Play therapy

Play therapy is a method of meeting and responding to the mental health needs of children and is extensively acknowledged by experts as an effective and suitable intervention in dealing with children’s brain development. It is generally employed with children aged 3 years through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As child experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves.

Play therapy
Children playing during a session with a psychologist
ICD-9-CM93.81, 94.36
MeSHD010989

Play as therapy

According to Jean Piaget, "play provides the child with the live, dynamic, individual language indispensable for the expression of [the child’s] subjective feelings for which collective language alone is inadequate."[1] Play helps a child develop mastery over his innate abilities resulting to a sense of worth and aptitude. During play, children are driven to meet the essential need of exploring and mastering their environment. Play also contributes in the advancement of creative thinking. Play likewise provides a way for children to release strong sentiments making them feel relieved. During play, children play out undesirable life experiences by breaking them down into smaller parts, discharging emotional states or frames of mind that go with each part, integrating every experience back into the understanding they have of themselves and gaining a higher level and a greater degree of mastery.[2]

General

Play therapy is a form of counseling or psychotherapy that uses play to communicate with and help people, especially children, to prevent or resolve psychosocial challenges. This is thought to help them towards better social integration, growth and development, decreased aggression,[3] emotional modulation, social skill development,[4] empathy,[5] and trauma resolution. Play therapy also develops self-efficacy[6] and coping skills[7]

Play therapy can also be used as a tool for diagnosis. A play therapist observes a client playing with toys (play-houses, pets, dolls, etc.) to determine the cause of the disturbed behavior. The objects and patterns of play, as well as the willingness to interact with the therapist, can be used to understand the underlying rationale for behavior both inside and outside of therapy session. Caution, however, should be taken when using play therapy for assessment and/or diagnostic purposes.[8]

According to the psychodynamic view, people (especially children) will engage in play behavior in order to work through their interior obfuscations and anxieties. According to this particular viewpoint, play therapy can be used as a self-help mechanism, as long as children are allowed time for "free play" or "unstructured play." However, some forms of therapy depart from non-directiveness in fantasy play, and introduce varying amounts of direction, during the therapy session.

An example of a more directive approach to play therapy, for example, can entail the use of a type of desensitization or relearning therapy, to change troubling behaviors, either systematically or through a less structured approach. The hope is that through the language of symbolic play, such desensitization will likely take place, as a natural part of the therapeutic experience, and lead to positive treatment outcomes.

History

Play has been recognized as important since the time of Plato (429–347 B.C.) who reportedly observed, "you can discover more about a person in an hour of play than in a year of conversation" [This quote may be erroneously attributed to Plato, see https://quoteinvestigator.com/2015/07/30/hour-play/].[9] In the eighteenth century, Rousseau (1712–1778), in his book Emile, wrote about the importance of observing play as a vehicle to learn about and understand children.[10] Friedrich Fröbel, in his book The Education of Man (1903), emphasized the importance of symbolism in play. He observed, "play is the highest development in childhood, for it alone is the free expression of what is in the child's soul...children's play is not mere sport. It is full of meaning and import."[11] The first documented case, describing the therapeutic use of play, was in 1909 when Sigmund Freud published his work with "Little Hans". Little Hans was a five-year-old child who was suffering from a simple phobia. Freud saw him once briefly and recommended that his father take note of Hans' play to provide insights that might assist the child. The case of "Little Hans" was the first case in which a child's difficulty was related to emotional factors.[12][13]

Hermine Hug-Hellmuth formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyze the child.[14] In 1919, Melanie Klein (1955) began to implement the technique of using play as a means of analyzing children under the age of six. She believed that child's play was essentially the same as free association used with adults, and that as such, it was provide access to the child's unconscious. Anna Freud (1946, 1965) utilized play as a means to facilitate positive attachment to the therapist and gain access to the child's inner life.

In the 1930s David Levy developed a technique he called release therapy.[15] His technique emphasized a structured approach. A child, who had experienced a specific stressful situation, would be allowed to engage in free play. Subsequently, the therapist would introduce play materials related to the stress-evoking situation allowing the child to reenact the traumatic event and release the associated emotions.

