International Journal of Play Therapy, (4) 1, pp. 51-59 Copyright 1995, APT, Inc.
PLAY THERAPY WITH HOSPITALIZED
CHILDREN Judy R. Webb Sam Houston State University ABSTRACT: This article provides a limited review of the literature pertaining to the use of play therapy in the hospital setting. Specific attention is given to situations involving the terminally ill child. Axline's original principles of play therapy are examined and applied to the play therapist's role in interactions with the hospitalized and/or terminally ill child. INTRODUCTION His head is bald. His legs are skinny and often bruised, but more often covered with jeans and cowboy boots. His smile is full of mischief. However, it is the eyes that catch one's attention - eyes that reflect excitement, disappointment, curiosity, pain, questions, and wisdom. Those eyes speak, and they speak loudly. They also take in so much, including the reactions of the adults in his world. During play he does not talk much, but he says volumes with his play and with his eyes. He is just one child, but in many ways he is typical of so many hospitalized children, some of whom experience hospitalization as a brief interlude in an otherwise healthy life, others who come to see weeks in the hospital as normal routine. A child in either category can benefit from play therapy. Hospitalized Children A limited review of the literature reveals several approaches by which play is used in the hospital setting. D'Antonio (1984) described therapeutic play as it could be approached by nurses working with young hospitalized children. It was proposed that, through understanding play, nurses could both ascertain the effects that hospitalization and illness had on the children and also enhance Judy R. Webb, MA, 101 West Houston, Dayton, TX 77535 52 Webb children's emotional growth. Cases were cited in which children's perceptions of their hospital experiences were directly assessed through play. Play opportunities were also seen as an opportunity for a child to exert mastery and relieve stress, while in an environment where he or she was likely to feel helpless and quite anxious. Through play, especially with medical equipment, the child could establish a sense of control. It was concluded that use of therapeutic play could make a difference as to whether the hospitalization was a positive or negative experience for the child. D'Antonio (1984) noted that play in the hospital setting was restricted both by the child's physical limitations and by the environment. Webb (1991) also noted differences in play therapy conducted with hospitalized children, but of a somewhat different nature. She focused on differences such as greater informality, more flexibility, lack of time boundaries, and interruptions such as treatment. She emphasized the needs of hospitalized children for play, in that "play is the reservoir and wellspring of a child's fundamental capacity to assimilate and adapt creatively to life experiences" (p. 296). The experience of being hospitalized, with its inherent anxiety, appears to create a situation in which the child has a heightened need to communicate through play. Webb even cited one case in which the therapist played things out as per the instructions of a quadriplegic child, thereby providing him with a passive play experience that seemed to help him express himself. Child Life programs have been developed as a specific approach to using play with hospitalized children, with the intent of both limiting anxiety and promoting growth (Froehlich, 1984). Such programs generally emphasize medical play, providing common medical supplies and equipment. "In an environment in which things are threatening and nearly everything is out of the child's control, helping children achieve and maintain a sense of comfort, safety, and well-being is a major challenge to the child life specialist" (Webb, 1991, p. 296). Sessions are generally somewhat structured and are most often conducted in groups because this both encourages socialization and allows children to benefit vicariously from the play of other patients (Adams, 1976). Benefits of this play include helping the child separate reality from fantasy, rectifying misconceptions, addressing personal Hospitalized Children 53 concerns, and increasing cognitive learning about procedures (Doak & Wallace, 1975). While the benefits of play therapy for hospitalized children seem apparent, and numerous reports exist of case studies, there appear to be few outcome studies based on experimental designs used to assess treatment effect. One of these was reported by Clatworthy (1981). In a pretest-posttest design, 114 children admitted to general pediatric units at two locations were assessed for level of anxiety upon admission and again upon discharge or on the seventh day of their stay. Children in the experimental group participated in play therapy sessions 30 minutes per day. Significant differences were found between the experimental group and the control group in that the level of anxiety did not increase significantly in children who had received play therapy during their hospital stay, but anxiety level did increase significantly in the control group. It would appear that as little as 30 minutes per day in a therapeutic play setting kept children's anxiety from escalating. Another study using a pretest-posttest design was conducted by Rae, Worchel, Upchurch, Sanner, and Daniel (1989) at Scott and White Memorial Hospital in Temple, Texas. Forty-six children were randomly assigned to four experimental groups (verbal support, diversionary play, therapeutic play, and control). While differences between groups were not apparent in either parents' or nurses' reports of children's anxiety, significant differences were found in children's self-reports. Children in the therapeutic play group reported a significant reduction in fear; this difference was not found in any of the other groups. It is interesting to note that these children received only two 30-minute play sessions. Abused children. While there are numerous global