Play Therapy A Case based Example of a Nondirective Approachby Timothy Lawver, DO, and Kelly Blankenship, DOFrom the Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.Psychiatry Edgemont 2.Editors Note All cases presented in the series Psychotherapy Rounds are composites constructed to illustrate teaching and learning points and are not meant to represent actual persons in treatment.Series Editor.Paulette M.Gillig, MD, Ph.D, Professor of Psychiatry, Department of Psychiatry,Boonshoft School of Medicine, Wright State University, Dayton, Ohio.Abstract. Jetaudio V8 2 7 1000 Plus Vx Rar Files . Play therapy is a treatment modality in which the therapist engages in play with the child.Its use has been documented in a variety of settings and with a variety of diagnoses.Treating within the context of play brings the therapist and the therapy to the level of the child.By way of an introduction to this approach, a case is presented of a six year old boy with oppositional defiant disorder.The presentation focuses on the events and interactions of a typical session with an established patient.The primary issues of the session are aggression, self worth, and self efficacy.Group Activities For Reality Therapy' title='Group Activities For Reality Therapy' />These themes manifest themselves through the content of the childs play and narration of his actions.The therapist then reflects these back to the child while gently encouraging the child toward more positive play.Though the example is one of nondirective play therapy, a wide range of variation exists under the heading of play therapy.Key Wordsplay, child, axline, childhood, therapy, play therapy, nondirective.INTRODUCTIONIn her original work on the subject of play therapy, Virginia Axline wrote, There is a frankness, and honesty, and a vividness in the way children state themselves in a play situation.As universal as it is mysterious, imaginative play predominates the lives of most young children.More and more, we are identifying and appreciating childhood mental disorders and how they pull children away from normal functioning.This can affect their home lives, academic performances, as well as their play with peers.Play therapy offers a direct route to engage children on their terms, in their world, giving them a chance to, play through what adults talk through.The goal is to identify and address themes that arise in the course of play, although childrens relative strengths and weaknesses do become apparent in terms of cognitive processing and social skills.Studies have shown the effective use of play therapy in children with different psychiatric diagnoses.Using pre test, post test comparison design to evaluate 1.Danger, et al., showed a benefit in improving both receptive and expressive language skills in children with speech difficulties.In theory, the safe practice environment of the therapy provided an environment conducive to working on these areas without exacerbating self esteem and social anxiety issues.An exploratory study of nondirective play therapy with an autistic boy using video analysis of 1.It was the authors opinion in this paper that the therapeutic relationship helped to enhance and accelerate the emotionalsocial development of children with severe autism, as they were able to observe attachment behavior from the child towards the therapist.Legoff and Sherman ran a three year retrospective study on children with autism spectrum disorders involved in LEGO therapy, a play therapy centered around the commercially available building blocks.In a two tiered approach, Robinson, et al., describe using filial play therapy to teach fifth grade students to then be therapeutic change agents in play sessions with kindergarten children identified as having adjustment difficulties.Gold Steinberg and Logan detail the use of psychodynamically oriented play therapy as an adjunct to pharmacotherapy for a child with obsessive compulsive disorder OCD.Virginia Ryan details some of the difficulties and gains in play therapy with a child in transition with serious attachment problems.In another case example, play therapy was used to alleviate anxiety, which was contributing to migraine headaches in a 1.In this case, the boy with preexisting migraines began to experience increased anxiety in the wake of the 91.Clinical focus.Compassionfocused therapy and compassionate mind training arose from a number of observations.First, people with high levels of shame and self.World Trade Center.The tracked symptom was migraine frequency, which had increased with his anxiety.Through play and art he was able to accomplish a resolution of his fears by bringing them to the surface, directly and indirectly in the content of his play and art projects.As his play and art became less dark and fearful, both his subjective anxiety and migraines decreased.In a related case, play therapy was used as treatment for a four year old boy with a psychosomatic postural symptom that resolved quickly over a course of play therapy.A four year old boy had begun tilting his head forward and to the left subsequent to his parents learning of a left kidney defect in his as of yet unborn sister.He also had marked regression in speech and increasingly needy or clingy behavior.Through play the therapist was able to explore his competing themes of aggression toward his younger sister, the new holder of his parents attention, and a fantasy based guilt of having in some way wished his sisters malady into existence.The