Play therapy as a treatment for children and adolescents with PTSD

How commonplace is PTSD in the young?

A 2019 flagship study published in The Lancet Psychiatry journal reported that one in every 13 young people in England and Wales has post-traumatic stress disorder before the age of 18. Symptoms include feeling isolated, emotional withdrawal, insomnia, and flashbacks.

This report suggested that current interventions to help treat PTSD in young people were inadequate. Despite the fact that: “Providing effective treatments early on could prevent mental health problems continuing into adulthood,” according to Dr Stephanie Lewis, the lead researcher (who is based at King’s College London Institute of Psychiatry, Psychology and Neuroscience).

So, what help is there for childhood PTSD?

The value of play therapy

Playing is fun, and a way for all ages to explore the world around them, test themselves and learn new skills. It’s also a wonderful source of tension and anxiety release and a distraction.

This is why play therapy is used in a multitude of situations, by a wide range of professionals who deal with development and mental health issues in the young. Play can be used to grow confidence, stimulate imagination and create relaxation.

However, for some children and young people with PTSD – who have compartmentalised their trauma and worked hard to keep it contained – all of this can be a ‘big ask’. They may have lost the ability or desire to play.

This often means professional child therapists must re-engage under 18s with PTSD in the act of playing, to use it as a therapeutic tool.

According to researcher and author David Crenshaw, “In my clinical experience, a lack of desire to play in children results from exposure to deliberate trauma, extensive or devastating abuse, or domestic or neighbourhood violence. However, the inability to play can sometimes result from accidental trauma.“

How is play therapy delivered?

Once initial reluctance or lack of confidence is overcome, play therapy would be delivered in a way best suited to the individual child or adolescent, and would incorporate a strategic series of tasks to help address their issues.

This may involve using generalised play as a relaxant, to support talking therapies. The child or adolescent is given empathetic support to chat at their own pace, in a safe, non-threatening environment.

Or, it could involve using specific toys and activities to invite the child to explore their experiences, to diffuse some of the lasting anxiety and hypervigilance. Primarily, employing creative visualisation and role-playing techniques.

An example of this would be the use of dolls or action figures to provide the child or adolescence with opportunities for mastery and empowerment, and ways to contextualise their trauma.

David Crenshaw, describes the case of Bobby, who was 2 years old. “He and his mother were visiting family friends and the children went out to play in the back yard, where Bobby suddenly fell through the rotting boards covering an abandoned well.

After the terrifying plunge, he was submerged in five feet of cold, dark water at the bottom of the well. A neighbour, pulled him out of the murky depths, forced the water out of his lungs, and revived him before he was taken to a hospital. He stayed in the hospital for two days.

By the time he was released from the hospital, he’d stopped talking and playing. He clung to his mother, couldn’t sleep, and showed little appetite or interest in food. He’d become hysterical when his parents tried to give him a bath.”

Crenshaw began play therapy with Bobby. “I got down on the floor immediately and started playing with the toys. Bobby watched intently while tightly clutching his mother’s arm. Clearly this little boy’s anxiety was sky-high, so I deliberately avoided creating any play scenarios depicting conflict or threat, but instead evoked a playful kind of magic, using puppets to play harmless tricks on each other in a spirit of fun. I had the Wizard puppet try to practice magic tricks, but the Monkey puppet kept taking his magic wand and hiding it. The repetition of these silly scenes, accompanied by comic patter, often makes children laugh more and more with each subsequent enactment. At first, Bobby smiled hesitantly, but after the fourth repetition, he was fully engaged in belly laughing, along with his parents, watching the Wizard puppet get increasingly frustrated with the Monkey puppet for taking his magic wand.

Why did I use the theme of tricks and trickery? Falling into an abandoned well that was supposed to be sealed over could be experienced as trickery of the worse kind, with nothing fun or playful about it. But doing several variations of this game with a range of puppets and going to extremes to punctuate the trickery as playful, joyous, and shared fun among friends I thought might help Bobby process the terrible “trick” played on him, while providing a healing antidote via the world of enthusiastic, funny, safe play.

On the way out of the office, the parents said it was the first time that their son or they had laughed since the terrifying accident. Given the distress of the child and the parents, we decided to make the next session two days later.

When the family arrived for the second session, I’d poured a small amount of water into a rectangular plastic container. While Bobby and his parents watched, all of us sitting on the floor, I put some of the play animals into the water, starting with the jungle animals. Then I had them splash playfully around, making gleeful noises, such as “whee! and “whoopee!” The lion roared—not scary roars, but muffled sounds of delight.

Bobby didn’t seem visibly shaken, but the water was shallow, covering only the animals’ feet. I took out the jungle animals and put in farm animals, then domestic animals, and finally people, including a whole family, who all enjoyed a romp in the water. When I started putting the farm animals gently into the water, I asked Bobby’s parents if they wished to help. They started adding some of the sheep, goats, cows, and horses. Bobby then picked up a pig and tentatively dropped it in the water, and then did the same with a cow, a horse, and some sheep. Gradually, he became a little more animated, making grunting sounds and laughing as he dropped each animal into the water, though he didn’t yet start engaging the animals in playful actions with the others.

