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19
Introduction
Play therapy aims to help children and young
people suffering from a range of psychological
difficulties including depression, anxiety and
aggression. It is often used to help children and
young people resolve difficult life experiences such
as a family breakdown, abuse, trauma, grief and
domestic violence. The aims of play therapy include
helping children and young people to modify their
Gemma Clack is a graduate of the MSc Play and Therapeutic Play course of the University of Glamorgan.
Dr Kevin Crowley is a Principal Lecturer in Psychology at the University of Glamorgan.
Lisa Waycott is a practicing Play Therapist and a Senior Lecturer in Play Therapy at the University of Glamorgan.
Dr Jane Prince is a Principal Lecturer in Psychology at the University of Glamorgan.
Nicola Birdsey is a Senior Lecturer in Psychology at the University of Glamorgan.
behaviours, build healthy relationships and clarify
their self-concept. In play therapy, the relationship
between a child and a therapist is regarded as
paramount in helping to explore, express and make
sense of complex and distressing experiences
(British Association of Play Therapists, 2010).
The foundations of play therapy can be seen
in the work of Freud (1928) and Klein (1932) who
used play as a substitute for verbal responses in their
efforts to apply analytic techniques to their work
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
Gemma Clack
Kevin Crowley
Lisa Waycott
Jane Prince
Nicola Birdsey
University of Glamorgan, Wales
Abstract
This study investigated the awareness of play therapy in childcare practitioners working in the areas of
health, social care, education and childcare. Questionnaires were distributed to 65 workers drawn from
these occupational categories in order to investigate their understanding of issues such as the nature of play
therapy, the referral process, and the distinction between play therapy and other forms of play based
interventions. In addition, one child care professional from each of the four sectors was selected to take part
in a follow-up interview to build on the information generated from the questionnaires. The results from
the questionnaires and follow-up interviews showed that while most of the child care professionals had
heard of this approach, they had a limited knowledge of the nature of play therapy. There was also much
confusion amongst the child care professionals around the difference between play therapy and other play
based interventions as well as around different professionals’ roles and responsibilities for referring children
and young people to therapeutic interventions. The implications of these findings for the practice of play
therapy are considered.
Key words: Play therapy, childcare practitioners, awareness, knowledge, perceptions.
Bri. J. Play Therapy, Vol. 6 (2010), pp 19–34
20
with children. Another milestone in the
development in play therapy occurred when Axline
(1947) developed a non-directive model of play
therapy (later referred to as Child-Centred Play
Therapy) based on the Rogerian model of
psychotherapy. Over the years, play therapy
continued to develop in the UK and internationally
to include a cluster of treatment models, approaches
and theoretical schools of thought. These include
humanistic (Axline, 1947, Rogers, 1976),
behavioural (Knell, 1995), gestalt (Oaklander,
1994) and psychoanalytical (Freud, 1928; Klein,
1932). During the 1980s and 1990s a wide range
of specific play therapy models emerged, based on
practitioners’ theoretical views and personal
experiences of working with children. These
included gestalt play therapy (Oaklander, 1994),
Adlerian play therapy (Kottman, 1995), prescriptive
play therapy (Schaefer, 2001) and ecosystemic play
therapy (O’Connor, 1999) to highlight a few. In
the UK, Jennings (1990, 1999) and Cattanach
(1992, 1994,) integrated elements of non directive
Play Therapy to formulate a British Play Therapy
movement. Whilst the various models and
approaches may differ philosophically and in their
technical application, they all recognise and value
the therapeutic and developmental aspects of play in
helping children to resolve past psychological
difficulties to achieve healing and emotional
wellbeing.
It is important to differentiate play therapy
from other specialisms that make use of play
methods. These include therapeutic play, where the
objectives are to increase the emotional wellbeing of
a child or young person. This differs from play
therapy in that it is used to treat mild, or recently
emerging emotional or psychological difficulties
from becoming more entrenched. Play therapy can
also be differentiated from the work of hospital play
specialists who use free or directed play methods.
Their goals are to help children prepare and cope
with anxieties and feelings associated with hospital
procedures as well as supporting a child or young
person’s family and contributing to clinical
judgements through play based observations
(Hubbuck, 2009).
There is a sizeable body of research on
outcomes of play therapy, indicating that this
approach can be used to help children suffering
from a variety of problems (e.g. Bratton, Ray, Rhine
& Jones, 2005; Dougherty and Ray, 2007).
However there appears to be less emphasis on play
therapists, clients and particularly childcare
professionals’ perceptions of this relatively new (in
the UK) therapeutic approach. Bratton and Ray
(2000) carried out a review of eighty-two play
therapy research studies from 1942 to 2000. They
identified the 1970’s as the height of play therapy
research with studies focussing mainly on children’s
difficulties with social adjustment and the self. Prior
to this, research in this field focused primarily
around intelligence and school achievement. More
recently, there has been a shift in research focusing
on social problems such as domestic violence, drug
and sexual abuse as well as diagnoses such as
depression and conduct disorder amongst children.