head tilt, along with the regressive behaviors served as attention seeking behavior.Also, as much of his play involved things being broken, needing to be fixed, and the idea of punishment by being hit on the head, the therapist was able to extrapolate that the symptoms also served as self punishment.By repeating these themes in the face of safe, gentle correction by the therapist, all symptoms resolved for the most part within four sessions.Snow, et al., described two case studies followed over a six week period.One case was a three year old boy brought in by his grandmother for increasing aggressive behavior and violent tantrums.The other case was that of a six year old boy showing regressive behavior in imitation of and perhaps competition with his younger, disabled brother.The caregiver filled out the Child Behavior Checklist of Thomas M.Achenbach and Craig Edelbrock so that the authors could track the course of behavioral outcomes.The authors tracked the themes present in play from session one to session six based on a standard format.Of note was that changes in play themes in therapy were paralleled by changes in behavior at home.Outside of the context of specific psychiatric diagnoses, play therapy has been used in a variety of other settings.Scott, et al., conducted a 1.Here client centered refers to a slight variation in how the play therapy session is run, although the overall format still consists of play based on themes and interests initiated by the child.However, their findings showed only mixed support for the use of play therapy in this setting.A pre test and post test assessment battery were completed both by the patient and the primary caregiver.Many subjects showed a trend toward clinical improvement 8 of 2.Reliable Change Index formula failed to show a statistical difference.Baggerly advocates for the use of play therapy with homeless children to help them gain in fantasy what they long for in reality.Mullen, et al., explored the use of play therapy with young people, facing transitions as a result of relocation.He presents a case study of a middle schoolage girl upset by her familys move to a more affluent neighborhood.She was able to work through the effects of this relocation and come to terms with the change through bringing the material up in the context of play therapy.In another study, play therapy was used in the preoperative period to reduce state anxiety scored in children.Li, Lopez, and Lee found a reduction in state anxiety scores and fewer negative emotions at induction of anesthesia.Two hundred and three children admitted for day surgery were randomly assigned to experimental or control groups.In the experimental group, the children received therapeutic play while the control group received routine information preparation.The authors found a reduction in state anxiety scores and fewer negative emotions at induction of anesthesia.Introducing compassion focused therapy BJPsych Advances.Abstract.Shame and self criticism are transdiagnostic problems.People who experience them may struggle to feel relieved, reassured or safe.Research suggests that a specialised affect regulation system or systems underpins feelings of reassurance, safeness and well being.It is believed to have evolved with attachment systems and, in particular, the ability to register and respond with calming and a sense of well being to being cared for.In compassion focused therapy it is hypothesised that this affect regulation system is poorly accessible in people with high shame and self criticism, in whom the threat affect regulation system dominates orientation to their inner and outer worlds.Compassion focused therapy is an integrated and multimodal approach that draws from evolutionary, social, developmental and Buddhist psychology, and neuroscience.One of its key concerns is to use compassionate mind training to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self compassion.The healing properties of compassion have been written about for centuries.The Dalai Lama often stresses that if you want others to be happy focus on compassion if you want to be happy yourself focus on compassion Dalai Lama 1.Although all clinicians agree that compassion is central to the doctorpatient and therapistclient relationship, recently the components of compassion have been looked at through the lens of Western psychological science and research Gilbert 2.Davidson 2.Neff 2.Compassion can be thought of as a skill that one can train in, with increasing evidence that focusing on and practising compassion can influence neurophysiological and immune systems Davidson 2.Lutz 2.Compassion focused therapy refers to the underpinning theory and process of applying a compassion model to psychotherapy.Compassionate mind training refers to specific activities designed to develop compassionate attributes and skills, particularly those that influence affect regulation.Compassion focused therapy adopts the philosophy that our understanding of psychological and neurophysiological processes is developing at such a rapid pace that we are now moving beyond schools of psychotherapy towards a more integrated, biopsychosocial science of psychotherapy Gilbert 2.Clinical focus.Compassion focused therapy and compassionate mind training arose from a number of observations.First, people with high levels of shame and self criticism can have enormous difficulty in being kind to themselves, feeling self warmth or being self compassionate.Second, it has long been