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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
A practical look at how play therapy can promote mental health wellness in children and adolescents Revised and expanded, The Therapeutic Powers of Play, Second Edition explores the powerful effects that play therapy has on different areas within a child or adolescent's life: communication, emotion regulation, relationship enhancement, and personal strengths. Editors Charles Schaefer and Athena Drewes--renowned experts in the field of play therapy--discuss the different interventions and components of treatment that can move clients to change. Leading play therapists contributed to this volume, supplying a wide repertoire of practical techniques and applications in each chapter for use in clinical practice, including: * Direct teaching * Indirect teaching * Self-expression * Relationship enhancement * Attachment formation * Catharsis * Stress inoculation * Creative problem solving * Self-esteem Filled with clinical case vignettes from various theoretical viewpoints, the second edition is an invaluable resource for play and child therapists of all levels of experience and theoretical orientations.
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Contents
Cover
Praise for The Therapeutic Powers of Play: 20 Core Agents of Change, Second Edition
Title Page
Copyright
Dedication
Preface
Acknowledgements
About the Editors
About the Contributors
Chapter 1: Introduction: How Play Therapy Causes
Therapeutic Factors
Therapeutic Powers of Play
How Best to Use the Material in This Book
References
Part I: Facilitates Communication
Chapter 2: Self-Expression
Why Is Self-Expression Therapeutic?
Empirical Support of the Power of Self-Expression in Play Therapy
Role of Self-Expression in Facilitating Change
Strategies and Techniques in Facilitating Self-Expression
Applications
Clinical Vignettes
Summary
References
Chapter 3: Access to the Unconscious
Introduction
The Power of Play Therapy to Access the Unconscious
Empirical Support
The Role of Accessing the Unconscious in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
Summary
References
Chapter 4: Direct Teaching
Introduction
Role of Direct Teaching in Causing Change
Strategies and Techniques
Empirical Support
Clinical Applications
Vignette
Summary
References
Chapter 5: Indirect Teaching
Introduction
Indirect Teaching
Empirical Support
Role of Indirect Teaching in Causing Change
Strategies and Techniques
Clinical Applications and Vignettes
Conclusion
References
Part II: Fosters Emotional Wellness
Chapter 6: Catharsis
Introduction
Description of Catharsis
Empirical Support
Role of Catharsis in Causing Change
Clinical Applications
Techniques
Contraindications
Clinical Vignettes
References
Chapter 7: Abreaction
Introduction
Description of Abreaction
Empirical Support
Role of Abreaction in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
References
Chapter 8: Positive Emotions
Introduction
Description of Positive Emotion
Empirical Support
Role of Positive Emotion in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
References
Chapter 9: Counterconditioning Fears
Description of Counterconditioning Fears
The Role of Counterconditioning Fears in Causing Change
Play Strategies and Techniques
Empirical Support
Clinical Applications
Case Vignettes
Conclusion
References
Chapter 10: Stress Inoculation
Description of Stress Inoculation
Empirical Support for Stress Inoculation
Role of Stress Inoculation in Causing Change
Strategies and Techniques
Clinical Vignettes
Conclusion
References
Chapter 11: Stress Management
Introduction
Description of Stress Management
Empirical Support
Role of Stress Management in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
References
Part III: Enhances Social Relationships
Chapter 12: Therapeutic Relationship
Introduction
Description of the Therapeutic Relationship
Empirical Support
Role of the Therapeutic Relationship in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
Conclusion
References
Chapter 13: Attachment
Introduction
Description of Attachment
Empirical Support
The Role of Attachment in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignette
Conclusion
References
Chapter 14: Social Competence
Introduction
Description of Social Competence
Empirical Support
Role of Peer Relationships in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
Conclusion
References
Chapter 15: Empathy
Introduction
Description of Empathy
Empirical Support
Components of Empathy
Role of Empathy in Causing Change
Strategies and Techniques
Clinical Applications
Summary
References
Part IV: Increases Personal Strengths
Chapter 16: Creative Problem Solving
Introduction
Description of Creative Problem Solving
Role of Creative Problem Solving in Causing Change
Clinical Applications
Empirical Support
Clinical Vignette
References
Chapter 17: Resiliency
Description of Resiliency
Role of Resiliency in Causing Change
Clinical Applications
Empirical Support
Clinical Vignette
References
Chapter 18: Moral Development
Description of Moral Development
Empathy
Neurobiology
Role of Moral Development in Causing Change
Individual Play Therapy Techniques
Group Play Therapy Techniques
Child-Parent Relationship Therapy
Clinical Vignettes
Applications
References
Chapter 19: Accelerated Psychological Development
Introduction
Importance of the Specific Power
Empirical Support
Role of Accelerated Psychological Development in Causing Change
Strategies and Technique
Clinical Applications and Clinical Vignettes
References
Chapter 20: Self-Regulation
Introduction
The Power of Self-Regulation
Executive Function Allows for Goal-Directed (Intentional) Behavior
An Experience of Empowerment: Emphasizing the “Self” in Self-Regulation
Empirical Support: What the Research Shows
A Developmental Perspective: How Self-Regulation Is Internalized
The Zone of Proximal Development
The “Future Child”
The Role of Play in the Development of Self-Regulation
Strategies for Assessment and Treatment: Staying in the Zone
Summary
References
Chapter 21: Self-Esteem
Introduction
Description of Self-Esteem
Empirical Support
Role of Self-Esteem in Causing Change
Strategies and Techniques
Clinical Applications and Clinical Vignettes
Conclusion
References
Author Index
Subject Index
Praise for The Therapeutic Powers of Play: 20 Core Agents of Change, Second Edition
“This first chapter of this book uses the concept of ‘therapeutic factors’ to create a very logical framework/rationale for pulling together the theories and techniques one might integrate into a prescriptive approach to play therapy. This is incredibly useful as it allows therapists to tailor their work to the needs of their child clients in a logical and systematic way. The remaining chapters describe some of those therapeutic factors and play strategies from which the prescriptive play therapist might draw in creating individualized treatment approaches.”