In 1955, Gove Hambidge expanded on Levy's work emphasizing a "structured play therapy" model, which was more direct in introducing situations. The format of the approach was to establish rapport, recreate the stress-evoking situation, play out the situation and then free play to recover.

Jesse Taft (1933) and Frederick Allen (1934) developed an approach they entitled relationship therapy.[16] The primary emphasis is placed on the emotional relationship between the therapist and the child. The focus is placed on the child's freedom and strength to choose.

Carl Rogers (1942) expanded the work of the relationship therapist and developed non-directive therapy, later called client-centered therapy.[17] Virginia Axline (1950) expanded on her mentor's concepts. In her article entitled 'Entering the child's world via play experiences', Axline summarized her concept of play therapy, stating, "A play experience is therapeutic because it provides a secure relationship between the child and the adult, so that the child has the freedom and room to state himself in his own terms, exactly as he is at that moment in his own way and in his own time" (Progressive Education, 27, p. 68). Axline also wrote Dibs in Search of Self, which describes a series of play therapy sessions over a period of a year.

In 1953 Clark Moustakas wrote his first book, Children in Play Therapy. In 1956 he compiled Publication of The Self, the result of the dialogues between Moustakas, Abraham Maslow, Carl Rogers, and others, forging the humanistic psychology movement.

Filial therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy during the 1960s. The filial approach emphasizes a structured training program for parents in which they learn how to employ child-centered play sessions in the home. In the 1960s, with the advent of school counselors, school-based play therapy began a major shift from the private sector. Counselor-educators such as Alexander (1964); Landreth;[18][19] Muro (1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute significantly, especially in terms of using play therapy as both an educational and preventive tool in dealing with children’s issues.

1973 Moustakas continued his journey into play therapy and published his novel The child's discovery of himself. Moustakas' work as being concerned with the kind of relationship needed to make therapy a growth experience. His stages start with the child's feelings being generally negative and as they are expressed, they become less intense, the end results tend to be the emergence of more positive feelings and more balanced relationships.

Models
An individual engaging in sandplay therapy.
Equipment used for sandplay therapy.
An example of spontaneous adult psychotherapic sand play.

Play therapy can be divided into two basic types: non-directive and directive. Non-directive play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy.[20] Both types of play therapy have received at least some empirical support.[21] On average, play therapy treatment groups, when compared to control groups, improve by .8 standard deviations.[21]

Nondirective play therapy

Non-directive play therapy, also called client-centred and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. In other words, non-directive play therapy is regarded as non-intrusive.[22] The hallmark of non-directive play therapy is that it has few boundary conditions and thus can be used at any age.[23] This therapy originates from Carl Rogers' non-directive psychotherapy and in his characterisation of the optimal therapeutic conditions. Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is widely considered the founder of this therapy.[24] Different techniques have since been established that fall under the realm of non-directive play therapy, including traditional sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms is covered briefly below.

Play therapy using a tray of sand and miniature figures is attributed to Margaret Lowenfeld, who established her "World Technique" in 1929. Dora Kalff combined Lowenfeld's World Technique with Jung's idea of the collective unconscious and received Lowenfeld's permission to name her version of the work "sandplay" (Kalff, 1980).Kalff, Dora M. (1980). Sandplay. Boston, MA: Beacon. As in traditional non-directive play therapy, research has shown that allowing an individual to freely play with the sand and accompanying objects in the contained space of the sandtray (22.5" x 28.5") can facilitate a healing process as the unconscious expresses itself in the sand and influences the sand player. When a client creates in the sandtray, little instruction is provided and the therapist offers little or no talk during the process. This protocol emphasises the importance of holding what Kalff (1980) referred to as the "free and protected space" to allow the unconscious to express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may not choose to talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may offer supportive response that does not include interpretation. The rationale is that the therapist trusts and respects the process by allowing the images in the tray to exert their influence without interference.[25]

Sand tray therapy can be used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also when a family works together on a sandtray, the therapist may make several observations, such as unhealthy alliances, who works with whom, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships.[26]

Using toys in non-directive play therapy with children is another common method therapists employ. This method was derived from the creative toys used in Freud's theoretical orientations.[27] The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalisation of their feelings. Through these actions, then, children may be able to experience catharsis, gain more or better insight into their consciousness, thoughts, and emotions, and test their own reality.[28] Popular toys used during therapy are animals, dolls, hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to encourage dramatic play or creative associations, both of which are important in expression.[27]

