not being ready to problem solve.