Play therapy has much to offer children who have had traumatic experiences or suffer from mental health and other problems. Play therapist Nina Rye explains   
Nina Rye BSc(Hons) PGCE MA(Play Therapy) Play Therapist Norfolk and Waveney Mental Health PartnershipPlay Therapy1
Play therapy is a child-centred therapy for children between the ages of 3 and 16 years who have mental health and/or other difficulties. The play therapist works one to one with the child, allowing children to explore their inner emotional world in almost any way they choose in the play room. The therapist sets a few necessary behavioural limits in order to safeguard physical and emotional safety during the weekly sessions. Children from all kinds of families come for play therapy. Some have witnessed domestic violence, or experienced abuse or other trauma. Some have conflicted relationships with the parents or carers arising out of insecure attachment and/or other issues. Provided that the child has some level of symbolic play, play therapy has the potential to help. The other provisos are that the home environment is sufficiently supportive at a basic level, and that the parent or carer is willing to support therapy. Children typically have play therapy for between two and 12 months, depending on the complexity of their difficulties. Play therapists analyse sessions and track changes to determine when to plan the ending with the child.
Play therapists come from a range of professions and undertake full-time or part-time training in play therapy leading to a post-qualifying diploma or Master's degree. Qualified play therapists work in, or undertake work for, Child and Adolescent Mental Health (CAMH) services, Children's Services (Social Care), schools, and voluntary sector agencies.
Journal of Family Health Care 2008; 18(1): 17-19

Key points 
_ Play therapy in the UK is a specific form of childcentred therapy for children and young people between the ages of 3 and 16
_ Rather than using play to get a child to talk about their difficulties, play therapy allows the play itself to be the outward expression of the child's inner emotional world

_ Play therapy helps children who have experienced difficulties such as trauma, abuse and family break-up, or who have problems with behaviour, relationships and mental health
_ With a few exceptions it is suitable for most children and young people, including those with learning disabilities and physical disabilities
_ To train as a play therapist involves 18 months to three years of study at a university (sometimes part time) for an accredited postgraduate diploma
_ Play therapists work in a range of statutory and voluntary settings, including Child and Adolescent Mental Health Services. liaising with other professionals and with parents/carers
_ Play therapists monitor a child's progress by analysing changes in play themes and other differences in the way the child presents. Sessions are usually weekly for eight weeks, up to a year, or longer

"Play therapy" is a term that is still applied quite loosely in this country and is sometimes taken to mean a set of skills that can be imported into a social worker's or health professional's work with a child. Some assume it is the same as the hospital play specialist's work, others that it is for very young children only. They are surprised to learn that many play therapists work predominantly with 8-12 year olds. In fact, play therapy is a specific form of structured therapy suitable for a wide range of children with mental health and other difficulties between the ages of 3 and 16 years.

What happens in play therapy? Play therapy 2 
Unlike other therapies, where play might be a means to engage the child in talking about his or her problems, play therapy accepts and values the child's play as their communication. (Although both boys and girls have play therapy and play therapists may be male or female, for convenience the child will be referred to as "he" and the therapist "she" from this point.) Most play therapists work one to one rather than with a group. One reason is that group work requires a minimum of two play therapists, and there are few if any places where more than one is employed. In the 60-minute play therapy session, the child leads the play and sets the agenda; the therapist follows. She lets the child know he can do almost anything he likes, and that if there is something he is not allowed to do, then she will tell him. While all feelings are fully accepted, the therapist sets firm limits on behaviour as and when these are needed. Basic limits are that the child may not hurt himself or the therapist; he may not damage the room or the toys deliberately; other practical limits about the use of paint, sand, water etc. are introduced as they arise. Limits are necessary to safeguard physical and emotional safety. The experience of making choices about behavioural limits is an important part of the therapy for many children. Most children have some ability to use play to express their feelings, as any observer of preschoolers' play in the "home corner" could testify. Children referred for play therapy, for example in a mental health setting, may not be able to express themselves freely in play. Some are very fearful, anxious to please, needing to hide their hurts and worries from themselves and the therapist. Some never had enough opportunity to play as an infant or toddler; they have only rudimentary symbolic or "pretend" play. Others dive straight into complicated role play involving robberies, shootings and stabbings, fires, imprisonment, and all kinds of dramatic incident.

"Tuning in" to the child's inner world   
The play therapist accepts whatever the child presents of himself in the play room. Her job is to "tune in" to the child's inner emotional world, to focus on his feelings and ideas both in play and in the relationship. The play therapist offers attunement, as defined by Stern1. Close empathic attunement recreates the optimal socialisation patterns between an emotionally available primary carer and infant, as discussed by Ryan and Wilson2. This enables the child to rework earlier stages of development through regressive play with the therapist.