There has been a small amount of research
looking at the issue of play therapists’ experiences
and perceptions of play therapy. Examples include a
study by Phillips and Landreth (1988), who
surveyed 1166 American play therapists on their
perceptions of the effectiveness of play therapy, and
issues such as their referral criteria and their views
on which disorders were most amenable to play
therapy. This study found that the therapists
believed that 80% of their cases had a successful
outcome, and that for the majority of the therapists,
type of disorder and the age of the child were the
key criteria for referral. A more recent study
reported by Nalavany, Ryan, Gomory and Lacasse
(2005) investigated American play therapists’ views
of the qualities, competencies and skills of an
effective play therapist. Each therapist was asked to
identify 3 qualities of a ‘good’ therapist, and the
responses were collated and organised into 7
clusters. The therapists were then asked to rate the
ease of acquisition of each cluster of abilities, and
the importance of each to their practice. Sensitivity
and responsiveness to the child were rated as being
most important, and theoretical knowledge and
skills with family were rated as being most difficult
to acquire.
A number of studies have examined
perceptions of play therapy from the point of view
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
21
of the child. Axline (1950) carried out follow-up
interviews with 22 American children who had
received either individual or group play therapy
which was deemed to be successful. The children
were aged between 4 and 14 years at the time of
therapy and the interviews were conducted up to
five years after the final therapy session. The aim of
the study was to gain some insight into children’s
perceptions of their experiences and their interpre-
tation and memory of the process of therapy.
Overall, the study found that the experience of play
therapy was a positive one for the children and all of
the children remembered their experiences vividly.
A recurring theme was the children’s growing
awareness of their thoughts and feelings and
positive changes arising from this. The children also
commented favourably on their relationship with
their therapist and their freedom to be able to act
spontaneously and direct the sessions. The children
also reported the therapeutic sessions to be ‘fun’.
More recently, Carroll (2002) interviewed fourteen
English children aged between 9 and 14, as well as
their therapists, to gain an awareness of the
children’s perceptions of the Play Therapy
experience. As with Axline’s (1950) sample, all of
these cases were deemed to be successful. The results
were similar to those of Axline in that many of the
children regarded the intervention as fun. The
therapists however, tended to ascribe more meaning
to the play. For the children, having fun in the
context of the therapeutic relationship appeared to
be the most significant aspect of the therapeutic
process. The children talked about the warmth of
their therapist as well as their therapists’ willingness
to help and act as an advocate for them and in
ensuring that they felt comfortable and safe. Green
and Christensen (2006) interviewed 7 American
children on their experiences of counselling with
school counsellors who employed play therapy
techniques. The children valued the therapeutic
relationship as providing them with empathy and
acceptance as well as collaborative problem solving
and being given the freedom direct the sessions. The
participants also indicated that the therapeutic
relationship was important in helping to bring
about change as their behaviours and feelings
became more positive. Jager and Ryan (2007)
investigated the use of play-based techniques to
investigate the views of 12 English children who
were participating in a school-based NSPCC
therapeutic programme and found that these
techniques revealed both positive and negative views
among the children receiving therapy; the therapist
was then able to use this information to adapt and
modify the therapeutic approach. Jager and Ryan
argue that play-based methods are ideal for
evaluating child therapy generally as they provide a
highly suitable means for children to express
themselves.
Siu (2009) evaluated the effectiveness of
Theraplay in reducing internalising problems in a
group of Hong Kong children, from the point of
view of the children and their parents. The findings
demonstrated that among the children who
participated in a Theraplay intervention,
internalising problems had decreased compared to a
control group of children who received no
intervention. Follow-up interviews showed that
Theraplay received positive evaluations from both
the parents and the children. Parents were asked to
rate their satisfaction with the programme and the
likelihood that they would recommend the
programme to other parents. The majority of the
parents described themselves as being ‘very satisfied’
with the programme and that they would
recommend the programme to others. In addition,
parents reported that they had fun with their
children during the intervention. Among the
children, most perceived the activities to be “fun”
and said that they were happy playing games with
their parent.
While there is some very positive research on
perceptions of play therapy from the point of view
of the child and the therapist, another important
issue relates to knowledge and perceptions of play
therapy in the wider population, and particularly
among childcare practitioners. It is clear from the
studies reviewed above that play therapy can be a
beneficial intervention for children, but children
can only benefit if parents, carers and professionals
engaged with working with the child are aware of
this approach and are willing to consider play
therapy as an option. Practitioners working in
health, education, social care and childcare are in an
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
22
ideal position to identify children with difficulties
that may benefit from a play therapy intervention.
However there are questions as to what extent
workers in these areas are aware of the value and
relevance of play therapy. If they have heard of play
therapy, do they know what it is about? Do they see
play therapy as distinct from other forms of play
specialisms such as therapeutic play and playwork?