We started taking out the farm animals and drying them off. Bobby watched intently and didn’t want to join in this task at first, but soon indicated he wanted to help. It wasn’t until the rest of us had the dogs playing in the water that Bobby engaged in interactive play with the dogs for the first time, making them chase each other through the water. During this session, he was laughing and squealing with enjoyment.

Before the family arrived for the third session, three days later, Bobby’s mother called to say they were thrilled that his speech was returning, although it was mostly babbling rather than the distinct words he’d used before the accident. He was also less irritable and clung less to her, though he still wasn’t sleeping well.

The same props were in place for the third session, but the plastic container was filled slightly higher. I was careful in this session, as I had been in the previous one, to make sure the water was room temperature, because I didn’t want to expose Bobby to the cold water he’d experienced in the well. The water was clear and shallow as well.

I began the session by demonstrating the play action of the day. I put the larger animals into the water, but then I had them come bouncing back out in a gleeful way, as if there were a submerged trampoline in the container. I repeated the action several times with each animal.

The parents took their turns doing the same thing. When it was Bobby’s turn, he was a bit hesitant, so I asked if his mom would like to assist. Together they took turns dipping the animals in the water, only to have them spring out again and again.

A clear indication that Bobby was healing was his increasing ability to play again, both in the session and at home. He entered the play in each subsequent session with more gusto, even at times with screams of delight. This was particularly significant because the trauma event occurred while Bobby was running around in the backyard playing. Meanwhile, at home, he was recovering his language ability, was less fretful, and usually slept through the night, much to his parents’ relief.

But there was one more major step left to accomplish: we needed to “bracket” the event for Bobby—make it clear that what he’d experienced was extremely unlikely to occur again. I conferred with the parents beforehand. This time, when the family figures entered the water to swim, some of the children would get out and start playing with the dog, and suddenly the dog would drop off the table into a bucket of cold water that I had coloured with brown food colouring. According to the plan, the dog would be rescued by the parents, dried off, soothed, and told that the bucket of water shouldn’t have been there and that mom and dad would make sure that it never happened again. They’d say emphatically that the dog was safe now and that the bucket would be removed and taken away for good.

When the dog fell into the water, Bobby gasped. But when his dad’s hand went under the water and pulled the dog quickly to the surface, the mom and dad dried it off, and then made it clear that nothing like that would ever happen to him again, the look of relief in Bobby’s face was unmistakable. The bucket of “murky water” was immediately taken away and Bobby was told it would never be allowed in the room again. He was then told that he could decide when the dog would want to go back into the clear water and rejoin the family. In the meantime, he and his mother would stay close to the dog and make sure it felt safe.

The rest of the family and the other dogs began romping again in the clear water again. For the next two sessions, the play within the water continued, and in the following session, the eighth, Bobby put the dog back in the water and he began to play with the others.

We decided to space sessions out to make sure the gains were solid. The parents reported no further PTSD symptoms after one month and then at another follow-up session three months later. At that time, the parents said, ‘We have our little boy back.’

I followed up by phone a year later, and Bobby’s mother reported that they hadn’t observed any residual effects of the experience that had terrified both their son and them. The magical powers of play facilitated Bobby’s healing, drawing on the only language (symbols and fun) available to him at the time.”

When is play therapy unsuitable for PTSD treatment?

There is evidence that play therapy works in addressing various specific childhood problems. However, opinion is divided on its value as a PTSD treatment.

Play therapy activities – which indirectly or directly address PTSD in under 18s – must certainly be delivered by trained professionals. This manages the risk of worsening symptoms or providing an ineffectual intervention.

Among the concerns expressed about play as a therapeutic tool for PTSD is that it can be difficult to evaluate progress and sometimes isolates the child from parents while they engage with the therapist. Play therapy can be viewed as a slow way to tackle PTSD symptoms in the young too, and a method that gives them too many opportunities for avoidance.

However, even those with concerns do agree that play therapy could be valuable in very young children who are unable to articulate their symptoms and experiences. Or for specific cases where play therapy could break down barriers to progress.

What’s the alternative to play therapy?

One view is that play therapy can be used to relax and engage a young person with PTSD, as a forerunner to other treatment options. The happiness and healing it provides must then be underpinned by more robust ways to address PTSD symptoms in the young.

We have covered a range of therapy options for PTSD elsewhere on this website, and many are equally applicable to different ages. Treatment recommended by NICE covers  Eye Movement Desensitisation Reprocessing (EMDR) and trauma focused cognitive behavioural therapy (CBT). when it is modelled and delivered to be relevant to the under 18s.

Please remember, these aren’t meant to be medical recommendations, but they’re tactics that have worked for others and might work for you, too. Be sure to work with a professional to find the best methods for you and your child.

For more information, and to find a play therapist in the UK, you can visit the BAPT website. The British Association of Play Therapists is the first and foremost professional body for Play Therapists in the UK. We seek to promote our standards for Play Therapy practice and maintain a Voluntary Register of members who demonstrate that they have met our standards.