What the child can gain   
Many children in play therapy gain a more secure attachment with the parents or carers (the term "parent" will be used from this point). This in turn frees the child to form more satisfying peer relationships. Another major gain is an increased ability to self-regulate: tantrums become fewer, of shorter duration, and eventually cease; the withdrawn child begins to talk to his parent about what troubles him; the child who disrupted  classmates' learning can concentrate on his work.

Unconditional acceptance and freedom to explore feelings The play therapist facilitates the child's play without directing it, working in Vygotsky's3 "zone of proximal development". From the play therapist's verbal and non-verbal responses, the child learns that she accepts him unconditionally. She respects him and refrains from steering him toward material that is too threatening for him. Instead, she lets him set the pace. The child-centred play therapist does not interpret the child's play back to him but keeps her comments within the play metaphor: "The baby is scared, there is no-one to look after him," rather than "I think you felt scared when your mum left you alone." This allows a safe distance, a creative space in which the child can explore and resolve angry, sad, and confused feelings.

Which children have play therapy?   
Play therapists are trained to work with children in all kinds of families: some are in blended families; live with a grandparent or other relative; some are in foster care or residential units; others are in adoptive families. Children may have a learning or physical disability. Problems range from the relatively straightforward, such as the experience of a single trauma, to the more complex where there is a cluster of behavioural, emotional and other issues. Some examples are shown in Table 1.

Table 1: Children who can benefit from play therapy 
_ Children who have experienced physical, emotional and sexual abuse, neglect, and/or multiple trauma of other kinds
_ Children who have witnessed domestic violence
_ Children whose parents have physical and/or mental health problems
_ Children who refuse school
_ Children who are excluded from school
_ Children with the following problems or conditions:
Attention deficit hyperactive disorder (ADHD)
Asperger's syndrome
Conduct disorder
Reactive attachment disorder
Are physically aggressive towards others
Show excessive fear or timidity
Are bullied
Are bullies themselves
This list is not exhaustive.

When does play therapy not work?Play therapy 3   
A vital part of the job is to work closely with parents. The play therapist meets with the parent(s) before meeting the child, in order to gather (or update) information about the family, the child's history, education and so on. The therapist aims to build a therapeutic alliance with parents. It is not a matter of "bringing the child to be fixed" but of therapist and parents working in partnership to support the child in making changes.
The therapist will meet with parents at least every six sessions, in order to review the child's progress. This means that parents have to be prepared - and able - to make changes themselves. Sadly, some parents are not able to do this. A proportion of children referred to a Child and Adolescent Mental Health (CAMH) service have a parent with clinical depression or other mental health issue. While some parents nevertheless manage to respond, and begin to be more emotionally available, others are too preoccupied, or even hostile toward the child.
The child in this situation is like a pot-bound plant - unable to grow or develop healthily. The play therapist will do her best to assess whether or not parents can support play therapy before beginning the intervention. But in some cases the inability or unwillingness of the parent to allow changes does not become apparent until the play therapy is seen to be "not working": the child has made little or no progress for several weeks or months.
Crucially, the play therapist must be satisfied that the child is safe enough from abuse and neglect at home, and has at least one reliable adult carer to turn to. If not, the therapist will not work with the child at that point but will involve colleagues and/or other agencies, making a referral to Child Protection agencies whenever necessary. Although there is sometimes a grey area, as a rule of thumb play therapy is for children who have experienced difficulties in their circumstances but are now in a safer and more stable environment where they can work through their unresolved worries, fears and hurts.

Training to become a play therapist 
Trainee play therapists come from a range of professions including nursing, clinical psychology, occupational therapy, social work and teaching. They study typical and atypical child development, with perhaps more emphasis on the cognitive, psychosocial and emotional than the physical (although the physical is not left out). Extensive child observation is an important component of the training. Trainees also get a thorough grounding in the theoretical basis of the model of play therapy specific to their university. At York, for instance, the model is Non-Directive Play Therapy as described by Wilson and Ryan4. Most importantly, all courses include supervised clinical practice, where trainees undertake play therapy on a one-to-one basis with children. For more information on training, and the British Association for Play Therapy (BAPT), see Table 2.