The current study is exploratory in nature and seeks
the views of childcare practitioners working in the
fields of health, education, social care and childcare.
Although there are different approaches to play
therapy, this research did not distinguish between
these as the study was primarily concerned with
general awareness of this form of therapy.
Research Methodology
In order to investigate this issue, two
approaches – quantitative and qualitative – were
used. The quantitative aspect took the form of a
questionnaire study in which participants were
asked a series of basic questions about play therapy,
and the numbers of participants making particular
responses to each question were analysed. In this
way, some basic quantitative information could be
obtained on issues such as the percentage of
participants who had heard of play therapy, the
various sources of awareness, and knowledge of
aspects of play therapy. However while such
quantitative information is very useful, it is also
interesting to understand the factors that may
underlie responses to questionnaire items. For this
reason, the quantitative questionnaire study was
followed by a small-scale qualitative interview study.
Qualitative data can be useful supplements to
quantitative data, as they can “…help the account
‘live’ and communicate to the reader through the
telling quotation or apt example” (Robson, 1993,
p.371). Therefore it was decided to follow up four
of the participants in the questionnaire study and
conduct interviews that would allow them the
opportunity to expand on the responses given on
the questionnaires.
Questionnaire Study
Participants
The sample consisted of 65 childcare
professionals from four sectors including health,
social care, education and child care. The sample
consisted of nineteen participants working in social
care including social workers, children’s charity
project workers and project co-ordinators as well as
youth workers and a parent therapist. Twenty
participants were working in education, these
included class teachers, teaching assistants,
SENCOs, educational psychologists and a head
teacher. Eighteen of the participants were working
in the health sector, including staff nurses, senior
staff nurses, a speciality registrar, a paediatrician and
a junior doctor. The remaining eight participants
worked in child care and included nursery officers
and a nursery manager.
The sample comprised ten males and fifty-
five females The participants ranged in age from
under 25 years to over 60 years of age. The
participants can be regarded as a convenience
sample in that they were workers approached by the
first author who were available and willing to
participate in the study.
Questionnaire
A brief questionnaire was constructed in
order to investigate participants’ knowledge and
perceptions of play therapy. This consisted mainly
of closed questions, where participants were asked
to select the options which related to their
knowledge and perceptions of play therapy. Some
questions required simple ‘yes/no’ answers, such as
Have you heard of play therapy prior to this study?
Other questions required the participant to select
what they felt was the most appropriate response or
responses from a list (e.g. What do you believe play
therapists do?). Where a list of responses was
provided, these also included an ‘other’ response in
order not to constrain the respondents and miss out
on useful information. The questions were
generated by the first author, drawing upon her own
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
23
experience of working as a child care practitioner.
The questionnaire was also piloted on two child
care professionals, one working in education and
one in social care, who were not participating in the
study. This was to ensure that the questions were
well understood. Participants responded to the
questionnaire in their own time and in a location
convenient for them. All participants were assured
that the questionnaire was for research purposes
only and all responses were anonymous and
confidential. Participants were also asked to indicate
if they would be willing to take part in a follow-up
interview if required and to provide a means of
contact for this. Prior to conducting the study,
approval was sought and gained from the ethics
panel of the University of Glamorgan’s Psychology
Department. The research was also conducted
within the BAPT ethical framework.
Findings
The first question asked simply if the
participants had heard of play therapy. The
responses organised by sector of employment are
displayed in Figure 1. This chart and all subsequent
charts display responses to questionnaire items in
terms of the percentage of participants responding
in a particular way.
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CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
Figure 1: Awareness of play therapy by sector.
Awareness was highest among the healthcare
workers (100%), followed by social care and child
care workers (90% and 88% respectively).
Awareness was lowest amongst the education
workers with 75% of this group reporting that they
had heard of play therapy. Taking the sample of
participants as a whole, the majority have heard of
play therapy (88% of the entire sample), but a
minority had never heard of this approach (12% of
the total sample).
Participants were also asked if they had heard
about of other forms of therapeutic intervention.
Responses are displayed in figure 2.
In general, there appears to be a high degree
of awareness of other forms of therapeutic
intervention. Awareness was lowest in the case of
drama therapy (44% of participants had heard of
this) and attachment therapy (52%). Regarding
other forms of therapy, awareness rates in excess of
80% were reported.
24
The next question of interest concerned the
participants who had heard of play therapy and
asked for the specific source of awareness. The
results are presented in Figure 3.
The above chart shows that by far the greatest
source was hearing via a colleague or another
agency. Research papers were another important
source, with 21% of participants hearing about play
therapy through this channel. The media was the
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
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Figure 2: Awareness of other forms of therapy
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Figure 3: Sources of awareness of play therapy
source of awareness for 10% of respondents.
