Therapeutic Play: With and Without Intervention

Cindy Dell Clark
Inter-University Centre Dubrovnik (IUC)
June 2004



            Play therapy—the use of play as a conscious therapeutic intervention—has favorably endowed psychology in two important ways.  First, play therapy has attained a solid, recognized track record of treating children in crisis or pain through the use of play mediated by a therapist (Schaefer, 1993;  Webb, 1991).   Second, beyond the clinical setting play therapy  has made a pronounced and lasting impact on theories of development and play.  Erik Erikson’s classic work Childhood and Society  (1950)  is grounded in case history material drawn from the play sphere of children whom Erikson treated as a clinician.  Donald Winnicott, a giant among practitioners of therapeutic play with children, developed his theory of transitional space and the transitional objects in the course of  his clinical practice. Winnicott’s dedication in Playing and Reality  (1971), “To my patients who have paid to teach me,” testified to the relevance of therapeutic practice to his conceptions of development. Winnicott’s ideas are now widely adopted in fields as diverse as literature, religious studies, and psychology.


            On the other hand, an argument against the exporting of clinical cases to developmental theory has been that psychopathologies, although intriguing, are merely exceptional.  By this view, clinical cases are treated as unrepresentative of central, shared patterns of human functioning. How cases of dysfunction teach us about normal function, in childhood, is the question of critics.  Play therapy, by this argument, provides mere anecdotal evidence, and is questionable in its wider relevance. 


            But what if the behaviors and shifts of meaning central to play therapy could be systematically observed in psychologically-well children during the course of a study of everyday experience, and not just in clinical settings? Such evidence comes from my extended ethnographic research with forty-six American children ages five to eight.  All of them were healthy in a psychosocial sense, although all forty-six children suffered from the physical conditions of diabetes or severe asthma (Clark, 2003).   The original purpose of the investigation was not to study therapeutic play.  Rather, the original intent of the study was to document children’s own conceptions and practices related to living with chronic illness.  As the principal investigator, I wanted to explore illness using children’s frames and categories by employing ethnographic methods including repeated in-depth home interviews with young informants.  Indirect observation of children (reported in interviews with parents, parental field notes, and parent-aided photography of children’s daily lives) was also employed in the research (Clark, 2004; Clark, 2003; Clark,1999). Spontaneous therapeutic play by children, as a means of coping with the vicissitudes of illness and treatment, was pervasive and evidenced through multiple modes of investigation—in interviews with children, in children’s drawings, in photographs of children’s lives, in parental field notes, in participant observation notes at three illness camps (kept by three separate observers), and in parental interviews. Children used fantasy-based play as a means of reassurance about painful treatments, worrisome symptoms, and as a compensation for the powerlessness of illness and treatment.  The use of play to cope with the everyday strains and pains of chronic illness was found throughout various ages of children, both boys and girls, diagnosed with either diabetes or asthma.  Play, with and without family participation, was used by children during insulin injections for diabetes or during other medical treatments.   The nature of play during medical events was idiosyncratic, but a pattern of reinterpreting the meaning of treatment recurred from case to case.  Across variations in play, the resulting meaning gave the child a positive sense of personal intactness and control.  Here are some examples of spontaneous play, without therapeutic intervention, that assisted children in coping. 


*A boy, 5, sang “Alleluia” from the chorus of Handel’s Messiah each time he was given a shot—whether by his father (who first suggested the ritual), his mother, or a babysitter.

*A boy, 6, pretended that the insulin-filled syringe with its demarcated lines was a zebra.  His mother joined this play, imagining that the “zebra” kissed the boy as she injected  him.  The boy protested that the “zebra” hurt him, and he  stomped on the syringe to express his justifiable anger at the hurt.  (This play was repeated with each injection.)

*A girl, homesick and frightened while away at asthma camp, began to take a caring role with a stuffed animal presumed to suffer from asthma.  Her care-taking role towards the toy seemed to improve her confidence in her own ability to cope with her illness while away from home and family. 