Kevin O'Connor, PhDDistinguished ProfessorCalifornia School of Professional Psychologyat Alliant International University
“The hallmark of a good play therapist is a clear understanding of why play interventions are pertinent, how they work to foster therapeutic change, and how to select and facilitate play therapy processes in ways that are theoretically grounded and empathically attuned to their clients' needs. The Therapeutic Powers of Play provides breadth and depth in exploring the essential features of play operating within the therapy process. Each chapter describes a fundamental therapeutic power of play, empirical support for it, its role in bringing about change, and case material to illustrate. This volume provides a key avenue for play therapists to understand the inner workings of their craft, and thereby, to enhance their use of play therapy with a wide range of client challenges.”
Risë VanFleet, PhD, RPT-S, CDBCAuthor of Child-Centered Play Therapy;Filial Therapy: Play Therapy With Kids and Canines, and OthersPresident, Family Enhancement and Play Therapy CenterPast Chair of the Board, the Association for Play Therapy
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Library of Congress Cataloging-in-Publication Data:
Schaefer, Charles E.
The therapeutic powers of play : 20 core agents of change / Charles E. Schaefer, Athena A. Drewes. — Second edition.
pages cm
Includes bibliographical references and index.
ISBN 978-1-118-33687-8 (pbk.)
ISBN 978-1-118-41658-7 (ebk.)
ISBN 978-1-118-66211-3 (ebk.)
ISBN 978-1-118-422020-1 (ebk.)
1. Play therapy. 2. Play therapy—Methodology. I. Drewes, Athena A., 1948- II. Title.
RJ505.P6S28 2014
618.92′891653—dc23
2013007485
This book is dedicated to a clearer, more understandable, andmore effective application of the therapeutic powers ofplay by everyone.
Preface
Numerous reviews of play therapy outcome research have shown that play therapy is effective, with effect sizes ranging from medium to large (Bratton, Ray, Rhine, & Jones, 2005). The question remains, however, why and how does play therapy work? It is necessary to study the mechanism of change underlying play therapy to understand the specific forces that cause therapeutic improvement in a client. The goal of The Therapeutic Powers of Play: 20 Core Agents of Change, Second Edition is to provide the reader with a comprehensive understanding of the active ingredients in play that produce therapeutic change.
The basic purpose of psychotherapy is to bring about change for the client. Thus, the identification of the change agents in play is of central importance to child and adolescent practitioners. We believe these therapeutic powers of play constitute play therapy's innermost core, its essence, its “heart and soul”!
Many leaders in the field of psychotherapy, including Alan Kazdin (2003) and Irving Yalom (1985), have proposed that the study of change agents is the best way to improve clinical practice. Such study, they maintain, fosters a more targeted and efficient treatment delivery. Clearly, a greater understanding of the active forces of change in child and play therapy will not only broaden practitioners' repertoire of treatment strategies but aid their ability to tailor them to meet the needs of individual clients.
Schaefer (1993) was the first to present a list of the major therapeutic powers of play, including self-expression, relationship enhancement, abreaction, and attachment formation. This second edition of The Therapeutic Powers of Play will further clarify and deepen our knowledge of the core healing powers of play (Table P.1) in light of accumulating clinical experience and research findings.
Table P.1 Major Therapeutic Powers of Play.
The basic premise of this book is that play is not just a medium or context for applying other interventions but that inherent in play behaviors are a broad spectrum of active forces that produce behavior change. It is hoped that through a better understanding of these change agents, practitioners can become better clinicians, as well as researchers better able to hone their studies to isolate and validate how and why change occurs.
In reading the second edition, one might focus in isolation or in combination on the specific powers that one would like to understand more fully and implement more effectively. Other readers will want to read the entire book so as to develop a wider repertoire of the therapeutic powers of play to use in their clinical practice. The book also serves as a practical reference for identifying and applying the power(s) of play best suited for treating specific presenting problems of children and adolescents. Each chapter offers suggested practical techniques and applications, along with clinical case vignettes from various theoretical viewpoints that help illustrate each therapeutic power and how to maximize its benefits. As a result, this volume should become an invaluable resource for play and child therapists of all levels of experience and of all theoretical orientations.
Charles E. SchaeferAthena A. Drewes
References
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 376–390.
Kazdin, A. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, 44(8), 1116–1129.
Schaefer, C. E. (1993). Therapeutic powers of play. Northvale, NJ: Aronson.
Yalom, I. D. (1985). The theory and practice of group psychotherapy. New York, NY: Basic Books.
Acknowledgments
We want to express our gratitude to our editor, Rachel Livsey. This book would not exist had it not been for her constant encouragement and guidance. We would also like to thank Amanda Orenstein at John Wiley & Sons for her editing assistance from draft to final copy.
About the Editors
Charles E. Schaefer, PhD, RPT-S is professor emeritus of psychology at Fairleigh Dickinson University in Teaneck, New Jersey. He is co-founder and director emeritus of the Association for Play Therapy. He is also founder of the Play Therapy Training Institute in New Jersey and the International Play Therapy Study Group held annually throughout the world.
Among his books on play therapy are: Play Therapy for Preschool Children; Empirically-Based Play Interventions for Children; Contemporary Play Therapy; Short-Term Play Therapy for Children; The Playing Cure: Individualized Play Therapy for Specific Childhood Problems; Game Play; 101 Favorite Play Therapy Techniques; Adult Play Therapy; Adolescent Play Therapy; Play Therapy for Very Young Children; and Play Diagnosis and Assessment. In 2006, he received the Lifetime Achievement Award from the Association for Play Therapy. Dr. Schaefer is a frequent presenter at national and international play therapy conferences. He has been a guest on the Good Morning America, Today, and Oprah Winfrey TV shows. His private practice in clinical child psychology is located in Hackensack, New Jersey.
Athena A. Drewes, PsyD, RPT-S is a licensed child psychologist, certified school psychologist, and registered play therapist and supervisor. She is director of clinical training and APA-accredited doctoral internship at Astor Services for Children & Families, a large multiservice nonprofit mental health agency in New York. She has more than 30 years' clinical experience in working with sexually abused and traumatized children and adolescents in school, outpatient, and inpatient settings. Dr. Drewes has worked more than 17 years with therapeutic foster care children in treatment. Her treatment specialization is children with complex trauma, sexual abuse, and/or attachment issues.
