Promoting Play Therapy: Marketing Dream or Empirical Nightmare?

Terence W. Campbell1

ABSTRACT: The frequency with which variations of play therapy are used for assessment and treatment in cases of alleged sexual abuse raises issues regarding the appropriateness of these techniques.  Intuitively appealing as play therapy may seem, the available outcome research does not support it as an effective treatment procedure.  Play therapy's paradigmatic assumptions result in practices that can be counterproductive as well as ineffective.  While the mainstream of psychotherapy has undergone profound changes over the last 40 years, play therapy remains frozen in time as an anachronistic curiosity. Consequently, the American Psychological Association's publication and vigorous promotion of A Child's First Book About Play Therapy (Hardcover)(Paperback) is inconsistent with its status as a scientific-professional organization.  In view of its uncritical endorsement of First Book, APA invites indictments for pursuing the self-serving interests of a professional guild.

Above and beyond its traditional commitment to scholarly and professional journals, the American Psychological Association is expanding the diversity of its publications.  APA has ventured into the areas of public information and marketing by publishing A Child's First Book About Play Therapy (Nemiroff & Annunziata, 1990).

First Book prepares children for play therapy by describing what they can expect from that experience.  It is written expressly for youngsters between the ages of 4 and 7 using simple language they can easily understand.  Because the authors encourage parents to read this book with their children, it also influences how they react to their child's treatment.  First Book perceptively assumes that parents who understand and accept the principles of play therapy are more inclined to endorse it for their children.

First Book portrays play therapy in a manner that effectively solicits parental approval for this treatment.  It discusses the problems of children so as to normalize them; consequently, neither parents nor children feel stigmatized by the difficulties supposedly requiring the services of a play therapist.  The authors indicate that while parents can help their children with many problems, there are some problems so difficult and persistent that they demand the "special help" of professionals called "child therapists."

Readers also learn that child therapists assist youngsters to "understand their feelings while they play."  The authors emphasize the importance of this understanding by explaining, "Children's problems seem to get better when they understand their feelings."  Nevertheless, children and parents are advised to be patient because, "Getting better is hard and it takes a long time."

First Book promotes play therapy so convincingly that it qualifies as a marketing dream.  It indicates that the difficult problems which burden children often leave them severely distressed (thus arousing a sense of need for a particular service).  First Book then informs its audience about the expertise of play therapists who assist youngsters to overcome their difficulties (thus promoting a service that supposedly aids the previously cited need).

First Book evokes images of increasingly secure children triumphing over troublesome feelings, and then sharing a final hug with their therapist who will not forget them.  In turn, one can readily imagine parents smiling gratefully out of appreciation for the good works of perceptive therapists who relate to their children with such warmth and understanding.  If produced as a TV-commercial with appropriately scored background music, these scenes could provoke misty-eyed smiles from millions of deeply-touched viewers.

Appealing as First Book might be to advertising agencies, it does not respond appropriately to a portion of its intended audience.  In order to make informed-consent decisions about their children's treatment, parents seek more than cheerfully illustrated propaganda; they expect specific information.  In particular, parents want to know more about the limits of confidentiality, and the possibility of iatrogenic outcomes in addition to the benefits of treatment (Jensen, McNamara, & Gustafson, 1991).  Instead of providing parents with this information, First Book blithely reassures them via unsubstantiated optimism.

Despite its shortcomings, APA seems sufficiently pleased with First Book to vigorously publicize it.  Advertisements touting it as an "invaluable resource" have appeared in the American Psychologist, APA Monitor, Clinical Psychology Review, Journal of Consulting and Clinical Psychology, Professional Psychology, and Psychotherapy.  One can only assume that APA's publication office sees considerable sales potential in First Book.  Perhaps its sentimental impact will prompt sequels titled Second Book, Third Book, etc. that are as inspirationally moving as their predecessor.

Outcome Research In Play Therapy

Obviously, however, considerations of ethical responsibility and intellectual honesty dictate that relevant research prevail over intuitive appeal when assessing the value of any treatment modality.  In the case of play therapy, these obligations result in sobering conclusions.  Despite its impressive marketing potential, the empirical evidence available to verify the effectiveness of play therapy is quite unimpressive.  Play therapy does not appear to increase academic and intellectual achievement (Clement & Milne, 1967; Clement, Fazzone, & Goldstein, 1970; Elliot & Pumphrey, 1972).  It fails to enhance the communicative and social behaviors of schizophrenic children (Ney, Palvesky, & Markeley, 1971).  Treatment effects for play therapy are conspicuously absent when dealing with specific behavioral disorders (Kelly, 1976; Milos & Reiss, 1982).  Also, play therapy does not improve the interpersonal adjustment of children who participate in it (McBrien & Nelson, 1972; Yates, 1976).

