Promoting Play Therapy: Marketing Dream or Empirical
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 ()()
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
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
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, 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.
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
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
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
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.
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.
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).
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
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
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
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
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
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
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
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
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W. Campbell is a clinical and forensic psychologist at 36040
Dequindre, Sterling Heights, MI 48310. [Back]