Efficacy

Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years.[29] Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as cognitive behavioral therapy.[20] They also argue that therapists focus more on the institution of play rather than the empirical literature when conducting therapy [30] Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies included small sample sizes, which limits the generalisability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment.[31][32] Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.[30]

Research is lacking on the overall effectiveness of using toys in non-directive play therapy. Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during non-directive play therapy were not more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checker game.[27] There is also ongoing controversy in choosing toys for use in non-directive play therapy, with choices being largely made through intuition rather than through research.[28] However, other research shows that following specific criteria when choosing toys in non-directive play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and lead to play that can be easily interpreted by a therapist.[28]

Several meta analyses have shown promising results toward the efficacy of non-directive play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for non-directive play therapy.[22] This finding is comparable to the effect size of 0.71 found for psychotherapy used with children,[33] indicating that both non-directive play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups.[20] These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71,[33] 0.71,[34] and 0.66.[22] Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with non-directive play therapy.[21] Results from all meta-analyses indicate that non-directive play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.[20][21]

There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes.[20] Although positive effects can be seen with the average 16 sessions,[24] there is a peak effect when a child can complete 35-40 sessions.[22] An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment [21] Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child.[35] Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behaviour problems.[36] Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.[20][21]

Directive play therapy

Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself.[37] Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities.[38] This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy.[37]

Directed sandtray therapy is more commonly used with trauma victims and involves the "talk" therapy to a much greater extent. Because trauma is often debilitating, directed sandplay therapy works to create change in the present, without the lengthy healing process often required in traditional sandplay therapy.[39] This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives.[39]

Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate.[31] Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of Beck's cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy.[40] In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children's verbalizations in these interactions but rather on their actions and their play.[38] Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists in order to change children's maladaptive thinking.

Efficacy

The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have.[20] Similarly in 2005 meta analysis by authors Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while nondirective play therapy had an effect size of 0.92.[21] Although the effect sizes of directive therapy are statistically significantly lower than those of nondirective play therapy, they are still comparable to the effect sizes for psychotherapy used with children, demonstrated by Casey,[33] Weisz,[34] and LeBlanc.[22] A potential reason for the difference in the effect size may be due to the amount of studies that have been done on nondirective vs. directive play therapy. Approximately 73 studies in each meta analysis examined nondirective play therapy, while there were only 12 studies that looked at directive play therapy. Once more research is done on directive play therapy, there is potential that effect sizes between nondirective and directive play therapy will be more comparable.[20][21]

Electronic Games

The prevalence and popularity of video games in recent years has created a wealth of psychological studies centered around them. While the bulk of those studies have covered video game violence and addiction, some mental health practitioners are becoming interested in including such games as therapeutic tools. Since the introduction of electronic media into popular culture, the nature of games has become "increasingly complex, diverse, realistic, and social in nature."[41] The commonalities between electronic and traditional play (such as providing a safe space to work through strong emotions) infer similar benefits. Video games have been broken into two categories: "serious" games, or games developed specifically for health or learning reasons, and "off-the-shelf" games, or games without a clinical focus that may be re-purposed for a clinical setting.[42] Use of electronic games by clinicians is a new practice, and unknown risks as well as benefits may arise as the practice becomes more mainstream.[43]

Most of the current research relating to electronic games in therapeutic settings are focused on alleviating the symptoms of depression, primarily in teens and adolescents. However, some games have been developed specifically for children with anxiety[44] and Attention Deficit Hyperactivity Disorder (ADHD),[45] The same company behind the latter intends to create electronic treatments for children on the autism spectrum, and those living with Major Depressive Disorder, among other disorders.[46] The favored approach for mental health treatment at this time is through cognitive behavioral therapy (CBT).[47] While this method is effective, it is not without its limits: for example, boredom with the material, patients forgetting or not practicing techniques outside of a session, or the accessibility of care.[48] It is these areas that therapists hope to address through the use of electronic games. Preliminary research has been done with small groups, and the conclusions drawn warrant studying the issue in greater depth.[49]

