“We don’t stop playing because we grow old,” Irish poet and playwright George Bernard Shaw once said. “We grow old because we stop playing.”

Granted, Shaw wasn’t a doctor. And he probably never set foot in a psychotherapist’s office. He certainly wasn’t a model for healthy living, vociferously opposing the smallpox vaccine and calling alcohol “the anesthesia by which we endure the operation of life.” But even Shaw knew it: play is invaluable. It’s an essential part of our mental, physical, and emotional well-being.

So why don’t more therapists play? And why don’t we encourage clients to play as much as we tell them to worry less, sleep more, and eat better? It seems only natural. After all, we learn to play before we learn to walk and talk. In the hustle and bustle of it all, when did we forget such a vital part of ourselves?

Maybe if we want to shake off the rust, recapture some of that creative energy, and kindle more joy in our work and in our clients’ lives—without going too nuts—we can take a page from the playbook of our colleagues in the play therapy community.

You might be wondering, But how can you have fun when the subject matter is heavy? What clinically useful information can I glean from toys or a sand tray? How does play fit into my existing approach? How will I explain this to my insurance company? Is this even therapy? For more than a century, play therapists have been asked and have been asking themselves many of the same questions. To fully understand the answers, and how we can play in therapy as adults, we’ll need to start at the beginning, where it all began—with children.

Hang on to your hand puppets.

The story of play therapy, like so much of psychotherapy, begins in Vienna. The year was 1909, and Sigmund Freud had been working with the father of five-year-old Herbert Graf. The elder Graf told Freud how his son had become afraid to go outside after witnessing a cart horse collapse in the street. The younger Graf’s story, which became popularized as “The Story of Little Hans,” was immortalized in Freud’s Analysis of a Phobia in a Five-Year-Old Boy, in which Freud concludes that “Hans” had an Oedipus complex.

Freud, however, had little interest in working directly with children, believing them to be less willing therapy participants than adults (as anyone who’s ever asked a rambunctious child to sit still can understand). But one of Freud’s protégés, a 27-year-old fellow Viennese psychoanalyst by the name of Melanie Klein, thought otherwise. Although, like Freud, she believed her work was to help make the unconscious conscious, she also believed that children—closer to infancy than adults—had readier access to their primordial emotions. She decided to use Freud’s Analysis as a blueprint for her own work, and by 1919, was seeing child clients in her home in Berlin.

If that wasn’t enough of a detour for psychoanalysis, Klein took another one. Rather than explore children’s anxieties and defenses through talk therapy alone, she decided to do so by engaging them in play. On a low table, she’d scatter wooden figurines of men and women, cars, trains, animals, and houses. The children would do the rest, she found, crafting scenes that brought out their innermost thoughts and feelings. Sometimes, Klein joined in, taking on roles the children assigned to her. Other times, she monitored them with what she described as reserved interest. “It is when the child plays with the small toys that we can see the expression of opposing emotions most distinctly,” she later wrote in her book Narrative of a Child Analysis.

But Klein wasn’t the only psychotherapist of her time using play in therapy with children. Freud’s own daughter, Anna, 15 years Klein’s junior, developed an interest in it too. In 1923, then in her mid-20s, she opened her own psychoanalytical practice for children—the first of its kind—and soon afterward took a job teaching child analysis at the Vienna Psychoanalytic Training Institute.

Although their philosophies overlapped, Klein and Anna Freud clashed on several points. Freud claimed that a child’s superego was nonexistent, and that given a child’s strong attachment to its parents, it would never fully attach to an analyst. Klein disagreed. The two developed a heated rivalry, which Sigmund Freud’s grandson later called The Psychoanalytic Civil War.

Both Klein’s and Freud’s ensuing work were shadowed by hardship. After being interrogated by the Gestapo in 1938, Freud and her father fled to London, where he died a year later after suffering from cancer of the jaw. The younger Freud went on to found the Hampstead Nursery for homeless children in 1941 and continued doing child psychoanalysis, writing the first of three books on child development in wartime.

Meanwhile, Klein was reeling after the 1934 death of her eldest son. Perhaps as a way of coping, she turned her attention to studying grief, despair, and Freud’s “death instinct.” But even as her depression deepened and her clinical focus shifted, she acknowledged the reparative qualities of play. “The root of creativity,” she wrote, “is found in the need to repair the good object destroyed during the depressive phase.”