*A boy, 8, carried his white Power Ranger action figure to his doctor’s appointment, a session that included painful procedures necessary to monitor his diabetes.  The boy privately imagined that the Power Ranger figure also had diabetes, so that the action figure went through (in fantasy) the same procedures as the boy.  The fantasy gave the boy a kind of company in misery, completely unknown to his mother or the doctor. The boy silently and privately reassured his toy companion, and felt reassured himself.

            Imaginal coping, as I have called the use of imagination for purposes of coping, was so pervasive that some children drew pictures without any direct probing, telling and showing narratives of how they used play to cope.  Such a case is that of Grace, a 7-year-old diabetic, who told me about her hospitalization five years earlier as she drew an illustrative picture from memory.  Grace explained that in the hospital, she was kept in a “jail bed” (the hospital crib with its metal bars) and that those adults who entered her room often hurt her (with medical procedures).  The “jail bed” was clearly illustrated in Grace’s drawing.   Also prominent in Grace’s picture was a very large tiger, positioned next to Grace’s “jail bed.”  The tiger was in fact a stuffed toy, presented to her by her uncle when she was diagnosed with diabetes and hospitalized at age twenty-two months.  The hospital scared Grace with its cage-like crib and hurtful procedures.  Grace explained, “I hated lying in that bed … and I had a tiger. …It’s like a huge tiger.  The nurses used to take it away because they thought it would scare me.  But it didn’t.”  Grace sobbed at this remembered loss of her toy, which had become a full fledged transitional object.  The pretend tiger, she explained, made her feel safe by keeping her company and serving to protect her.  Grace had overlaid a therapeutic fantasy on a plaything, unbeknownst to the nurses.  Ironically it was the nurses that scared Grace, not the stuffed tiger which they mistakenly thought to be frightening to her.   


            Peter, seven years old and a severe asthmatic since the age of three, also made use of character-protectors to feel safe amidst illness.  I asked him to draw a picture of “the worst time you ever remember, with your asthma,” and he set out to draw a picture of himself sick in bed.  At first he drew his own face wearing a concerned frown.  Then he added to his drawing the sheets on his bed, which happened to be decorated with super-heroic TV characters, the Teenage Mutant Ninja Turtles.  Upon drawing the Ninja Turtles on the sheets, Peter erased the frown and drew a smile on his own face instead.  The Turtles on his sheets, as Peter visually recorded, brightened his attitude. Peter, due to allergies, could not own stuffed toys.  But Peter engaged in playful interaction with the figures on his bed linen. Peter imagined that the Turtles on his bed sheets were strong enough to protect and help him, especially if he was sick at night, alone in his room, unable to breathe and unable to get help.   “I’d think about they’d be real, and they like, [would] help me try to… stop being sick and everything.”   How would they do this?  According to Peter, “He [Raphael, one of the Turtles] would disguise himself and go to the doctor’s office in a suit.  He would go in a doctor’s office” and say, “I’ve got a real sick person at the house, and he needs your help because his mom doesn’t know what to do, and we need your help.” 


            Playthings are appropriated by children for the purposes of therapeutic play, even when the child has no human playmate with whom to interact.  Imaginal coping fulfills Erik Erikson’s (1950) formulation that play remodels perceptions of past, present and future experience.  Play involves the capacity to see and experience what is immediately present, but also to believe in an alternative—such as the possibility that a tiger or Ninja Turtle will protect a vulnerable, fearful self.  Children with chronic illness expressed and redressed past and present experience in their play while seeking strength for the challenging future that might come. 