Responses classified as ‘other’ included hearing
about play therapy through participation on
training courses, modules taken at university, or
working with a child who had been through play therapy.
The participants who were aware of play
therapy were then asked if they knew the route of
referral for play therapy. The responses to this
question are presented in figure 4.
It can be seen that despite the fact that these
participants were aware of play therapy, the vast
majority (83% of respondents) did not know the
route of referral to a play therapist.
Following the questions on basic awareness of
play therapy, there then followed a series of
questions relating to participant’s perceptions of
play therapy. For each of these questions,
25CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
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Figure 4: Participants’ knowledge of the route of referral
Figure 5: Perceptions of type of intervention
participants were free to choose as many responses
from a list as they felt were appropriate.
Firstly, participants were asked what type of
intervention they perceived play therapy to be. The
responses are displayed in figure 5.
It can be seen that the majority of
participants correctly perceived play therapy as an
intervention for dealing with emotional and
behavioural difficulties (92% and 80%
respectively). However 32% of participants also
believed that play therapy also involved simple
provision of play opportunities, indicating perhaps
a degree of confusion of play therapy with other
forms of play work. A considerable number of
participants (57%) thought that play therapy could
also be used as an intervention for physical
26
The responses to this question did indicate a
degree of confusion about the nature of play
therapy. While many participants accurately
perceived play therapists as working with families as
a whole (55%) and working with children on a 1:1
basis (68%), there also is some indication of
confusion with other forms of therapy. For example,
48% of the participants also thought that play
therapy involves the therapist talking with children
about difficulties indicating perhaps a general
perception of therapy as a ‘talking’ process, and
37% of participants viewed play therapy as playing
with children and having fun, again perhaps
indicating confusion with other forms of play work.
This generally confused view of play therapy can
also be seen by the fact that 83% of participants saw
play therapists using play methods as part of the
intervention and only 25% of participants
accurately saw play therapy as solely involving play
methods.
Finally, participants who were aware of play
therapy were asked if they had ever been involved in
referring a child to play therapy, or were aware of a
child who had been referred to play therapy. A
minority of these individuals (29%) answered yes to
this question. These participants were then asked to
report the outcome of the referral. The responses are
displayed in figure 7.
None of the respondents reported the
outcome to be unsuccessful, however only a
minority (22%) reported the outcome as successful
and the majority (78%) reported the outcome as
partially successful.
difficulties, again perhaps indicating confusion with
other interventions where play may be used as part
of a wider set of techniques, such as the work of
occupational therapists.
Participants were next asked what they
thought play therapists do in their therapeutic
work. The responses are displayed in figure 6.
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
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Figure 6: Perceptions of what play therapists do
Summary of Questionnaire Findings
Although the questionnaire was of an
exploratory nature, some potentially interesting
findings have emerged which would be worthy of
further investigation. Most of the participants have
heard of play therapy, and there seems to be a
generally high level of awareness of the various
forms of therapeutic intervention. However, while
participants are aware of the existence of play
therapy, the majority would not know how to refer
a child to a play therapist. Participants appear to be
aware that play therapy can be used as an
intervention for children with emotional and
behavioural difficulties, but some participants
(including some of those who accurately identified
play therapy as an intervention for emotional and
behavioural problems) also see a role for therapists
as simply providing an opportunity for children to
play. This may indicate confusion of the work of
play therapists with other specialists such as play
workers or perhaps a view that play therapists
provide play opportunities alongside therapeutic
services. Some participants also saw play therapists
as working with children with physical disabilities.
This may be seen as a further example of play
therapy being confounded with other forms of work
involving the use of play, such as the work of
occupational therapists with physically disabled
children. Evidence of confusion can also be seen in
their responses to the question of what play
therapists do within their interventions. The
responses here seem to indicate that many workers
still see play therapy as just another form of ‘talking
therapy’ where play is simply used to facilitate
communication. Just 25% of participants seemed to
be aware that in play therapy, play is the form of
communication, rather than just a means to an end.
Interview Study
Participants
In order to build on the information gained
from the questionnaires, follow up interviews were
conducted with 4 participants who had also taken
part in the questionnaire study, one from each of the
four sectors sampled. The following individuals
agreed to take part in an interview:
Participant A: A 35 year old female working
as a Nursery Officer.
Participant B: A 55 year old male who works
as a Manager for a charity which runs youth projects
as well as providing services for vulnerable women
and their children.
27CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
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Figure 7: Reported success of referrals made to play therapy
28
Participant C: A 24 year old female working
as a Junior Doctor. At the time of interview she was
coming to the end of a four month placement in the
Paediatrics ward of a large hospital.
Participant D: A 56 year old female working
as a year 4 class teacher in a Primary school.
Interview Schedule
The interviews were semi-structured in
nature. The interview schedule consisted of eight
main questions which were designed to be answered
in a flexible manner or reframed by the participants.
