Children need our help. According to the Centers for Disease Control and Prevention, 1 in 7 young children have a diagnosed mental, behavioral, or developmental disorder, and that number goes up to one in five after age nine. Yet despite the fact that they make up nearly a quarter of the population, children are rarely a central part of therapists’ practices. In fact, nearly every state in the nation—43 of them, to be exact—is facing a severe shortage of child mental health practitioners.
If my experience is any indication, most beginning therapists are also offered little to no basic training in clinical work with kids. Why is this? The kinds of interventions that are most effective with children are based in play, and maybe that seems somehow less than professional, not so sophisticated, a little embarrassing. So play therapy gets relegated to a kind of cheerful corner of practice, while purportedly deep and transformative adult-centered talk therapies take up most of the field’s floor.
For me, who’s made a career out of therapeutic play and seen profound clinical results, this is unfortunate. Play is a remarkably powerful therapeutic tool, backed up by cutting-edge research, and teaching families how to apply it at home can bring about profound systemic changes. Because play allows children to relate through something other than the confusing terrain of adult language, and instead engage in a mode of being that they’ve already mastered, family therapists could be more effective if they added it to their repertoires.
I didn’t set out to practice psychotherapy with children. Work in a child welfare agency was the first job I stumbled into out of graduate school. Although it turned out to be the best residency I could’ve wished for, the pay was bad, and I was overwhelmed by the gamut of the child welfare process I worked: from kids who lived with their mentally ill, drug-addicted biologic parents, to kids who were in foster care but visited their parents with the hope of returning home, to kids who were adjusting to an adoptive home because their birth parents had been deemed unfit or were nowhere to be found. Most of these children were receiving some type of individual or family therapy within the agency, but when I spoke to the parents, I discovered that most of them felt left out of the therapy, misunderstood, and resentful of the system. They told me therapy wasn’t helping.
In graduate school, I hadn’t learned anything about children beyond general child development and a survey of psychodynamic theories. All I knew about working with kids came from babysitting and being a camp counselor. Nevertheless, I quickly learned the type of child psychotherapy I didn’t want to practice: it was the kind most children in the agency were receiving, where the therapist considered herself to be the main relational focus and placed little emphasis on working in session with the caregivers.
I asked a lot of questions when I started out. How could a therapist truly help a child she sees for only 45 minutes a week? What about the potential influence of the parents or caregivers who were with the child every day? These were the people who bathed him, comforted him when he had a nightmare, took him to the school carnival, and dealt with his destructive meltdowns. Why were they not included in therapy? The answers I got from my supervisor and the treating therapists were at polar extremes. On the one hand, I was told that many parents don’t want to come to therapy—they’d rather drop the kid off and have them be “fixed” by the therapist. On the other hand, I heard that the therapists were wary of including the parent because it could “contaminate the therapeutic relationship” between themselves and the child.
On the occasions that caregivers were asked to come in, it felt as though they were guests or observers. During parent meetings, the therapist gave clinical impressions and provided guidance on dealing with problematic behaviors at home from the point of view of the expert. These meetings didn’t seem useful because no real relationship existed between the therapist and the parents. The disconnect between the therapy room and the home environment was really a chasm, and considering the amount of distress the families were in, whatever therapy was happening had little relevance to the child’s home life. I was bewildered and disillusioned.
Then one day the police dropped four-year-old Timmy and his two older brothers off on the agency’s doorstep. They’d just watched their mother bleed to death after being stabbed repeatedly by her boyfriend. When they arrived, the older brothers looked shocked and disoriented, but they could at least nod their heads to questions like “Do you want a drink?” or “Can you come sit here?” Timmy, in contrast, was just a shell of a child, stooped low and on the verge of collapse. He found the first couch in the lobby and balled himself into it like the smallest water bug coiled against a predator. Various people tried to approach him, asking if he could sit up, telling him there was a nice playroom down the hall where there were toys. Timmy stayed in his tight ball. The minutes passed. No one could elicit the slightest response from him. The only indication that he was alive was a shallow rise and fall of his tiny back as he breathed.
