Trauma, Play Therapy, and Research

Source: Courtesy of Cathy Malchiodi, Ph.D.

As a psychologist and expressive arts therapist, I have relied on the work of my colleagues in the field of play therapy for several decades. Play therapy is very similar to expressive arts therapy in its approaches that capitalize on experiential forms of treatment because it is characterized by action-oriented, often implicit, and body-based methods. But like expressive arts therapy, play therapy has been questioned as to its efficacy and its role within psychotherapy and counseling.

Some of these questions are valid because both fields have struggled with establishing data through a quantifiable methodology. But it is also inaccurate to imply that play therapy has little evidence of efficacy; as a field, it has made tremendous strides in both quantitative and qualitative research.

In the spirit of helping both professionals and the public gain a complete understanding of the role of play therapy in the treatment of traumatic stress, I share the following statement by well-known play therapist and researcher Dr. Dee C. Ray. It provides a more balanced view of the existing literature and studies (including randomized controlled trials) on the effectiveness of play therapy to address a variety of issues, including adverse childhood events and traumatic stress in children. I encourage you to follow this link presented in Ray's statement to read more about the extensive and growing number of studies that are informing the application and credibility of play therapy.

Trauma, Play Therapy, and Research: The Problem with Misinformation — Dee C. Ray, PhD., LPC-S, NCC, RPT-S

Recently, the play therapy community was unsettled by claims that play therapy is not an appropriate intervention for children who are diagnosed with post-traumatic stress disorder (PTSD). The claims were made by a mental health professional and researcher who subscribes to a cognitive-behavioral approach in working with children. The claims were resolute in their assertions that play therapy was an unnecessarily lengthy intervention, shrouded in secrecy from parents and unsupported by research for children who have experienced trauma. Additionally, play therapists were characterized as untrained in other effective approaches to PTSD.

The Board of the Association for Play Therapy (APT) has written a statement that details the theory, rationale, and research supporting the facilitation of play therapy as an effective treatment for children with trauma (see "Why Play Therapy is Appropriate for Children with Symptoms of PTSD"). For the sake of transparency, I am an APT board member and co-author on that statement, and I am also a researcher in play therapy, as well as a practitioner. As a researcher, I have conducted two meta-analyses on play therapy outcomes and over 20 randomized controlled trials (RCTs) on the effectiveness of play therapy, including studies exploring the impact of play therapy with attention problems, aggression, anxiety, depression, academic achievement, social/emotional skills, relationship stress, and adverse childhood experiences.

Play therapy is recognized as an evidence-based practice by professional organizations for anxiety, disruptive behaviors, and victims of domestic violence. Play therapy research dates back over 100 years, becoming especially more rigorous in the last 25 years. Historically, play therapists have demonstrated a keen interest in studying the effects and process of play therapy, a tradition handed down from the earliest practitioners. Across presenting issues that have been studied, play therapy consistently demonstrates positive effects with few exceptions.

It is true that play therapy has not been recognized as an evidence-based practice for PTSD. It is further true that there are no play therapy studies that qualified participants based on a PTSD diagnosis. One might be curious as to why this is the case. I believe there are several reasons. PTSD is a narrow term, diagnosed within a narrow band of descriptive symptoms. Children may begin to show symptoms immediately following traumatic events or may have a delayed response, especially in cases of complex trauma. Symptoms may meet the threshold of the descriptors for PTSD or trauma may be manifested in a myriad of symptoms common among children in distress, such as inattention, hypervigilance, withdrawal, and aggression, among others. Often, symptoms of trauma are not clearly distinguishable from symptoms present in other diagnoses. Children are likely to respond to trauma events with multiple behavioral and emotional reactions, presenting with co-morbid issues. Restricting participation in a research study to children who present with a confined PTSD diagnosis results in turning away children who demonstrate trauma symptoms that present in ways common for children, thereby limiting the generalizability of treatment outcomes to only the limited number of children who are diagnosed with PTSD.

Play therapists have concentrated on the developmental, preventative model of working with children by focusing their research and practice on interventions designed to prevent expected negative outcomes or further deterioration of functionality. Play therapists recognize that children have most likely adopted a survival reaction necessary to endure through a traumatic event or ongoing trauma events. Borrowing from the adverse childhood experiences context, play therapists are more likely to ask, "What has happened to this child?" rather than "What's wrong with this child?" Play therapists target the goals of therapy to allow the full expression of children who are having normal reactions to abnormal experiences.

As a result, play therapy researchers have focused on assessing the impact of play therapy with children who exhibit problematic behaviors or have experienced traumatic events. In research specifically on trauma, play therapy has shown positive outcomes for children who have experienced domestic violence, refugee experiences, sexual abuse, and natural disasters. In all of these studies, researchers noted that play therapy allowed children to work through their own unique reactions and perceptions to the traumatic experiences through an empathic therapeutic relationship with a skilled play therapist and the ability to express themselves through their developmental language of play. Play therapy research clearly and consistently demonstrates the effectiveness of play therapy for children who have experienced trauma.

Therapy Essential Reads

How Sliding Scale Fees Work in Therapy

The Trouble With a Sliding Scale for Therapy

In addition to the research supporting the use the play therapy with children of trauma, substantial theoretical and anecdotal rationale exists among the fields of neuroscience, trauma, child development, education, and psychology. While van der Kolk (2014) provides evidence for the limitations of cognitive-behavioral therapy for trauma, Malchiodi (2020) presents a cogent justification and description for the use of expressive arts therapies for children of trauma. These are just two primary examples of the many works available to understand the theoretical intentionality that matches play therapy to trauma (see APT statement).

I'll end by coming back to the beginning of this statement. The play therapy community was unsettled by misinformation related to the use of play therapy mostly because practitioners work with children every day who have experienced significant and life-changing trauma. Play therapists witness how children are provided with developmentally inappropriate interventions or no intervention at all. They see that play therapy works and the depth at which it works when a child feels heard, understood, and cared for in a developmentally responsive relationship. So, yes, play therapists want the record set straight.

Note: Dee C. Ray, PhD., LPC-S, NCC, RPT-S, is an Elaine Millikan Mathes Professor in Early Childhood Education and Director of the Center for Play Therapy at the University of North Texas.