The questions were generated by the first author
who also conducted the interviews, and explored
participants’ knowledge of play therapy, their
understanding of the distinction between play
therapy, therapeutic play and other play specialisms
and their views on referring children for therapeutic
interventions. The interview schedules were piloted
to the same two childcare professionals as with the
questionnaire. This was to ensure that the context,
phrasing and order of the questions were logical and
well understood. A digital dictaphone was used to
record the interviews. Ethical issues were also
addressed including participants’ anonymity, their
right to decline answering any questions which they
did not want to, their right to end the interview at
any point and their right to withdraw from the
study. All participants gave consent for their
responses to be used for publication, including the
use of anonymous verbatim quotes.
Interview Findings
All 4 participants reported that they
encountered children suffering from emotional,
behavioural and social difficulties during the course
of their work. The 4 participants were all aware of
the existence of play therapy, but their knowledge
appeared to be limited. For example, when asked for
her understanding of play therapy, participant A
responded:
“Play therapy is where you have a child
and they have experienced or are about
to experience a certain difficulty and you
work out a way of preventing that from
happening to the child and it’s like there
is thought gone into it.”
This example also illustrates some confusion
around the difference between Play Therapy and
other play based interventions as participant A’s
definition is more akin to the work of hospital play
specialists. Indeed participant A revealed that she
had previously worked in a hospital alongside play
specialists:
“I worked in a hospital for a couple of
years before I was here and I did play
therapy there with the hospital
specialists.”
This reinforces the impression that this
participant regards the work of hospital play
specialists as synonymous with play therapy.
This confusion was also evident in the
responses of other participants. Participant C
admitted that she was confused around the different
roles of play workers, play therapists and hospital
play specialists:
“…quite often they introduce themselves
as ‘I’m a play assistant’, ‘I’m a play
worker’, ‘I’m a play specialist’ and they
all obviously know their roles but to us
it’s difficult to distinguish.”
Despite this confusion however, it was
participant C who provided the best description of
play therapy, using her perception of therapies in
general as a concept:
“In my understanding of it, play therapy
sounds more like a treatment program
rather than just play specialists. Play
therapy sounds more like there is a goal
towards the end of it, you’re looking to
achieve something out of the play therapy
itself.”
Participants were generally unsure of the
distinction between play therapy and therapeutic
play. For example, when asked if he understood the
distinction participant B responded:
“Well…no, but I’m sure there is, or that
people say there is and can perhaps
quantify that”.
Participant A also was also unsure about the
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
29
distinction between play therapy and therapeutic
play and when asked what she understood by the
term therapeutic play, gave the following answer:
“…therapeutic play could range from a
play where you’re dressing up with
scarves and it’s therapeutic, the child is
comfortable, it’s relaxing. You could have
child playing with a tray full of shaving
foam and it’s therapeutic.”
There was also a mixed knowledge of
the difference between play work and play
therapy. Play therapy also tended to be
viewed as rather adult led as opposed to play
work. According to participant D:
“I guess I see play work as any situation
which allows a child to play and interact
with others. I see this as free play and
giving children the opportunity to express
themselves. Where as I think Play
Therapy is probably very structured,
where the therapist is either trying to
understand or get children to express
their difficulties or trying to give them
an outlet in order to express those
difficulties and then be worked on.”
In addition to the confusion as to the exact
nature of play therapy, there was also evidence of
some suspicion about this approach to therapy.
When asked to describe the difference between play
work and Play Therapy, participant B reframed the
question and put forward a rather negative
perception of Play Therapy:
“Well I think it’s a difficult thing. I’ve
always been nervous about moving
something that’s very normal and very
everyday into the area of therapy. Parents
have been playing with their children for
ten thousand years so I’m always a bit
nervous when an everyday thing such as
swimming becomes swimming therapy.”
Later, when asked about the distinction
between play therapy and therapeutic play,
participant B made the following observation:
“I remember going to *** Hospital and
watching some different interventions.
Some of them were really nutty and it
just seemed like people had read a bit of
a book and had a new idea…clients
were just doing everyday things such as
swimming but professionals were
convinced it was therapy.”
Another issue probed in the interviews was
practitioners’ views relating to identifying children
with problems and referring to play therapy and
other interventions. A theme which flowed through
all four interviews was a general lack of clarity
around child care professionals’ roles and responsi-
bilities for referring children and young people to
play therapy. None of the participants saw making
referrals for children with emotional, behavioural or
social difficulties as part of their role:
“I think we would probably ask the
educational psychologist or social services
perhaps for their input on different
interventions and also how to refer.”
(Participant D)
“We wouldn’t really have to consider that
(making referrals) because it would be
totally out of our hands.” (Participant A)
Participant A also appears to not see herself as
part of a wider team in being responsible for
ensuring that a child is referred to the most
appropriate intervention and that input is given by
all agencies working with a child.