Dorfman's (1958) work with children who adjusted poorly to school is frequently cited to support the effectiveness of play therapy; however, she expressed her own reservations about the magnitude of the treatment effects and their clinical significance.  Other than the reports indicating that puppet play reduces the anxiety of children prior to surgery (Cassell, 1965; Johnson & Stockdale, 1975) — results attributable more to desensitization and modeling effects than the presumed effects of play procedure — the existing outcome research provides little encouragement for play therapists.  Thus, in addition to its status as a marketing dream, play therapy also qualifies as an empirical nightmare.

In a more recent review of the effectiveness of psychotherapy for children, Kazdin (1991) responded to Paul's (1967) admonition that outcome research must identify: "What treatment, by whom, is most effective for this individual with that specific problem under which set of circumstances?" (p. 111). Kazdin cited interventions such as problem-solving skills training, parent management training, and functional family therapy for their potential effectiveness — but his review made no reference to play therapy.  In another overview of child therapy, Kendall and Morris (1991) also seemed less than impressed with play techniques.  They introduced their discussion by citing Davids' (1975) observation that the era of blind faith in the activities of play therapy rooms has ended.

In summarizing his comprehensive review of play therapy research that reported mostly nonsignificant outcomes and some equivocal results, Phillips (1985) lamented:

This is a disheartening state of affairs for those who feel strongly about play therapy. The data lead to a puzzling paradox — Why is it that clinical wisdom regarding the value of play therapy is unsubstantiated by the empirical results?  Is a clinical activity being utilized whose value is at least suspect? (p. 757).

Instead of conceding the value of play therapy as exceedingly suspect, Phillips advocates additional research that would capitalize on more sophisticated methodologies.  Of course, one can always continue calling for improved research methods until the null hypothesis is confirmed.  If Phillips' comments accurately reflect the attitudes prevailing among play therapists, then play therapy finds itself inundated by a crisis of enormous proportions.  Rather than accept the obvious conclusions to which the accumulated data lead, Phillips seems more inclined to cling to unverified assumptions supporting the clinical value of play therapy.  Consequently, his position reminds one of Hegel's tongue-in-cheek observation: "If the facts do not agree with the theory, so much the worse for the facts."

Chapman (1973) has examined the inability to undertake conceptual revisions in response to data that demand them.  He demonstrated that scientists interpret data objectively when they favor no particular theory relevant to the data they are evaluating.  But when scientists endorse a particular theory related to the data they are interpreting, they often overlook evidence incompatible with their theoretical preferences.  Unfortunately, play therapists appear to commit what might be called "Chapman's error" with great regularity.  Otherwise, the play therapy literature would have long ago called for a massive paradigm shift (Kuhn, 1970) in its practice.

Paradigmatic Inadequacy

This article takes the position that play therapy contends with its enormous crisis as a result of serious shortcomings within its paradigm.  Play therapy's paradigmatic assumptions result in at least three mistaken practices of major consequence: (1) Play therapists appoint themselves to positions of undeserved importance in their clients' lives. (2) Play therapy indulges in irrelevant procedures that disregard the clients' needs. (3) Play therapy neglects its clients' relationships with other people in their lives who are important to them.

Therapist Centrality

Play therapists act as if their supposedly unique skills, and only their skills, can assist children to resolve their problems.  As a result, parents are expected to maintain substantial distance from their child's treatment.  Play therapists insist that the efficacy of their endeavors necessitates a confidential relationship with their clients (Nemiroff & Annunziata, 1990).  Thus, they explain to parents:

What a child actually does in his therapy must be between him and me.  Only then will he feel free to bring to me those things that he has secreted in little grubby hideaway holes in his mind or that he has interred more spoorlessly for fear that they will frighten or destroy (Baruch, 1952, p.15).

Any therapist who engages in practices such as these risks disqualifying parents from helping their own children.  This preoccupation with confidentiality pushes parents to a peripheral role in their child's therapy, while simultaneously, play therapists assume a position of excessively central significance.