Role-playing games (RPGs) are the most common type of electronic game used as part of therapeutic interventions. These are games where players assume roles, and outcomes depend on the actions taken by the player in a virtual world.[50] Psychologists are able to gain insights into the elements of the capability of the patient to create or experiment with an alternate identity. There are also those who underscore the ease in the treatment process since playing an RPG as a treatment situation is often experienced as an invitation to play, which makes the process safe and without risk of exposure or embarrassment.[51] The most well-known and well-documented RPG-style game used in treatment is SPARX. Taking place in a fantasy world, SPARX users play through seven levels, each lasting about half an hour, and each level teaching a technique to overcome depressive thoughts and behaviors. Reviews of the study have found the game treatment comparable to CBT-only therapy[48][52] though one review noted that SPARX alone is not more effective than typical treatment.[53] There are also studies that found role-playing games, when combined with the Adlerian Play Therapy (AdPT) techniques, lead to increased psychosocial development.[54] ReachOutCentral is geared toward youth and teens, providing gamified information on the intersection of thoughts, feelings, and behavior. An edition developed specifically to aid clinicians, ReachOutPro, offers more tools to increase patients' engagement.[55]

Biofeedback (sometimes known as applied psychophysiological feedback) media is more suited to treating a range of anxiety disorders. Biofeedback tools are able to measure heart rate, skin moisture, blood flow, and brain activity to ascertain stress levels,[56] with a goal of teaching stress management and relaxation techniques. The development of electronic games utilizing this equipment is still in its infancy, and thus few games are on the market. As point of fact, The Journey to Wild Divine's developers have asserted that their products are a tool, not a game, though the three installments contain many game elements. Conversely, Freeze Framer's design is reminiscent of an Atari system. Three simplistic games are included in Freeze Framer's 2.0 model, using psychophysiological feedback as a controller.[57] The effectiveness of both pieces of software saw significant changes in participants' depression.[52] A biofeedback game initially designed to assist with anxiety symptoms, Relax to Win, was similarly found to have broader treatment applications.[58] Extended Attention Span Training (EAST), developed by NASA to gauge the attention of pilots, was remodeled as an ADHD aid. Brain waves of participants were monitored during play of commercial video games available on Playstation, and the difficulty of the games increased as participants' attention waned. The efficacy of this treatment is comparable to traditional ADHD intervention.[59]

Several online-only or mobile games (Re-Mission, Personal Investigator,[60] Treasure Hunt,[61] and Play Attention)[62] have been specifically noted for use in alleviating disorders other than those for anxiety and mood.[63] Re-Mission 2 especially targets children, the game having been designed with the knowledge that today's youth are immersed in digital media.[64] Mobile applications for anxiety, depression, relaxation, and other areas of mental health are readily available in the Android Play Store and the Apple App Store.[65] The proliferation of laptops, mobile phones, and tablets means one can access these apps at any time, in any place. Many of them are low-cost or even free, and the games do not need to be complex to be of benefit. Playing a three-minute game of Tetris has the potential to curb a number of cravings,[66] a longer play time could reduce flashback symptoms from Post-Traumatic Stress Disorder (PTSD),[67] and an initial study found that a visual-spatial game such as Tetris or Candy Crush, when played closely following a traumatic event, could be used as a "'therapeutic vaccine" to prevent future flashbacks.[68]

While the field of allowing electronic media a place in a therapist's office is new, the equipment isn't necessarily so. Most children are familiar with modern PCs, consoles, and handheld devices even if the practitioner is not. An even more recent addition to interacting with a game environment is virtual reality equipment, which both adolescent and clinician might need to learn to use properly. The umbrella term for the preliminary studies done with VR is Virtual Reality Exposure Therapy (VRET). This research is based on traditional exposure therapy and has been found to be more effective for participants than for those placed in a wait list control group,[63] though not as effective as in-person treatments. One study tracked two groups - one group receiving a typical, lengthier treatment while the other was treated via shorter VRET sessions - and found that the effectiveness for VRET patients was significantly less at the six-month mark.[58]

Efficacy

In the future, clinicians may look forward to using electronic media as a way to assess patients,[59] as a motivational tool,[69] and facilitate social in-person and virtual interactions.[70] Current data, though limited, points toward combining traditional therapy methods with electronic media for the most effective treatment.[43][49][71][72]

