Guided Interaction
in Play Therapy
Ken Schwartzenberger, LCSW, RPT-S
Guided Interaction with children and parents in play therapy is a synthesis of the evidence based Parent-Child Interaction Therapy (Eyberg, 1972), Interaction Guidance (McDonough, 1992, Beebe, 2000) and Filial Therapy (Guerney, 1971) theoretical models. It is an interactive and developmentally based method of guiding caregivers and children in the play therapy process. Guided interaction methods include caregivers directly in the interactive play therapy process, focusing on the regulation of parent-child interactions and teaching essential nurturing and protective parenting skills. Parents are guided in dyadic interactions that support their children in developing effective emotional and behavioral self-regulation skills.
Parent-Child Interaction Therapy was designed to help parents build warm and responsive relationships with their children and manage their behavior more effectively. It is based on the theory that improving parent-child interactions will result in improvement in both child and family functioning (Eyberg & Robinson, 1982, Foote, Eyberg & Schuhmann, 1998). Research has demonstrated the effectiveness of parent-child interaction therapy for reducing child behavior problems and changing the interactional style of parents in play situations with the child (Eyberg & Robinson, 1982, Foote, Eyberg & Schuhmann, 1998). Studies have documented significant increases in child compliance and decreases in disruptive behaviors, which have been shown to generalize to interactions with other children in the family and to the child's behavior at school (Eyberg & Robinson, 1982).
Interaction Guidance (McDonough, 1992, Beebe, 2000) was created specifically to work with infants and mothers for assessment and parenting skills instruction in interactive sessions. The treatment approach focuses on the infant-caregiver relationship rather than either the infant or the caregiver. Mother-child interactions in play are observed and videotaped. The therapist reviews select scenes from the video with the child’s mother and focuses on her parenting strengths. Mothers are guided in learning to interact in attunement with the child’s emotions and behavior. Research evidences the effectiveness of this treatment method in treating infants with growth failure, pediatric disorders – sleeping, feeding, elimination, excessive crying, and substance exposed and genetic disorders (McDonough & Boukydis, 1993, 1995).
Filial Therapy (Guerney, 1971) was developed to strengthen child-parent relationships through play. Through a sequence of instructional sessions, parents are taught to recognize and reflect emotions through empathic listening and to engage in imaginary child-centered play. Parents are provided information about child development and supervised in child-centered play with their children (Van Fleet, 1994). Research supports the effectiveness of this educational and skill development model in shifting parent’s perceptions of the child’s behaviors and enhancing the child-parent relationship.
Guided Interaction with children and parents in play therapy integrates the methods and techniques of Developmental Play Therapy (Brody, 1993), Experiential Play Therapy (Norton & Norton, 1997), and Child-Centered Play Therapy (Axline, 1969, Landreth, 1991). With play interactions as the focus of intervention, the therapist forms therapeutic relationships, engages parents and caregivers directly in therapeutic play sessions, provides didactic parenting instruction, reinforces interactions of nurturing and protective parenting, and transitions the play therapy process to the parents.
Developmental Play Therapy is based on attachment theory (Bowlby, 1988) and draws from the theoretical models of Theraplay (Jernberg, 1979, DeLauriers, 1962)) and Touch Therapy (Field, 2003) in child-parent therapy. The theoretical premise is that children who experience rich sensory experiences, nurturing physical affection and caring touch in the child-parent relationship will develop a core sense of self and move toward healthy physical and social-emotional development (Brody, 1993). Developmental play provides children with critical developmental experiences essential in child-parent attachment. Research evidences the efficacy of the use of caring touch and safe and respectful physical affection with children.
Experiential Play Therapy extends the principles of the theoretical models of Relationship Play Therapy (Moustakas, 1959) and Child-Centered Play Therapy (Axline, 1969, Landreth, 1991). Experiential play therapy is reaching children through interactive play and relating to children with depth on an experiential level. Entering a child’s play and interacting on an experiential level allows for immediate access to the child’s emotional pain and facilitates movement into earlier stages of development. Playing with the child defines and strengthens the therapeutic relationship. The living relationship between the child and the therapist is the key and essential dimension in the child’s therapeutic process (Moustakas, 1959).
There are four phases in guided interaction with children and parents in play therapy. These include integrating parents and caregivers in play sessions, guiding parents and caregivers in play sessions, consulting with parents and caregivers, and transitioning interactive play and the play therapy process to the parents and caregivers.
Integrating Parents and Caregivers in Play Sessions
In forming therapeutic alliances and connecting with parents and caregivers, the initial focus must be upon active listening, accepting, and validating parent’s styles and perspectives of the child. In listening to the parent the therapist gains important information regarding the parent’s perception of the child, the parents’ sets of responses to the child’s behaviors, and existing interaction patterns in the child-parent relationship. Communicating respect for the parent’s cultural identity and ways of relating to the child is essential in developing honest and authentic relationships. Treatment planning that includes parents and caregivers in determining treatment needs and goals for change is empowering and communicates value and respect for the parents. Studies show that including parents in the treatment planning and the play therapy process sustains progress and increases successful outcomes in therapy for the child (LeBlanc & Ritche, 1999).