That day, our clinical consultant, Sandy, happened to be in the building. Witnessing this distressing scene, Sandy approached Timmy. She crouched down by his side and started singing in a soft, rhythmic way “Timmy, Timmy, you are here today. What did you bring with you? You are here today.” She hummed a few more bars. She said, “Oh, I see you brought your elbow. It’s a fine elbow. I bet it’s a pointy one, like mine. Or maybe it’s soft or squishy. I don’t know. I’m going to check and see.” Sandy reached her hand out and gently cupped Timmy’s elbow. Timmy didn’t budge, but he didn’t recoil either. “Oh!” Sandy whispered with a bit of energy. “It’s pointy. Just like mine!” She continued this way, gently cooing at Timmy, finding ways to connect with him physically, like drawing a shape on his back and seeing if she could feel all five toes within his spider man sneakers. She asked him to wiggle his toes if he had all five of them, and then Timmy wiggled them ever so slightly. Sandy exclaimed quietly but with energy, “You do! You do have five toes in there!”
I saw Timmy’s breathing slow and deepen. After about five minutes, he agreed to sit up, and Sandy offered him a piggyback ride to the playroom, where he could be more comfortable. She told him there were blankets and places to hide there. Climbing on her back, he hid his face in Sandy’s hair as she carried him down the hall, walking a steady, firm pace, humming her Timmy song all the way. Once in the playroom, Timmy accepted a drink and slowly oriented to his new surroundings. All the while, Sandy sat next to him with her hand on his back or cupping her hands around his.
I watched this scene in awe. Sandy had never met Timmy before. How did she know how to reach this little person? How did she have the courage to approach him so closely? And how could Timmy trust a stranger after what he’d just been through? Neuroscientist and trauma researcher Stephen Porges knows.
According to Porges’s polyvagal theory, it was Sandy’s singsongy, rhythmic voice that reassured him, her lack of hesitation to connect with him through touch at the right moment, with the right pacing, her focus on the here-and-now of his physical presence on this earth, her complete confidence in his humanity, and her lack of fear about what had happened to him. That’s what brought Timmy out of his paralysis: nonverbal codes that transmitted the message to his brain, “You’re safe, you’re safe.”
I thought it was magic. I thought Sandy was a magician, and my mind locked onto her like a person possessed. I wanted to be her. But how?
My great fortune was that right in Chicago where I lived was The Theraplay Institute, where Sandy had been trained. Theraplay is based on the attachment work of John Bowlby and two theories promoted by Donald Winnicott: his holding environment—the idea that good parents and therapists can create a nurturing emotional environment for children—and his theory that play is the best way a child can experience her true self.
Theraplay is also derived from intersubjectivity and interpersonal neurobiology research. It emphasizes all the nonverbal elements of Sandy’s engagement with Timmy—behaviors that, in a split second, tell a child that he’s safe: the rhythmic, sing-songy voice; the curious, open face; the smooth, coordinated gestures; the touch and playfulness. I jumped at the opportunity to take the training, and it dramatically enhanced my work and changed my career.
A Fast Road to Connection
It’s commonly acknowledged that many of us became therapists because, as children, we ourselves experienced the pain of feeling isolated, shamed, or mistreated. But if this is true, why do so few of us work in child mental health?
I have a few hypotheses. First, children don’t operate with adult mores. How many times have I walked into a session geared with all my child-development knowledge and had a child reduce me to an angry fool? More than I can count! Why? Because children, like dogs and horses, can sense right away that I have an agenda, and they can run circles around me as I try to cajole, reason, or clown them into cooperating.
Second, working with children can be uncomfortable. It’s the rare child who’ll sit still and talk about feelings. Usually, children don’t know why they do what they do. When a child comes to therapy, you have to be ready to loosen your expectations and sense of control over the session. Children don’t filter their feelings as much as adults. They have temper tantrums, throw things, and tell you that you have bad breath, or that you’re fat or old or ugly or stupid. They force you to get in touch with your most basic impulses. They can easily trigger the feelings of powerlessness and shame you felt as a child, or the feelings of rage you saw on your own parents’ faces. Playing can make adults feel vulnerable, and I’ve often heard people express trepidation as if they don’t quite feel playful enough to do this kind of work, or that they’ve “forgotten” how to play, or that only people with a lot of charisma can hold a child’s attention.
Last, working with a child is twice as much work for half the pay. In addition to the time it takes to clean up the mess they make in your office, children come with parents. Parents are often needy, angry, and blaming. They email you the ugly chronicles of their horrible weekend, upset you didn’t manage to “fix” their child. They demand you talk to the teacher, the principal, the occupational therapist, and that you do a home visit. They ask for advice and then reject it.
