Play is the natural way that young children discharge the tensions of their daily lives. When children are picked on at school, they may come home at the end of the day and enlist siblings, friends, or even stuffed animals to play out a drama in which the child, transformed into the school principal, gets to ream out the bully and send him or her to detention.
But when children are too anxious, afraid, or traumatized to play, they can't utilize this natural resource of childhood to relieve a painful emotional state. Instead, they must use their energy to compartmentalize the trauma, keeping it out of direct awareness. Because play is both releasing and disarming, it may be too threatening for the child to give up control sufficiently to enter into it.
Child therapists can help children reclaim this vital feature of emotional self-regulation by teaching, modeling, and setting the stage for the child to play. But as when you're teaching children with attachment problems to tolerate emotions, this must be done gradually.
The child therapist approaches the child who can't play by introducing play activities one step at the time. I typically minimize the need for young children (10 and under) to talk, since they may have difficulties verbalizing their experience, particularly those who've been "incubated in terror," as child psychiatrist Bruce Perry, a senior fellow of the Child Trauma Academy in Houston, describes them. Children with serious emotional interference in their development or who have a history of exposure to trauma may function emotionally and socially at an age significantly younger than their years. It may be more natural for any child, regardless of age, who's developmentally 7 or younger, to work through trauma and other issues in the language of play.
When a young child who's too fearful to play enters my office with the family, I typically get down on the floor and start playing with the toys myself. Even if the identified child won't join me, I can usually get the siblings and the parents to participate. Gradually, the nonplayful child—who up to then has stayed close to one parent, usually the mother—will begin experimenting with some of the toys. At that point, I slowly try to join with the child, always takings my cues from the child. I make no demands on the child to verbalize, although I may provide some narrative myself, based on the toy selected or the child's actions with the toy, such as, "Oh, I see you've discovered that the fire engine has a back compartment where the small rescue truck is stored."
If my verbalizations or physical proximity seems intrusive to the child or increases anxiety, I'll move away slightly and/or decrease the frequency of my comments. Eventually we arrive at a pace and level of intensity that the child can tolerate. Safety is the overriding concern. Unless I can establish a safe place for the child in the therapy session, nothing useful will happen.
However, what feels safe for the child will vary, not only from session to session, but even within the same session. If, for example, a child is comfortably playing with the fire truck and rescue vehicles, but then spots a school bus on the toy shelf that triggers a memory related to a traumatic event, the child may suddenly stop playing. This is what Charles Sarnoff, a psychoanalyst in Manhattan, called a "switch moment." The therapist may help the child "recover" at such a moment by taking the school bus to the garage and making sure the child understands that the school bus will stay in the garage until the child decides it's time for it to come out. Giving the child a sense of personal control in such situations is crucial because two central elements of trauma are a total lack of control and utter helplessness.
In my clinical experience, a lack of desire to play in children results from exposure to deliberate trauma, extensive or devastating abuse, or domestic or neighborhood violence. However, the inability to play can sometimes result from accidental trauma. Bobby, age 2, was an accidentally traumatized child, and the youngest child I've seen who no longer played. He and his mother were visiting family friends and the children went out to play in the back yard, where Bobby suddenly fell through the rotting boards covering an abandoned well.
After the terrifying plunge, he was submerged in five feet of cold, dark water at the bottom of the well. A neighbor, who fortunately was a volunteer fireman, pulled him out of the murky depths, forced the water out of his lungs, and revived him before he was taken to a hospital. He stayed in the hospital for two days, where he was treated for injuries that included bruises and facial lacerations.
By the time he was released from the hospital, he'd stopped talking and playing. He clung to his mother, couldn't sleep, and showed little appetite or interest in food. He'd become hysterical when his parents tried to give him a bath. In the first session with the family, a week after the accident, he was fussy and irritable, and either sat in his mother's lap or stood next to her, clinging to her.
I got down on the floor immediately and started playing with the toys. Bobby watched intently while tightly clutching his mother's arm. Clearly this little boy's anxiety was sky-high, so I deliberately avoided creating any play scenarios depicting conflict or threat, but instead evoked a playful kind of magic, using puppets to play harmless tricks on each other in a spirit of fun. I had the Wizard puppet try to practice magic tricks, but the Monkey puppet kept taking his magic wand and hiding it. The repetition of these silly scenes, accompanied by comic patter, often makes children laugh more and more with each subsequent enactment. At first, Bobby smiled hesitantly, but after the fourth repetition, he was fully engaged in belly laughing, along with his parents, watching the Wizard puppet get increasingly frustrated with the Monkey puppet for taking his magic wand.