            In its interpretive dynamic, play is a pivot-point for meaning among chronically ill children.  Play can throw meaning topsy-turvy, rendering the weak powerful and engendering alliances with powerful characters.  Play holds the potential to vandalize convention, allowing a child to rise to power, and even to pretend to be a physician when playing doctor.  The  act of overthrowing reality through play can be a means of recalibrating inequities and subordinations, thereby operating within conventional bounds of play to shore up a child’s social relatedness. The lowly (a child patient) becomes high (the role of a  dominant physician) in enacted play, leading to a recalibrated sense of self (Bakhtin, 1994).  Play reverses roles, whereby the child pretends to deliver medical help to a playmate, pet, or toy.  Such role reversals, these forms of playing doctor (or sometimes nurse or veterinarian), were common among asthmatic and diabetic children.


            Forms of children’s own imaginal coping have been reported as helpful to children in varied circumstances.  Children awaiting out-patient surgery in a waiting room stocked with toys engaged in role reversing play, taking the role of doctor and  listening to a doll’s heart, taking the doll’s temperature, or gently reassuring the doll that “This will be alright” or “This won’t hurt at all”  (Clark, in press). Imaginal coping has been helpful with other sorts of crises affecting children, such as traumatic disasters.  Traumatized child survivors of a flood have been reported to drown their dolls in play, following their own survival of the trauma  (Kuznets, 1994).  Children who experienced Hurricane Hugo in 1989 played at dinnertime with their broccoli, dousing the broccoli with gravy to represent rushing flood waters (Sleek 1998).  Children who survived the 1995 Oklahoma City bombing played “hospital” using play figures with missing limbs  (Sleek, 1998).  Play appears to be helpful when children are struggling to interpret and make sense of a trauma.  Play therapists, of course, explicitly intervene with a play-based process when working with traumatized child patients in therapy  (Raynor, 2002). However, my research demonstrates that explicit intervention does not seem to be required in order for children to use imagination as a means of struggling with issues of meaning in trauma or in illness. 


            Family support of imaginal coping can facilitate the child’s play process. Families who keep on hand toy medical kits, toy syringes (for diabetic children) and other props useful in medical play are supportive of their child’s initiatives.  In some families, certain kinds of play make direct use of an adult participant.  For example, play during medical procedures sometimes called on adults to “play their part” in a joint game.  The game of “zebra” played when a mother injected her diabetic son with insulin required her willingness to play the part of a zebra.  In another family, a child with asthma liked her mother to playfully count while she held in her breath, as prescribed, during a treatment with a single dose inhaler.  The mother obliged her, counting to ten in various languages and in other sorts of playful ways.  Such games seemed to lighten the meaning of treatment and have an interpretive implication in redefining the  tone and meaning associated with an injection, an inhalation treatment, or any other intrusive procedure.  


            Cynthia Monahan (1993), in a book of advice for dealing with children experiencing trauma, writes that adults should sensitively support the child’s need to “play out” the trauma.  Monahan described a case history of a five-year-old girl who witnessed an air show accident that killed her cousin (Monahan, 1993. pg. 107). The child’s toys did not include an airplane.  Her mother found, after adding a toy plane (with removable pilots) to her daughter’s toy collection, that the new plaything was used by the girl to repeatedly simulate plane crashes over a period of months.  In other sorts of trauma it can be helpful to provide a child with a doctor kit, toy ambulance, toy fire engine, etc., when such toys fit the trouble or circumstance.  Child life specialists who work in hospitals with child patients in the United States and elsewhere provide medical toys to children that can help them to make sense of medical experiences, such as intubations, amputation, or other difficult medical events (Oremland, 2000). Even though therapeutic play is often child-initiated, adults can scaffold such play by providing appropriate play material.  Even a song can be appropriated by children for play, at times in reaction to an adult suggestion, such as the singing of Alleluia upon injection (mentioned earlier), or when a family of children sang a tongue-in-cheek “song of fear” upon reentering a residence that had undergone attack during war (Klingman, 2002). 