In short, working in child mental health can be a hot mess. But I’ve stayed in this area for nearly two decades because of what I experienced between Timmy and Sandy, and many other dyads like them. Seeing healing connections being made that help children feel safe and seen keeps me coming back, and therapeutic play keeps proving to be the most effective medium to create these connections.
Katrina, age seven, was the middle of three sisters in foster care. Each week, they were reunited for family visits with Amy, their birth mother. Everyone on our staff suspected that Amy’s parental rights would soon be terminated since she hadn’t demonstrated that she could be trusted to keep herself, let alone her children, safe. It was only because of legal delays that she still had visiting rights.
I believe Amy was living too much in active trauma to know how to parent. She’d been kicked out of her birth home as a teen because of physical conflicts with her alcoholic father, and she’d run away from a series of unsafe foster homes. She’d lived on the streets and continually abused drugs. Unfortunately, Amy was making little progress with her treatment goals of staying away from her abusive boyfriend, going to parenting classes and individual therapy, and acknowledging the abuse and neglect she’d inflicted on her girls. In the few instances that she did show forward movement, she was granted unsupervised weekend visits. But during one of these visits, her eldest daughter, tying to make spaghetti, had scalded herself while Amy was oblivious on the couch, having passed out from too many over-the-counter drugs. Unsupervised visits were quickly revoked.
To her credit, Amy, who had many health problems, still showed up religiously at our child welfare agency for her weekly supervised visits with her girls. She’d heave herself up the flight of stairs to our second-floor offices, always carrying a bag of McDonald’s happy meals and a tray of milkshakes. Upon entering the play room, she’d fall dramatically into a deep sofa and remain there as the girls arrived in succession from their foster homes. The oldest was usually controlled and obedient, the youngest coy, but Katrina invariably arrived in a state of fight and flight combined. She’d cry, scream, kick, cling, tear, run—a whirling dervish of distress. Every week, my colleague and I watched this drama unfold, and half the visit would be spent trying to calm Katrina down.
Amy tried the best she could to connect with the girls by offering them the fast food she’d brought, but the girls wouldn’t sit at the little table to finish more than two chicken nuggets. They kept getting up to look at a toy or peer out the observation window. They’d flit around the playroom, taking out games but not playing with them. It appeared that their little bodies were vibrating with chaos inside, and they just couldn’t settle down. But rather than getting up and going to them or helping them stay engaged with a toy, Amy would just sit on the sofa and drone at them to “Stop that. Get off. Sit down.”
Our clinical manager told us to facilitate a game of Candy Land to give some structure to the visit. But Katrina would get mad every time she didn’t advance on the board, and Amy would harp on her to play fair, muttering, “Quit it, Katrina.” It’d take Katrina only a few passes at struggling to control herself before she’d look defiantly into Amy’s eyes and knock the board off the table, scattering lollipop and ice cream cards across the floor.
My colleague and I, having just completed our first Theraplay training, decided to step in and ask Amy if she’d allow us to lead activities with her and her daughters for the next visit. She agreed, and the next week, as soon as the girls arrived, we kicked off a sense of playfulness by suggesting we all walk to the playroom with little bean bags on our heads, holding hands to see if we could balance them all the way down the hall. Amy, it turns out, was particularly skilled with her beanbag, but Katrina refused to cooperate. With a deep scowl, she grabbed the bean bag we placed on her head and threw it as hard as she could. “Good,” I said in response. “Let’s throw it down the hallway!” That Katrina would do, allowing us to get closer and closer to the visiting room.
Once there, we arranged the chairs in a circle so everyone could face each other and play simple games like passing a “hello” around the circle and checking to see if everyone’s hands were cold or warm. Amy and Katrina’s hands were warm, but the two other sisters’ hands were cold, so we had them warm their hands together as partners. We then bopped a balloon around, led a hokey-pokey dance, and copied funny sounds that each person made in turn. We had the three adults (myself, my colleague, and Amy) decorate the girls with colorful feathers and then look at themselves in the mirror as princesses, warriors, or eagles. We then all decorated Amy with feathers, which the girls particularly enjoyed. “Take our picture as a family of princess warriors!” the girls squealed.