Play Therapy Goes International

Across the Atlantic, another shift was under way. By 1940, a 38-year-old psychotherapist and Ohio State University professor by the name of Carl Rogers had just begun to cement what he was calling person-centered therapy, later simply called Rogerian therapy. Person-centered therapy subscribed to the radical notion that therapists weren’t the experts in the room—clients were. The therapy Rogers and his disciples practiced was less directive and more empathetic, reflecting the belief that inside every client was the potential to solve their own problems.

But Rogers, like Freud, had difficulty applying his concepts to children. One of his graduate students, a 29-year-old named Virginia Axline, saw a way through: she’d take a Rogerian approach to the models developed by Klein and Freud, decentering therapy and following the child-client’s lead. The result was nondirective play therapy, which later became known as child-centered play therapy (CCPT). As part of CCPT, Axline outlined eight core principles, including a nonjudgmental therapeutic environment, in which the child could “feel uninhibited” and the therapist could model unconditional acceptance, doing therapy at the child’s pace, and acting “as the shadow, allowing the child to lead the therapeutic journey.”

“Play therapy is based upon the fact that play is the child's natural medium of self-expression,” Axline wrote in her 1947 book Play Therapy, now considered a seminal work on the subject. “It is an opportunity which is given to the child to ‘play out’ his feelings and problems just as, in certain types of adult therapy, an individual ‘talks out’ his difficulties.”

Rogers knew Axline was onto something. They became work partners at Ohio State, and in 1945, when Rogers moved to the University of Chicago to open a counseling center with a play therapy room, Axline followed as his equal. “Next to Rogers,” his biographer Howard Kirschenbaum later wrote, Axline “became the best-known figure in the Center.”

But Axline wasn’t finished. In 1964, she penned Dibs in Search of Self, a book that gave a firsthand account of her work with a five-year-old client named Dibs, breaking down a year of their play therapy sessions in detail. It quickly became a bestseller, launching play therapy to prominence in the United States and earning Axline the honorific of “the Mother of Play Therapy.”

Systems, Systems, Systems

In 1957, as Axline and her approach were rising to prominence, recent graduates Bernard and Louise Guerney were standing on their back porch in New Brunswick, a short drive from where they both taught at Rutgers University. The husband-and-wife duo had spent their internship year at the Menninger Institute’s Child Guidance Clinic in Houston, where, at lunch, they’d watched as therapists working with adults butted heads with those working with children. With the latter camp under attack for its child-centered approach—perceived by the former as a lack of adult involvement—Bernard approached Louise with an idea: what if they could mix the best of both worlds by throwing parents into the mix?

Blending the nascent field of family therapy with psychoeducation, they developed filial therapy, in which moderated play therapy was used to position parents as the primary agents of change in their child’s life. Sessions were overseen by trained play therapists to help these parents develop play skills, and the sessions were often recorded on videotapes for training purposes.

Filial therapy was the new kid on the therapy block, a novelty. An article in the January 1975 edition of the American Psychiatric Association’s Psychiatric News, sandwiched between an advertisement for the Department of Veterans Affairs’ “newly reorganized mental health system” and another for Valium, opens as follows:

A father is in a clinic playroom with his son. The child is playing with some plastic cowboys and horses. Then, the father hears a voice through a small receiver in his ear: "Why don't you go over and play with him." The voice is that of a psychiatrist observing through a one-way mirror, along with the mother of the family. What sort of therapy is this?

The answer, according to the Guerneys, was one that combined the strongest elements of mainstream psychotherapy—a fusion of psychodynamic, humanistic, interpersonal, behavioral, developmental, cognitive, and family systems approaches, remaining client-centered in its attention to both the adult and the child in the room.

Eventually, the Guerneys shifted their clinical focus away from play therapy and more fully toward family therapy. Bernard would go on to coauthor Salvador Minuchin’s renowned 1967 book Families of the Slums, examining the problems of the urban poor.

But the floodgates had been opened, and play therapy was becoming a household name. Over the next two decades, there was an explosion of offshoots, each with its own moral, clinical, and educational mission.

Therapist Ann Jernberg led the democratization of play therapy. A former director of Chicago’s Head Start program, she sought to fill coverage gaps by personally training dozens of graduate students and Head Start mothers in a new attachment-based approach she dubbed Theraplay. By the time her institute of the same name opened in 1971, the method was quickly becoming a staple in daycares, child guidance clinics, speech clinics, and private practices across the Midwest.

In California, therapist Violet Oaklander extended play therapy to society’s most vulnerable. After completing training as a Gestalt therapist in 1972, the former schoolteacher to emotionally troubled youth—once branded a communist for singing Woody Guthrie songs to her students—began blending Gestalt approaches with creative exercises like playing with clay, puppets, and sand trays. A pillar of her method, which became known as The Oaklander Model, was to establish the trust and safety that had long eluded young trauma survivors like her students.