I should note here that one absolute prerequisite for being a child therapist is the willingness to make a complete fool of oneself. You must be willing to engage in the play wholeheartedly—without irony or self-consciousness—no matter how ridiculous you may appear to adults, including the parents in the room, or you'll surely fail.
Why did I use the theme of tricks and trickery? Falling into an abandoned well that was supposed to be sealed over could be experienced as trickery of the worse kind, with nothing fun or playful about it. But doing several variations of this game with a range of puppets and going to extremes to punctuate the trickery as playful, joyous, and shared fun among friends I thought might help Bobby process the terrible "trick" played on him, while providing a healing antidote via the world of enthusiastic, funny, safe play.
On the way out of the office, the parents said it was the first time that their son or they had laughed since the terrifying accident. Given the distress of the child and the parents, we decided to make the next session two days later.
When the family arrived for the second session, I'd poured a small amount of water into a rectangular plastic container. While Bobby and his parents watched, all of us sitting on the floor, I put some of the play animals into the water, starting with the jungle animals. Then I had them splash playfully around, making gleeful noises, such as "whee! and "whoopee!" The lion roared—not scary roars, but muffled sounds of delight.
Bobby didn't seem visibly shaken, but the water was shallow, covering only the animals' feet. I took out the jungle animals and put in farm animals, then domestic animals, and finally people, including a whole family, who all enjoyed a romp in the water. When I started putting the farm animals gently into the water, I asked Bobby's parents if they wished to help. They started adding some of the sheep, goats, cows, and horses. Bobby then picked up a pig and tentatively dropped it in the water, and then did the same with a cow, a horse, and some sheep. Gradually, he became a little more animated, making grunting sounds and laughing as he dropped each animal into the water, though he didn't yet start engaging the animals in playful actions with the others.
We started taking out the farm animals and drying them off. Bobby watched intently and didn't want to join in this task at first, but soon indicated he wanted to help. I showed him different-colored hand towels and let him choose a blue one, and then he joined the rest of us drying off the animals. It wasn't until the rest of us had the dogs playing in the water that Bobby engaged in interactive play with the dogs for the first time, making them chase each other through the water. During this session, he was laughing and squealing with enjoyment.
Before the family arrived for the third session, three days later, Bobby's mother called to say they were thrilled that his speech was returning, although it was mostly babbling rather than the distinct words he'd used before the accident. He was also less irritable and clung less to her, though he still wasn't sleeping well.
The same props were in place for the third session, but the plastic container was filled slightly higher. I was careful in this session, as I had been in the previous one, to make sure the water was room temperature, because I didn't want to expose Bobby to the cold water he'd experienced in the well. The water was clear and shallow as well.
I began the session by demonstrating the play action of the day. I put the larger animals into the water, but then I had them come bouncing back out in a gleeful way, as if there were a submerged trampoline in the container. I repeated the action several times with each animal.
The parents took their turns doing the same thing. When it was Bobby's turn, he was a bit hesitant, so I asked if his mom would like to assist. Together they took turns dipping the animals in the water, only to have them spring out again and again.
There are several elements of the play action that are instrumental to the healing process. More than 60 years ago, British psychoanalyst David Levy used similar methods of selecting toys that would closely resemble the traumatic experience. He called the approach Release Therapy, because his emphasis was on abreaction. In recent decades, however, due to the groundbreaking work on therapy with traumatized children of Lenore Terr, clinical professor of psychiatry at the University of California, San Francisco, and Eliana Gil, director of the Starbright Training Institute for Child and Family Play Therapy, we know that abreaction is just one of the needed steps. The children also need to derive an experience of mastery and empowerment from the play, and to engage in some corrective action. The action need not be real-world based—in fact, reality-based corrections aren't always viable or possible for trauma events. The action or solution can, instead, be fanciful and magical, which naturally appeals to children and can better provide the sense of empowerment so vital to countering the feeling of powerlessness created by the trauma.