known that problems of shame and self criticism are often rooted in histories of abuse, bullying, high expressed emotion in the family, neglect andor lack of affection Kaufman 1.Andrews 1.Schore 1.Individuals subjected to early experiences of this type can become highly sensitive to threats of rejection or criticism from the outside world and can quickly become self attacking they experience both their external and internal worlds as easily turning hostile.Third, it has been recognised that working with shame and self criticism requires a therapeutic focus on memories of such early experiences Kaufman 1.Schore 1.Brewin 2.Gilbert 2.This work can overlap substantially with the therapeutic interventions developed for trauma Lee 2.Ogden 2.Van der Hart 2.Wheatley 2.And fourth, there are clients who engage with the cognitive and behavioural tasks of a therapy, and become skilled at generating say alternatives for their negative thoughts and beliefs, but who still do poorly in therapy Rector 2.They are likely to say, I understand the logic of my alternative thinking but it doesnt really help me feel much better or I know Im not to blame for the abuse but I still feel that I am.A key element of compassion focused therapy is related to the observation that individuals prone to high levels of shame and self criticism can find it very difficult to generate feelings of cosntentment, safeness or warmth in their relationships with others and themselves.Evolution and the neurosciences.One way of approaching this problem is to focus on the evolved functions that underpin certain types of feeling and styles of social relating Gilbert 1.What are the affect systems that enable us to feel reassured, content and safe, or to register human warmthResearch into the neurophysiology of emotion suggests that we can distinguish at least three types of emotion regulation system Depue 2.I will explore each of these in turn and their relationship to compassion focused therapy.These are not by any means the only way our emotional regulation system can be mapped and conceptualised, and they can be subdivided in various ways Panksepp 1.A simple depiction of their interaction is given in Fig.FIG 1.Affect regulation systems.From Gilbert 2.Routledge. Threat and protection.All living things have evolved with basic threat detection and protection systems Box 1.The neurophysiology of this system in humans is increasingly well understood Le.Doux 1.Panksepp 1.Its function is to notice threats quickly through attention focusing and attention biasing and then give us bursts of feeling such as anxiety, anger or disgust.Jodorowsky Lama Blanco Vol 1 '>Jodorowsky Lama Blanco Vol 1 .These feelings ripple through our bodies, alerting and urging us to take action to do something about the threat to protect ourselves.The behavioural outputs include fight, flight and submission Marks 1.Gilbert 2.The genetic and synaptic regulation of serotonin plays a role in the functioning of the threat protection system Caspi 2.Partly because the system is programmed in favour of better safe than sorry Gilbert 1.Rosen 1.BOX 1. Threat protection systems.All living things have evolved threat detection and protection systems.Stimuli impinging on organisms must be checked out for potential threat.Mammalian defences include a menu of emotions e.Threat protection systems have evolved to be attuned to certain kinds of threats and operate a better safe than sorry policy.Sensitivity and response to specific threats are the result of an interaction between genes and learning.Response options within the threat protection system can conflict, creating confusion.Brain states choreographed from the threat protection system can bias other processing systems.Over and underdevelopment of sensitivities in threat protection underpin many psychopathologies.The smooth operation of the threat protection system may be difficult, because, for example, many of its response options conflict with each other.It is difficult to engage in both fight and flight behaviour at the same time, and submissive behaviour may involve staying put, being passive and inhibiting both fight and flight.In compassion focused therapy, clinicians explain and explore this with clients.The formulation explores how early life events may have sensitised the individuals threat protection system, leading to the development of safety strategies that can operate automatically, as conditioned and perhaps conflicting responses.For example, some people have well developed submissive safety strategies.These predispose them to being aware of the rank, status and power of others in relation to themselves, to perceiving themselves as inferior, to being quick to feel socially anxious and uncertain, to engaging in appeasing behaviours, and to avoidance in the face of interpersonal conflict Gilbert 2.Such strategies can increase their vulnerability to anxiety and depression, lower their self esteem and interfere with their ability to pursue life goals.So in the evolutionary model, strategies can involve combinations of styles of thinking, behaving and feeling.Sensitised strategies and phenotypes for threat detection and protection can become major influences on the ways in which a person perceives and navigates their world.The clinician will identify, historically plot and validate the functions and origins of safety strategies partly to de shame them Linehan 1.Ogden 2.Van der Hart 2.Gilbert 2.
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