International Journal of Play Therapy, (9)1, pp. 11-33 Copyright 2000, APT, Inc.
AN INTEGRATIVE APPROACH TO PLAY THERAPY WITH AN AUTISTIC GIRL
Maureen C. Kenny Florida International University
Charles B. Winick Florida International University
Abstract: Autistic children who are brought for psychological treatment are usually experiencing social and emotional difficulties common to autism. In addition, their parents may be in need of support. An integrative approach to treatment that utilizes the rapport building component of nondirective play therapy with directive techniques is presented. This approach targets maladaptive behavior and parent education. This case study describes a brief course of therapy in which an 11-year-old autistic female client experienced increases in social behavior and compliance at home and displayed a less irritable mood. The course of her therapy and specific interventions are examined.
Play therapy is often recognized as an effective approach for the psychotherapeutic treatment of children (Cohen, 1995; O’Connor & Schaefer, 1994). Play therapy has undergone many revisions, and many applications of play techniques today are used with a variety of children. It is used to treat children who are victims of abuse and neglect (Kot, Landreth, & Giordano, 1998; Mann & McDermott, 1983; VanFleet, Lilly, & Kaduson, 1999), children of divorced parents (Mendell, 1983), cross- gender identified children (Rekers, 1983), and those children described as aggressive/acting out (Allan & Levine, 1993; Willock, 1983). In addition, play therapy is utilized in the treatment of children with obsessive-compulsive disorder (Gold-Steinberg, & Logan, 1999), learning
Maureen C. Kenny, Ph.D., and Charles B. Winick, Psy.D., Florida International University, Fort Lauderdale, Florida.
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disabilities (Guerney, 1983b), anxiety (Kottman, 1998; Oaklander, 1993), physical impairments (Salomon, 1983), and developmental disabilities (Leland, 1983).
Unfortunately, little has been written on the use of such techniques with children suffering from pervasive developmental disorders, such as autism. In fact, a survey of play therapists conducted by Phillips and Landreth (1998) reported that fewer than 20% of the respondents believed that pervasive developmental disorders and problems associated with mental retardation would be amenable to play therapy. It may be that play therapists dismiss the use of play therapy with these children, believing that such children have cognitive or play deficits that would inhibit the therapy (Phillips & Landreth, 1998). This paper will demonstrate the use of an integrative play therapy approach with a mildly autistic girl.
Play is described as a child’s occupation and the toys as the child’s tools (Erikson, 1950). Play, according to Axline (1969), is the most natural medium for self-expression and is an excellent means for communicating between adults and children and among children. In addition to its developmental value, play is also deemed to be psychologically necessary (Landreth, 1991). Play allows children to express their inner world as a means to express and explore their emotionally significant experiences and to “act out” these experiences and feelings in a self-healing process (Landreth, 1991). Play therapy emerged out of the naturally occurring phenomenon of play as a treatment that utilizes children’s natural language and process for making sense of the world (Holmberg, Benedict, & Hynan, 1998).
Child-Centered Play Therapy In 1947, Virginia Axline pioneered nondirective play therapy,
now commonly referred to as child-centered play therapy. She fashioned her therapy after the nondirective, humanistic approach of Carl Rogers (Landreth, 1991). The goal of this type of play therapy is self-acceptance, where children will learn to be themselves and feel accepted through understanding, warmth, and a sense of security from the therapist. Axline (1969) outlined eight basic principles of her play therapy that are essential for the success of the treatment. One of these principles
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emphasizes empathy and building a relationship with the child, wherein the child sets the direction for the play. The child is responsible for the progress of the sessions; the therapist does not force progress (Axline, 1969). In the playroom, children are allowed to make all decisions. No one criticizes them or tells them what to do. This is often an unfamiliar experience for children who are frequently told what to do. The therapist’s role is to facilitate growth in children by allowing them to act out their feelings. This is described by Axline (1969) as “an opportunity that is offered to the child to experience growth under the most favorable conditions” (p. 16). The therapist should be attuned to the feelings communicated through the child’s play and reflect these back to the child.
Autistic Disorder Autistic disorder is classified as a pervasive developmental
disorder with no known etiology. The symptoms consist of qualitative impairments in social interactions, verbal and nonverbal communication, and a markedly restrictive repertoire of activities and interests (American Psychiatric Association, 1994). These disturbances are present before age 3 and have a continuous course. Approximately 75% of autistic children function in the mentally retarded range (DSM- IV, 1994). The severity and chronicity of autism can place a serious burden on the family (Dawson & Castelloe, 1992).
The increasingly predominant view of autistic disorder as a developmental and biological disorder has led to the adoption of structured treatments and an abandonment of more psychologically oriented therapies. Treatment of autistic disorder has traditionally consisted of medications and other biological interventions and behavioral techniques such as behavioral modification. A wide range of drugs is used to reduce aggressive and self-injurious behaviors, increase attention span, control seizures, decrease agitation, reduce stereotyped behavior, and alter other maladaptive behaviors (Dawson & Castelloe, 1992). Behavioral techniques are used to teach language to autistic children and to help reduce inappropriate behaviors such as hand clapping and other self-stimulatory behaviors (e.g., toe walking, rocking,
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finger flapping) (Foxx & Azrin, 1973; Lovaas, Young, & Newsom, 1978; Russo, Carr, & Lovaas, 1980).
