Child-centred play therapy for Autistic children and young people

boy playing with fall leaves outdoors

Child-centred play therapy (CCPT) is a psychotherapeutic intervention used to support children to explore and express their thoughts, emotions and experiences through play. During these sessions, children are allowed to free-play with very few limits imposed upon them, allowing the therapist to observe the child’s decisions, choices and play style (Landreth, 2012). Play therapy is based in contemporary theories of play in childhood and in psychodynamic treatment; it reflects research into childhood cognition and the interplay of the child’s intrapsychic life and their relationship with their therapist (Bruschweiler-Stern et al., 2007; Lyons-Ruth, 2006; Vivona, 2014). Play is used by children to develop their own growth and independence, when this innate need is obstructed frustrations build until they can be resolved (Axline, 1982). CCPT allows children to explore their feelings and experiences, supporting them to express themselves in healthier ways, whilst appreciating that children have the capacity to appropriately direct their own development through play (Meersand & Gilmore, 2017).

The child-centred approach allows clients to take a lead in the therapeutic process, enabling them to discover their own solutions, whilst the therapist encourages and supports their learning (Axline, 2013). Child-centred therapeutic interventions, including CCPT, are based around three core values; unconditional positive regard, empathy, and congruence. Therefore, therapists should be emotionally open to the child in a way that does not inhibit the therapist in challenging the client’s ability to problem solve (Mearns & Thorne, 2007).

Play therapy is grounded in development theory which outlines play as an innate process which actively integrates first hand experiences, thoughts and emotions (Bruce, 2015). Taking this perspective children are understood as autonomous learners, capable of agency and self-direction. This posits that professionals should be facilitators of play and learning, observing the children in order to plan for their ‘next steps’ (Montessori, 1948). Play is often creative and pleasurable, however as a form of therapy ‘play’ represents a framework of theory-grounded techniques that require therapists to have substantial knowledge and resourcefulness (Galatzer-Levy 2008). Therapists need to manage the inevitable tension between engaging as an immersed play participant and a reflective interpreter of play meanings. Additionally, they must understand the need to adapt play scenarios to suit the needs and interests of the child, whilst maintaining tolerance for ambiguous play (Kronengold, 2010). Play therapists have the demanding task of being an emotional container for the children they support, whilst working in an  over-stimulating playroom (Warshaw 2010). Play therapy relies on the good practice, knowledge, emotional resilience and continued professional development of therapists.

Despite potential issues with the theory which grounds CCPT, it has been shown to effectively support a wide range of outcomes including academic success (Blanco et al., 2015; Blanco et al., 2017; Blanco & Ray, 2011) and issues related to life stressors such as divorce, chronic illness and abuse (Ray et al., 2015; Reddy et al., 2005). Play therapy helps children regulate and understand their emotions and learn social and relational skills, and is often used in mental health, education and residential provisions (Carmichael, 2006). Meta-analytic reviews of over 100 play therapy effectiveness studies have suggested that the overall treatment outcomes of CCPT ranges from moderate to high positive effects. These studies reviewed research dated between 1942 and 2000 and found that play therapy was equally effective across gender, age and ‘presenting issues’ (Bratton et al., 2005; LeBlanc & Ritchie, 2001; Lin & Bratton, 2015). However, findings suggest that CCPT is less effective for those who have chronic mental health issues such as schizophrenia and borderline personality disorders in which children may get more benefit from child-parent relationship therapy (Rogers et al, 1957, cited by McLeod, 2005; Bratton et al., 2005). Additional research is needed to understand the efficacy of play therapy in more contemporary contexts. Comparing and contrasting CCPT and child-parent relational therapy may also be useful in creating therapeutic techniques which are used across the home and playroom.

Human ecology theory can be used to understand the effectiveness of child-centred play therapy, as this theory understands that the experiences within the playroom are affected by the social and physical environment, relationships and cultural contexts of the therapist and the child (Brofenbrenner, 1979). These factors influence the therapist’s ability to maintain unconditional positive regard, especially when their values are incongruent with the reason why they are referred to therapy, such as young people who exhibit extreme sexual violence (Landreth, 2012). CCPT may also lack cultural adaptability, in Japanese culture for example, the community is the prevalent psychological outlook suggesting that individualised therapy may be counter-cultural (Mearns & Thorne, 2007). Moreover, different cultures value and react differently to play; some recognise play as an important element of development whereas others may limit the amount of play for children, replacing it with activities which are considered more important (Gaskins, Haight & Lancy, 2007). Not only will these differences affect the efficacy of play therapy it may actually inhibit access to this intervention. Cultural influences on past experiences are often disregarded in CCPT which typically focuses on treating present behaviour and symptoms without considering underlying mental health issues (Warshaw 2010). Despite working with different genders, ages and issues, CCPT needs to be significantly adapted to be used effectively across different cultures across the world.