Parent/child play therapy

Several approaches to play therapy have been developed for parents to use in the home with their own children.[73]

Training in nondirective play for parents has been shown to significantly reduce mental health problems in at-risk preschool children.[74] One of the first parent/child play therapy approaches developed was Filial Therapy (in the 1960s - see History section above), in which parents are trained to facilitate nondirective play therapy sessions with their own children. Filial therapy has been shown to help children work through trauma and also resolve behavior problems.[75]

Another approach to play therapy that involves parents is Theraplay, which was developed in the 1970s. At first, trained therapists worked with children, but Theraplay later evolved into an approach in which parents are trained to play with their children in specific ways at home. Theraplay is based on the idea that parents can improve their children’s behavior and also help them overcome emotional problems by engaging their children in forms of play that replicate the playful, attuned, and empathic interactions of a parent with an infant. Studies have shown that Theraplay is effective in changing children’s behavior, especially for children suffering from attachment disorders.[76]

In the 1980s, Stanley Greenspan developed Floortime, a comprehensive, play-based approach for parents and therapists to use with autistic children.[77] There is evidence for the success of this program with children suffering from autistic spectrum disorders.[78][79]

Lawrence J. Cohen has created an approach called Playful Parenting, in which he encourages parents to play with their children to help resolve emotional and behavioral issues. Parents are encouraged to connect playfully with their children through silliness, laughter, and roughhousing.[80]

In 2006, Garry Landreth and Sue Bratton developed a highly researched and structured way of teaching parents to engage in therapeutic play with their children. It is based on a supervised entry level training in child centred play therapy. They named it Child Parent Relationship Therapy.[81] These 10 sessions focus on parenting issues in a group environment and utilises video and audio recordings to help the parents receive feedback on their 30-minute 'special play times' with their children.

More recently, Aletha Solter has developed a comprehensive approach for parents called Attachment Play, which describes evidence-based forms of play therapy, including non-directive play, more directive symbolic play, contingency play, and several laughter-producing activities. Parents are encouraged to use these playful activities to strengthen their connection with their children, resolve discipline issues, and also help the children work through traumatic experiences such as hospitalisation or parental divorce.[82]