Play Therapy and Autism The use of toy-based therapy with autistic children is not a
unique concept. Some researchers have focused their attention on facilitating social responsiveness in these children by using toys in treatment. Dawson and Adams (1984) used toys to increase social skills and decrease perservative play. Research by Dawson and Galpert (1990) has shown that by having mothers imitate their autistic children’s play with toys, they were able to increase their children’s attention and decrease repetitive play. Leland (1983) suggests that toys afford the opportunity for children with developmental delays to control, create, and change aspects of their surroundings. In this manner, these children increase their awareness of the world around them, which helps them enhance their ability to make adaptive coping decisions.
Bromfield (1989) describes the successful treatment of a high functioning autistic boy with psychoanalytic-oriented play therapy. The treatment consisted of twice weekly play therapy sessions. This child had obvious autistic features (i.e., hand flapping, repetitive movements, and avoidance of eye contact), but he also had an uncommon feature for an autistic child. He displayed a desire for close relationships with others, especially the therapist. He often appeared sad at the end of therapy sessions. As the child progressed in therapy, he was able to communicate more clearly and comfortably than at the outset of therapy. A decrease in autistic motor behaviors was observed, and the child seemed able to handle frustration and anxiety more effectively (Bromfield, 1989).
In another case example of play therapy and autistic disorder, Turley (1998) described her existential play therapy approach. A 5-year- old girl, who was diagnosed with Pervasive Developmental Disorder and described as having “autistic like features” (limited verbalizations and social indifference), was treated with weekly sessions over the course of a year. In play, the girl primarily painted, played in the sand, and eventually expanded her interaction with the therapist and other toys. She mostly chattered nonwords and constantly tested the limits of
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the play therapy with such actions as taking toys from the room. Turley (1998) reported that the child’s mother stated that at the end of the year the child was happier and more verbal at home. Turley also reported that the girl was able to develop a capacity for happiness and self- expression, establish a relationship with a trusted adult, and have a more mainstreamed school placement at the year’s end.
Despite some documented play therapy success with autistic children, many therapists have been reluctant to use conventional forms of psychotherapy with such children. The repetitive and supposedly noncreative play of autistic children has been cited as one reason to prevent the use of traditional therapy (Wulff, 1985). However, for the autistic child who has difficulty communicating verbally, as in the case cited previously, play therapy may be the treatment of choice. Because these children are likely to be functioning at a reduced cognitive level, they may be more receptive to play therapy, regardless of their chronological age. Many higher functioning autistic children also respond to play therapy (Bromfield, 1989). Several researchers substantiate the use of play with autistic children. Wulff (1985) discussed the use of play as an assessment tool for autistic children because of their severe communication or language deficits. Given the success of imitative play in increasing autistic children’s social responsiveness, Dawson and Galpert (1990) suggest that play may be generalized to other psychological concerns.
An Integrative Play Therapy Approach The following case example illustrates how an integrative
approach to play therapy was used with a preadolescent autistic girl. The rationale for using a flexible, integrative approach is based on the multiplicity of difficulties displayed by this child as well as her developmental level. Procedures from different treatment approaches were combined into a coherent intervention sequence (Shirk, 1999). Judy (fictional name), an 11-year-old white female from an intact home, seemed unhappy, was noncompliant at home, and lacked some basic living skills. The integrative approach used combines (a) nondirective play therapy, (b) directive interventions focused on personal hygiene and social skills, and (c) parent education and support.
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Child-centered play therapy was chosen for its reliance on nonverbal communication as well as its accepting and open attitude toward the child. It was implemented throughout the treatment. Due to her cognitive delays, Judy still enjoyed play. The child-centered therapeutic components of this integrative model provide a medium in which children are accepted without outside intrusions. Additionally, play therapy allows children with developmental disabilities to discover the physical and emotional strengths they have in relation to their deficits (Carmichael, 1993). The more directive aspects were incorporated to specifically address the mother’s concerns about the child’s personal hygiene skills (often deficient in autistic children). This was introduced midway through the treatment. The use of more direction at times allowed the therapist to introduce tasks such as functional activities necessary for Judy to learn. This was based on Leland’s (1983) directive approach designed to improve social skills and responsiveness. As Rasmussen and Cunningham (1995) state, “Nondirective and focused therapy are not mutually exclusive” (p. 17). Finally, the therapist communicated with the mother in an educational and supportive manner while also using information from the mother to gain an understanding of the family dynamics. This component of the treatment was constant throughout the child’s sessions. Salomon (1983) suggested that parents of children with disabilities are in need of more support and information than other parents. Collateral work with parents addresses their needs and allows them to continue to support their children’s treatment. This collateral work is desirable (O’Connor, 1991) and contributes to the success of the treatment. It was hypothesized that this integrative approach would provide a comprehensive treatment for Judy and provide her parents with the necessary support.