Toward the end of the visit, we went around the circle and named the features we saw on the person to our right. I looked at one child and said, “I notice you have rosy cheeks.” That girl then looked at her mom and said, “You have soft hair.” Then Amy looked to her right at Katrina, and Katrina looked at her—and looked and looked. Finally, Amy said with surprise, “You have greenish-blue eyes!” It was the first time she’d really noticed Katrina’s eyes. They held each other’s gaze for several moments more, and the intensity of the connection was palpable.
Right before we ended the visit, we created a group handshake to which everyone contributed a segment. We practiced it and said we’d remember it for the next visit. For the first time in two years, Katrina parted calmly with her birth mom, almost prancing out the door to her foster mom’s car.
Sadly, it turned out there was no supervised visit after that. The court had finally completed the termination process, and Amy said goodbye to her girls at their respective foster homes. So does it matter for Katrina that for one moment, amid years of chaos and pain, her birth mom looked at her intently? What impact can one hour of connection and harmony with Amy really have? Will Katrina even remember it?
If I, as a witness, was able to feel the intense connection, then I believe Katrina certainly would hold that memory in her body. I believe children like Katrina, who’ve been tossed around like empty soda cans in the tumultuous waves of the child welfare system, need moments like these. I believe Amy wanted desperately to give her girls a sense that they were important, unique, and cherished by her, even if she couldn’t raise them. She didn’t know how to do it—but that one session helped. It might seem too good to be true that playing in a structured, nurturing, and fun way would dissolve such a painful family drama. But I believe it gave Katrina and Amy the opportunity to get unstuck from their troubling dynamic and redefine an aspect of their relationship.
I’m not claiming that structuring and creating the family visit as we did healed all the ripples of loss and trauma that Katrina had endured and will continue to endure in life, but I do believe that it offered this fractured family a bit of dignity, hope, and meaning. And I believe that family therapists should be equipped with skills to facilitate these small but transformative moments.
The Power of Play
The quickest and most powerful way to get to transformative moments with children is through play—meaning interactive, face-to-face, reciprocal, cooperative interactions that rely on movement, rhythm, touch, a prosodic voice, and eye contact. I call this primary play because it appeals to the developmentally younger levels of the brain: the brainstem, the diencephalon, and the limbic brain. It doesn’t engage the neocortex, the part of the brain that develops after the second year of life and uses logic, planning, verbal communication, and imagination. Instead, it uses tools that say to a child’s limbic brain, “You’re safe and worthy, and I enjoy connecting with you.”
Embedded in play are moments of connection and surprise, with sudden dynamic shifts. For example, you’re quietly studying a child’s face when he reaches out to touch your nose and you make a resounding BEEEEP sound. The child is suddenly alert. Looking straight into your eyes, he giggles spontaneously at the surprising, funny shared event between the two of you, and you laugh in turn. This element of surprise, so important in play, is the growing edge for a child to learn that new things can happen, and that these new things can be both exciting and safe.
Something important happens when two people share this kind of dyadic state of consciousness. Such moments are often called now moments. For those few seconds after you’ve made the beep sound, you and the child are in a brand new, shared space, created by the two of you, and you’re intensely focused on each other. You each give meaning to the event as pleasant, and the giggling both conveys and amplifies the moment. The more such moments occur, the more the child learns that it’s pleasurable and safe to be completely caught up in a moment of shared joy or attention with another person. Once this has happened, a deeper sense of connection has been established between you.
Play helps a child learn to share and expand joyful experiences and also to modulate them so they don’t become overwhelming. Think of the common parental game of throwing a baby in the air in the right rhythm and height and just the right number of times, so she increasingly enjoys the experiences but doesn’t spit up, start to cry, or get aggressive from too much stimulation. Children crave vigorous, physical playfulness that involves body contact, and these activities help them not only expand and manage their positive feelings, but also counteract negative emotions. Amplification and modulation of positive affect is one of the cornerstones of a well-regulated self.
Play is also the arena in which all of a child’s psychic drama is enacted. If a child has been hurt or mistreated by a significant attachment figure, it’ll come out in these simple games. One misstep from the adult and the child will inevitably replay her feelings of shame and mistrust. The benefit is that adults can then repair with the child—which is the definitive therapeutic act in early relational trauma.
One example of this was my work with four-year-old Clara, who’d been found at age two in an empty apartment, along with her three-year-old brother. Rancid garbage was strewn about, and rats were crawling freely around them. Clara and her brother were placed in a great adoptive home, but after a year and half, Clara’s adoptive parents felt they couldn’t reach her. She’d coyly ask for things and then reject them. Or she’d fall and cry for help but when her mother came, she’d start to giggle and kick her away.