See also

References
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Further reading
  • Andronico, M. (1996). Filial therapy: A group for parents of children with emotional problem. In M. Rosenbaum (Ed.), Handbook of short-term therapy groups (pp. 3–21). New Jersey: Jason Aronson.
  • Abidin, Richard R. (2002). Parenting Stress Index. Psychological Assessment Resources, Inc.
  • American Psychological Association. (1982). Report of the Task Force on the Evaluation of Education, Training, and Service in Psychology (Washington, DC: American Psychological Association).
  • Alexander, E (1964). "School centered play-therapy program". Personnel and Guidance Journal. 43 (3): 256–261. doi:10.1002/j.2164-4918.1964.tb02671.x.
  • Allen, F (1934). "Therapeutic work with children". American Journal of Orthopsychiatry. 4 (2): 193–202. doi:10.1111/j.1939-0025.1934.tb06284.x.
  • Axline, V. (1947). Nondirective therapy for poor readers" Journal of Consulting Psychology 11, 61-69 .
  • Axline, V (1950). "Entering the child's world via play experiences". Progressive Education. 27: 68–75.
  • Axline, V. (1969, revised ed.). Play Therapy. New York: Ballantine Books.
  • Berger, S. N.; Tyler, J. L. (1994). "The color-emotive brain: Gone a long journey". International Journal of Play Therapy. 3 (1): 57–70. doi:10.1037/h0089057.
  • Barnett, L (1984). "Research note: Young children's resolution of distress through play". Journal of Child Psychology and Psychiatry. 25 (3): 477–483. doi:10.1111/j.1469-7610.1984.tb00165.x. PMID 6746795.
  • Barrett, C. Hampe, T.E. & Miller, L. (1978). Research on child psychotherapy. In Garfield, S. & Bergin, A. (Eds.). Handbook of Psychotherapy and Behavior Change. New York: Wiley.
  • Bornsterin, M. H.; Tamis-LeMonda, C. S. (1995). "Parent- child symbolic play: Three theories in search of an effect". Developmental Review. 15 (4): 382–400. doi:10.1006/drev.1995.1015.
  • Bracken, Bruce A., and Keith, Lori K. (2004) Clinical Assessment of Behavior: Parent Extended Rating Form. Psychological Assessment Resources, Inc.,
  • Burroughs, M.; Wagner, W.; Johnson, J.T. (1997). "Treatment with children of divorce: A comparison of two types of therapy". Journal of Divorce & Remarriage. 27 (3–4): 83–99. doi:10.1300/j087v27n03_06.
  • Cangelosi, D. M. (1997). Play therapy for children from divorced and separated families. In H. G. Kaduson, D. Cangelosi, & C. Schaefer (Eds.), The playing cure: Individualized play therapy for specific childhood problems (pp. 119–142). Northvale, NJ: Jason Aronson.
  • Crow, J (1990). "Play therapy with low achievers in reading (Doctoral dissertation, University of North Texas, 1989)". Dissertation Abstract International. 50: 2789.
  • DeGangi, G.; Wietlisbach, S.; Goodin, M.; Scheiner, N. (1993). "A comparison of structured sensorimotor therapy and child-centered activity in the treatment of preschool children with sensorimotor problems". The American Journal of Occupational Therapy. 47 (9): 777–786. doi:10.5014/ajot.47.9.777. PMID 7509573.
  • Dogra, A.; Veeraraghavan, V. (1994). "A study of psychological Intervention of children with aggressive conduct disorder". Indian Journal of Clinical Psychology. 21: 28–32.
  • Duff, S (1996). "A study of the effects of group family play on family relations". International Journal of Play Therapy. 5 (2): 81–93. doi:10.1037/h0089348.
  • Fall, M (1997). "From stages to categories: A study of children's play in play therapy sessions". International Journal of Play Therapy. 6 (1): 1–21. doi:10.1037/h0089411.
  • Freud, A. (1946). The psycho-analytic treatment of children. London: Imago.
  • Freud, A. (1965). The psych-analytical treatment of children. New York: International Universities Press.
  • Freud, S. (1909). The case of "Little Hans" and the "Rat Man." London: Hogarth Press.
  • Froebel (1903). The education of man. New York: D. Appleton.
  • Guerney, B., Guerney, L., & Andronico, M. (1976). The therapeutic use of children's play. New York: Jason Aronson.
  • Guldner, C.A.; O'Connor, T. (1991). "The ALF group: A model of group therapy with children". Journal of Group Psychotherapy, Psychodrama & Sociometry. 43: 4.
  • Hambridge, G (1955). "Structured play therapy". American Journal of Orthopsychiatry. 25 (3): 601–617. doi:10.1111/j.1939-0025.1955.tb00156.x. PMID 13238577.
  • Harris, Z. L.; Landreth, G. (1997). "Filial therapy with incarcerated mothers: A five week model". International Journal of Play Therapy. 6 (2): 53–73. doi:10.1037/h0089408.
  • Hug-Hellmuth, H (1921). "On the technique of child-analysis". International Journal of Psycho-Analysis. 2: 287–305.
  • Johnson, L.; McLeod, E. H.; Fall, M. (1997). "Play therapy with labeled children in the schools". Professional School Counseling. 1 (1): 31–34.