Case Study Family background and personal history. Judy (age 11) is the
only child in an intact family. Her parents, Mr. and Mrs. C, were married for 5 years at the time of Judy’s birth. They obtained prenatal care, and there were no complications at birth. Both Mr. and Mrs. C. were in good health with no family history of autism on either side. Mrs.
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C. described Judy as meeting her early developmental milestones on time; however, by her 3rd year of life, signs of autism began to appear. She had deficient language skills, inordinate need for sameness, and some stereotypical behaviors.
Mr. C. was employed by the phone company and frequently worked long hours. Mrs. C. was not employed outside the home and had basically dedicated her life to helping Judy in seeking needed resources and services. Both Mr. and Mrs. C accompanied Judy to the first session, which was held on a Sunday morning. Mrs. C. provided most of the history and presenting problems. Mr. C. nodded in confirmation. Mrs. C. complained that Mr. C. spent too much time at work and, in turn, was not very involved in caring for Judy. However, Mr. C. contended that his efforts toward more active parenting were rebuffed by both Judy and Mrs. C. More specifically, he described an extremely attached relationship between Judy and her mother. He reported that at times when he had tried to spend time with Judy, Mrs. C. would criticize his ways or interfere. For example, on one Saturday, Mr. C. took Judy to the park to play ball. Rather than be pleased with the time Mr. C. spent with Judy, Mrs. C. complained that he did not take her jacket with him and that they returned late for lunch. Mr. C tried to explain that they were enjoying themselves and were not hungry enough to rush home. He cited this example to demonstrate what he perceived as his wife’s criticism of his attempts at a closer relationship with Judy.
Assessment. Mrs. C reported that Judy was diagnosed as autistic during her preschool years. Thus, she had participated in special education classes throughout her academic career. Mrs. C’s description of Judy’s schoolwork revealed activities consistently below her age level. Although formal intelligence testing was not completed, adaptive testing was conducted prior to initiating treatment. Jackson (1998) advises that “play therapists should routinely include some form of objective or subjective psychometric instruments in their daily practice for assessing” (p. 7). In addition, Leland (1983) suggests that the therapist meet with the parents to do an adaptive behavior evaluation. Performed by the therapist, adaptive testing revealed that Judy’s developmental level (in regards to everyday coping skills, tasks, and behaviors) was significantly
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below average. The Vineland Adaptive Behavior Rating Scale Interview Edition (Sparrow, Balla, & Cicchetti, 1985) was conducted with the mother during the session. The following scores were obtained: Communication Domain, 75; Daily Living Skills Domain, 67; Socialization Domain, 55; Motor Skills Domain, 90; and the Adaptive Behavior Composite, 287. All of the domain scales have a mean of 100 and a standard deviation of 15. Thus, Judy’s communication skills (receptive, expressive, and written communication), daily living skills (personal living habits, domestic tasks, and behavior), and socialization skills (interactions and sensitivity to others, use of free time) were significantly below average for her age. However, her motor skills (gross and fine motor coordination) were just slightly below average.
Presenting problems and current status of the child. At age 11, Judy was referred to a psychologist (CW) by her neurologist due to aggressiveness and oppositional behavior at home and school. Mrs. C. attributed these behaviors to Judy’s manifestation of autism. She depicted Judy’s developmental history as characterized by a lack of connection to other people. However, she emphasized that Judy had always maintained a positive maternal relationship. Judy’s teacher (who was contacted by phone) confirmed the close relationship of mother and child. The teacher stated that Judy often expressed love for her mother and, in turn, frequently called for her when she became agitated or upset at school. In general, the teacher explained that Judy was cooperative at school and performed the work assigned to her. Judy was in a contained special education classroom with other autistic children. The teacher also reported that Judy did not seem to have any significant attachments to the other children but did gravitate toward a few other girls in her class at lunchtime. Mrs. C. also described the ongoing power struggles between herself and Judy. More specifically, she stated that Judy sometimes required considerable prompting before completing daily tasks. Furthermore, Mrs. C. reported that Judy refused to either brush her teeth or let her mother brush them.
Conceptualization and model application. During the initial sessions, it became clear that many of Judy’s difficulties were related to her autism, but also tied into family dynamics. The therapist hypothesized that Judy’s anger was related to her relationship with her
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mother. Although unable to express it directly, Judy appeared at times to feel suffocated by her mother. She may have resented the constant attention she was given and the lack of independence afforded her by her mother. Further, the therapist believed that the issue with control of one’s self was paramount for Judy. Having to rely on others, mostly her mother, for many of her needs, appeared to leave her feeling helpless at times. She was unable to communicate this frustration verbally, but rather expressed her frustration in the form of oppositional behavior at home and school. Given Judy’s unexpressed feelings, it was further believed that child-centered play therapy would grant her the ability to direct her own actions.