She is a former board of director of the Association for Play Therapy (2001–2006) and founder/past president of the New York Association for Play Therapy (1994–2000) and its newly elected president. She has written extensively about play therapy and has been a sought-after invited guest lecturer on play therapy throughout the United States, England, Wales, Taiwan, Australia, Ireland, Argentina, Italy, Denmark, Mexico, and Canada.
About the Contributors
Kristin Bemis, MEd, LPC, RPT has been working at Children's Medical Center in Dallas in various capacities for more than 10 years, and is currently a clinical therapist on the psychiatry consult team providing play therapy and consultation services to families and children with a wide range of medical and mental health diagnoses. Additionally, she has served on the board of directors for the Texas Association for Play Therapy and is active in presenting at the local, state, and national levels.
Mary Morrison Bennett, PhD, LPC-S, RPT-S is an associate professor in the professional counseling program at Texas State University-San Marcos. Dr. Bennett is the director of the Texas State Institute for Play Therapy. She is a past president of the Texas Association for Play Therapy. Dr. Bennett has presented on play therapy across the United States and in England, Ireland, and Russia. She provides play therapy and serves as the mental health consultant for children at an orphanage in Port-au-Prince, Haiti. Her research interests include international adoption, trauma, and the play therapy process.
Angela M. Cavett, PhD, RPT-S is a child and adolescent psychologist and registered play therapist-supervisor. She is co-owner of Beacon Behavioral Health Services and Training Center in West Fargo, North Dakota, where she provides psychological evaluation as well as individual, family, and play therapies. She is on the adjunct faculty at the University of North Dakota. She provides training internationally on child psychopathology and treatment. She is the author of Structured Play-Based Interventions for Engaging Children and Adolescents in Therapy and Playful Cognitive Behavioral Techniques for Children (in press).
David A. Crenshaw, PhD, ABPP is the clinical director of the Children's Home of Poughkeepsie, New York. He is past president of the New York Association for Play Therapy, Fellow of APA, and fellow of the Division of Child and Adolescent Psychology. Crenshaw is the author or editor of several books on play therapy, child trauma, and aggression in children. His latest co-edited book with Cathy Malchiodi is Creative Arts and Play Therapy with Attachment Trauma (2013, Guilford Press).
Athena A. Drewes, PsyD, RPT-S is director of clinical training and APA-accredited doctoral internship, and clinician, at Astor Services for Children & Families, New York. She served on the board of directors of the Association for Play Therapy; founder, founding president, and current president of the New York Association for Play Therapy. With 30-plus years of clinical experience, she is a prolific writer of articles and chapters on play therapy and is the editor/co-editor of six books on play therapy, including Blending Play Therapy with Cognitive Behavioral Therapy and Integrative Play Therapy. She is a renowned national and international guest lecturer on play therapy.
Stephanie Eberts, PhD is an assistant professor at Texas State University in the professional counseling program. She worked in K-12 schools for 10 years prior to becoming a counselor educator. She has written and presented in the areas of play, school counseling, and group work.
Lennis Echterling, PhD is director and professor of counseling at James Madison University. He has more than 30 years of experience in promoting resilience, particularly following crises and disasters throughout the United States, Latin America, Europe, the Middle East, and India. His books include Crisis Intervention: Promoting Resilience and Resolution in Troubled Times and Thriving! A Manual for Students in the Helping Professions. Dr. Echterling has received the James Madison University's Distinguished Faculty Award, Virginia Counselors Association's Humanitarian Award, the national Counseling Vision and Innovation Award, and Virginia's Outstanding Faculty Award.
Theresa Fraser, MA, CPT-S is a Canadian play therapist and international presenter who specializes in working with adoptive and foster children and their families. She has published two books, Billy Had to Move and Adopting a Child With a Trauma and Attachment Disruption History. Theresa is also full-time professor at Sheridan College and the current president of the Canadian Association for Child and Play Therapy. She and her husband have also been treatment foster parents for more than 20 years.
Diane E. Frey, PhD, RPTS. is professor emeritus at Wright State University, licensed psychologist and private practitioner for 40 years in Ohio. Dr. Frey served on the board of the Association for Play Therapy and the editorial board of the International Journal of Play Therapy. She received APT's Lifetime Achievement Award. She is author/co-author of 17 books, and of numerous chapters and journal articles, writing primarily on self-esteem, play therapy, and psychosocial needs of the gifted. Dr. Frey appeared on ABC News 20/20 and NPR speaking on self-esteem and adult play therapy. She is an internationally and nationally recognized speaker on play therapy.
Richard L. Gaskill, EdD, LCP, RPT-S, has worked in mental health for more than 38 years. Currently he serves as clinical director of Sumner Mental Health Center in Wellington, Kansas. He is a psychotherapist, counselor, and RPT-S. Dr. Gaskill teaches play therapy at Wichita State University and was named Fellow of the Child Trauma Academy in 2004. He received the Chairman's Award from Future's Unlimited in 1997 and the Kansas Head Start Partner of the Year in 2005. Dr. Gaskill has published articles and book chapters on the neurobiology of play therapy and has lectured extensively in the United States, Canada, and Australia.
Terry Kottman, PhD, NCC, RPT-S, LMHC founded the Encouragement Zone, where she provides play therapy training and supervision, life coaching, counseling, and “playshops” for women. Terry developed Adlerian play therapy, an approach that combines the ideas and techniques of individual psychology and play therapy. She regularly presents workshops and writes about play therapy, activity-based counseling, school counseling, and life coaching. She is the author of Partners in Play, Play Therapy: Basics and Beyond, and several other books.
Julie Nash, PhD, RPT-S is a licensed clinical psychologist. She works at the Community Health Center, Inc. as the foster care clinic coordinator and training director for the psychology postdoctoral residency training program. As such, Dr. Nash provides psychological assessments and therapy services as well as supervises postdoctoral residents. She is also an associate faculty member at Post University. She has co-authored a number of book chapters regarding play therapy, especially on its use with social skills development. Dr. Nash serves on the New England Association for Play Therapy board of directors and is a reviewer for Play Therapy magazine.
Jill Packman, PhD, RPT-S is a licensed psychologist and registered play therapist supervisor. She is associate professor at the University of Nevada.