The therapist begins by conducting individual play sessions with the child through the initial stages of the play therapy process. The decision to introduce the parents into the play session is made with careful consideration of the parents’ motivation and capability to participate in the play interactions. Parent’s perceptions and images of a care giving relationship are shaped from their own early child-parent nurturing experiences and childhood traumas. These experiences affect interaction styles and parenting capabilities and influence the parent’s perceptions and expectations of the child. The therapist must carefully assess the select time in the play therapy process to integrate the parents as the play themes and play action may be difficult for the parents to understand and accept. The child’s play action and the metaphorical themes in the play may elicit reactions and responses from the parents that may result in projections of feelings of past disturbing relationships with their parents onto their child (Davies, 1999).
Parents and caregivers are prepared for playfully interacting with the child prior to entering the play session. Parents may find it awkward and difficult to play with their child and not understand the importance of play in the child’s therapy. The parents are initially invited to join the therapist in select parts of the play sessions with the child. The therapist models entering the child’s play and engaging the child through the use of statements and reflections of the action sequences.
Guiding Parents and Caregivers in Play Sessions
Parents are guided in safe and empowering child-parent interaction experiences in therapeutic play with their children. Therapists coach parents in using new skills as parents play with their children in a therapeutic context. Elements of learning theory are integrated with play therapy with emphasis on restructuring parent-child interaction patterns. Through the use of coaching in the live session and, at times, with the use of an audio listening device from behind a one-way mirror the therapist provides directives and prompts for the parents. Interactive play sessions with the child and the parent may also be videotaped and reviewed in parent consultations.
In attunement with the child’s lead, rhythm and pace, parents are prompted in reflecting play action and emotions, active listening, and therapeutic limit setting. The therapist may interact with the toys rather than directly with the child, as reflecting through the toys allows the child the safety of distance and anonymity in the interactions with the therapist and the parent in the play (Norton & Norton, 1997). Play therapy techniques including reflective listening, the use of developmentally sensitive verbal responses, therapeutic limit setting and redirection are introduced in child-centered play. The therapist introduces experiential-developmental play techniques and models a repertoire of caring touch and nurturing physical affection play activities for the parents and caregivers to use in interactions with the child.
The therapist works with the parents to attain interaction regulation in the child-parent dyad. The therapist makes suggestions, sensitive to the parents’ strengths and vulnerabilities, to adjust and modify interactions that disrupt or disturb the child’s play action and focus of the imaginative play. This may include suggesting that the parents reflect the child’s play and verbalizations, pause and wait, use therapeutic limit setting and redirection, voice the toys, allow the child to lead and pace the play, increase physical affection, use statements rather than questions, and decrease power interactions in the play. Parents have the unique opportunity to practice these skills with their children in interactive play sessions and are encouraged to spend special playtime with their child at home. The therapist gradually reduces active guidance in the session as the parents increasingly take the initiative in the play therapy process.
With the therapist as the guide in imaginative play, the parents assist the child in mastering emotional issues, resolving trauma, completing open stages of development, and repairing disrupted attachment in the child-parent relationship. There is increased emotional attunement as parent-child interactions are regulated through the play. Consistent with family systems theory, adaptations or changes in either the child or the caregiver can change the relationship and directly influence the course of development (Wachtel & Wachtel, 1986).
Consulting with Parents and Caregivers
Consultations with parents and caregivers are scheduled frequently for discussion and review of the guided interaction experience. Parents are invited to share their perspectives and reactions to participating in the play sessions. Therapists acknowledge and validate the parents’ efforts and strengths in order to reinforce positive parenting interactions in the play sessions. Emphasizing observed strengths and crediting parents for positive changes and outcomes for the child in play therapy empowers the parents and reinforces positive shifts made in parenting sets and perceptions of the child.
Together with the therapist, parents view select videotape (8-10 min.) of the sessions as the therapist translates the action sequences into words and validates the parents’ efforts with their child in the session. This form of video intervention and microanalysis is rich in examples of child-parent interactions. Through review of the videotape, child-parent interaction patterns are identified and strengthened in an effort to enhance the parent’s ability to deepen and expand the child’s play action. The therapist provides clinical translation of specific details of the child-parent interaction patterns, metaphorical representations of the play themes, and key moments in the play sessions. Review and discussion of play sessions reinforces positive shifts in interaction patterns and allows parents to recognize interactions and projections onto the child that may stem from childhood interactive memories in their own child-parent relationships.
Edited copies of videotape of guided interaction in play can be shared with parents and caregivers who may have resisted or may have not been available to participate in the treatment process with the child. Sharing videotape of this experience with other family members to view and hear what is said and done by the parents and the therapist in the play session can motivate them to participate in the play therapy process. It can provide a source of validation for the parents in their attempt to restructure and shift perceptions and interactions with their child. As change may take time, retrospective viewing of videotape illustrating progress over time can encourage parents to continue treatment.