The use of directive techniques and more structured play therapy was based on Leland’s (1983) work. He advises that the play sessions be structured only as much as is needed to assist the child in learning to modify a few socially unacceptable behaviors. Leland (1983) states that “the more retarded the child appears in the therapy sessions, the greater the amount of directed play and directed intrusions must come from the therapists” (p. 437). The goal is to raise the level of functioning of the children and assist them in controlling behavior. The rationale behind this approach is that as children learn to do more for themselves, they will be happier and more self-confident. The structure is introduced in the play because behavioral change requires modification. Leland proposes that if the child learns through play to cope with problems, this learning may be generalized into daily living. Although this technique differs from nondirective play therapy, the rationale is that it will lead to greater socially acceptable behavior by the child, a desired outcome of therapy.
Parent training and education with Mrs. C. proved valuable. Play therapy does not require any parent involvement (Guerney, 1983a), and many play therapists do not see the need for concurrent work with parents. However, Landreth (1991) advises that parents should be included in some form of therapeutic procedure whenever possible. Parent education provides a means by which the child’s therapist can interact with the parents to gain information (Brems, 1993). Leland (1983) stresses the importance of including parents to increase the pace of progress. For example, the parents can administer reinforcement at
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home for behavioral change. Additionally, parents who are involved in the treatment process are more likely to keep their children in treatment. Support from the child’s therapist can be invaluable to parents experiencing stress (Brems, 1993), and utilizing parental motivation for change does seem to increase the probability of success (Guerney, 1983a). Given these notions and the presenting problems, it was determined that neither Mr. nor Mrs. C. required individual psychotherapy; instead, the therapist would provide support and education regarding autism and education and effective parenting skills. The weekly sessions with Judy lasted 45 minutes, and Mrs. C was seen for the remaining 15 minutes of the hour. In addition, she was encouraged to call the therapist with any concerns or issues that might occur during the week. Mr. C, who worked on the day of the sessions, was unable to attend regularly. The therapist encouraged Mrs. C. to relate to her husband what was discussed in the sessions. Further, since Mr. C. was present at the first session, he was also informed by the therapist to contact the therapist with any questions or observations. He appeared supportive of the therapy, but given his work schedule, he was unable to participate weekly.
Treatment and Case Illustration of Technique The application of nondirective play therapy. During the initial
stages of therapy (sessions 1-7), Axline’s (1969) child-centered play therapy was utilized as the sole therapeutic approach. It was hypothesized that Judy would respond positively to the essentially unrestricted nature of the play sessions. For the most part, Axline’s eight principles of nondirective play therapy were diligently applied during the initial course of Judy’s psychotherapy. The following is an exploration of some of these principles within the context of Judy’s psychological treatment.
From the outset, the therapist established limits of play therapy sessions consistent with that described by Axline (1969), Landreth (1991), and Leland (1983). According to Axline, “The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship” (Axline, 1969, p. 74). The therapist explained that Judy
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could do almost anything she wanted in the sessions. A few exceptions were noted. Judy was told that she could not physically hurt herself or the therapist, nor was she permitted to damage any of the toys. She was also informed that she could play with anything she wanted in the playroom. Finally, she was told that she would be there for 45 minutes (the therapist showed her the time on the wall clock), at the end of which she could rejoin her mother.
Judy was compliant with the majority of the limits pertaining to the playroom. For example, she almost always immediately entered the therapy room at the start of a session and left at the end of the session. On several occasions, she asked to leave the playroom to see her mother. The therapist responded by reflecting Judy’s feeling, “You miss your mom and want to see her now.” The therapist then showed Judy on the clock how much time was left in the session and when she could see her mother.
Axline (1969) stipulates that “The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible” (p. 73). Rapport was quickly established as Judy realized that the therapist would allow her to make her own choices regarding toys and type of play. During the first session, Judy was reluctant to leave her mother and enter the play therapy room, so her mother accompanied her. However, soon after entering the room and seeing the toys, she seemed to forget that her mother was there, and Mrs. C was able to leave. During the first few sessions, Judy barely interacted with the therapist. At times, she appeared indifferent to his presence. However, after several sessions, in an attempt to engage him she began to show him the toys with which she was playing. Rapport was maintained throughout the therapy through light-hearted reminiscence about shared experiences. For example, Judy had a proclivity for playing with plastic food and dishes. Toward the middle and latter stages of therapy, a comment from the therapist such as, “I never would have expected you to choose to play with those . . .” elicited a smile from Judy. She tended to choose the same toys each session, evidence of the autistic feature of perservative play.
Axline’s (1969) principle that “The therapist accepts the child exactly as he is” (p. 73) was employed consistently. Judy clearly had
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limitations not manifested by the typical child in play therapy. For example, Judy’s entire communication with the therapist took the form of grunts, gestures, and body language. The therapist, expressing no frustration or resentment when unable to understand Judy’s vocalizations, accepted this type of communication. When Judy would host a tea party in the session, she would hand the therapist a cup and grunt. The therapist would take the cup and respond with a “Thank you.” At times, Judy would continue to grunt and gesture until the therapist understood what she wanted.
