play therapy with hospitalized children

8/11/2019 Play Therapy With Hospitalized Children

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International Journal of Play Therapy, (4)

1,

pp . 51-59 Copyright1995,APT, Inc.

PLAY THERAPY WITH HOSPITALIZED

CHILDREN

Judy R. Webb

Sam Houston

State University

BSTR CT This article provides a limited review o f 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 exam ined and applied to the play therapist s role in

interactions with the hospitalized and/or terminally illchild.

INTRODUCTION

His head is bald. His legs are skinny and often bruised , but

more often covered w ith jeans and cow boy boo ts. His sm ile 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, bu t 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 norm al rou tine. 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 hosp ital setting. D 'Anto nio (1984) described

therapeutic play as it could be approached by nurses working with

young hospitalized children. It was prop osed that, through

understanding play, nurses could both ascertain the effects that

hospitalization and illness had on the children and also enhance

JudyR.Webb, MA,1 1 West Houston, Dayton,TX 77535


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Webb

children's emotional grow th. Cases w ere cited in which children's

perceptions of their hospital experiences were directly assessed through

play. Play opportunities w ere also seen as an op po rtun ity for a child to

exert mastery and relieve stress, while in an environment where he or

she was likely to feel helpless and quite anxio us. Th roug h play,

especially with medical equipment, the child could establish a sense of

control. It was concluded that use of therapeutic play could m ake 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

na ture. 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 ada pt 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 expresshimself.

Child Life programs have been developed as a specific

approach to using play with hospitalized children, with the intent of

both limiting anxiety and prom otin g grow th (Froehlich, 1984). Such

programs generally emphasize medical play, providing common

medical supplies and equipment. In an env ironm ent 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

(Adam s, 1976). Benefits of this play include help ing the child separate

reality from fantasy, rectifying misconceptions, addressing personal


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Hosp italized 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

treatm ent effect. One of these was repo rted by Clatw orth y (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 be tween 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 ap pear that as little as 30 m inutes pe r 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

Mem orial Hospital in Temple, Texas. Forty-six children w ere random ly

assigned to four experimental groups (verbal support, diversionary

play, therapeutic play, and control). W hile differences betw een 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 w as not found in any of the other gr ou ps . It is

interesting to note that these children received only two 30-minute play

sessions.

A bused children. W hile there are num erou s 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 therapeu tic play. One

population of interest is children who have been abused and/or

neglected. Chan and Leff (1988) ad dres sed the con tribu tion of play to

the acute pediatric care of the abused child. Ch ildren admitted for

acute care following abuse display characteristics which make play

therapy an ideal approach for meeting their need s. M any of these

young patients express themselves much better through actions than

through words, and provision of typical play therapy materials in a safe


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environment with an empathic adu lt allows them to learn how to use

play to express, explore, and w ork th rou gh the ir 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 pa tient and his or he r family face a

possibly fatal disease, a potentially long course of treatment, and

num erou s hospital stays (Adam s, 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 trea tm ent. 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 m ad e. 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 gro wing interest in the emotional

impact of cancer (p. 310), du e probably to the fact tha t 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 prov ide th e 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) m ad e a strong case

for programs such as the one at Sloan-Kettering Cancer Center, where

an interdisciplinary appro ach is stressed. Grou p play the rap y sessions

take place twice per week and are led by a team consisting of a nurse

and a social worker. An active netw ork of comm unica tion exists,

allowing the entire pediatric staff to better treat the child.

Terminally

Children

While the survival rate for childhood

cancer is overwhelmingly higher than it was just 20 years age, the

terminally ill child in the ped iatric oncology unit is still a reality. While

the value of play therapy for these children is obvious, a special

challenge exists for those therapists w ho w ork with this p opula tion.