Eileen Prendiville is the course director for the MA in humanistic and integrative psychotherapy and play therapy, and for the postgraduate diploma in child psychotherapy and play therapy at the Children's Therapy Centre in Ireland. She was a founder member of the Children at Risk in Ireland Foundation and was its national clinical director until 2004. She is a psychotherapist, play therapist, supervisor, and teacher. She is the current chairperson of the Irish Association of Humanistic & Integrative Psychotherapy. Her first co-edited book, Play Therapy Today: Contemporary Practice With Individuals, Groups and Carers is due for release by Routledge in 2014.
Siobhan Prendiville, MEd, diploma play therapy and psychotherapy, is a teacher, psychotherapist, and play therapist who specializes in the use of play in education and in therapy. She currently teaches in a primary school and delivers specialized training in a wide range of institutions in Ireland. She lectures in a master's of arts program in humanistic and integrative play therapy and psychotherapy and is involved in training teachers in pilot programs to influence the teaching methodologies utilized in Irish primary schools. In addition to her teaching positions, she maintains a private play therapy practice.
Sandra W. Russ, PhD is professor of psychology at Case Western Reserve University. She has served as president of the Society for Personality Assessment, and Division of Aesthetics, Creativity and the Arts in the APA. Her research has focused on pretend play, creativity, and adaptive functioning in children. She developed the Affect in Play Scale, which assesses pretend play in children. She is author of several books, including Play in Child Development and Psychotherapy: Toward Empirically Supported Practice (2004, Erlbaum), and Russ and Niec (Eds.), Play in Clinical Practice: Evidence-Based Approaches (2011, Guilford Press).
Charles E. Schaefer, PhD, RPT-S is professor emeritus of psychology at Fairleigh Dickinson University in Teaneck, New Jersey. He is co-founder and director emeritus of the Association for Play Therapy in Fresno, California. Dr. Schaefer is the author/editor of more than 60 books, including Foundations of Play Therapy, 2nd Edition, Empirically Based Play Interventions for Children, and Play Therapy for Very Young Children.
John W. Seymour, PhD, LMFT is professor of counseling at Minnesota State University, Mankato, where he teaches graduate courses in family therapy, play therapy, and clinical supervision. He has been a family therapist for more than 30 years and has served in a variety of practice settings such as agencies, residential treatment centers, and private practice. Professional publications and presentations have included topics such as counselor ethics, clinical supervision, resiliency, families facing chronic illness, and play therapy. Along with his teaching, he continues to work with children, teens, and their families at the Journeys Toward Healing Counseling Center in Mankato.
Anne Stewart, PhD, professor at James Madison University, has implemented projects addressing man-made and natural disasters in Cambodia, Jordan, and Vietnam and served as a consultant following Hurricane Katrina, the 9/11 attacks, the Virginia Tech University and Sandy Hook School shootings, and other catastrophic events. She has authored book chapters and articles on play therapy, crisis intervention, resilience, and supervision. Anne is a recipient of the Association for Play Therapy's Distinguished Service Award and the Virginia Outstanding Faculty Award. She is founder of the Virginia Association for Play Therapy and has been a playful practitioner of play therapy for 25 years.
Aideen Taylor de Faoite, educational psychologist and play therapist, has worked with children in health and educational settings for more than 25 years. She has a number of publications, with the most recent being her book Narrative Play Therapy, Theory and Practice. Aideen continues to explore and develop methods of using play to support children's well-being.
Kathleen S. Tillman, PhD, is an assistant professor of psychology at the State University of New York at New Paltz where she teaches future school and mental health counselors courses about play therapy and disorders of childhood. She has worked in residential treatment centers with child survivors of trauma and abuse and has co-authored treatment manuals for clinicians assisting children and families after disasters. She recently authored a book, Group Counseling with Elementary Students.
Tammi Van Hollander, LCSW, RPT, is an associate at the Center for Psychological Services in Ardmore, Pennsylvania. She has spent more than 20 years working with children, families, and individuals. She has presented lectures and workshops to professionals throughout the nation both independently and with Cross Country Education.
Claire Wallace, BS, is a graduate student in the doctoral program in clinical psychology at Case Western Reserve University, specializing in working with children and families. She works with Dr. Sandra Russ, studying pretend play and creativity in children. Her current research project, her master's thesis, is a longitudinal study examining correlates of children's early pretend play, including later resiliency, creativity, and coping ability. Claire plans to continue researching pretend play and its potential role in the clinical treatment of young children.
William F. Whelan, PsyD, is co-director of the Mary D. Ainsworth Child-Parent Attachment Clinic in Charlottesville, Virginia. Bill was a faculty member at the University of Virginia School of Medicine (14 years in pediatrics and psychiatric medicine), and now provides teaching and consultation services regarding the use of assessment instruments and evidence-based intervention protocols for at-risk children and their caregivers. He has had research funding from the NIH and has written articles and book chapters about the assessment and treatment of high-risk attachment and regulation patterns.
Daniel Yeager, LCSW, RPT-S, is a psychotherapist and mental health consultant with the Yeager Center for Children and Families in Lafayette, Louisiana. He presents training nationwide for professionals on topics related to ADHD, executive function, and play therapy. He is the co-author of Executive Function and Child Development and of Simon Says Pay Attention: Help for Children With ADHD.
Marcie Fields Yeager, LCSW, is a psychotherapist with the Yeager Center for Children and Families in Lafayette, Louisiana. She is also an award-winning designer of the therapeutic game, Think It Over. She is the co-author of Executive Function and Child Development and of Simon Says Pay Attention: Help for Children With ADHD.
Chapter 1
Introduction
How Play Therapy Causes Therapeutic Change
Athena A. Drewes and Charles E. Schaefer
Therapeutic Factors
Virgil (n.d.) once wrote “Fortunate the man who can understand the cause of things” and how true that is for child and play therapists with regard to conducting treatment and research. An accurate understanding of how play therapy works to cause change involves looking inside the black box to identify the therapeutic factors that operate to produce a treatment effect (Holmes & Kivlighan, 2000).
