Is Play Therapy Appropriate for Children With PTSD?

Source: Wikimedia Commons

Cognitive-behavioral therapy (CBT) has been proven effective for PTSD in very young children in several randomized clinical trials. CBT is the treatment that has been most studied and is the best evidence-based method to treat children with post-traumatic stress disorder (PTSD). CBT includes components of parent and child psychoeducation, teaching new skills to cope with distress, telling a trauma narrative, and putting all those together in systematic exposure therapy exercises. To accomplish all those tasks in 10 to 15 sessions, therapists must be directive.

There is an enormous amount of evidence that the superiority of evidence-based treatments (EBTs) over usual care in the community is widespread and consistent (Weisz et al., 2013). Despite this, few clients actually receive EBTs (Shafran et al., 2009). Instead, what very young children most often likely receive is play therapy.

Play therapy is a form of psychotherapy that primarily uses play to help children express their thoughts and feelings. Play therapy capitalizes on children’s strengths of knowing how to play and on therapists’ strengths of being compassionate, empathic, and listening. Play therapy may include creative visualization, role-playing, and sand play. Therapy rooms are stocked with toys, puppets, stuffed animals, masks, dolls, action figures, and arts and crafts. Play therapy is based on the assumption that while children play, they will feel safe to express negative feelings without fear of retaliation, whereupon therapists will find opportunities to make interpretive comments. Some forms of play therapy are non-directive so as to allow children to express themselves at their own pace.

Play therapy was justified 25 years ago before the advent of CBT. With the testing of CBT in young children and the evidence in multiple randomized clinical trials, it seems valid to ask when, if ever, play therapy is indicated these days for post-traumatic problems. In my view, there are six possible reasons for why play therapy would not be indicated for a child with PTSD:

1. Play therapy can be slow. In my review of Eliana Gil’s book Post-traumatic Play in Children (Scheeringa, 2018), I noted the ethical concern of letting children set their own pace in therapy. Gil reported spending long periods of time getting to know children before they spontaneously started their so-called post-traumatic play. Gil reported cases in which periods with no discussion of trauma experiences lasted three months, four months, five months, and six months. The total treatment length of one case lasted two years.

2. Play therapy may allow avoidance. Avoidance is one of the key symptoms of PTSD. Because play therapy may be non-directive, it is very possible that children will avoid remembering and verbalizing their trauma memories until forced to do so by therapists.

3. Play therapy is not well studied for PTSD.

(This section was modified 4/11/20 to add more details about the evidence-base after readers contacted the author to express disagreement). The website for the Association for Play Therapy claims that “Meta-analytic reviews of over 100 play therapy outcome studies (Bratton, Ray, Rhine, & Jones, 2005; LeBlanc & Ritchie, 2001; Lin & Bratton, 2015; Ray, Armstrong, Balkin, & Jayne, 2015) have found that the over-all treatment effect of play therapy ranges from moderate to high positive effects. Play therapy has proven equally effective across age, gender, and presenting problem” (APT website, accessed 4/4/20). It has not. There are no credible research trials of play therapy for PTSD.

There is only one randomized clinical trial (RCT) of play therapy published in peer-reviewed journals which measured PTSD as an outcome. Schottelkorb and colleagues (2012) recruited 31 refugee children, six-to-13 years-old, from three schools. They allocated 14 to child-centered play therapy and 17 to TF-CBT, and conducted the treatments in schools. By both child report and parent report there were no significant changes in PTSD scores for either group. When the researchers constrained the analyses to only the most severe cases who scored above a cutoff for “Full PTSD” both groups significantly improved by child and parent reports. The constrained analyses had only seven children in the CCPT group and eight in the TF-CBT group by child report, and five children in each group by parent report. The small sample size limits the confidence in the results. However, the main problem is that there was no report of what trauma events the children had experienced. The majority of the children experienced being in a combat region in their home country, but there were no details about those experiences and there were no details at all about the experiences of the minority. When conducting research on PTSD the basic methods must include verification of whether participants experienced life-threatening traumatic events. There are many different types of refugee experiences and not all of them include life-threatening experiences. Thus, it is possible that none of the children in the study had PTSD. The problem of false positive PTSD diagnoses when non-trauma stressful experiences are counted as traumas has been noted before (see my previous blog Stress Is Not Trauma from 6/7/2017).

Two other RCTs claimed to treat trauma reactions with play therapy. Reams, R., & Friedrich, W. (1994) conducted an RCT with maltreated preschoolers, and Tyndall-Lind and colleagues (2001) treated children who had witnessed domestic violence. Both studies failed to measure PTSD symptoms.

4. Parents are not always involved in play therapy. As I wrote in a previous blog, "The Dark Pool of Psychotherapy" (12/25/2018), it is a major problem that many therapists still take children back to their offices alone and never inform parents of what goes on in sessions. Parents need to be informed partners in psychotherapy, and they have a right to know what happens in treatment.

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5. Play therapy has been fertile ground for misinformation. Even the advocates of play therapy acknowledge that what they do is difficult to study. Because of this, it can be the Wild West of claims that go unchallenged. This allows unproven claims of eccentric concepts like toxic play, post-traumatic play, and stages of play to be tossed around as if they were facts.

6. Play therapists are not necessarily trained more broadly. For patients with difficult or uncommon problems, the best doctors are those who are trained broadly in different techniques. The psychotherapy industry, however, is infamous for therapists who cling to their favorite school of psychotherapy. If play therapists were trained in CBT for PTSD, they would be doing CBT.

Play therapy may be appropriate for children younger than 3 years and special cases of older children, but that has not been the recommendation of the Association for Play Therapy.

In addition, note that there are key differences between play therapy and using play during other types of therapy. Every therapist who conducts CBT with young children also uses play during sessions to facilitate the CBT techniques with communication and engagement. Using play does not make CBT into play therapy, and using spotty CBT techniques during play therapy does not make it CBT.

Play therapy has a useful place in the treatment of children, but play therapists can do better at both producing research evidence and articulating for consumers what the research evidence supports and does not support. In my opinion, the theory behind play therapy for PTSD is weak and unproven. There is no high-quality research evidence to suggest that play therapy is effective as a treatment for children with PTSD. There are many cases of play therapy lasting excessively long times while there are other, more rapid, proven techniques available. Non-directive play therapy for months or years may have been the community standard long ago, but with other methods proven effective over a much shorter duration, consumers deserve a clear justification for the use of play therapy.