Trauma researcher Bessel van der Kolk emphasizes the "frozen inaction" that he views as a core feature of PTSD, preventing the person at the moment of terror from taking effective action. He's supported a variety of kinesthetic therapeutic methods, including EMDR, body movement, and dance therapies that allow the person to take effective, empowering action that releases them from the frozen inaction. Play therapy for younger children can accomplish this same purpose. In Bobby's case, the empowering, corrective action consisted of first observing and then participating in dropping the animals in the water and playfully making them rebound, like coiled springs, out of the water, and repeating this action over and over.
In the fourth session, we continued with these playful activities—dropping in and springing out of the water—repeated many times with the jungle animals, farm animals, dogs, and the figures of adults and children. All of them were jumping into and out of the water, obviously having a good time. Bobby's parents' active participation in the play therapy intervention was crucial because they, too, were "shell-shocked" by this horrific experience of almost losing their son, their only child, and had no idea how to help him. Engaging in the play activities with Bobby was empowering for them and for him.
A clear indication that Bobby was healing was his increasing ability to play again, both in the session and at home. He entered the play in each subsequent session with more gusto, even at times with screams of delight. This was particularly significant because the trauma event occurred while Bobby was running around in the backyard playing. Meanwhile, at home, he was recovering his language ability, was less fretful, and usually slept through the night, much to his parents' relief.
But there was one more major step left to accomplish: we needed to "bracket" the event for Bobby—make it clear that what he'd experienced was extremely unlikely to occur again. Even adult trauma survivors often find their assumptions of safety in the world so shattered that they need help placing traumatic events in a meaningful context, so they can realize emotionally that the trauma will not endlessly recur. Children have less ability to put traumatic events into perspective and understand that what happened was a rare, improbable event that won't need to be confronted over and over again. This bracketing of the trauma event was a challenge with a child as young as Bobby.
I conferred with the parents beforehand to prepare them for the symbolic trauma reenactment that I planned to do in the fifth session, proposing that we start as we had during the previous two sessions with having the animals and then the family romp in the clear water. But this time, when the family figures entered the water to swim, some of the children would get out and start playing with the dog, and suddenly the dog would drop off the table into a bucket of cold water that I had colored with brown food coloring. According to the plan, the dog would be rescued by the parents, dried off, soothed, and told that the bucket of water shouldn't have been there and that mom and dad would make sure that it never happened again. They'd say emphatically that the dog was safe now and that the bucket would be removed and taken away for good. At that point, I'd take the bucket out of the room. The dog was to be told that when it was ready, it could come back into the clear water and romp and play with the rest of the family, but only when it was ready.
When the dog fell into the water, Bobby gasped. But when his dad's hand went under the water and pulled the dog quickly to the surface, the mom and dad dried it off, and then made it clear that nothing like that would ever happen to him again, the look of relief in Bobby's face was unmistakable. The bucket of "murky water" was immediately taken away and Bobby was told it would never be allowed in the room again. He was then told that he could decide when the dog would want to go back into the clear water and rejoin the family. In the meantime, he and his mother would stay close to the dog and make sure it felt safe.
The rest of the family and the other dogs began romping again in the clear water again. For the next two sessions, the play within the water continued, and in the following session, the eighth, Bobby put the dog back in the water and he began to play with the others.
We had one more water-play session, and then, in the tenth session, Bobby began to explore the room and became interested in the other toys for the first time. The compelling need to rework the trauma event was behind him. He played with the fire truck, the ambulance, the rescue trucks, all of which were likely related to the trauma experience, but he did so without evident anxiety. Later in the session, he played with the dinosaurs and building blocks.
We decided to space sessions out to make sure the gains were solid. The parents reported no further PTSD symptoms after one month and then at another follow-up session three months later. At that time, the parents said, "We have our little boy back."
I followed up by phone a year later, and Bobby's mother reported that they hadn't observed any residual effects of the experience that had terrified both their son and them. The magical powers of play facilitated Bobby's healing, drawing on the only language (symbols and fun) available to him at the time.
By Lawrence Diller
While I was trained in play therapy, I must admit that the approach so consistently let me down over the early years of my career that I began to question its effectiveness for most problems. My skepticism increased when, over and over again, I met families that initially chose play therapy instead of psychopharmacology for their child's problem, only to spend six months to a year (and a lot of money) in weekly treatment to get nowhere. Nevertheless, I was generally impressed with the sensibleness of David Crenshaw's approach in this case.
Although he tells us that Bobby is 2 years old, when patients are that young, I like to know whether that means they're 24 or 35 months old. At that early stage of life, 11 months makes a huge difference in terms of language and development. Since Bobby lost significant language after his fall into the well, I'm going to assume he was at least 30 months old.