applications of play therapy in the hospital setting, there is also reason to believe that children with specific needs, beyond the general anxiety produced by hospitalization, will benefit from therapeutic play. One population of interest is children who have been abused and/or neglected. Chan and Leff (1988) addressed the contribution of play to the acute pediatric care of the abused child. Children admitted for acute care following abuse display characteristics which make play therapy an ideal approach for meeting their needs. Many of these young patients express themselves much better through actions than through words, and provision of typical play therapy materials in a safe 54 Webb environment with an empathic adult allows them to "learn how to use play to express, explore, and work through their difficulties" (p. 170). Children with cancer. Children with cancer present a special need for play therapy because, in addition to the normal stress induced by hospitalization, the young cancer patient and his or her family face a possibly fatal disease, a potentially long course of treatment, and numerous hospital stays (Adams, 1976). This, along with the side effects of treatment and the possible disruption of family life, creates a scenario in which play therapy can meet the very real need of the child to express herself or himself and work through issues. In interviewing numerous children in preparation for writing a book on children surviving cancer, Bombeck (1989) noted the isolation imposed on children by their disease and its treatment. She noted the differences in the way adults in a child's world change their responses to the child once a diagnosis of cancer has been made. It would seem, then, that the play therapist, by providing an atmosphere of acceptance, absent of pity or negative adult emotion, could fill a void that exists for these children. Webb (1991) recognized the growing "interest in the emotional impact of cancer" (p. 310), due probably to the fact that the survival rate for children with cancer has soared since the early 1970s. She stressed the need of the child both to continue normal growth and to deal with the concept of death. Play therapy can provide the climate in which young patients can develop a sense of control, an opportunity to "manage their own lives their own way" (p.329). Citing several case studies involving the use of play therapy with young cancer patients, Cooper and Blitz (1985) made a strong case for programs such as the one at Sloan-Kettering Cancer Center, where an interdisciplinary approach is stressed. Group play therapy sessions take place twice per week and are led by a team consisting of a nurse and a social worker. An active network of communication exists, allowing the entire pediatric staff to better treat the child. Terminally 111 Children. While the survival rate for childhood cancer is overwhelmingly higher than it was just 20 years age, the terminally ill child in the pediatric oncology unit is still a reality. While the value of play therapy for these children is obvious, a special challenge exists for those therapists who work with this population. Hospitalized Children 55 Most authors writing about the dying child agr.ee that often the child develops an awareness of his or her impending death, even though the adults in the child's world refuse to speak of it (Adams, 1976; Buckingham, 1989; Knapp, 1986; Price, 1989; Webb, 1991). In many cases, this awareness creates a unique type of isolation for the child. Children and parents often live under a condition that Buckingham (1989) calls "mutual pretense" (p. 60). Both know the child is dying, but neither acknowledges it. It is not uncommon for the child to develop a need to protect parents and others from what he or she is experiencing. Citing work by Bluebond-Langer, Buckingham (1989) proposed that the child should be allowed to "maintain open awareness with those who can handle it and, at the same time, mutual pretense with those who cannot" (p. 62). It is essential, then, that the play therapist working with the terminally ill child falls into the category of those who are capable of open awareness. In providing the atmosphere of acceptance so essential to play therapy, the therapist must accept the ultimate result of the child's illness. Since the child is so alert to unspoken cues, and more astute at interpreting these cues than most of the adults in his or her world realize, it is essential that the therapist work through his or her own feelings about working with a dying child. As Landreth (1991) so touchingly points out in reporting his experiences with Ryan, a dying child, there was a point before each session where he had to acknowledge to himself that the feelings he was experiencing were "my problem, not Ryan's" (p. 295). According to Grace Zambelli, clinical psychologist and art therapist, "You have to be very clued into the symbolic messages of their art, play, body language" (McCullough, 1993). All the skills needed by the play therapist in other settings are also needed in working with the terminally ill child. Play therapy appears to provide these children, especially, with brief interludes when they can feel in control (Landreth, 1991; Webb, 1991). Externalizing frustrations and fears and enhancing self-concept are seen as important needs to be met by those working with these children (Price, 1989). Dying children are experiencing much for which they have no words, but, through play, children can express to themselves and to an alert therapist much about their emotional conditions. 