Additionally, Judy would frequently fail to respond to the therapist. His attempts to track her play seemingly went unheard. Although this was at times frustrating for the therapist, he accepted her lack of acknowledgment of his words. For example, he would frequently reflect on her actions, “You are feeding the baby.” This would elicit no response from Judy. The therapist had hoped she would come to acknowledge him at least minimally. On some occasions, she would turn her body into the corner and not let him see her play activity. The therapist did not intrude into her play but rather waited for a signal from Judy to join.
The therapist found it essential to the therapeutic success that Judy be allowed to express any feelings. Axline suggested that “the therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely” (1969, p. 73). The therapist allowed for direct expression of feeling, as well as symbolic expression through play. Judy frequently expressed anger in the sessions. On one occasion, Judy appeared angry when entering the therapy office. She began to play with the plastic food as was usual, but then she started to throw some pieces of food she did not like. The therapist reflected that she appeared angry and allowed her to throw the food back in the toy box, but not at him.
Judy’s autistic need for constancy was evident in the playroom. On one occasion, a stuffed animal that Judy enjoyed playing with was missing from the room. She searched frantically for it, with no success. At once realizing what she was looking for, the therapist stated, “You are looking for the dog.” She stared at him blankly. He stated that it was missing, and that he thought someone else must have taken it. Judy ran
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from the room and began crying and screaming. The therapist followed her and tried to reflect her anger and sadness. He led her back to the room where they continued to search together. Eventually, Judy found another, smaller stuffed dog and seemed content to play with it.
Axline’s (1969) fourth principle is that “the therapist is alert to recognize the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behavior” (p. 73). This principle easily applied to the work with this girl since her communication was largely nonverbal and needed to be understood by the therapist. In an effort to promote insight, reflections often focused on central issues in the play. For example, reflections pertaining to anger often focused on Judy’s relationship with her mother. One day, Judy did not want to enter the playroom. She threw a temper tantrum in the waiting area. The therapist spoke softly to her and told her to come with him to the playroom, where she could stay angry if she wanted. The therapist also made statements such as, “You are real mad about being here this morning” and “You don’t want to come in, and you are angry that your mom brought you here.” Judy’s reluctance to enter the therapy room may have been her way of communicating her anger at her mother for what she perceived as not giving her a choice (i.e., being able to choose whether she wanted to come to therapy or not). Mrs. C. explained that they had driven by a McDonald’s that morning on the way to the session, and Judy had begun to cry out. Mrs. C. did not stop, as they would have been late for the session.
Initially, Judy’s demeanor was extremely irritable, and she only minimally acknowledged the therapist. She often acted as if the therapist did not exist by failing to include him in her play or to acknowledge him. She seemed content as she played with different toys in the playroom. The therapist used consistent reflection of Judy’s actions and their effect on the environment. For example, the therapist would say, “You do not want me to play with you” or “You like to enjoy the toys by yourself.” On occasion, Judy was oppositional during the session. She would angrily move the toys around the room and refuse to acknowledge any of the therapist’s statements. Mrs. C. usually indicated that this behavior was precipitated by a disagreement or fight between herself and Judy prior to coming to the session. To this extent, Judy’s
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excessive anger was viewed as related both to frustration at the frequent difficulty of coping with the world around her and resentment of the limits and structure provided by Mrs. C. On a deeper level, Judy struggled between dissatisfaction with excessive maternal dependency and recognition of her frequent inability to maintain independent functioning. The therapist would reflect these feelings of frustration to Judy in an attempt to help her gain insight.
Application of directive techniques. Midway through therapy, Mrs. C reported that Judy seemed to be making significant progress. More specifically, she reported fewer mother-daughter arguments and a reduction in Judy’s irritability. For example, Judy was much more compliant at home when asked to do something by her mother, and her temper tantrums decreased in number. However, the problems with personal hygiene remained. Based on the mother’s concerns about these activities of daily living, it was decided that at this time, specific skill activities would be introduced into the play therapy. Hence, after eight sessions with Judy, the therapist introduced Leland’s (1983) more directive techniques in working with children with developmental delays.
The directive play therapy differed from Axline’s approach in that Judy was not always given the “responsibility to make choices and to institute change” (Axline, 1969, p. 73). Additionally, in the directive play therapy sessions, the therapist did attempt to direct Judy’s actions. The fact that Judy may never independently develop the capacity to solve problems (given her cognitive deficits) and make choices led the therapist to provide directive interventions. Judy’s mom reported that Judy refused to brush her teeth, and she was concerned about Judy’s dental health and also the smell of her breath. The therapist took responsibility for introducing and following through on this behavior. Specifically, structured coping tasks were introduced into the play therapy. For example, the therapist tried to help Judy learn to brush her teeth.
The therapist began by introducing a toothbrush and a doll in the session. He brushed the doll’s teeth and then complimented the doll on how pretty her teeth looked. He would say such things as “Your teeth are so clean and bright.” Then, he would encourage Judy to help brush
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the doll’s teeth. Judy did not respond positively to these attempts. She often ignored the therapist and refused to participate. The tooth brushing activity seemed to bring about incredible anxiety for Judy. The therapist encouraged Judy’s mother to use a doll at home and then encourage Judy to brush her own teeth. Her mother reported that she would “freak out” at home when she attempted to work with her on this task. This “freaking out” may be interpreted as Judy’s frustration at being unable to do this herself and resentment of her mother’s and the therapist’s intervention. This approach was clearly not successful with Judy.