This period also witnessed the emergence of large-scale training opportunities for play therapy, solidifying the modality’s presence. In 1973, the University of North Texas hosted the first play therapy conference, which became an annual tradition and eventually led to a unanimous vote by the school’s counseling department to create a permanent graduate-level training program in 1987, the Center for Play Therapy. On the heels of UNT’s conference, the first professional society for play therapy was founded in California in 1982. The Association for Play Therapy kicked off its own annual conference, in addition to offering trainings and credentialing.

Even as play therapy raced forward, some therapists looked to the past for inspiration. Therapist John Allan brought his Jungian analytical play therapy to the fore with his 1988 book, Inscapes of the Child’s World, combining play with Carl Jung’s theory that change lies in unconscious, self-healing elements. By 1990, therapist Terry Kottman was doing the same with the teachings of Alfred Adler, blending Adlerian therapy’s focus on interpersonal relationships with storytelling exercises, role-playing, art, and toys.

“We’re hatching and growing,” Allan later remarked about the rise of play therapy. “We’ve hatched an identity. We’re being registered, we’re being supervised. There’s a solid identity of play therapy in the mental health discipline.”

Play therapy had demolished the therapist–client hierarchy, was socially progressive, and walked in near lockstep with cultural trends. It honored the newcomers while tipping a hat to psychotherapy’s forefathers. It blended the best of the old with the best of the new. What wasn’t there to like?

Into the Archives

Immortalized online is a scan of a paper copied and recopied so many times that even the smallest flecks of dust stand out. “An abstract of the thesis of Elizabeth Emily Hoyser,” the opening page reads, “for the PhD in education.” The date is handwritten in a loopy cursive. “Presented on August 6th, 1970.” The uneven typewriter font veers right as it continues down the page, the product of another hasty copier scan.

The paper proceeds to outline Hoyser’s thesis, a study of 107 third-grade boys from her small hometown in Oregon, all underperforming in reading comprehension. Group members, she writes, were evenly divided into four experimental pods: therapeutic nondirective play and reading, therapeutic nondirective play only, reading only, and control. Over the course of the study, each group underwent 27 half-hour therapy sessions.

Nearly 70 pages later, Hoyser’s conclusion lands with a thud.

“The present experiment,” she writes, “was not successful in showing significant differences in academic performance level of the underachiever in reading who was exposed to a therapeutic nondirective play treatment. Nor was there supportive evidence to indicate that therapeutic play would significantly contribute to a change in reading attitude.”

But Hoyser’s study wasn’t for naught.

“However,” she continues, “the students who experienced play therapy produced some significant evidence in regard to feelings about self-to-role expectancies and self-concept. Perhaps for those children who have experienced failure, therapeutic play offers the opportunity to experience success, and as a result, a more positive academic self-concept emerges.”

Hoyser’s study is small and specific. It doesn’t have a large sample size, NIH funding, or perhaps the finest quality controls. But it lays bare the Achilles’ heel of many therapies considered disruptive or avant-garde, including play therapy: sometimes, even if it shows something important, the method is ignored, and people will say that lack of measurability means it’s not worth further examination.

“There was a time when people were very dismissive of play therapy,” says Dee Ray, Director of the University of North Texas’s Center for Play Therapy. “A lot of people said ‘Oh, it’s play, it’s fun, and so it can’t possibly be therapeutically helpful. These crazy play therapists are just doing their own thing.’”

Ray has worked with the Center for Play Therapy for 20 years and been its director for five, so she’s seen some of these reactions firsthand. But as someone who studies and teaches the history of play therapy, she says these kinds of dismissals have been common throughout its existence.

Dell Lebo, a Florida State University student who took aim at play therapy in research reviews throughout the 1950s, called evidence of play therapy’s success more propaganda than research. Eugene Levitt, a professor at Indiana University’s School of Medicine, published a series of reviews throughout the 50s, 60s, and 70s that child psychologists considered devastating, calling into question the efficacy of not just play therapy, but all therapy with children. And in 1985, University of Rochester professor Roger Phillips lamented the state of play therapy with an article published in the peer-reviewed journal Psychotherapy.

“There’s a lack of a conceptual model of how children are helped or changed by it,” he wrote. “It may be that play therapy in general suffers from a credibility problem. As a society, children's play is taken only half-seriously; for adults to be concerned with play, even in a specialized setting like therapy, raises thinly veiled skepticism.”