Crenshaw doesn't say whether he met with the parents first, but I must assume he did. I routinely get a history and do some early assessment of the marriage without children present. Right from the start, he involves the parents in the play, which from Jay Haley's point of view, might have been even more important than the play itself.
He shows his skill and experience by approaching this anxious child (and his parents) by taking the "feeding wild deer" approach and going very slowly. Quite quickly he engages the child and parents in directed play. This is another important aspect that distinguishes Crenshaw's case from other approaches to play therapy I've seen over the years. He has clear treatment goals: to desensitize the child and parents by the slow, metaphorical reenactment of the trauma—always conscious of allowing all of them to have a sense of control of the situation (no "forced" exposure here).
His willingness to be "a complete fool" for Bobby is a good idea, not just for children, but for the parents, too. Whenever preadolescent children are part of a family session in my practice, at least 15 to 20 minutes of the time is spent playing as a family. This helps offset the worst (and most accurate) criticism a child might make of therapy: that it's "boring." At the same time, I don't feel the parents or I must entertain the children all the time, or that treatment must always be fun.
Anyway, Bobby gets better rather quickly, and at 10 sessions, the frequency of the treatment is tapered off. I remember a long time ago someone smart telling me that "people get into trouble when they make a big deal of a little thing or don't pay attention to a big deal." I think most of us would agree that falling into a well when you're 2 is a rather big deal and requires some attention. However, I'm not really sure that Bobby might not have gotten better with a session for the parents and the first visit as described by Crenshaw. Providing less in-session directed play and giving the family a bit more time between visits might have worked just as well.
There's a lot of healing that goes on in families when the parents can be reassured and given some simple strategies of engagement and limits with children this young. I know there's an inherent belief about the vulnerability of children that runs strongly through the play therapy literature. The trick is finding the balance between supporting the child and family through play and advising the parents, while not making the trauma the central event defining the rest of the kid's life. In this case, although Crenshaw seems to do everything right, I'm just not sure all of what he did was necessary.
Lawrence Diller is correct that I should have specifically noted Bobby's age by months (29 in this case), because, as he aptly says, a child's growth is so rapid during this period that simply indicating that he was 2 doesn't say enough.
To go to the heart of his question as to whether working with the parents alone in the beginning would have been equally effective, I don't know the answer. But I think his suggestion is quite plausible. I actually prefer the parent intervention suggested by Diller, and would usually work primarily with the parents—meeting the child in at least one session for direct observation, and then coaching and guiding the mother and father.
Right or wrong, the reason I chose to work so actively with the child in the presence and with the participation of the family was that the parents appeared to be as anxious and traumatized by the experience as their toddler. Garry Landreth, a well-known play therapist, has frequently stated that children don't play when they're anxious beyond a certain point, and for play to serve its role of natural desensitization, those playing with the child can't be overly anxious either. Therefore, I felt desensitization was necessary for the parents as well as Bobby.
My clinical judgment led me to model the intervention aimed at desensitization and to "bracket" the experience as a rare occurrence. I also wanted to create perspective for both the child and family within the session, and then let the parents provide repetitions of the play at home.
Finally, I heartily concur with Diller's recommendation that the therapist actively intervene to keep the trauma event from becoming an organizing or defining force in the life of the child and/or family. That was the whole purpose behind the bracketing of the fall in the well as a single event that wouldn't recur through the symbolic language of play that even a 29-month-old child could understand.
David Crenshaw, Ph.D., is founder of the Rhinebeck Child and Family Center in Rhinebeck, New York. He's the author of several books on child and adolescent psychotherapy, including Evocative Strategies in Child and Adolescent Psychotherapy and Therapeutic Engagement of Children and Adolescents. His latest, edited book is Child and Adolescent Psychotherapy: Wounded Spirits and Healing Paths. Contact: email@example.com. Letters to the Editor about this department may be e-mailed to firstname.lastname@example.org
Lawrence Diller, M.D., practices behavioral pediatrics and family therapy in Walnut Creek, California. He's the author of Running on Ritalin: A Physician Reflects on Children, Society and Performance in a Pill. His latest book is The Last Normal Child: Essays on the Intersection of Kids, Culture, and Psychiatric Drugs. Contact: email@example.com; website: www.docdiller.com.
CategoriesClinical Practice & Guidance Kids & Teens
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