Therapeutic factors are the actual mechanisms that effect change in clients (Yalom, 1995). They represent a middle level of abstraction between general theories and concrete techniques. Theories, such as humanistic, psychodynamic, and cognitive-behavioral, comprise the highest level of abstraction. They offer a framework for understanding the origin and treatment of problematic behaviors, and often a philosophical view on the nature of human life. Therapeutic factors, the middle level of abstraction, refer to specific clinical strategies, for example, catharsis, counterconditioning, and contingency management, for obtaining the desired change in a client's dysfunctional behavior. Techniques, the lowest level of abstraction, are observable clinical procedures designed to implement the therapeutic factors, for example, sand play, role playing with puppets, and storytelling. Therapeutic factors have been given various names, for example, “therapeutic powers,”“change mechanisms,”“mediators of change,”“causal factors,” and “principles of therapeutic action.” These terms have been used interchangeably to refer to the same concept, that is, the overt and covert activities that various theoretical systems use to produce change in a client. A therapeutic power may be a thought, for example, insight; a feeling, for example, a positive affect; or a behavior, for example, role play. What they have in common is that they all act to produce a positive change in the client's presenting problem. Therapeutic powers transcend culture, language, age, and gender. They are considered to be “specific” factors versus “common” factors” in psychotherapy (Barron & Kenny, 1986). Specific factors refer to causal agents of change specific to a particular therapeutic approach. Common factors, on the other hand, refer to change agents common to all theoretical orientations, for example, a supportive relationship, or the instillation of hope.
Historical Background
Initially, the literature on therapeutic powers was largely anecdotal and consisted of clinicians describing the change principles they found effective in treatment. Corsini and Rosenberg (1955) are considered the first to offer a taxonomy of therapeutic factors in psychotherapy. They reviewed the group psychotherapy literature for observations reflecting change mechanisms and compiled a list of nine factors. Irving Yalom (1995) expanded the list to 11 factors that he described in his classic group psychotherapy text. In accord with his belief that other group members are the major source of change for group members, his factors included “universality” (realization that you are not alone and others are struggling with the same problem), “vicarious learning” (client improves in response to the observation of another group member's experience), “catharsis” (release of pent-up feelings in the group), and “interpersonal learning” (learning from personal interactions with other clients in the group). Interest in identifying and researching the specific therapeutic powers in other forms of psychotherapy, for example, individual, couples, and family therapy has also grown in recent years (Ablon, Levy, & Katzenstein, 2006; Holmes & Kivlighan, 2000; Spielman, Pasek, & McFall, 2007; Wark, 1994).
Therapeutic Powers of Play
The therapeutic powers of play refer to the specific change agents in which play initiates, facilitates, or strengthens their therapeutic effect. These play powers act as mediators that positively influence the desired change in the client (Barron & Kenny, 1986). In other words, the play actually helps produce the change and is not just a medium for applying other change agents nor does it just moderate the strength or direction of the therapeutic change. Based on a review of the literature and the clinical experiences of play therapists, we have identified 20 core therapeutic powers of play, which are the focus of the following chapters in this book. Among these powers are change agents that improve a client's attachment formation, self-expression, emotion regulation, resiliency, self-esteem, and stress management. In the following chapters, the contributors describe the nature of these powers and illustrate their therapeutic application to clinical cases.
Transtheoretical Model of Play Therapy
The therapeutic powers of play transcend particular models of play therapy by defining treatment in terms of cross-cutting principles of therapeutic change (Castonguay & Beutler, 2005; Kazdin & Nock, 2003). While some play therapists will be interested primarily in the narrow band of change agents underlying their preferred theory, for example, cognitive-behavioral play therapy, a growing number of play therapists will seek to understand and apply all of the multiple change agents in play therapy. By adopting a transtheoretical orientation (Prochaska, 1995), play therapists avoid becoming locked into a single theory that they then must apply to all clients in a “one-size-fits-all” Procrustean Bed manner. Clearly, no single theoretical approach has proven strong enough to resolve all the diverse presenting problems of clients. Indeed, empirical research has supported the “differential therapeutics” concept that certain change agents are more effective for specific disorders than other agents (Frances, Clarkin, & Perry, 1984; Siev & Chambless, 2007).
Transtheoretical play therapy entails selecting and adding to your repertoire the best change agents from among all the major theories of play therapy. Among the underlying premises of this eclectic, transtheoretical approach to psychotherapy are:
Each of the major theories of play therapy has practical change agents that can increase one's clinical effectiveness (Prochaska, 1995).The more therapeutic powers of play in your repertoire, the better able you will be to eclectically select the one(s) with the best empirical support for treating a particular disorder (Schaefer, 2011).With multiple change agents at your disposal, you can implement an evidence-based treatment plan that prescriptively tailors your play intervention to meet the individual needs and preferences of a client as well as your own skills and judgment (Schaefer, 2001).Theoretical integration involves the synthesis of two or more change agents in the belief that the resulting integration will surpass the effect of a single change mechanism. The integrative movement in which therapists shift from adherence to a single theory to a broader orientation has become particularly strong of late in the field of play therapy (Drewes, Bratton, & Schaefer, 2011).
The editors of this volume personally believe that the field of play therapy is advanced by the trend toward the application of a transtheoretical approach to play therapy. Although various labels have been applied to the transtheoretical play therapy movement, for example, prescriptive, prescriptive/eclectic, and integrative play therapy, it is characterized by a dissatisfaction with single-school approaches and a simultaneous desire to look beyond school boundaries to determine what play therapy change mechanisms contained in other theories can be learned and added to one's practice. The ultimate aim of doing so is to enhance one's effectiveness and efficiency as a play therapist.
Future Directions
Many prominent psychotherapists have called for a shift in psychotherapy training from an emphasis on broad theories of psychotherapy to a focus on therapeutic change mechanisms. Two main reasons a greater understanding of change agents is of vital importance to play therapists and other clinicians are:
In our opinion, we need the full arsenal of the therapeutic powers of play to effectively and efficiently overcome the many forces of psychopathology. In addition to expanded instruction and training on the importance and application of the causal mechanisms in play therapy, we need to substantially expand process research studies on play therapy so as to further identify and validate the specific therapeutic powers of play. We believe these change mechanisms are the essence, the “heart and soul” of play therapy and, as such, deserve much greater attention by play therapists and researchers.
We appreciate the efforts of the chapter contributors in this book to deepen our understanding and application of the therapeutic powers of play.