This was the view of psychotherapy’s old guard, Ray says, those who held fast to the notion that therapy needed a research base and manualized structure. “Personalities definitely clashed because of philosophies,” she adds. “The biggest clash was between the play therapists who advocated a humanistic, child-centered perspective and those who advocated a more directive approach. Does the child lead or does the therapist? And if you let the child lead, when do you direct them to where they need to go? Those questions created some real rifts.”

Even when play therapy was gaining steam, other therapy movements that might’ve been complementary steered clear. “In the 70s,” Ray says, “the Philadelphia Child Guidance Clinic was one of the first places to do play therapy, but they didn’t really give it a form; they just knew that none of what therapists had been doing was working, and we needed something new. But for most of their histories, play and family therapy remained two separate groups that didn’t talk to each other much, and what you’d have is family therapy where a three-year-old would be running around the room and ignored.”

Play therapy had everything working for it, and everything working against it. It was progressive, but too progressive. It was free-form, but too free-form. Whatever positive gains came from play therapy, they were often seen as too nebulous to measure. Not to mention the associations that followed play. In the end, detractors asked, was this even therapy?

In short, play therapy had an evidence problem. Plus, it was the 1990s, the height of psychotherapy’s battle for legitimacy, the Decade of the Brain, and the zenith of Big Pharma. A time when evidence meant everything.

Lyford Spot Image

Once unheard of, primary care doctors and pediatricians now refer parents to play therapists.

What Saved Play Therapy

In 1995, the American Psychological Association’s Division 12 Task Force on Promotion and Dissemination of Psychological Procedures was established to identify empirically supported treatments. The designation of “empirically supported” was—and remains—a highly coveted distinction that by many standards immortalizes a brand of therapy.

At the time, cognitive behavioral therapy was leading the pack in empirically supported treatments, and more than a dozen of its variants would soon make APA’s list, the most of any modality. Although CBT had been developed nearly 30 years earlier, practitioners now began turning toward its potential applications for children and adolescents. Unsurprisingly, some play therapists began to wonder if they could increase their chances of professional survival by glomming on to this evidence-based juggernaut.

As it happened, a therapist by the name of Susan Knell had begun blending play therapy with CBT two years earlier. Her cognitive behavioral play therapy combined CBT’s directive, goal-oriented approach and examination of the client’s thoughts and perceptions with aspects of play therapy, including role playing. Many cognitive behavioral play therapists took to using three-headed dragon puppets to explain to children the famous CBT triangle, demonstrating the relationship between thoughts, feelings, and behaviors.

But as it turned out, only a small number of play therapists made the leap to cognitive behavioral play therapy. The approach went mostly unnoticed, its more directive qualities running counter to the client-centered approach that had become synonymous with play therapy. “Play therapy,” Ray explains, “really maintained its roots in being humanistic and child-centered.”

In large part, training programs like the Center for Play Therapy and professional associations like the Association for Play Therapy were to thank. With rich collections of play therapy knowledge archived in-house, they’d become meccas for play therapists using the client-centered model. Fledgling play therapists flocked from all over the world to study at the center, and upon graduating, became flagbearers for client-centered play therapy. They didn’t need it to conform to any new psychotherapy zeitgeist or have robust clinical studies to prove its worth.

Even when presented with the opportunity to reinvent itself under a more widely recognized brand, more palatable to the psychotherapy establishment, the play therapy community chose to stay true to its roots. In the end, it was unapologetically itself, and that was enough.

“Even if you aren’t familiar with play therapy, I think there’s something about it that makes sense to people,” Ray says. “There’s something that makes sense about a child speaking to a therapist through their play. When a parent watches their child playing, they know something’s happening beyond just wasting time.”

Here to Stay

The last 20 years have seen play therapy cement itself as a respected, recognized discipline, in and outside the therapy community. Thousands of books and articles have been written about play therapy. Once unheard of, primary care doctors and pediatricians now refer parents to play therapists. Play therapy has spread globally, with training centers sprouting up across Europe and Asia, each taking cultural differences into consideration. In 2018, the United Nations Human Rights Council declared play a human right, critical to children’s physical, emotional, social, and cognitive development.

One hundred years after Melanie Klein borrowed Freud’s notes, play therapy is still breaking new ground. Over the last decade, play therapists have been examining how nonverbal play therapy can be used with infants to help them build stronger attachment bonds, as well as to help adults build parenting skills.

Thanks in part to the work of the late Charles Schaefer, cofounder of the Association for Play Therapy, the last few years have even seen a surge of play therapy specifically for adults, used to treat cognitive and physical shortcomings in senior homes and care centers for adults with developmental disabilities.