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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; W ebb, 1991). In

many cases, this awareness creates a unique type of isolation for the

child. Children and parents often live un de r a condition that

Buckingham (1989) calls mutual pre tense (p. 60). Both know the child

is dying, but neither acknow ledges it. It is not un com m on 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 aw areness w ith

those who can handle it and, at the same time, mutual pretense with

those who cannot (p. 62). It is essen tial, then , tha t the play therapist

working with the terminally ill child falls into the category of those who

are capable of open aw areness. In pro vid ing the atm osph ere 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 w here 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 sym bolic 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 the rapy appears to prov ide

these children, especially, with brief interludes when they can feel in

control (Landreth, 1991; Webb, 1991). Ex ternaliz ing 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.


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56 Webb

At the same time that the child is dealing w ith facing d eath , 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 app ear tha t med ical 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 hospita l personnel

is often directed at helping the pa ren ts cope with the psychological

upheaval of tending to a terminally ill child (Buck ingham , 1989, p . 66).

It would seem, then, that the relationship offered by the play therapist

wou ld be especially valuable to the child d uri ng 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 vi rus. Because the

condition is relatively new, little research is available, but this would

appear to be another population for whom play therapy during

hosp italization would be highly beneficial. As W ebb (1991) stated ,

There exists a population of intellectually intact school-age children

who have AIDS. The risk for psychological suffering am ong these

children is self-evident (p. 336). Not only are these child ren 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 A pplied

As in play therapy w ith any other child, w hen wo rking w ith the

hospitalized child, the play therapist hold s the key to the success or

failure of the play therapy process (Hy de, 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 m ust deve lop a w arm , friendly relationship

with the child, in which good rap po rt is established as soon as possible

(p .73). Many of the adults in the hosp ital, of necess ity, m us t in the

course of treatmen t produce physical pa in for the child. In this


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Hospitalized Children 57

situation, the child needs som eone who has a different type relationship

with him or her, a therapist who clearly tries to see the world from the

child's po int of view .

2.

The therapist accep ts the child exactly as he is (p. 73). In

the case of the hospitalized child, acceptance includes accepting the

physical cond ition. Furtherm ore , in the case of the term inally 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 perm issiveness in the

relationship so that the child feels free to express his feelings

completely (p. 73). The hosp italized child may ha ve many feelings

related to his illness and treatment tha t 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 paren ts,

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 th erapis t 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 ow n problems if given an oppo rtun ity 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 adu lt to attem pt to solve the child's problem s 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 attem pt to direct the child's actions

or conversation in any mann er. The child leads the way; the therapist

follows (p. 73). Particularly in the case of the dyin g child, this can be a

real challenge. Many adu lts in the child's world are shying aw ay from

dealing with the issues of death and dying; the the rapis t m us t be willing

to follow the child into these issues if that is where the child chooses to

go-

7. The therapist does not attem pt to hu rry the therapy along.

It is a gradual process and is recognized as such by the the rap ist (pp.


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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

determ ine the pace. With the dyin g child, the temptation for the

therapist is to try to accomplish as much as possible in the remaining

time, bu t only the child know s the prop er 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 aw are of his responsibility in the relat ion sh ip (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 com munica te 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 throug h the challenges they are facing. Play

therapy prov ides a situation in wh ich this is possible. The youngster

with the bald head and the big eyes has m uch to com mu nicate. 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 vocabu lary .

REFERENCES

Adam s, M. (1976). A hospital play pro gram : He lping children with

serious illness. merican Journalof

Orthopsychiatry,

46, 416-424.

Axline, V. (1969).

Play

therapy.New York: Ballantine.

Bombeck, E. (1989). /wanttogrow hair I want to grow up, and I want to

go to Boise:

Children

surviving

cancer.

New York: Harp er Collins.

Buckingham, R. (1989). Careofthedying 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.

Cla tworthy, S. (1981). Therapeutic play : Effects on hospitalized

chi ldren. Journal of the Association for the Care of Children in

Hospitals, 9(4), 108-113.


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play therapy with hospitalized children

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