Where do play therapists work? 
Play therapists are employed in CAMH services, in Children's Services (Social Care), in schools, and in voluntary organisations such as NCH and Barnardos. Many play therapists are freelance, undertaking private work where parents selfrefer, as well as work for agencies in the statutory and voluntary sectors. Some play therapists have expertise in doing Court assessments. Whatever the setting, the play therapist is not a "lone ranger". It is important for the safety both of the child and the therapist that she co-ordinates her work with that of others in the network surrounding the family. This might include making referrals or recommendations, for example for family therapy, personal therapy for a parent, or a Young Carers' group. If the play therapist thinks the child has, for example, undiagnosed depression, attention deficit hyperactive disorder, Asperger's syndrome, or posttraumatic stress disorder, she will make (or recommend, if she does not work in a mental health setting) a referral for a psychiatric or other assessment as appropriate. The play therapist attends case conferences, core groups and childspecific planning meetings, other multi-agency meetings and professionals' meetings whenever possible.

When does a child leave play therapy? Play therapy 4   
Children with relatively straightforward problems and a supportive environment can benefit from just eight sessions. Others will need 6-12 months of weekly sessions, or even longer. The play therapist plans the ending with the parents and, most importantly, with the child. Many children do not want to end. They need time to work through their sadness, disappointment, and anger at the play therapist. Others are quite happy to go, knowing that they no longer need the play therapist in the way they once did.
In order to gauge when a child is ready to leave, the therapist gathers feedback from the child's parent and other sources. She also looks for changes in the child's play themes. Every week, the therapist analyses the session for dominant themes and other changes in the child. Some themes are developmental. Erikson's theory5 of psychosocial development in infancy and early childhood is a useful framework. Other themes are emotional. Examples include "abandonment vs. rescue", "friendship vs. alienation", and "injury vs. restitution". "Powerful vs. powerless" is a common theme for children who have witnessed domestic violence.
Over the weeks or months, play themes gradually change. Developmental themes connected to infancy and other early stages disappear as the child's basic needs are met and old deficits are "repaired" in play. Themes around use and abuse of power resolve into themes about working together, friendship, and ordinary "happy families" having meals and shopping. 

Play therapy is fascinating work because one is always learning from the child. The play therapist strives to understand each individual's inner emotional world. The child works at his own pace toward his own solutions, gaining mastery of fears and resolution of hurts and worries. He makes gains in self-confidence and achieves a healthier self-esteem. He becomes more aware of his own feelings and behaviour, which in turn helps him to self-regulate more appropriately.
These gains are almost always made to some degree, even for children who continue to struggle at home and school. Those with supportive homes gain most. They have found their own solutions and adaptive coping strategies for life's contingencies. They are like fledglings, ready to fly.

1. Stern DN. The Interpersonal World of the Infant: A View from  Psychoanalysis and Developmental Psychology. New York: Basic Books, 1985
2. Ryan V, Wilson K. Non-directive play therapy as a means of recreating optimal infant socialization patterns. Early Development and Parenting 1995; 4(1): 29-38
3. Vygotsky LS. Thought and Language. Cambridge, Massachusetts: Massachusetts Institute of Technology (MIT) Press, 1962
4. Wilson K, Ryan V. Play Therapy: A Non-Directive Approach for Children and Adolescents. (2nd edn.) Oxford: Baillière Tindall, 2005
5. Erikson EH. Childhood and Society. (2nd edn.) New York: Norton, 1993

Table 2: Training to be a play therapist
The British Association of Play Therapists (BAPT)
Registered charity no. 115673 www.bapt/info  

BAPT is the principal professional body that governs play therapy, training, registration, research and practice in the UK. Their website has information about training and education for play therapists, standards, ethics, research, publications. There is also user-friendly information for parents, carers and children which explains what play therapy is.

Training for play therapists

Four universities in the UK offer courses to become a play therapist: Roehampton University (South West London), University of York (with sites at York and in Cork, Republic of Ireland), Liverpool Hope University College, and the Notre Dame Centre, Glasgow (in association with the University of Strathclyde). The University of Plymouth has plans to offer training starting in September 2008.
Five post-qualifying courses are accredited by the British Association of Play Therapists (see above). The 18-month diploma course at Roehampton University in South West London is full time. Roehampton, The University of York, and  Liverpool Hope University College, all run part-time two-year diploma courses. Notre Dame Centre in Glasgow (inassociation with the University of Strathclyde) has a three-year diploma course. All four universities offer a Master's degree in play therapy. For more detailed information on training courses, see the BAPT website www.bapt/info There is a difference of opinion in some quarters about what constitutes a professional qualification. "Play Therapist" is not yet a protected title under the Health Professions Council. (BAPT are applying for this status.) While other courses exist in the UK, it is safe to say that only those diplomas that reach BAPT standards are recognised universally as professional qualifications in play therapy.