Sandplay
Play therapy using a tray of sand and miniature figures is attributed to Dr. Margaret Lowenfeld, a paediatrician interested in child psychology who pioneered her "World Technique" in 1929, drawn from the writer H. G. Wells and his Floor Games published in 1911.[39] Dora Kalff, who studied with her, combined Lowenfeld's World Technique with Jung's idea of the collective unconscious and received Lowenfeld's permission to name her version of the work "sandplay".[40] As in traditional non-directive play therapy, research has shown that allowing an individual to freely play with the sand and accompanying objects in the contained space of the sandtray (22.5" x 28.5") can facilitate a healing process as the unconscious expresses itself in the sand and influences the sand player. When a client creates "scenes" in the sandtray, little instruction is provided and the therapist offers little or no talk during the process. This protocol emphasises the importance of holding what Kalff referred to as the "free and protected space" to allow the unconscious to express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may not choose to talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may offer supportive response that does not include interpretation. The rationale is that the therapist trusts and respects the process by allowing the images in the tray to exert their influence without interference.[41]
Sandplay therapy can be used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also when a family works together on a sandtray, the therapist may make several observations, such as unhealthy alliances, who works with whom, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships.[42]
Winnicott's Squiggle and Spatula games
Donald Winnicott probably first came upon the central notion of play from his collaboration in wartime with the psychiatric social worker, Clare Britton, (later a psychoanalyst and his second wife), who in 1945 published an article on the importance of play for children.[43] By "playing", he meant not only the ways that children of all ages play, but also the way adults "play" through making art, or engaging in sports, hobbies, humour, meaningful conversation, etc. Winnicott believed that it was only in playing that people are entirely their true selves, so it followed that for psychoanalysis to be effective, it needed to serve as a mode of playing.
Two of the playing techniques Winnicott used in his work with children were the squiggle game and the spatula game. The first involved Winnicott drawing a shape for the child to play with and extend (or vice versa) – a practice extended by his followers into that of using partial interpretations as a 'squiggle' for a patient to make use of.[44]
The second involved Winnicott placing a spatula (medical tongue depressor) within the child's reach for her/him to play with.[45] Winnicott considered that "if he is just an ordinary baby he will notice the attractive object...and he will reach for it....[then] in the course of a little while he will discover what he wants to do with it".[46] p. 75–6. From the child's initial hesitation in making use of the spatula, Winnicott derived his idea of the necessary 'period of hesitation' in childhood (or analysis), which makes possible a true connection to the toy, interpretation or object presented for transference.[44] p. 12.
Efficacy
Winnicott came to consider that "Playing takes place in the potential space between the baby and the mother-figure....[T]he initiation of playing is associated with the life experience of the baby who has come to trust the mother figure".[46] "Potential space" was Winnicott's term for a sense of an inviting and safe interpersonal field in which one can be spontaneously playful while at the same time connected to others.[44] p. 162. Playing can also be seen in the use of a transitional object, a term Winnicott coined for an object, such as a teddy bear, which may have a quality for a small child of being both real and made-up at the same time. Winnicott pointed out that no one demands that a toddler explain whether his Binky is a "real bear" or a creation of the child's own imagination, and went on to argue that it was very important that the child be allowed to experience the Binky as being in an undefined, "transitional" status between the child's imagination and the real world outside the child.[46] p. 169. For Winnicott, one of the most important and precarious stages of development was in the first three years of life, when an infant grows into a child with an increasingly separate sense of self in relation to a larger world of other people. In health, the child learns to bring his or her spontaneous, real self into play with others; whereas in a False self disorder, the child may find it unsafe or impossible to do so, and instead may feel compelled to hide the true self from other people, and pretend to be whatever they want instead.[47] Playing with a transitional object can be an important early bridge "between self and other", which helps a child develop the capacity to be creative and genuine in relationships.[46] p. 170-2.
Research
Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years.[48] Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as Cognitive behavioral therapy.[27] They also argue that therapists focus more on the institution of play rather than the empirical literature when conducting therapy[49] Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies included small sample sizes, which limits the generalisability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment.[50][51] Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.[49]
Outside of the psychoanalytic child psychotherapy field, which is well annotated,[52][53] research is comparatively lacking in other, or random applications, on the overall effectiveness of using toys in non-directive play therapy. Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during non-directive play therapy were no more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checkers board game.[37] There is also ongoing controversy in choosing toys for use in non-directive play therapy, with choices being largely made through intuition rather than through research.[38] However, other research shows that following specific criteria when choosing toys in non-directive play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and lead to play that can be easily interpreted by a therapist.[38]
Several meta analyses have shown promising results about the efficacy of non-directive play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for non-directive play therapy.[34] This finding is comparable to the effect size of 0.71 found for psychotherapy used with children,[54] indicating that both non-directive play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups.[27] These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71,[54] 0.71,[55] and 0.66.[34] Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with non-directive play therapy.[28] Results from all meta-analyses indicate that non-directive play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.[27][28]
Predictors of effectiveness
There are several predictors that may also influence the effectiveness of play therapy with children. The number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes.[27] Although positive effects can be seen with the average 16 sessions,[36] there is a peak effect when a child can complete 35–40 sessions.[34] An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment[28] Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child.[56] Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behaviour problems.[57] Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.
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