Judy’s social skills were targeted as well, as it was believed that this would lead to more positive social interactions. In the session, the therapist would wait for Judy to do something (e.g., play with a doll). Then the therapist would make an observation about the play (e.g., “You are feeding the baby”). If Judy responded, she would be reinforced by being allowed to continue to play. However, if she did not acknowledge the therapist, he would intervene and stop the activity (removal of reinforcement), explaining that play could not continue until the child gave some type of response. This technique was used by Judy’s therapist in her treatment to increase social reciprocity. The therapist would announce that it was time for Judy and him to work on making friends. This verbal introduction served to let Judy know that the structured part of the hour was beginning. In one session, Judy began to prepare food with toy plates and play dough. The therapist asked if she was making lunch. She did not respond at all. The therapist then informed her that the toys would be put away if she did not respond (punishment). Judy quickly glanced at him but would not speak. She continued to roll the play dough into a pizza. The therapist informed her again of his request and began to put the plates away. Judy blurted out “pizza . . . pizza” and moved to hand the therapist some. He smiled and thanked Judy, letting her know that he enjoyed having pizza with her. The next time he made an observation, “That is a big pizza!”, Judy looked up at him and smiled. There appeared to be long-term effects from this approach. By the end of therapy, Judy was smiling and jumping excitedly when she was the therapist.
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In Judy’s treatment, the skill activity would be introduced for a part of the session. After a period of time, Judy would be allowed to resume nondirective play therapy. Judy’s demeanor usually became more upbeat when the coping skill task was abandoned. For example, she would begin to smile and excitedly take out the toys with which she wanted to play. In order to remain as nondirective as possible, Judy was given the responsibility both to make choices and to lead the play during the remaining unstructured parts of each session. At these times, Judy selected both the toys to be used and the manner in which they would be played.
Parent education/training. From the beginning of Judy’s treatment, the therapist spent time alone with Mrs. C. The therapist encouraged parental patience with the therapeutic process and to look for slow, steady progress. An educational approach was used to help Mrs. C. understand Judy’s limitations. As with many parents of autistic children, Mrs. C. was feeling high levels of stress and concern for her child (Sanders & Morgan, 1997). She spoke about the demanding nature of raising a child with a disability and expressed concern that she was not doing her best as a mother. She blamed herself for having an autistic child. She also expressed stress over her lack of free time and feelings of fatigue. The therapist helped Mrs. C. understand that she would likely struggle with Judy throughout her life. Further, Mrs. C.’s feelings about raising an autistic child were explored. She was encouraged to focus on small successes with Judy. For example, if Judy learned to master tooth brushing, Mrs. C. would no longer have to perform it for her. Mrs. C. began to realize that even this small achievement would provide relief from the constant fighting with Judy over this self-care habit.
Results of Therapy Judy seemed to continue to benefit from nonstructured aspects
of play therapy. Mrs. C. reported that Judy’s neurologist had remarked how much calmer Judy appeared, both before and during the appointment. Since Judy’s physician had not prescribed any medication, he complimented the therapist on Judy’s progress. Mrs. C. also explained that Judy’s teacher had noticed positive behavioral changes at school. Judy was exhibiting fewer temper tantrums and angry outbursts.
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She was more compliant with her teacher’s requests as well. The teacher also noticed that during the times that Judy would get upset, she would not cry for her mother as much as she had in the past.
As time progressed, Judy also became more attached to the therapist, as evidenced by her including the therapist into her play more often. Additionally, Judy’s physical proximity to him increased and she rarely turned her back to him. Mrs. C. reported that Judy would often get excited before her therapy sessions. She would frequently ask when they were going to return and get ready quickly before the session. Judy made emotional and behavioral changes resulting from the therapeutic interventions. However, Judy continued to avoid the structured task in therapy. Her changes were observed at home, school, and by significant people in her life (i.e., parents, teacher, and physician). After 11 sessions, Judy’s mother reported feeling satisfied with Judy’s and her own progress, and therapy was terminated.
This case presented an integrative play therapy approach for a preadolescent autistic girl with emotional and behavioral problems. In this case, the approach that integrated both directive and child-centered play therapy and parent education was partially successful. The early phase of treatment focused on a relationship-oriented intervention that allowed Judy to play nondirectively with the toys, while establishing a relationship with the therapist. Later, more directive techniques were focused on deficit behaviors. Judy clearly responded much more positively to the child-centered play therapy, and her emotional progress and behavioral changes can be attributed to such. The fact that Judy responded positively to only the nondirective play therapy is of clinical and theoretical interest. The child-centered play therapist provides the core conditions of empathy, warmth, and genuine respect for the child (Carmichael, 1993). This experience, if conducted properly, should be beneficial for any child. Child-centered play therapy allows the child to feel competent and begin to establish a greater sense of self-esteem, something that many autistic children may be lacking given their
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reliance on others. Judy’s affect improved during the course of the therapy, and her play repertoire increased.