            Play is more than a matter of cognitive representation; it entails human interpretive processes, akin in many ways to processes of narrative, ritual, and humor.  All these interpretive domains involve contradictions, subversions, and ambiguities, thereby defying pat, logical deduction. The ambiguity of play allows for active manipulation, which permits experience to be signified with license and flexibility.  Play involves meaning in flux, so that children can take up cultural symbols and animate those symbols with some scope. Coping through play is inherently pivotal and transformative. Alone or in concert with others, children improvise and restage dilemmas of meaning through play. This is what makes play (like ritual or humor) so invaluable to human tensile strength, to the ability to cope with even unfathomable and shaking events. 


            Surprisingly, although imaginal coping was commonplace in the chronically ill children I studied through ethnographic methods, this form of coping is rarely mentioned in medical literature on chronic illness.  One possible explanation for past disregard of therapeutic play in medical research is that play is antithetical to western biomedical assumptions of objective, detached, controlled intervention. Therapeutic play involves ambiguity of meaning and subjective interpretation by  the child, in a manner consistent with the child’s everyday social meanings. These meanings may contradict the meanings of health care providers. Arnoff and Linquist (1997) described how children seek meaning from illness, yet the grown-ups who treat children may overlook or misunderstand children’s attempts at interpretation, even unwittingly contributing to psychological distress.  A seven-year old hospitalized boy, for example, assumed that a bone marrow aspiration meant that he was to be killed by bow and arrow (Arnoff & Linquist 1997).   


            It is feasible that the distanced objectivity and controlled intervention of biomedicine—so at odds with the unfixed, anomalous spirit of play—has caused play to  be disregarded or overlooked by many physicians. However, there are exceptions to this pattern.  A notable instance is the pediatric neurosurgeon Fred Epstein (2003), who writes in his recent memoirs about the courageous ways in which children handle brain tumors, neurosurgery, and the threat of death.  One source of children’s courage, according to Epstein, is play.  Consider Epstein’s description of Matthew, a 4-year-old patient who loved to role-play and had a collection of costumes for his fantasy indulgence.  From his hospital bed, Matthew dressed in the hook hand, pirate hat, and painted mustache of Captain Hook (a character well known for threatening vulnerable male children, in the play Peter Pan).  By impersonating Captain Hook, Matthew might be said to engage in role reversal play—taking on a dominant, threatening fantasy role in which he is, through role-play, ascendant over others.  Matthew decided to dress as Batman on the day of his brain surgery, and his Mom cooperated by purchasing the needed outfit at a costume shop.  Matthew donned his Batman attire in the car when he arrived at the hospital parking lot.  Complete with a hood cloaking his head, the masked Matthew strode into the hospital with his mother trailing a few steps behind.  As Matthew passed, people in the hospital yelled out in recognition, “Hey Batman!”  Ten years later, Epstein reports that Matthew now has only minor deficits tracing to his earlier brain dysfunction and surgery.  Matthew no longer dresses like super-heroes, although he has earned a first-degree black belt in Tae Kwon Doe.  Even mature recreation holds the potential to frame ourselves with admirable strength.  


            Epstein (1933, pg. 81-96) also tells of one boy’s attachment to a soft, sensitive plaything—a teddy bear—which of course is itself a mediating metaphor of a powerful animal in docile form.  Six year-old Luis, as Epstein describes, entered the O.R. clutching his teddy bear, which was sent ahead to the recovery room after Luis was anesthetized.  Epstein’s surgery on Luis was long and traumatic—in fact, Luis’ heart stopped beating for an anguished 29 minutes midway through the surgery to open his spinal cord and remove a large and insidious tumor.  When Luis awoke from the operation, the surgical team was relieved to see that his brain function allowed the boy to inquire “who took his teddy bear, ” as his first line of conversation. 


            Even without the benefit of a play therapist, play heals by shifting significance and offering a field for transformative meaning construction—thereby  converting vulnerability into protection, or painful injections into cause for singing. Whether a child carries a teddy bear to surgery, or simply wears a super-hero bandage on an everyday scraped knee, a playful act can serve to reframe threat through an assembly of symbols.  In this, imaginal coping reveals that children actively engage in  therapeutic play, even without a hired therapist. 



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