Transitioning Play to Parents and Caregivers
In the transition phase the therapist provides support and supervision as the parents take the initiative in conducting play sessions with the child. Follow-up consultations are scheduled with parents and caregivers to provide support in parental self-efficacy and assess the success of the treatment process. A fundamental goal of parent training and family intervention programs is for parents to become more independent, resourceful, and self-directed in their parenting. The goals of guided interaction in play therapy include assisting the child and the parents in attaining interaction regulation that restructures, restores and strengthens the child-parent relationship, facilitates the healing process for the child, enhances parenting skills, and prepares the parents and caregivers to continue the therapeutic process with the child. The transition of the child’s therapeutic care to the parents and caregivers completes the play therapy treatment process.
Summary
Mental health professionals are in need of effective play therapy methods and interventions in working with parents and caregivers including biological parents, grandparents, foster parents, legal guardians and adoptive parents. Guiding parents in developmental-experiential play methods immediately addresses the developmental and therapeutic needs of children that have experienced neglect and abuse trauma.
Parents and caregivers participating in play sessions and family play sessions in select stages of the play therapy process and provided with guided interaction in developmental-experiential play and playful parenting, enhance attachments in the child-parent relationship and ensure nurturing and protective care for the child (Schaefer & Carey, 1994, Whitaker, 1998, Brody, 1993, Cohen, 2001, Guerney, et. al. 1999). Play therapy and child counseling research evidences that the parent’s participation positively affects successful outcomes in the therapeutic process (Guerney & Stover, 1971, LeBlanc & Ritchie, 1999, Strouther & Jacobs, 1986). The parent’s involvement enhances the therapeutic alliance with the child and accelerates the treatment process.
REFERENCES
Axline, Virginia M. (1969). Play therapy. NY: Ballantine Books.
Beebe, B. (2000). Brief mother-infant treatment using psychoanalytically informed video
microanalysis: integrating procedural and declarative processing. N.Y. Psychiatric
Institute.
Bowlby, J. (1969). Attachment and loss: Vol. 1 Attachment. NY: Basic Books.
Brody, Viola (1997). The dialogue of touch. New Jersey: Jason Aronson, Inc.
Cohen, L.J. (2001). Playful parenting. NY: Ballantine Books.
Davies, D. (1999). Child development – a practitioner’s guide. NY: Guilford Press, Inc.
DeLauriers, A. (1962). The experience of reality in childhood schizophrenia. CT: Int. Univ.’s Press.
Eyberg, S.M. & Robinson, E.A. (1982). Parent-child interaction training: Effects on
family functioning. Journal of Clinical Child Psychology, 11, (pp. 130-137).
Field, T. (2003). Touch. MIT Press.
Foote, R., Eyeberg, S.M., & Schuhmann, E. (1998). Parent-child interaction approaches
to the treatment of child behavior disorders. In T.H. Ollendick & R.J. Prinz (Eds.)
Advances in Clinical Psychology, 20, NY: Plenum Press.
Guerney, B., Guerney, L. & Andronico, M (1999). Filial therapy. In Schaefer, C. (Ed)
The therapeutic use of child’s play (pp. 553-566). NJ: Jason Aronson.
Guerney, B., & Stover, L. (1971). Filial therapy. PA: Penn. State University.
Jernberg, A. (1979). Theraplay. San Francisco: Jossey-Bass.
Landreth, Garry L. (1991). Play therapy: The art of the relationship. Muncie, IN: Accelerated Development Inc. Pub.
LeBlanc, M., & Riche, M. (1999). Predictions of play therapy outcomes. International Journal of play therapy. Fresno, CA.
McDonough, S. (1993). Interaction guidance. In C. Zeanah (Ed), Handbook of Infant Mental Health. NY: Guilford, 414-426.
McDonough, S.C., & Boukydis, C.Z. (1992). Family assessment of substance exposed infants and the caregivers. Report to Governor’s Commission on Child Mental Health. Providence, RI: Department of Children, Youth and Families.
Moustakas, C.E. (1952). Psychotherapy with children: The living relationship. NY: Harper & Row Pub.
Norton, C., & Norton, B. (1997). Reaching children through play therapy: An experiential approach. Denver, CO: Pub. Cooperative.
Sameroff, A.J., McDonough, S.C., Rosenblum, K.L. (2003). Treating parent-infant relationship problems: Strategies for interventions. NY: Guilford Press.
Schaefer, C.E. & Carey, L.J. (1994). Family play therapy. NJ: Aronson.
Strouther, J., & Jacobs, E. (1986). “Parent consultation: a practical approach.” School Counselor, 33, 292-296.
Van Fleet, R. (1994). Filial therapy: Strengthening parent-child relationship through play. Sarasota, FL: Prof. Resource Press.
Wachtel, E.F., & Wachtel, P.L. (1986). Family dynamics in individual psychotherapy: A guide to clinical strategies. NY: Guilford Press.
Whitaker, C.A., & Bummery, W.M. (1988). Dancing with the family: A symbolic-experiential approach. NY: Brunner/Mazel, Inc.