How Best to Use the Material in This Book
Ideally the reader would benefit from reading the entire book in order to gain the most benefits. However, each chapter stands alone and can be read separately from the other chapters to address a specific issue or area of interest. There are also sections and chapters that flow together that can be read as a cluster depending on the treatment being done and the client being served. As mentioned earlier, a prescriptive approach is best utilized, thinking about your client's needs, where they currently are, and what symptoms and goals you are addressing in your treatment plan. Are your clients dealing with cognitive processes, emotional processes, or interpersonal processes (O'Connor, 2010; Shirk & Russell, 1996)? Or perhaps all of these at one time or at various stages in the treatment?
Cognitive processes involve learning adaptive or compensatory cognitive skills such as social skills; the reorganization of the meaning of experiences; and the gaining of an increased self-awareness (O'Connor, 2010; Shirk & Russell, 1996). Examples would be those of children struggling with a trauma that has impacted their worldview, thus creating cognitive distortions and misconceptions, or children with Asperger's disorder who lack the knowledge of friendship skills and how to respond in socially acceptable ways, or children with executive functioning difficulties due to an attention deficit disorder.
In these types of cases the therapist might focus on change agents involving the direct and indirect teaching of skills such as social and problem-solving skills or teaching compensatory or adaptive skills, along with ways to increase a client's cognitive development, self-esteem, and resiliency (O'Connor, 2010).
Chapters That Best Help With Cognitive Processes Include:
If the client does not seem to display an ability to develop insight and needs help in reorganizing the meaning of their experiences (cognitive distortions and misattributions) and modifying assumptions and expectations that might be brought to the session, which might be seen in the content of the play (symbolically) or from direct verbalizations, the reader might want to also focus on the chapters on:
Clients may display difficulty in the area of emotional processes (O'Connor, 2010; Shirk & Russell, 1996). More specifically, they may show deficits in feelings identification, emotional expression, discharge of negative emotions, and integration of emotions. This may be due to a variety of causes ranging from trauma (sexual abuse, physical abuse, domestic violence) to systemic and biological issues. In these cases, the therapist would want to look at chapters that focus on helping with affect regulation through the cathartic release of feelings that results in mastery or control; teaching the client how to recognize, as well as be aware of, name and talk about their own feelings and those of others; the integration of their feelings and personal emotional experience; and the development of coping strategies or psychological defenses that would avoid emotional dysregulation (O'Connor, 2010).
Chapters That Assist in Treatment of Maladaptive Emotional Processes Include:
If the client, perhaps as a result of trauma or other developmental issues, develops specific fears and phobias, the reader would want to be sure to also look at Chapter 9, Counterconditioning Fears.
Clients may show deficits in interpersonal processes (O'Connor, 2010; Shirk & Russell, 1996) and need treatment designed to foster positive relationships. Attachment difficulties may be present due to prolonged separations from parents due to hospitalizations/placements or due to parental neglect, abuse, disengagement, or loss. Through the therapeutic relationship the client is able to utilize the play therapist as a secondary attachment figure to work through past negative experiences and to develop an alternative relationship of trust and connection. Difficulties with peer relationships and forming friendships might necessitate treatment that offers social-emotional support as well as supportive scaffolding in bolstering the client's functioning with the environment (school, after-school activities, engaging parents) (O'Connor, 2010).
Chapters That Help in Focusing on Such Social Difficulties Include:
It is our hope that the reader will frequently utilize this book as a guide and resource in creating treatment plans that are tailor-made to overcome an individual client's problems. We are confident that a greater understanding of the therapeutic powers of play will not only result in more effective treatment gains for clients, but also in better formulated and focused research. To further move the field of play therapy into the mainstream, we need studies designed to show how play is the active ingredient that leads to therapeutic change.
References
Ablon, J., Levy, R., & Katzenstein, T. (2006). Beyond brand names of psychotherapy: Identifying empirically supported change processes. Psychotherapy: Theory, Research, Practice, & Training, 43(2), 216–231.
Barron, R., & Kenny, D. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality & Social Psychology, 5, 1173–1182.
Castonguay, L., & Beutler, L. E. (2005). Principles of therapeutic change that work. New York, NY: Oxford University Press.
Corsini, R., & Rosenberg, B. (1955). Mechanisms of group psychotherapy: Process and dynamics. Journal of Abnormal and Social Psychology, 51, 406–411.
Drewes, A., Bratton, S., & Schaefer, C. (2011). Integrative play therapy. Hoboken, NJ: Wiley.
Frances, A., Clarkin, J. F., & Perry, S. (1984). Differential therapeutics in psychiatry: The art and science of treatment. New York, NY: Brunner/Mazel.
Goldfried, M. R., & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66, 143–150.
Holmes, S. V., & Kivlighan, C. (2000). Comparison of therapeutic factors in group and individual treatment processes. Journal of Counseling Psychology, 47(4), 1–7.
Kazdin, A. (2001). Bridging the enormous gaps of theory with therapy, research, and practice. Journal of Clinical Child Psychology, 30, 59–66.
Kazdin, A., & Nock, M. (2003). Delineating mechanisms of change in child and adolescent therapy: Methodological issues and research recommendations. Journal of Child Psychology and Psychiatry, 44(8), 1116–1129.
O'Connor, K. (2010). Beyond the power of play: Using therapeutic change processes in play therapy. Presented at the Association for Play Therapy conference, Louisville, KY.
Paul, G. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31, 109–119.
Prochaska, J. O. (1995). An eclectic and integrative approach: Transtheoretical therapy. In A. S. Gurman & S. B. Messer (Eds.), Essential psychotherapies: Theory and practice (pp. 403–440). New York, NY: Guilford Press.
Schaefer, C. E. (2001). Prescriptive play therapy. International Journal of Play Therapy, 10(2), 57–73.
Schaefer, C. E. (2011). Prescriptive play therapy. In C. E. Schaefer (Ed.), Foundations of play therapy. Hoboken, NJ: Wiley.
Shirk, S. R., & Russell, R. L. (1996). Change processes in child psychotherapy. New York, NY: Guilford Press.
Siev, J., & Chambless, D. (2007). Specificity of treatment effects: Cognitive therapy and relaxation for generalized anxiety and panic disorders. Journal of Consulting & Clinical Psychology, 75, 513–527.
