Psychiatry - October 2008 - (Page 25)

ABSTRACT Play therapy is a treatment modality in which the therapist engages in play with the child. Its use has been documented in a variety of settings and with a variety of diagnoses. Treating within the context of play brings the therapist and the therapy to the level of the child. By way of an introduction to this approach, a case is presented of a sixyear-old boy with oppositional defiant disorder. The presentation focuses on the events and interactions of a typical session with an established patient. The primary issues of the session are aggression, self worth, and self efficacy. These themes manifest themselves through the content of the child’s play and narration of his actions. The therapist then reflects these back to the child while gently encouraging the child toward more positive play. Though the example is one of nondirective play therapy, a wide range of variation exists under the heading of play therapy. INTRODUCTION In her original work on the subject of play therapy, Virginia Axline wrote, “There is a frankness, and honesty, and a vividness in the way children state themselves in a play situation.”1 As universal as it is mysterious, imaginative play predominates the lives of most young children. More and more, we are identifying and appreciating childhood mental disorders and how they pull children away from normal functioning. This can affect their home lives, academic performances, as well as their play with peers. Play therapy offers a direct route to engage children on their terms, in their world, giving them a chance to, “play through what adults talk through.”2 The goal is to identify and address themes that arise in the Psychiatry (Edgemont) 2008;5(10):24–28 course of play, although children’s relative strengths and weaknesses do become apparent in terms of cognitive processing and social skills. Studies have shown the effective use of play therapy in children with different psychiatric diagnoses. Using pre-test, post-test comparison design to evaluate 11 patients in an experimental group and 10 in the control group, Danger, et al., showed a benefit in improving both receptive and expressive language skills in children with speech difficulties.3 In theory, the safe practice environment of the therapy provided an environment conducive to working on these areas without exacerbating self esteem and social anxiety issues. An exploratory study of nondirective play therapy with an autistic boy using video analysis of 16 sessions suggests both feasibility and effectiveness of play therapy with noted improvements in the child’s autonomy and pretend play, though only mild improvement in decreasing ritualistic behaviors.4 It was the authors’ opinion in this paper that the therapeutic relationship helped to “enhance and accelerate the emotional/social development of children with severe autism,” as they were able to observe attachment behavior from the child towards the therapist.” Legoff and Sherman ran a threeyear retrospective study on children with autism spectrum disorders involved in LEGO therapy, a play therapy centered around the commercially available building blocks.5 In a two-tiered approach, Robinson, et al., describe using filial play therapy to teach fifth-grade students to then be ‘therapeutic change agents’ in play sessions with kindergarten children identified as having adjustment difficulties.6 GoldSteinberg and Logan detail the use of psychodynamically oriented play therapy as an adjunct to pharmacotherapy for a child with obsessive compulsive disorder (OCD).7 Virginia Ryan details some of the difficulties and gains in play therapy with a child in transition with serious attachment problems.8 In another case example, play therapy was used to alleviate anxiety, which was contributing to migraine headaches in a 10-year-old child with separation anxiety disorder.9 In this case, the boy with preexisting migraines began to experience increased anxiety in the wake of the 9/11 attacks as his father took part in the search and rescue efforts at the World Trade Center. The tracked symptom was migraine frequency, which had increased with his anxiety. Through play and art he was able to accomplish a resolution of his fears by bringing them to the surface, directly and indirectly in the content of his play and art projects. As his play and art became less dark and fearful, both his subjective anxiety and migraines decreased. In a related case, play therapy was used as treatment for a four-year-old boy with a psychosomatic postural symptom that resolved quickly over a course of play therapy.10 A four-yearold boy had begun tilting his head forward and to the left subsequent to his parents learning of a left kidney defect in his as-of-yet unborn sister. He also had marked regression in speech and increasingly needy or clingy behavior. Through play the therapist was able to explore his competing themes of aggression toward his younger sister, the new holder of his parents’ attention, and a fantasy-based guilt of having in some way wished his sister’s malady into existence. The head tilt, along with the regressive behaviors served as EDITOR’S NOTE: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment. ADDRESS CORRESPONDENCE TO: Timothy I. Lawver, DO, E-mail: timlawver@earthlink.net KEY WORDS: play, child, axline, childhood, therapy, play therapy, nondirective [OCTOBER] Psychiatry 2008 25

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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