  • Jones, K. D.; Casado, M.; Robinson (2003). "Structured play therapy: A model for choosing topics and activities". International Journal of Play Therapy. 12 (1): 31–47. doi:10.1037/h0088870.
  • Kaduson, H.; Finnerty, K. (1995). "Self-control game intervention for Attention-Deficit Hyperactivity Disorder". International Journal of Play Therapy. 4 (2): 15–19. doi:10.1037/h0089359.
  • Kaduson, H. (1997). Play therapy for children with Attention-Deficit Hyperactivity Disorder. In H. G. Kaduson, D. Cangelosi, & C. Schaefer (Eds.), The playing cure: Individualized play therapy for specific childhood problems (pp. 197–227). Northvale, NJ: Jason Aronson.
  • Kaniuga, N (1990). "The development and use of a locus-of-control board game for 7- through 11-year-old children (Doctoral dissertation, Western Michigan University, 1990)". Dissertation Abstracts International. 51: 2625.
  • Kazdin, A. E. (1991). "Effectiveness of psychotherapy with children and adolescents". Journal of Consulting and Clinical Psychology. 59 (6): 785–798. doi:10.1037/0022-006x.59.6.785.
  • Kernberg, P.; Chazan, S. E.; Normandin, L. (1998). "The children's play therapy instrument (CPTI)". Journal of Psychotherapy and Research. 7 (3): 196–205.
  • Kendall-Tackett, K (1992). "Beyond anatomical dolls: Professionals' use of other play therapy techniques". Child Abuse & Neglect. 16 (1): 139–142. doi:10.1016/0145-2134(92)90014-i. PMID 1544025.
  • Kot, S.; Landreth, G.; Giordano, M. (1998). "Intensive child-centered play therapy with child witnesses of domestic violence". International Journal of Play Therapy. 7 (2): 17–36. doi:10.1037/h0089421.
  • Landreth, G.; Allen, L.; Jacquot, W. (1969). "A team approach to learning disabilities". Journal of Learning Disabilities. 2 (2): 82–87. doi:10.1177/002221946900200203.
  • Landreth, G. (1972). Why play therapy? Texas Personnel and Guidance Association Guidelines, 21, 1.
  • Landreth, G. (1991). Play therapy: The art of the relationship. Muncie, IN: Accelerated Development Press.
  • Landreth, G. L. (2002). Play therapy: The art of the relationship. (2nd ed.). New York: Brunner-Routledge.
  • Leblanc, M.; Ritchie, M. (2001). "A meta-analysis of play therapy outcomes". Counseling Psychology Quarterly. 14 (2): 149–163. doi:10.1080/09515070126334.
  • Lebo, D (1953). "The present status of research on nondirective play therapy". Journal of Consulting Psychology. 17 (3): 177–183. doi:10.1037/h0063570. PMID 13061658.
  • Lowenfield, M (1939). "The world pictures of children: A method of recording and studying them". British Journal of Medical Psychology. 18: 65–101. doi:10.1111/j.2044-8341.1939.tb00710.x.
  • Levy, D (1938). "Release therapy in young children". Psychiatry. 1 (3): 387–389. doi:10.1080/00332747.1938.11022205.
  • Milos, M.; Reiss, S. (1982). "Effects of three play conditions on separation anxiety in young children". Journal of Consulting and Clinical Psychology. 50 (3): 389–395. doi:10.1037/0022-006x.50.3.389.
  • Morrison, T.; Newcomer, B. (1975). "Effects of directive vs. nondirective play therapy with institutionalized mentally retarded children". American Journal of Mental Deficiency. 79 (6): 666–669. PMID 1146857.
  • Muro, J (1968). "Play media in counseling: A brief report of experiences and some opinions". Elementary School Guidance and Counseling. 3 (2): 104–110.
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  • Nelson, R (1966). "Elementary school counseling with unstructured play media". Personnel & Guidance Journal. 45 (1): 24–27. doi:10.1002/j.2164-4918.1966.tb03061.x.
  • Phillips, R.; Landreth, G. (1998). "Play therapists on play therapy (Part 2) Clinical issues in play therapy". International Journal of Play Therapy. 6 (2): 1–24. doi:10.1037/h0089416.
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  • Reade, S.; Hunter, H.; McMillan, I. R. (1999). "Just playing...is it time wasted?". British Journal of Occupational Therapy. 62 (4): 157–162. doi:10.1177/030802269906200405.
  • Reams, R.; Friedrich, W. (1994). "The efficacy of time-limited play therapy with maltreated preschoolers". Journal of Clinical Psychology. 50 (6): 889–899. doi:10.1002/1097-4679(199411)50:6<889::aid-jclp2270500613>3.0.co;2-b. PMID 7896925.
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  • Play Therapy by Virginia Axline (original print 1947). ISBN 0-345-30335-0. Houfton Mifflin Company.
  • Play Therapy: The Art of the Relationship by Garry Landreth (Second Edition 2002). ISBN 1-58391-327-0. Brunner-Routledge.
  • Play Therapy Theory and Practice: A Comparative Presentation by Kevin O'Connor & Lisa Braverman (1996). ISBN 0-471-10638-0. Wiley.books
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