All of the participants believed that it is
difficult for child care professionals to distinguish
between the different therapeutic interventions and
treatments available to treat children and young
people with difficulties. Participant B demonstrates
this in his response but also suggests that this may
also be due to child care professionals having
reservations around referring to newer therapeutic
interventions such as play therapy:
“Yes, I think it is exceptionally difficult.
From my experience I think that
practitioners often stick to what they
know and are often nervous of new
things.”
When questioned about this issue,
participant D made the point:
“I think it’s quite easy to identify
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
30
children who have got certain difficulties
but I think that knowing what certain
therapy would be useful would be
something even maybe the head teacher
would be unsure about.”
In addition to a lack of certainty about
appropriate types of intervention, participants also
believed it to be difficult for practitioners to know
the route for referral for different therapeutic
interventions and treatments:
“Yeah, I think that’s a really big problem.
Partly because from our medical
training, I know you have to find things
out for yourself sometimes, but we’ve
never really been made aware of the
different options available for different
things. Also we move around hospitals so
much, the services available and the
referral routes differ so much from
hospital to hospital and you can’t keep up
with it.” (Participant C)
There also seemed to be a lack of awareness
around what happens and the outcome when a
child is referred for a specific intervention or
therapy:
“So they come in (CAMHS) and they
will decide which services are
appropriate and we never find out why
and we never find out where CAMHS
have sent them and whether it was
appropriate.” (Participant C)
Summary of Interview Findings
The follow-up interviews further confirmed
the findings from the questionnaires in that child
care professionals’ knowledge of play therapy was
somewhat limited. There was much confusion
amongst the four interviewees around the difference
between play therapy and other play based
interventions, such as therapeutic play, which were
largely viewed as the same. The follow-up interviews
also highlighted some confusion around the
different roles and responsibilities of play workers,
play therapists and hospital play specialists. This
confirms the finding from the questionnaires where
some of the child care professionals viewed play
therapy as providing play opportunities to children
and young people, therefore confusing play therapy
with play work. These findings help to demonstrate
the need for child care professionals to have an
awareness of other professionals’ roles and responsi-
bilities in order to be able to work in a multi-agency
context and to be able to make sense of referrals in
general.
In addition, all four interviewees believed it
to be difficult for child care professionals to
distinguish between the different therapeutic
interventions and treatments available to treat
children and young people with difficulties. These
findings help to build on those from the question-
naires, in that the majority of child care
professionals did not know the route for referral for
play therapy and possibly other therapeutic
interventions. This highlights a training need
amongst child care professionals around gaining an
awareness and basic knowledge of the different
therapeutic interventions available to treat children
and young people including the criteria and route of
referral.
The follow-up interviews also showed that
there appeared to be a general lack of clarity around
child care professionals’ roles and responsibilities for
referring children and young people to play therapy.
None of the interviewees saw making referrals to
play therapy or any other therapeutic interventions
as part of their role and were quite protective with
firm boundaries around their role.
There also appeared to be a lack of awareness
around what happens and the outcome when a
child is referred for a specific intervention or
therapy. This does not necessarily reflect a failing on
the part of the childcare workers and may simply
reflect the fact that these workers do not have the
time to follow up referrals and may also indicate a
need for more feedback from therapy providers.
These findings suggests that many child care
professionals may work in quite a disjointed
manner, meaning that it may be possible for
children and young people to miss out on being
referred to therapeutic interventions or when a child
is referred, there is a lack of communication
regarding the outcome of the referral.
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
31
Implications for Practice
This study was exploratory in nature, and
focussed on the knowledge and perceptions of a
small sample of childcare practitioners. It must also
be acknowledged that the participants were all based
in one geographic region (South Wales) and it
would be interesting to see if similar findings would
be observed in a larger scale study involving workers
based in other regions. However if the responses of
the participants in this study are indicative of
childcare practitioners in general, then the results
may be a cause of concern to the play therapy
profession. While there is a high degree of awareness
of the existence of play therapy (as well as other
forms of intervention generally), participants’
specific knowledge of play therapy is limited and in
some cases incorrect. While many practitioners
recognise that play therapy can be an effective tool
for treating emotional and behavioural disorders in
children, there also appears to be confusion between
play therapy and other forms of intervention using
play methods, and indeed some participants may
view any form of work involving play as ‘doing
therapy’. This is very much demonstrated by
interview participant A when commenting on her
experience of working alongside hospital play
specialists. This confusion in the case of hospital
play specialists has also been noted by Hubbuck
(2009) who reports that play specialists are often
mistakenly labelled by patients, families and
colleagues as ‘the play therapist’. She points out that
this can also cause problems for play specialists
themselves, as use of the term ‘therapist’ may lead to
incorrect expectations of their role and the services
they can provide for patients.