Children are typically brought to play therapy due to their perceived inability to advance along typical developmental trajectories. CCPT can be effective in supporting Autistic children with their executive functioning and emotional regulation whilst decreasing aggression and perceived  “challenging behaviours” (Ray, 2015; Salter et al., 2016). When play therapy commences, the therapist and parent/carer of the child meet in the playroom, allowing the parent to better understand the therapeutic process. Parents are usually encouraged to stay with their child for the first ten minutes of their introduction session so that the child can understand the playroom as a safe space and comfortably detach from their parent/carer (Landreth, 2012). This is especially vital for Autistic young people as they are more likely to have anxiety and attachment differences than their neurotypical peers (Bates, 2017). Additionally, this may be useful for parents who share similar anxiety traits, as they can learn to accept changes in routine and independence for their young person (Simpson et al., 2019).

Using similar interventions at home can also give the parent/carer a greater sense of agency, improving their mental health and the wellbeing of the family.  During the initiation phase of play therapy, a bond is created between the therapist and the child, whilst the child explores the toys, equipment and expectations of the playroom (Landreth, 2012). The playroom will maintain an identical layout with the same toys for the duration of the play therapy course, allowing stability and routine for the child – this is particularly useful for autistic children who often find comfort in routine and clear expectations (Bates, 2017). 

Typically, there is a phase of resistance from the child, when they are deciding how and when to confront the uncomfortable, scary or difficult experiences and emotions (Landreth, 2012). This can be especially distressing for young Autistic people, as they may experience alexithymia in which they cannot understand their emotions or be able to communicate them in an effective way (American Psychological Association, [APA], 2013). Frustrations which arise from misunderstood and miscommunication emotions can lead to meltdowns which can be both physically and emotionally harmful to the child and others around them.  However, once the child has negotiated this stage, they shall become fully immersed in the therapeutic process; continually healing, growing and developing in the areas of concern (Landreth, 2012). Within the work phase children begin to demonstrate better resilience and coping skills and may show a marked change in their communication and interactions, as well as their emotional and behavioural regulation. Therapists ensure that children feel prepared to continue without the use of CCPT before they finish their course of therapy with a reflective and happy goodbye (Lyons-Ruth, 2006).

During the play therapy process Autistic children should be accepted just as they are – there should be no pressure to play or interact in more ‘typical’ ways. When Autistic children experience full acceptance of themselves within the playroom they are more likely to practice self-regulatory skills and effective self-expression outside of their therapy  (Porges, 2011; Schore, 2001; Schottelkorb et al., 2020). Autistic young people may benefit from child centred play therapy as they are given autonomy over the structure of their sessions. The playroom is a low-pressure environment in which the child can set the sensory stimulation level. They are allowed to play and interact in any way that suits them, for many this may be the first time that they are encouraged to be authentically them (Balch & Ray, 2015).

Due to its relational nature, play therapy can instil independence and resilience in the child and the parent who may also be Autistic (Simpson et al, 2019). CCPT, as in other processes in their life, can be more intense for young Autistic people, however through this process they can experience full acceptance of themselves, improving their overall self-esteem.

CCPT can be effective in supporting Autistic children hwever, much of the evidence for this effectiveness is based on individual case studies (eg. Josefi & Ryan, 2004; Kenny & Winick, 2000), making it difficult to generalise results to the wider autistic population. To increase generalisability, it would be prudent to conduct research with larger participant groups. More black, indigenous, children of colour would also be useful in strengthening current research, especially due to concerns around cultural adaptability. The use of girls within studies would also be useful and appropriate, especially due to the current rise in Autistic diagnosis for girls (Bates, 2017). There remains a need for continued research into the effectiveness of child-centred play therapy for both neurotypical and Autistic children alike (Hillman, 2018).

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