More generally, it’s being used with adults simply looking to reclaim a sense of joy in their lives or do some playful self-exploration. “It’s easy to see how our ability to play freely for play’s sake has gotten lost amidst our societal need to excel,” Schaefer writes in his 2002 book Play Therapy with Adults. “Play therapy can increase our self-esteem. It invites access to states of well-being and calm as well as silliness and joy. When relaxed in play, we often have an increased capacity for empathy and intimacy.”

But adult play therapy can be deep work too, he adds, providing insight and giving form to emotion in ways that talk therapy alone sometimes cannot. “It is utterly wonderful work,” he writes, “because it brings enormous depth to the process. Look into the eyes of a person smashing clay and you see the moment and truth of the pain, not just the memory. It is awesome.”

That’s no surprise to Ray. In 2005, she and her associates conducted the largest-ever meta-analysis on play therapy outcome research, reviewing 180 documents from 1942 to 2000. Their findings reinforced play therapy as an effective intervention for several issues, including anxiety, depression, trauma, parent–child relationship problems, and disruptive behaviors. “We have a growing base of research,” she says. “That’s given play therapy a lot of credibility.”

Play therapy still hasn’t been recognized by APA’s Division 12 as empirically supported, and in an evidence-based therapy world, play therapists still find themselves having to explain how and why it works. But play therapy, Ray says, is finally coming into its own.

“As much as we love our founders and the people who led us to where we are, we’re at a point where we don’t need these dynamic personalities to stay afloat,” she explains. “It’s an exciting time for us.”

As play therapy continues to grow, Ray expects she’ll continue to run up against members of the clinical community who want more data, more targeted interventions, and more structure. But she adds that as a holistic intervention, play therapy has never been about those things: it’s been about the children it serves. “We’re focused on the child, not the problem,” she says. “We see children move toward health, whatever it means for them, so we know play therapy works. We’re here to stay.”

- - - -

Some say history is shaped by larger-than-life figures, whose ideas eclipse those of others. But not always. Sometimes it’s written by ordinary people, whose ideas are buried half-deep, waiting patiently to be rediscovered.

Elizabeth Emily Hoyser, the doctoral student from Oregon whose 1970 thesis about play therapy was inconclusive, passed away in 2013. She was 84 years old. According to her obituary, she went on to teach in England, Germany, and Cuba. She never did revisit her research question about whether play therapy worked, but she did live long enough to see others realize what she already knew.

“Therapeutic play,” she wrote in the last line of her thesis, “has a place in the development of the whole child. Not just in the making of a student, but of a person.”

 

ILLUSTRATION © ILLUSTRATION SOURCE/ANDREA COBB

In On the Joke

I don’t believe quick wit is one of my natural talents, but since therapy can be serious, I’m often on the lookout for ways to weave in small sparks of joy. This might take the form of poking fun at myself, like referencing my own journey as a recovering perfectionist, or telling a client about the time I wore two different shoes to work.

For some clients, I’ve found it more helpful to listen carefully for moments when they’ve used humor to get through a difficult situation. It’s a way to highlight the positive where it doesn’t appear to exist.

One of the more unconventional ways I’ve lightened up moments of darkness is by throwing a stuffed poop-emoji pillow at clients. I first did this several years ago with a client who’d routinely make sweeping negative generalizations about herself, saying things like, “I have no strengths” or “I’ll never learn how to do this new job.”

I’d recently added the stuffed poop emoji to my drawer of therapeutic knickknacks after my daughter won it at a state fair but had no interest in keeping it. I wasn’t sure how I’d use it. But when this client began to list off a litany of perceived faults, I instinctively threw the pillow into her lap, hoping to alert her to what she was doing in a gentle, meaningful way. She was confused at first, but then laughed and immediately got the meaning.

Since then, this has become my shorthand method of calling out clients when they begin down the path of self-deprecation. It almost always breaks the spell of negativity—at least for a few moments. Although it’s not appropriate for all clients (and not quite as effective in Zoom sessions), the success of this silly intervention has taught me to be on the lookout for ways to get out of the head and into some light-hearted engagement.  

Sandra Wartski, PsyD
Raleigh, NC

Chris Lyford

Chris Lyford is the Senior Editor at Psychotherapy Networker. Previously, he was Assistant Director and Editor of the The Atlantic Post, where he wrote and edited news pieces on the Middle East and Africa. He also formerly worked at The Washington Post, where he wrote local feature pieces for the Metro, Sports, and Style sections. Contact: clyford@psychnetworker.org.

Categories

Clinical Practice & Guidance Clinical Skills & Experience Families Kids & Teens