Play Therapy With a 6-Year-Old
In Play Therapy With a 6-Year-Old, Dr. Jane Annunziata demonstrates her approach to working with children. Play therapy is premised on the assumption that a child's problems come from unconscious conflicts and developmental deficits, both of which will be revealed in their play.
In this session, Dr. Annunziata works with a young boy named Matthew who has been sad and withdrawn. Through the process of play therapy, Matthew expresses more of his emotions, and the therapeutic alliance becomes stronger.
This video features a client portrayed by an actor on the basis of actual case material.
Psychoanalytic play therapy is based on an assumption that children's problems stem from unconscious conflicts and developmental deficits that will reveal themselves in their play. Through their play, their verbalizations, and their relationship to the therapist, children can be helped to understand what is troubling them. A child's behavior (problematic or not) is taken to be an attempt at meaningful communication of underlying thoughts and feelings, and, through therapeutic understanding of the child's communications, resolution of problem behaviors can occur.
Psychoanalytic play therapy includes the involvement of the child's parents. The therapist's familiarity with the child's parents helps the child feel accurately understood (which facilitates the resolution of the child's difficulties). Furthermore, this involvement provides parents with practical strategies for managing problematic behaviors at home. Symptoms can then improve, and troublesome behaviors diminish in frequency and intensity. In addition to working with parents, child therapists often coordinate with schoolteachers and counselors to help resolve any behavioral difficulties at school and increase understanding of the child's emotional issues.
In psychoanalytic play therapy, the child takes the lead in producing "material" in the form of play. It is a nondirective approach in which the therapist follows the child and not vice versa. When the therapist is careful to avoid giving advice or making suggestions, the child becomes increasingly able to reveal his or her emotional life in spontaneous play. The therapist attempts to understand what the child is communicating through his or her play (i.e., what the child is thinking and feeling, both consciously and unconsciously). As the child plays, the therapist comments on the play itself, its underlying (latent) meaning, and its relation to presenting symptomatology.
Play therapy is generally conducted once or twice a week, in 50-minute sessions. The child's therapist (or an adjunctive therapist working with the parents) usually sees the parents on a regular basis, ranging from once weekly to once monthly. Play therapy should be conducted in an appropriately equipped room such as a playroom. The length of treatment may vary, from as brief as 6 months (minor adjustment problems) to as long as 4 years (depending on a variety of factors including severity of pathology).
Sometimes therapists are uncertain about how to act and "be with" a young patient. Children respond best to therapists who can be themselves comfortably, who are at ease with play, and who are neither overly solicitous nor condescending. The therapist's task is to invite the child, through a calm demeanor and willingness to understand, to unfold his or her concerns in play and talk.
For Whom Is Play Therapy Indicated?
Play therapy is recommended for children between the ages of 3 and 11 who present a wide variety of emotionally based difficulties. These include problems relating to peers, problems with appropriate expression of anger, childhood depression, anxiety, adjustment reactions to specific life events, school difficulties that have an emotional component, deficits in self-esteem, persistent withdrawal, more severe character pathology, attention-deficit disorders, development disorders, and symptoms inappropriate to the youngster's current age (such as enuresis and encopresis). When a child experiences any of these difficulties to such an extent that symptoms are pronounced, recurrent, or continual, treatment may well be indicated.
The following factors are considered when determining whether or not treatment is indicated:
- how long the problem has persisted
- if the problem is interfering with family life
- if the child is experiencing significant internal distress, even though overt symptoms may be subtle
- if attempts have been made in the past to help the child overcome the problem
- how disruptive the problem is to the child's daily functioning
- if the problem is interfering with academic performance
- if the problem is interfering with normal maturation
- if the problem is unusual for the child's developmental stage
- if the problem is actually embedded in a pattern of symptoms (Nemiroff & Annunziata, 1990)
What Resources Must the Child Possess to Undertake Play Therapy?
For play therapy to be helpful, it is essential that the child have sufficient intellectual endowment. Play therapy has been meaningfully conducted with mildly mentally retarded children as well as with exceptionally bright children. The child must also have some capacity to form a relationship with a helping adult. In addition, at least a rudimentary observing ego should be present. Observing ego refers to the child's capacity for self-reflection and for claiming one's own behaviors, thoughts, and feelings rather than simply being told about them by the therapist. This is important because in psychoanalytic therapy, the goal is to try to understand the origins of problems in internalized conflict. The first step in this process is to be able to observe one's internal and external self.
The idea of symptoms residing in internalized conflict can be confusing as therapists struggle with the question of whether the problems are truly internal or are imposed on the child by the environment. Child therapists generally find that specific environmental events certainly impinge on a child's development and can contribute to the development of symptomatology. However, children then may respond to this stress with an internalized reaction and an adaptation that fosters and entrenches this symptomatology.
For example, a 5-year-old girl becomes distressed by the birth of a sibling. She has not learned to tolerate her angry feelings and thus guiltily inhibits them. She begins to wet her bed nightly, much to her shame. Psychoanalytic play therapy addresses her conflict regarding the expression of aggression and helps her come to understand her bed wetting as a compromise (i.e., compromise formation) between direct expression of sibling rivalry ("unacceptable" aggression), guilt about her aggression, and fear that she will disappoint her parents and thus lose their love if she should express her anger toward the sibling. The bed wetting, then, represents a neurotic symptom, born of conflict.
This example also demonstrates the importance of working with both symptomatic children and their parents. The parents, in coming to understand what ails their child, can respond to her distress in ways that will facilitate her therapeutic progress.
Some children, however, are primarily responding to a dysfunctional family system, without evidence of internalized conflict. Family therapy should be considered as the possible treatment of choice in this situation.
Dr. Annunziata identifies her approach as "play therapy." What does this imply to you? More specifically, what do you expect of her? Will Dr. Annunziata be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?
Jane Annunziata received her PsyD in clinical psychology from Rutgers University. For 5 years she was a member of the Children's Intensive Treatment Team at Woodburn Center for Community Mental Health in Annandale, Virginia. Dr. Annunziata has maintained a private practice specializing in child and family work in McLean, Virginia, for the last 10 years.
She coauthored A Child's First Book About Play Therapy, Solving Your Problems Together: Family Therapy for the Whole Family, Why Am I an Only Child?, and Help Is on the Way.
She has taught at the University of Bergen in Norway and at Mary Washington College and George Mason University in Virginia.
- Freud, A. (1946). The psychoanalytical treatment of children: Technical lectures and essays. New York: International Universities Press.
- Haworth, M. R. (Ed.). (1964). Child psychotherapy practice and theory. New York: Basic Books.
- Sandler, J., Kennedy, H., & Tyson, R. L. (1980). The technique of child psychoanalysis: Discussions with Anna Freud. Cambridge, MA: Harvard University Press.
- Singer, D. (1993). Playing for their lives: Helping troubled children through play therapy. New York: Free Press.
- Solnit, A. J., Cohen, D. J., & Mewbauer, P. B. (Eds.). (1993). The many meanings of play: A psychoanalytic perspective. New Haven, CT: Yale University Press.
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