It was also the case that the majority of
participants reported that they do not know the
referral route for play therapy, and most do not see
it as their role anyway. This has implications for the
ability of practitioners to identify and refer children
for play therapy. The main settings for play therapy
in the public sector are health (Child and
Adolescent Mental Health Service - CAMHS),
social services and education. Access to play therapy
via CAMHS can be made via a referral from GP’s,
Health Visitors, Social Services and other relevant
child care support agencies. However, in the third
author’s experience as a practicing Play Therapist,
there is no direct route for referring children for play
therapy within the UK. Individual agencies and
professionals offering play therapy have their own
specific referral processes. In the third author’s
experience in private practice, the majority of
children receiving play therapy are referred via
Social Services, the Health Service, via the Court or
via self-referral from the child’s parent or caregiver.
It is therefore important for Play Therapists to
adopt a proactive role in educating and advising
other professionals on how to access therapeutic
work for children. Cattanach states “the teaching
role of the Play Therapist is an important way to
help other professionals understand what play
therapy is about and how to use play within other
professional areas” (Cattanach, 2003, p.86)
Another key role of Play Therapists is to explain
their work to parents and carers prior to
undertaking Play Therapy sessions with their child.
Another potential finding of concern is the
responses in the questionnaire study of participants
who had referred or were aware of a child referred to
play therapy regarding the outcome of therapy.
While none of these participants reported the
outcome as unsuccessful, most regarded the
outcome as ‘partially successful’. A limitation of the
current study is that participants’ views as to what
constitutes a ‘partially successful’ outcome was not
probed further. However if professionals are going
to make use of play therapy, they must be confident
that it is an effective approach, and perhaps the
views of professionals who have made referrals to
play therapy could be explored in further research,
particularly around their expectations of play
therapy and their views of outcomes.
In addition to a rather mixed view of the
efficacy of play therapy, another issue relates to
general attitudes to play therapy, and whether or not
it is perceived as a credible approach to therapy. The
views expressed by participant B in the interviews
relating to “moving something that is very normal
and very everyday into therapy” illustrate this
concern. There is also the general issue highlighted
by participants of the difficulty in distinguishing
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
32
between the different therapeutic approaches.
Again, all of these factors could have a negative
effect on willingness to refer a child for play therapy.
The results of this study therefore suggest
that members of the play therapy profession may
need to give thought to educating childcare
practitioners and the wider public about the nature
of play therapy, and correct any misconceptions
about this therapeutic approach. There are a
number of possible steps that could be taken here.
BAPT members could offer short information
sessions about play therapy to local agencies, for
example, Social Services, Health and Education in
order to increase professional understanding
throughout the UK. Another useful step would be
the development of a database of qualified and
experienced Play Therapists throughout the UK
who would be able to respond to requests from the
media on children’s emotional wellbeing and the
value of play therapy as an effective intervention.
Consideration may also be given to the provision by
the BAPT of media training courses for play
therapists along the lines of the type of courses
provided by the British Psychological Society for
members of the Psychology profession. In the
current study, the media was a source of awareness
for only 10% of the workers and effective use of the
media could help to raise the profile of play therapy
among childcare workers and the wider public.
Regarding raising the public profile of play
therapy, another useful step would be to investigate
sources of awareness of other forms of therapy. The
results of the questionnaire study reported in this
paper indicate high levels of awareness of other
therapeutic approaches. However the question of
how participants came to hear of these approaches
was not examined in this research and this issue
could be explored in a future study. This might
provide information that can be used by the play
therapy profession to consider ways in which play
therapy could be better publicised.
It is clear from the current study that
participants are unsure of the distinction between
play therapy, other forms of therapy and other
forms of work involving play, and indeed some
participants may have reservations about play
therapy generally. A potentially important step that
could be taken to improve this situation would be to
make ‘play therapist’ a protected title with the
Health Professions Council (HPC). There is
currently no safeguard in place to prevent other
professionals stating they are play therapists. This is
a common problem throughout the UK and claims
made by other professionals are often done so with
limited on no professional training in play therapy.
The profession of Arts Therapist (encompassing the
titles of Art Psychotherapist, Art Therapist, Drama
Therapist and Music Therapist) is currently HPC
protected (Health Professions Council, 2010).
Serious consideration should be given by the play
therapy profession to following this trend. The title
of Play Therapist could then only be used by
graduates of properly accredited training courses
and this would eliminate the inappropriate use of
the term and reduce confusion that can be caused
by this.
Continued research into play therapy
practice as well as outcomes of therapy will continue
to enhance the image of play therapy, particularly
among childcare professionals. An important future
direction for research in play therapy is suggested by
Geidner (2008), who argues that rather than
focussing on outcomes, the emphasis should move
toward developmental and clinical processes – in
effect, demonstrating not only that play therapy is
effective, but also clearly indicating how play
therapy is effective. This would clearly ground play
therapy practices and approaches within the wider
field of research on child development and enhance
its credibility as an evidence-based approach to
therapy.