When more direction was introduced to the sessions, Judy became noncompliant. Despite the fact that Judy needed instruction on various coping skills and activities of daily living, the play therapy did not seem to be the arena to address these concerns. When the therapist introduced the structured tasks, Judy’s attitude and mood changed. She became much more sullen and less cooperative. The therapist’s directive nature may have been a repetition of the other authority figures in Judy’s life. She was resistant to the guiding, and it appeared to make her angry. In addition, the attempts at increasing Judy’s social skills proved somewhat successful. Judy made gains in this area and near termination would often seek out the therapist for play. However, it is not clear whether the applications of the nondirective approach were responsible or the structured approach. Certainly, Judy’s socialization may have increased as a result of Axline’s approach, the one that Judy seemed to favor.
The parent education and support components of the treatment proved fruitful. The time the therapist spent with the mother provided her with an opportunity to share her feelings of frustration over raising an autistic child. To this end, the therapist could be supportive but also help the mother with situations that would arise at home. Mrs. C. seemed to develop realistic expectations of her daughter, which motivated her to be more sensitive. She was able to plan activities for Judy’s future that would encourage growth. Finally, the information Mrs. C. provided gave the therapist insight into Judy’s behavior outside of the session.
This case demonstrates the partial effectiveness of a time-limited therapy approach with a preadolescent girl with autism. The effective aspects of the treatment were the child-centered play therapy and collateral work with the mother. Judy was treated in 11 play sessions, over the course of 3 months, with progress noted by her parents, teacher, and neurologist. In contrast to the length of treatment in the Bromfield (1989) case (5 years of twice weekly therapy), the present autistic child showed success in a relatively short period of time (11 sessions). This case further illustrates the importance of the therapist looking beyond
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the diagnostic label of a child when planning treatment. Another therapist may have abandoned the idea of play therapy completely, believing the child would not benefit from such treatment. However, in this case, child-centered play therapy was adapted and employed with success, whereas the more directive techniques proved less successful.
Although in this case there was limited but consistent contact independently with the mother, a more systemic focus may have helped in understanding the family dynamics. Future play therapists may need to examine the presenting problems in the context of the family situation. In this case, much of Judy’s oppositional behavior could be viewed as her frustration with her inability at times to function independently. Through the use of play therapy, she was able to regain feelings of pride and self-acceptance. However, work with both parents may have proved fruitful. The therapist could have explored more fully Mrs. C.’s reluctance to let Mr. C. get involved in the child care, as well as both parents’ feelings about having a child with autism and its effect on their relationship. Sanders and Morgan (1997) have shown that parents of children with autism perceive a great deal of stress associated with finding the time and effort to make use of their free time. Because of the demands of raising a child with autism, parents have less time and energy to spend in activities outside the home. Thus, the therapist may be able to help the parents explore their feelings and provide suggestions.
Play therapy may not be helpful for all children with autistic disorder, specifically those who engage in repetitive, stereotypic play with toys. Additionally, the cognitive level of the child should be considered before such an approach is implemented. More specifically, depending on the level of mental retardation of the child, he or she may not be physically able to work in a play therapy modality. Bromfield (1989) cautions that working with autistic children can be difficult, since often their cognitive limitations affect their verbalizations. Despite these limitations, it seems that some high functioning autistic children can benefit from child-centered play therapy.
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Allan, ]., & Levin, S. (1993). Born on my bum: Jungian play therapy. In T. Kottman & C. Schaefer (Eds.), Play therapy in action: A casebook for practitioners (pp. 209-244). Northvale, NJ: Jason Aronson.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Axline, V. (1947). Play therapy: The inner dynamics of childhood. Cambridge, MA: Houghton Mifflin.
Axline, V. (1969). Play therapy (Rev, ed.). Cambridge, MA: Riverside Press.
Brems, C. (1993). A comprehensive guide to child psychotherapy. Dedham Heights, MA: Allyn and Bacon.
Bromfield, R. (1989). Psychodynamic play therapy with a high- functioning autistic child. Psychoanalytic Psychology, 6(4), 439- 453.
Carmichael, K. (1993). Play therapy with children with disabilities. Issues in Comprehensive Pediatric Nursing, 16,165-173.
Cohen, D. (1995). Psychosocial therapies for children and adolescents: Overview and future directions. Tournal of Abnormal Child Psychology, 23(1), 141-156.
Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children. Tournal of Abnormal Child Psychology, 12, 209-225.
Dawson, G., & Castelloe, P. (1992). Autism. In C. E. Walker & M. C. Roberts (Eds.), Handbook of clinical child psychology (2nd ed.) (pp. 375-398). New York: John Wiley & Sons.
Dawson, G., & Galpert, L. (1990). Mother’s use of imitative play for facilitating social responsiveness and toy play in young autistic children. Development and Psychopathology, 2(2), 151-162.