Spielman, G., Pasek, L., & McFall, J. (2007). What are the active ingredients in cognitive and behavioral psychotherapy for anxious and depressed children? A meta-analytic review.Clinical Psychology Review, 27, 642–654.
Virgil (n.d.). BrainyQuote.com. Retrieved February 9, 2013, from http://brainyquote.com/quotes/authors/v/virgil.html
Wark, L. (1994). Therapeutic change in couples therapy. Contemporary Family Therapy, 16(1), 39–52.
Yalom, I. D. (1995). The theory and practice of group psychotherapy (4th ed.). New York, NY: Basic Books.
Part I
Facilitates Communication
Play, the natural language of the child, is often the easiest way for children to express troubling thoughts and feelings that are both conscious and unconscious. Also, by making learning an enjoyable experience, therapists are best able to impart information needed by clients to overcome knowledge and skills deficits.
Self-ExpressionAccess to the UnconsciousDirect TeachingIndirect TeachingChapter 2
Self-Expression
Mary Morrison Bennett and Stephanie Eberts
Four-year-old Sophie was just told that there will be a new baby in her family, that there is a baby in her mommy's tummy. Sophie begins to ask questions if other women have babies in their tummies and she requests to see the baby. As Sophie plays she comes out of her room with a baby doll under her shirt and sits on the couch next to her mommy. Sophie is working to understand and make sense of pregnancy. Although she thinks it will be fun to have a baby, she desires to understand what it is like to have a baby growing in her tummy and asks on a daily basis when the baby will be here. This type of play is common for young children, as their play is indicative of their perspective of their world.
Self-expression is a part of communication, emotional release, mastery, gaining understanding, creativity, and so much more. Play is a critical component of communication for children; play allows children the freedom to explore emotions, experiences and relationships (Axline, 1947). Play is critical to a child's development (Elkind, 2007). Therapy does not happen without self-expression in play. One might consider that all play is self-expression, that one cannot play without expressing oneself, just as it is impossible for adults to speak without expressing themselves. Schaefer (1993) established self-expression as a therapeutic power of play in play therapy.
Why Is Self-Expression Therapeutic?
Most would agree that self-expression is critical to our happiness as humans. Adolescents and adults express themselves in both verbal and nonverbal ways. However, few people consider how young children express themselves. Play provides children with the opportunity to express their feelings and thoughts and to make sense of their experiences.
Play Is a Child's Natural Language
Children do not have the vocabulary to accurately express their emotions or their understanding of situations. “Play therapy is based upon the fact that play is the child's natural medium of self-expression. 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” (Axline, 1947, p. 9).
Toys are their words, and play is their language (Ginott, 1960). Axline (1947) believed that play is the most developmentally appropriate mode of expression for children. Play enables children to fully express themselves without hesitation or fear because children at play feel safe (Landreth, Homeyer, & Morrison, 2006). Characteristically, young children do not have the vocabulary or abstract thinking ability to verbally express their inner world. However, they can readily express their thoughts, feelings, and wishes through their natural medium of expression—play.
Piaget (1951) stated that “Play provides the child with the live, dynamic, individual language indispensable for the expression of his subjective feelings for which collective language alone is inadequate” (p. 166). He further cited evidence from developmental studies on cognition, which indicated that for children below the age of junior high, the use of concrete play materials and activities are more suitable than verbal abstractions as a means of self-expression. It is important to note that spontaneous, free play and self-expression does not occur for children in extremely stressful or anxious situations such as with children who have been traumatized or who are depressed or highly anxious (Landreth, 2012). Erikson (1963) stated that allowing children to play out their experiences is the greatest self-healing modality available to children. It is through play that children explore the unfamiliar and make it familiar, thus facilitating understanding of self, others, and their experiences. Landreth (1993) stated, “Play facilitates understanding and understanding thus facilitates children's self-expression” (p. 45).
Play Allows Children to Talk in the Third Person
Pretend play allows children to “talk in the third person,” that is, have dolls, puppets, and make-believe characters express or act out for them the thoughts, feelings, and behaviors that are too difficult or threatening to express directly (Schaefer, 2012). Children can project intense feelings and emotions onto the toys in play, thus creating a safe and controlled way for emotional expression (Landreth, 1993). Gil (2006) stated that while some children may consciously choose to avoid talking about difficult feelings or emotions, they are drawn to replay such traumatic events through the use of symbols (toys) that provide a safe distance, allowing them to express their feelings and understanding about the event. This allows children to gain mastery over experiences and emotions resulting in an increased ability to self-regulate. Schaefer (1993) stated that play enables children to express both the unconscious as well as conscious feelings. Adults who are able to understand a child's play are able to see the inner world of the child and have a unique understanding of the child's world.
Play makes the unmanageable manageable (Landreth, 2012). It is critical that play be understood by adults from the child's perspective. A child's play gives us a window into the child's world. Often when adults look at play they see it as a simple activity of childhood, silly and without meaning. However, when a child plays, full expression of self occurs including past experiences, reactions to and feelings about those experiences, and what the child wishes, wants, and needs (Landreth et al., 2006).
Play Allows for an “As If,” Not Real-Life Quality
Pretend play allows for a distance from real life. Emotions, thoughts, wishes, and fantasies can be expressed in play that one might not express in real life. Play presents clients with plausible deniability concerning upsetting material, that is, it permits clients to suspend and if necessary to disavow its reality. After all it is just pretend or a game (Levy, 2008). Often in play therapy sessions, the emotions elicited in a child during play become too intense and the child needs a break. When children take a break from the emotions they are experiencing in play, a play disruption occurs (Findling, Bratton, & Henson, 2006). Children also enjoy the freedom that pretend play offers in trying out ideas and feelings to see if they fit. To illustrate, “A 12-year-old boy once said, ‘Puppet play is a good way to get our feelings out instead of expressing them in real life where they can really hurt or embarrass somebody. You can express feelings with puppets and if someone says, “Why did you feel that way? You say I don't know. I just made it up.” You can get out of it real easy’” (Schaefer, 2012, p. 6).