The relevant research clearly demonstrates that children derive greater benefit from treatment when both of their parents actively participate in it (Gurman & Kniskem, 1981; Wolman & Stricker, 1983).  In particular, ample parental and familial support significantly assists sexually abused children in recovering from their traumatic ordeals (Myers, et al., 1989).  For children of divorce, any therapy that excludes one of their parents (usually the non-custodian) frequently creates more problems than it solves (Campbell, in press-a).  Play therapy, however, too often disregards this research even when it involves parents in collaborative sessions of their own.  Rather than including parents as active participants in their children's treatment, collaborative sessions reduce them to the status of passive consultants.  As a result, play therapy responds more to its theoretical convictions than to applicable data.

When play therapists exclude parents from active participation in their children's therapy, they must rely on the therapeutic relationship as the primary treatment method.  Because children frequently take time to feel secure with a play therapist, play therapy can evolve into long-term treatment.  Nemiroff and Annunziata (1990) indicate that the termination phase of play therapy takes anywhere from one to eight sessions.  If termination takes that long, one can only speculate how many sessions an entire course of treatment consumes.

However desirable it might be for children to enjoy a sense of security with a therapist, it is altogether more desirable for them to enjoy that sense of security with their parents.  The manner in which conventional play therapy is structured can preclude this outcome.  Rather than promoting feelings of emotional security between children and their parents, too many play therapists seem determined to solicit those feelings for themselves.  As they attempt to create a sense of emotional security between themselves and their clients, play therapists often hug and hold children.  One play therapist described how she physically held a 7-year-old boy:

He came to the playroom each time and climbed straight into my lap.  No dubiousness.  No hesitance.  This was what he wanted.  Contact with me as though I were his mother (italics added).  To be held by me quite simply (Baruch, 1952, p.14).

In fact, this therapist was not the child's mother.  She seemed to recognize that her client needed this kind of warm, affectionate interaction with his real mother.  Nevertheless, the therapist did nothing to promote a warmer, more affectionate relationship between this mother and child.  While hugging and holding this boy, the therapist merely compensated for the presumed deficits in his mother-son relationship.  She sought to give him the warmth and affection that his parents allegedly could not.  Simultaneously, she was responding to this child as if his parents were merely sources of interference with her treatment (Sandler, Kennedy, & Tyson, 1982; Schowalter, 1986).  Like a neophyte child therapist, this therapist may have fantasized herself as replacing her client's parents (Adams, 1974).  Consequently, the little boy might have sensed that this treatment was blaming his parents in order to change him (Campbell, in press-b).

When play therapists act as if they are more prepared to meet the needs of children for affection than are their parents, they undermine their clients' psychological welfare.  Affectionate exchanges between children and their parents result in more positive outcomes than such exchanges between child and therapist.  Unfortunately, however, play therapy can lead its practitioners into competing with a child's parents (Adams, 1974; Coppolillo, 1987).  Consequently, play therapists who hug children should be regarded as abusive.  They are abusing the bonds of affection that should rightfully prevail between parent and child.

Irrelevant Treatment Procedures

Joann, who is 6-years-old, was referred for play therapy as a result of appearing nervous, tense, and withdrawn.  Joann's father had been deceased for three years.  She lived with her mother and her 10-year-old sister.  In the fourth therapy session, the therapist described how:

Joann comes into the playroom, sits down at the clay table, plays with the clay.  She is usually very quiet and does very little talking.  Every time she comes in she plays with the clay and makes the same thing — a figure of a man carrying a cane.  Each time, after he is finished, awful things happen to him.  He is punched full of holes, beaten with a stick, run over by the toy truck, buried under a pile of blocks (Axline, 1969, p.179).

By the seventh session, Joann was disinclined to continue her assault on the clay man.  Instead, she felt content making cats and dishes from the clay and playing with dolls.  The therapist never determined the identity of the clay man during the therapy sessions.  She thought identifying him inadvisable because... "it seemed important to Joann that she hide him behind anonymity" (Axline, 1969, p.180).

After this therapy terminated, the therapist met Joann's mother under coincidental circumstances.  The mother informed the therapist that she was considering remarriage, and indicated: "The only drawback,... is the fact that he (the man in mother's life) is a cripple and carries a cane.  Joann acts as if she is afraid of him" (italics added) (Axline, 1969, p.180).  The play therapist felt very pleased by this information.  For her, it explained why Joann had assaulted the clay man with such vigor.  Pleased as the therapist was by this news, her pleasure did not increase the effectiveness of Joann's treatment.