Erikson, E. (1950). Childhood and society. New York: Norton. Foxx, R., & Azrin, N. (1973). The elimination of autistic self-stimulatory
behavior by overcorrection. Tournal of Applied Behavioral Analysis, 6(1), 1-14.
Play Therapy and Autism 31
Gold-Steinberg, S., & Logan, D. (1999). Integrating play therapy in the treatment of children with obsessive compulsive disorder. American Tournal of Orthopsychiatry, 69(4), 495-503.
Guerney, L. (1983a). Client-centered (Non-directive) play therapy. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 21-64). New York: John Wiley and Sons.
Guerney, L. (1983b). Play therapy with learning disabled children. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 419-435). New York: John Wiley and Sons.
Holmberg, J., Benedict, H., & Hynan, L. (1998). Gender differences in children’s play therapy themes: Comparisons of children with a history of attachment disturbance or exposure to violence. International Tournal of Play Therapy, 7(2), 67-92.
Jackson, Y. (1998). Applying APA ethical guidelines to individual play therapy with children. International Tournal of Play Therapy, 7(2), 1-15.
Kot, S., Landreth, G., & Giordano, M. (1998). Intensive child-centered play therapy with witnesses of domestic violence. International Tournal of Play Therapy, 7(2), 17-36.
Kottman, T. (1998). Billy, the teddy bear boy. In L. Golden (Ed.), Case studies in child and adolescent counseling (2nd ed.) (pp. 70-82). Upper Saddle River, NJ: Prentice Hall.
Landreth, (1991). Play therapy : The art of the relationship. Muncie, IN: Accelerated Development, Inc.
Leland, (1983). Play therapy for mentally retarded and developmentally disabled children. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 431-454). New York: John Wiley and Sons.
Lovaas, O., Young, D., & Newsom, C. (1978). Childhood psychosis: Behavioral treatment. In B.B. Wolman (Eds.), Handbook of treatment of mental disorders in childhood and adolescence. Englewood Cliffs, NJ: Prentice Hall.
Mann, E., & McDermott, J. (1983). Play therapy for victims of abuse and neglect. In C. Shatter & K. O’Connor (Eds.), Handbook of play therapy (pp. 283-307). New York: John Wiley and Sons.
32 Kenny & Winick
Mendell, A. (1983). Play therapy with children of divorced parents. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 320-354). New York: John Wiley and Sons.
Oaklander, V. (1993). From meek to bold: A case study of gestalt play therapy. In T. Kottman & C. Schaefer, (Eds), Play therapy in action: A casebook for practitioners (pp. 281-300) Northvale, NJ: Jason Aronson.
O’Connor, K. (1991). The play therapy primer: An introduction of theories and techniques. New York: John Wiley & Sons.
O’Connor, K., & Schaefer, C. (1994). Handbook of play therapy (Vol. 2). New York: John Wiley & Sons.
Phillips, R., & Landreth, G. (1998). Play therapists on play therapy: II Clinical issues in play therapy. International Journal of Play Therapy, 7(1), 1-24.
Rasmussen, L., & Cunningham, C. (1995). Focused play therapy and non-directive play therapy: Can they be integrated? Tournal of Child Sexual Abuse, 4(1), 1-20.
Rekers, G. (1983). Play therapy with cross-gender identified children. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 369-386). New York: John Wiley and Sons.
Russo, D. C, Carr, E.G., & Lovaas, O. (1980). Self-injury in pediatric populations. In J. J. Ferguson & C.B. Taylor (Eds.), The comprehensive handbook of behavioral medicine, Vol. 3. New York: Spectrum Publications.
Salomon, M. (1983). Play therapy with the physically handicapped. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 455-469). New York: John Wiley and Sons.
Sanders, J. & Morgan, S. (1997). Family stress and adjustment as perceived by parents of children with autism or Down syndrome: Implications for intervention. Child and Family Behavior Therapy, 19(4), 15-32.
Shirk, S. (1999). Integrated child psychotherapy: Treatment ingredients in search of a recipe. In S. Russ & T. Ollendick (Eds.), Handbook of psychotherapies with children and families, (pp. 369-384). New York: Kluwer Academic/Plenum Publishers.
Play Therapy and Autism 33
Sparrow, S., Balla, D., & Cicchetti, D. (1985). Vineland adaptive behavior scales. Circle Pines, MN: American Guidance Services.
Turley, D. (1998). Fredirika: Wrapped in layers of burgundy wool. In L. Golden (Ed.), Case studies in child and adolescent counseling (2nd ed.) (pp. 143-163). Upper Saddle River, NJ: Prentice Hall.
VanFleet, R., Lilly, J. & Kaduson, H. (1999). Play therapy for children exposed to violence: Individual, family and community interventions. International Tournal of Play Therapy, 8(1), 27-42.
Willock, B. (1983). Play therapy with the aggressive, acting-out child. In C. Schaefer & K. O’Connor (Eds.), Handbook of play therapy (pp. 431-454). New York: John Wiley and Sons.
Wulff, S. (1985). The symbolic and object play of children with autism: A review. Journal of Autism and Developmental Disorders, 15(2), 139-148.