Play Allows for Expression of the Ineffable
At times, we cannot express inner states well in words but we may be able to depict them better in one of the creative arts, such as drawing, dance, play creations. For example, “A sand tray creation can translate a personal experience into a concrete three-dimensional form. Just as a picture can say more than a thousand words, a sand scene can express feelings and conflicts that previously had no verbal language. Hence, the sand scenes constructed in the playroom can offer a rich and highly individualized medium for pre-verbal and non-verbal expression” (Schaefer, 2012, p. 7). There are often experiences in life that are too complicated or amazing for words. Due to the limited verbal expression of children, this is a frequent occurrence and play is critical in facilitating children's expression of experiences.
Play Provides Safety in Facilitating Expression
When the child feels the safety of the environment and relationship, any self-consciousness is overcome. Children are often engrossed in their play and as a result, more likely to inadvertently express things that they would ordinarily not do. In the safe, enjoyable environment of the playroom, children are likely to let their guard down and reveal their inner self. This safe and relaxing environment often sets children at ease, thus allowing them to talk while playing in addition to express themselves through play (Schaefer, 2012).
Most adults would agree that there are few places and few relationships in which they can honestly express themselves; therefore it is critical for therapists to provide a safe environment to facilitate expression in order for clients to fully articulate themselves. Children may have a greater need for a safe, accepting, and inviting relationship due to their limited development, limited sense of self, self-efficacy, and confidence in their ability to express themselves. Children's expression is often limited; there are few times children are allowed to fully communicate their feelings. Adults often limit children's expression because their feelings are displayed through their behavior, which may be inappropriate by adult standards. In the therapeutic setting, self-expression is therapeutic because it is allowed and children are provided an environment where expression is welcome. They are in a relationship that is accepting and genuine and a developmentally appropriate environment created just for children.
For example, Virginia Axline (1947) described a situation involving one of her clients—Mikie, age 22 months. The boy's mother reported to Axline that Mikie would not eat. While playing in the sandbox Mikie overheard his mother's comment, got out of the sandbox, put the rag doll in the high chair, put sand in the toy dishes, and played out his experiences in eating, by shoving a spoonful of sand at the doll and saying, “Eat. Eat!” He then threw the spoonful of sand on the floor, scraping his feet in it and shouting “No. No. No!” This he repeated several times while his mother watched in amazement—and Axline said, “Someone wants the baby to eat, but the baby says ‘No.’” The mother realized she had become demanding that he eat what she put in front of him. Once she released this control, she reported to Axline that eating was no longer a battle.
Empirical Support of the Power of Self-Expression in Play Therapy
Self-expression as a therapeutic factor is a component of therapy that needs to be further researched, although it seems to be an accepted fact that it is healing for children to express themselves in play therapy. Several leaders in the field of play therapy have written on the importance of self-expression in play and the difference they have seen in the healing of children (Axline, 1947; Badenoch, 2008; Elkind, 2007; Kottman, 2003; Landreth, 1993, 2012; Piaget, 1951; Schaefer, 1993; Terr, 1981).
Self-Expression in Traumatic Play
Anna Freud and Dorothy Burlingham (1943) first described the play of a young child who had experienced a bombing in their work War and Children. While they described the repetitive play of Bertie bombing his bed with paper airplanes they did not describe his play as different from the play of normally developing children. Terr (1990) first noticed the “grim and monotonous” play of traumatized children expressing deeper emotions and experiences than children who had not experienced a trauma. Terr studied the play behaviors and themes of 12 traumatized children and one traumatized adult, who participated in 3- to 4-hour-long play therapy sessions. As a result of this research Terr identified 11 characteristic ways children express their posttraumatic play: compulsive repetitiveness, unconscious link to the traumatic event, literalness, failure to relieve anxiety, wide range of players, varying lag time prior to its development, carrying power to involve nontraumatized children, contagion to new generations, danger, art, and talk as alternative modes of playing, and usefulness of tracing post-traumatic play to an earlier trauma (Terr, 1981, p. 741).
Gil (2006) stated that the best outcomes occur when children engaged in posttraumatic play are in a therapeutic setting, in the presence of a trained clinician who can respond appropriately and provide support to the child's intense expressive and emotionally charged play.
Building on Terr's characteristics of posttraumatic play, Findling, Bratton, and Henson (2006) created the Trauma Play Scale (TPS) to be used in analyzing play in play therapy to determine if it could be considered posttraumatic play. In this pilot study the researchers studied children who had suffered a trauma and nontraumatized but clinically referred children who were participating in Child-Centered Play Therapy. Results indicated that children who suffered a trauma scored higher on the TPS than children who were clinically referred but had not been traumatized. These results indicated there is a difference in the play of these children. While both groups of children engaged in self-expression in play therapy the expression of the traumatized children had different qualities than the nontraumatized children. Meyers, Bratton, Hagen, and Findling (2011) completed a follow-up study to continue the development of the TPS. When compared with normally developing children, who were not clinically referred for therapy, results indicated that children with a history of interpersonal trauma scored higher in all five domains of the TPS. There was a significant difference between the two groups indicating a strong positive relationship between the trauma history and participants' scores on the TPS. While these results do not report specifically on self-expression, one can see the importance of and value of self-expression in play. There was a clear difference in the way expression occurs in the playroom depending on the personal history of the children.
Self-Expression Play in Brain Development
Providing a safe and open relationship where children lead the play activates areas of the limbic system (Badenoch, 2008). Neuroscience appears to be supporting the importance of freedom of expression in activating the self-healing of the brain.
The limbic system contains our motivational circuits and becomes active when children are in connection with adults, and experiencing caring, social bonding, and playfulness. Badenoch (2008) states that once this system is activated, the release of dopamine provides a sense of enjoyment, focus and the drive to complete tasks. She further states that in the presence of a supportive adult, children can find access to this system quickly. As the therapeutic relationship develops, the circuits of the middle prefrontal area and emotions of the limbic system balance and eventually give children the capacity for self-regulation. Badenoch cautions that when adults lead in the play process and especially if they become insistent or are off-target, the rage system is easily activated. This is easily repaired, if therapists see this rage and pull back to provide space for the child's whole being to emerge. In the therapeutic relationship the therapist must trust the child completely and agree to respond to his or her signals to facilitate emotional expression. Badenoch warns therapists to be cautious of pressure where therapists feel they must “make something happen,” for when we stray from the process, it rarely goes well. Therapists must use their clinical judgment to determine the best way to facilitate self-expression in children.