At the time of her play therapy, Joann faced potentially distressing changes in her life.  Her mother was contemplating remarriage, and the mother's decision to remarry would create wholesale adjustments for Joann.  In addition to functioning as a maternal figure, Joann's mother would also be a wife.  Joann would have a stepfather with whom she was forced to share her mother's attention.  She would also no longer reside in an exclusively female domain.  Instead, Joann would find herself interacting with an adult male on a regular basis.

Play therapy failed to assist Joann in adjusting to the potentially significant alterations in her life.  Despite the intensity with which she ventilated her feelings in treatment, her fears and conflicts remained unresolved.  After her therapy terminated, she felt no more prepared to accept her mother's fiancé than before treatment.  The therapist only discovered the circumstances of the fiancé in a fortuitous manner, and as a result, Joann's therapy had deteriorated into irrelevance.  Preoccupied with Joann's feelings, the therapist neglected to address the origins of her affective distress.

Disregard of Interpersonal Influence

An 11-year-old boy was referred for individual psychotherapy with a play oriented therapist.  The therapist provided the following intake narrative:

Colin is a "poor little rich boy" who was referred for difficulties concentrating in school, self-derogatory statements ("I'm no good," "I'm dumb"), social withdrawal, and a marked difficulty in expressing feelings and ideas.  He often appeared ready to burst yet could say nothing.  His father was quite distant and preoccupied with himself and his business affairs.  He involved himself in at best a peripheral way with the family.  Mother was involved and concerned, yet had great difficulty behaving toward Colin and his older brother in a consistent manner.  She was unable effectively to set limits on the physical and verbal abuse Colin received from his brother.  (Colin's brother was also in treatment and had been hospitalized twice.)  Colin struggled with a profound sense of rage toward every member of his family (Last, 1988, p.187).

Establishing any kind of personal relationship with Colin and obtaining his participation in the therapy process challenged this therapist's persistence.  Card games, discussions of dreams, and conversations about TV shows all failed to capture Colin's interest.  Eventually, the therapist discovered that he seemed to enjoy drawing pictures.  On occasion, he would even talk about his drawings with the therapist.  The therapist attributed substantial significance to Colin's drawings.  He explained:

About two months into the therapy a character emerged in his drawings who would remain a central focus in the next stage of therapy.  This was Calator, an incredibly powerful and sadistic creature who controlled the universe.  Calator could live forever and could change his shape at will.  He had slain his parents and had taken his father's magic sword and his mother's chin which gave him the power to control minds ... Calator had no remorse over his actions since, he said, "there is no good power in this universe."  Colin had found a vehicle to express his rage (Last, 1988, p.187).

The therapist also explained:

The case is still in process after one year.  Recently his mother has reported that Colin has begun more effectively to stand up to his brother and avoid the provocative traps set by his brother.  She also reports him to be much more direct in his statements to her at home.  In school his concentration is better (Last, 1988, p.188).

While the therapist applauded Colin for ventilating his anger, he ignored the problems creating that anger.  Rather than resolve the conflicts between Colin and other members of his family, the therapist acted as if he was a "self-contained individual" (Sarason, 1981) whose distress remained within himself.  Admittedly, Colin's mother reported some moderate gains on his part.  Nevertheless, the therapist could not know how accurate those reports were; he never took the opportunity to observe Colin's interactions with his brother, mother, and father.  Consequently, the mother's feedback may have been motivated by her desire to encourage a therapist who appeared committed to her son's welfare.

The therapist saw Colin twice a week, and he likely spent more time interacting with him than his own father did.  By virtue of this therapist's treatment decisions, a compensatory relationship developed between himself and Colin.  The therapist may have enjoyed the special significance he acquired in Colin's life; ultimately, however, that significance was counterproductive.  Play therapy neglected to change the distant relationship that prevailed between Colin and his father — instead this treatment merely compensated for it.