My treatment with Clara and her parents focused on setting up games between them that involved movement, touch, and turn-taking. In one game, I had Clara’s parents sit a few feet apart, each holding two ends of a small blanket laid out on the floor. When her parents lifted the blanket, Clara would get under it and crawl from one parent to the other, either slow or fast, depending on the rhythm of a song I’d sing. Clara delighted in crawling back and forth between her parents just in time before the blanket went down. I myself was having so much fun that I decided to up the ante, telling Clara that this time I wouldn’t let her know ahead of time whether to crawl fast or slow; she’d have to guess.
My intention was to be playful, but for Clara, the intensity was too much. Instead of waiting for my cue, she first crawled slow, then fast, then veered away from her parents to the corner of the room, where she collapsed and giggled in a breathy, high-pitched way. I instantly realized that I’d increased the stimulation above her ability to tolerate it, and I changed my playful voice to one of concern and tenderness. “Ohhh,” I said from across the room. “You ran all the way over there!” Clara looked away. “Was there something that scared you about that part of the game?”
“No” Clara quickly said.
“Okay, why don’t you come back to sit on your mommy’s lap,” I suggested. Clara complied. I looked at her intently as I continued in a sing-songy but concerned way, “Did something startle you about the way I played the game? I think you didn’t like not knowing if you were to do it fast or slow. I think that made you feel uncomfortable.” Clara stared at me with wide eyes. “Uh-huh, that makes sense. I’m not going to do that anymore. I’m going to tell you which way to crawl, okay?” Clara nodded and I started the game again with a clear, simple direction to crawl slowly. She crossed under the blanket and sat right in her father’s lap.
“Oooh,” I said with compassion and relief in my voice. “That’s better. See, I don’t think you liked it when you didn’t know what to do. It made you worried so you crawled away. That makes sense. Thanks for telling me.”
Clara thus learned that it wasn’t her fault that she’d felt stressed. She learned that adults could identify her discomfort, take responsibility for changing their response, and make her feel more secure. Her parents learned that if she falls on the floor, rather than chide her for being silly, they should approach her gently, put a hand on her back, and wonder aloud with her what might be making her uncomfortable. In repeating that cycle of misattunement and repair, her parents will teach Clara that she wasn’t damaged and alone, that her experience makes sense, and that they’ll be there to support her.
Although it’s been decades since I first watched Sandy, with her sing-songy play and gentle touch, reach out to traumatized Timmy, coiled on the couch like an impenetrable water bug, I can still recall my awe at that experience. Yet there are hundreds of thousands of Timmys in this country alone, and we need to make sure there are enough Sandys among us to help.
If I’ve convinced you that here and now, primary play interactions are what those children need, consider trying out games that facilitate trust and connection with the families in your own practice. Many books list delightful ideas, and once you’re in the zone of primary play, you can create an endless number of variations on them.
Of course, finding your courage to initiate these games may take time. So ask yourself: do you feel comfortable jumping into these games? If not, why not? Do you worry that you’re not a playful person? Have you had negative experiences in your personal or professional life, where playful interactions have gotten out of control and you haven’t known what to do? Are you wary of parents judging your work as not valuable because you’re “just playing”?
As you explore these questions, find opportunities to look at your face in the mirror and practice widening your eyes as much as you can to show openness and curiosity. Take a deep belly breath. Put some movement in your shoulders, arms, and hands so that they can flow with your overall presentation. Practice your singsongy, rhythmic, storytelling voice. And overall, trust the process of the magic of play. It’ll be worth it!
Photo © Chris Parker/Getty Images
Dafna Lender, LCSW, is an international trainer and supervisor for practitioners who work with children and families. She is a certified trainer and supervisor/consultant in both Theraplay and Dyadic Developmental Psychotherapy (DDP). Dafna’s expertise is drawn from 25 years of working with families with attachment in many settings: at-risk after school programs, therapeutic foster care, in-home crisis stabilization, residential care and private practice. Dafna’s style, whether as a therapist or teacher, is combining the light-hearted with the profound by bringing a playful, intense and passionate presence to every encounter. Dafna is the co-author of Theraplay: The Practitioner’s Guide (2020). She teaches and supervises clinicians in 15 countries in 3 languages: English, Hebrew and French. Visit her website.