56 Webb At the same time that the child is dealing with facing death, and often attempting to protect parents from his or her knowledge, it is likely that other adults in the hospital environment are withdrawing from the child as well. It would appear that medical personnel give less attention to the dying child than to those expected to survive (Price, 1989). Few pediatricians have training in "dealing with the death of a patient" (Buckingham, 1989, p. 75). The attention of hospital personnel is often directed at "helping the parents cope with the psychological upheaval of tending to a terminally ill child" (Buckingham, 1989, p. 66). It would seem, then, that the relationship offered by the play therapist would be especially valuable to the child during this time. While most research regarding working with terminally ill children is focused on children with cancer, another rapidly growing group is that of children infected with the AIDS virus. Because the condition is relatively new, little research is available, but this would appear to be another population for whom play therapy during hospitalization would be highly beneficial. As Webb (1991) stated, "There exists a population of intellectually intact school-age children who have AIDS. The risk for psychological suffering among these children is self-evident" (p. 336). Not only are these children faced with a terminal illness with an uncertain course of treatment, but, unlike the cancer patient, they also experience a high possibility of social rejection. Additionally, it is likely that the family from which the child comes has already undergone the illness and possible death of another family member. Principles of Play Therapy Applied As in play therapy with any other child, when working with the hospitalized child, "the play therapist holds the key to the success or failure of the play therapy process" (Hyde, 1971, p. 1366). Although the environment may present special challenges, the same principles outlined by Axline (1969) that serve as a guide to the therapist in other nondirective play therapy sessions can be applied to sessions with hospitalized children. 1. "The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible" (p. 73). Many of the adults in the hospital, of necessity, must in the course of treatment produce physical pain for the child. In this Hospitalized Children 57 situation, the child needs someone who has a different type relationship with him or her, a therapist who clearly tries to see the world from the child's point of view. 2. "The therapist accepts the child exactly as he is" (p. 73). In the case of the hospitalized child, acceptance includes accepting the physical condition. Furthermore, in the case of the terminally ill child, a necessary part of acceptance by the therapist is the acceptance that the child is indeed dying. 3. "The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely" (p. 73). The hospitalized child may have many feelings related to his illness and treatment that are not expressed openly. The play therapy session should be such that these feelings can be expressed in a confidential setting. The dying child, with need to protect parents, particularly needs this safe outlet. 4. "The therapist is alert to recognize the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behavior" (p. 73). As in any other play therapy setting, the child may or may not know the words for the feelings he or she is experiencing. By accurate reflection, the therapist not only gives the child additional vocabulary for feelings, but communicates an understanding of the child's emotions. 5. "The therapist maintains a deep respect for the child's ability to solve his own problems if given an opportunity to do so. The responsibility to make choices and to institute change is the child's" (p. 73). In the case of an ill child, it is even more tempting than normal for the adult to attempt to solve the child's problems for him. Even in the case of very serious illness, though, the child knows the issues with which he or she needs to deal. 6. "The therapist does not attempt to direct the child's actions or conversation in any manner. The child leads the way; the therapist follows" (p. 73). Particularly in the case of the dying child, this can be a real challenge. Many adults in the child's world are shying away from dealing with the issues of death and dying; the therapist must be willing to follow the child into these issues if that is where the child chooses to go- 7. "The therapist does not attempt to hurry the therapy along. It is a gradual process and is recognized as such by the therapist" (pp. 58 Webb 73-74). Even though play therapy done in the hospital is naturally limited by the length of the child's stay and may stop and start with repeated admissions for treatment, it is still necessary to let the child determine the pace. With the dying child, the temptation for the therapist is to try to accomplish as much as possible in the remaining time, but only the child knows the proper speed. 8. "The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship" (p. 74). Limit setting is as important in a therapy session with a hospitalized and/or dying child as it is with any other child. Limits communicate safety and establish a sense of normalcy for the child. CONCLUSION Hospitalized children have a need to express what they are feeling and to work through the challenges they are facing. Play therapy provides a situation in which this is possible. The youngster with the bald head and the big eyes has much to communicate. Though those eyes express the "wise innocence" (Buckingham, 1989, p. 124) so often seen in even the very young terminally ill child, he or she is still a child, and play is still his or her largest vocabulary. REFERENCES Adams, M. (1976). A hospital play program: Helping children with serious illness. American Journal of Orthopsychiatry, 46, 416-424. Axline, V. (1969). Play therapy. New York: Ballantine. Bombeck, E. (1989). / want to grow hair, I want to grow up, and I want to go to Boise: Children surviving cancer. New York: Harper Collins. Buckingham, R. (1989). Care of the dying child. New York: Continuum. Chan, J., & Leff, P. (1988). Play and the abused child: Implications for acute pediatric care. Child Health Care, 16(3), 169-176. Clatworthy, S. (1981). Therapeutic play: Effects on hospitalized children. Journal of the Association for the Care of Children in Hospitals, 9(4), 108-113. Hospitalized Children 59 Cooper, S., & Blitz, J. (1985). 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