Preoccupied with the distress supposedly confined within Colin, the therapist disregarded the distress in Colin's family.  For example, one must wonder how distressed Colin's mother felt with a husband who was so distant and aloof.  One should also question how upset Colin could feel as a result of his mother's distress.  Clearly, Colin's mother felt overwhelmed by the burden of her parental responsibilities.  Because of how her family was organized, the mother was forced to function as if she were a single parent.  Thus, Colin's play therapy ignored a family situation that demanded greater involvement from Colin's father.

Quite possibly, Colin's distressing symptoms were designed to increase his father's participation in the family.  The readiness of children to engage in self-sacrificing behavior, while pursuing the welfare of their parents, should not be underestimated (Madanes, 1984).  If Colin was responding to concerns about his parents' marital happiness, and/or to his own needs for a closer relationship with his father, play therapy neglected his psychological welfare.


While the mainstream of psychotherapy has undergone profound changes over the past 40 years, play therapy remains frozen in time.  The clinical examples of play therapy cited above from 1952 bear a remarkable similarity to those of 1969 and 1988.  Play therapy has insulated itself against change by clinging tenaciously to its unverified assumptions: Children benefit enormously from cathartic experiences while relating to a warm and understanding therapist — and, these conditions are both necessary and sufficient for therapeutic progress with practically all subjects under almost any circumstances.  Though optimizing the match between treatment technique and clinical condition characterizes the more efficient models of psychotherapy (Beutler, 1979; Beutler & Clarkin, 1990), this kind of conceptual sophistication has eluded play therapy.

At best, play therapy provides children with a compensatory relationship that appeals to them as an enjoyable pastime.  Nevertheless, whenever psychotherapy deteriorates into a compensatory relationship, it assumes the characteristics of a pleasant luncheon engagement — the affable exchanges between friends are more important than the substance of their meeting.  One could argue that play therapy offers children little more than the supportive understanding of an adult friend.  Thus, many play therapists merely operate "rent-a-friend" agencies; and, unlike spontaneous friendships with older companions, play therapists often promote long-term leases.

The compensatory features of play therapy can lead to serendipitous outcomes (Haley, 1981; Montalvo & Haley, 1973).  When children speak positively of a play therapist, parents may begin to feel competitive with this semi-anonymous figure who seems so important to their child.  Determined to restore themselves as the significant adults in their youngsters' lives, parents undertake greater involvement with their children so as to compete more effectively — thus, allowing play therapists to claim credit for improvements in parent-child relationships.

At worst, play therapy exacerbates the circumstances ultimately responsible for the psychological distress of children.  When play therapists pursue supportive, affectionate relationships with their clients, they encourage homeostatic stability (Minuchin & Fishman, 1982) in their familial environments.  In other words, play therapists can unwittingly encourage parents to embrace their status quo because therapy appears to meet their children's needs.  Therefore, the illusion of treatment effectiveness decreases the probability of parents altering how they relate with their children.

At a time when considerations of cost-containment and treatment efficiency increasingly influence health care policy, play therapy stands out as an anachronistic luxury that health care systems can ill afford.  Because play therapy lacks the data to qualify as therapeutically effective, the health insurance industry could legitimately designate it an experimental procedure and refuse to recognize it for reimbursement.  If insurance carriers were to adopt such a position, one wonders if APA would officially protest on behalf of play therapists.  Should this scenario actually ensue, it would likely reduce data-sensitive clinicians to head-shaking disbelief.

The readiness of APA to promote play therapy via its publication of First Book suggests that it disregards relevant research.  APA appears to endorse a treatment modality without sufficient empirical support to verify its effectiveness.  As a result, APA leaves itself open to charges of neglecting its scientific responsibilities.  At the very least, APA should have published First Book with the same responsible caution it expresses in its journals.  All APA journals contain the following statement or one similar to it:

The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the APA or the views of the editor.

Surprisingly enough, this kind of disclaimer appears nowhere in First Book.  By virtue of publishing First Book without an appropriate disclaimer, APA seems so preoccupied with who to market, and how to market, it blithely overlooks what it is marketing.  If First Book amounts to an advertisement for play therapy, then APA has seriously disregarded requirements for truth in advertising.  APA's vigorous promotion of First Book creates the appearance of a myopic organization unable to see beyond its self-serving interests as a professional guild.  As a result, this kind of ill-advised, public relations venture can only jeopardize the reputation of APA as a scientific-professional organization.


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1 Terence W. Campbell is a clinical and forensic psychologist at 36040 Dequindre, Sterling Heights, MI 48310.  [Back]

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