There is no doubt that play therapy is an
effective and child-friendly approach to therapy,
and many children have benefitted to this approach.
However it is important that play therapists concern
themselves not just with therapeutic work, but also
working together as a group of professionals in
order to educate and increase professional
understanding of the effectiveness of play therapy as
an intervention for children and young people. It is
important that childcare practitioners as well as
parents and carers are aware of the nature of play
CHILDCARE PRACTITIONERS’ KNOWLEDGE AND
PERCEPTIONS OF PLAY THERAPY
therapy, and see it as a credible, evidence-based
approach delivered by appropriately trained
therapists who are accountable to a professional
body. This will ensure that parents, carers and other
professionals are able to make informed choices
before referring children and young people to play
therapy.
REFERENCES
Axline, V. (1950). Play Therapy experiences as
described by child participants. Journal of
Counselling Psychology, 14, 53-63.
Axline, V. (1947). Play Therapy. New York:
Ballantine Books.
British Association of Play Therapists Website
(n.d.). Information for Professionals. Retrieved on
15th July 2010 from
http://www.bapt.info/professionalinfo.htm
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005).
The efficacy of play therapy with children: A meta-
analytic review of treatment outcomes. Professional
Psychology: Research and Practice, 36, 376-390.
Bratton, S., & Ray, D. (2000). What the research
shows about Play Therapy. International Journal of
Play Therapy, 9(1), 47-88.
Cattanach, A. (2003). Introduction to Play Therapy.
London: Routledge.
Cattanach, A. (1994). Play Therapy Where the Sky
Meets the Underworld. London: Jessica Kingsley
Publishers.
Cattanach, A. (1992). Play Therapy with Abused
Children. London: Jessica Kingsley Publishers.
Carroll, J. (2002). Play Therapy: The children’s
views. Child and Family Social Work, 7, 177-187.
Dougherty, J., & Ray, D. (2007). Differential
impact of play therapy on developmental levels of
children. International Journal of Play Therapy, 16,
2-19.
Freud, A. (1928). Introduction to the Technique of
Child Analysis (L.P. Clark, Trans). New York:
Nervous and Mental Disease Publishing.
Geidner, J. (2008). Developmental science looks at
play therapy. British Journal of Play Therapy, 4, 4-17.
Green, E.J., & Christensen, T.M. (2006).
Elementary school children’s perceptions of Play
Therapy in school settings. International Journal of
Play Therapy, 15(1), 65-85.
Health Professions Council (n.d.). Protected Titles.
Retrieved on July 15th 2010 from
http://www.hpc-uk.org/aboutregistration/
protectedtitles/
Jager, J., & Ryan, V. (2007). Evaluating clinical
practice: Using play-based techniques to elicit
children’s views of therapy. Clinical Child Psychology
and Psychiatry, 12(3), 437-450.
Hubbuck, C. (2009). Play for Children: Play
Specialists in Hospitals and Beyond. London: Jessica
Kingsley Publishers.
Jennings, S. (1999). Introduction to Developmental
Play Therapy. London: Jessica Kingsley Publishers.
Jennings, S. (1990). Dramatherapy with Families,
Groups and Individuals. London: Jessica Kingsley
Publishers.
Klein, M. (1932). The Psycho-analysis of Children.
London: Hogarth Press.
Kottman, T. (1995). Partners in Play: An Adlerian
Approach to Play Therapy. Alexandria, VA: American
Counselling Association.
Knell, S. (1995). Cognitive –Behavioural Play
Therapy. New Jersey: Jason Aronson Inc.
33
Nalavany, B.A., Ryan, S.D., Gomory, T., & Lacasse,
J.R. (2005). Mapping the characteristics of a ‘good’
Play Therapist. International Journal of Play Therapy,
14(1), 27-50.
Oaklander, V. (1994). Gestalt play therapy. In K.
O’Connor & C.E. Schaefer (Eds.), Handbook of
Play Therapy (Vol. 2, pp144-146). New York: Wiley.
O’Connor, K. (1999). Child protector, confident:
structured group ecosystem play therapy. In D.
Sweeney & L. Homeyer (Eds.), The Handbook of
Group Play Therapy. San Francisco: Jossey-Bass.
Phillips, R.D., & Landreth, G.L. (1998). Play
Therapists on Play Therapy: Clinical issues in Play
Therapy. International Journal of Play Therapy, 7(2),
1-24.
Robson, C. (1993). Real world Research: A Resource
for Social Scientists and Practitioner-Researchers.
Oxford: Blackwell.
Rogers, C. (1976). Client Centred Therapy. London:
Penguin Psychology
Schaefer, C. (2001). Prescriptive play therapy.
International Journal of Play Therapy, 10(2), 57-73.
Siu, A.F.Y. (2009). Theraplay in the Chinese World:
An Intervention Program for Hong Kong Children
with Internalising problems. International Journal
of Play Therapy, 18(1), 1-12.
34
