Abstract
This article reports on a follow-up study exploring the use of play-based evaluation methods to facilitate children’s views of therapy. The development and piloting of these techniques, with 12 children in the author’s own practice, was previously reported in this journal. It was argued that play-based evaluation methods reduce the power imbalance inherent in adult researcher/interviewer–child relationships and provide children with meaningful ways to share their views. In this article, follow-up research into play-based evaluations with 20 children and 7 different play therapists is drawn upon to explore in greater depth the strengths and weaknesses of these techniques. The study shows that play-based evaluation techniques are important and flexible methods for facilitating children’s views of child therapy. It is argued that those play therapists who incorporate their therapeutic skills effectively, maintain flexibility and sensitively attune to the child during the evaluation session, enable the child to explore their views most fully.
There has been a significant shift in societal attitudes towards children and the value of what children have to say is being acknowledged. This has been both in terms of children sharing their views about their own lives (Lansdown, 2010) and their thoughts on the effectiveness of a service (Cooper, 1993; Gersch, 1996). As previously noted, there is now a relatively large, and growing, amount of literature on children’s views of a whole range of services they use (Jäger & Ryan, 2007). However, research on children’s views of therapy interventions has been rather sporadic and patchy.
Furthermore, the need to develop methods that sensitively reflect children’s views of such a complex and emotionally laden process has been highlighted (Jäger & Ryan, 2007). Current examples of research in this specific area within play therapy include Axline (1950), Carroll (2002), Brownlie (2006, unpublished) and the author’s own pilot research previously reported in this journal (Jäger & Ryan, 2007). Within the wider child therapy context, Davies, Wright, Drake, and Bunting (2009) have reported on looked-after children’s views of individual child psychotherapy. Ross and Egan (2004) investigated service users’ experiences of a Child and Adolescent Mental Health Service (CAHMS). Day, Carey, and Surgenor (2006) conducted an exploratory study of children’s views of mental health care, and Strickland-Clark, Campbell, and Dallos (2000) reported on children’s views of family therapy sessions. As Davies and Wright (2008) highlight in their review of users’ views of therapy, primary school-aged children and younger are particularly underrepresented in the area of child therapy.
Carroll (2000) argues that determining young children’s views of their own therapy is even more challenging than obtaining their views of other services and experiences, due to the sensitive and confidential nature of therapy sessions. The gatekeeping issues and concerns seem to be magnified with this group of children. This is particularly due to professionals’ concerns over the potentially damaging effects that participating in research may have on a group of children who are perceived to be emotionally vulnerable. For instance, Strickland-Clark et al. (2000) found that family therapists were concerned about the disruptive and/or unsettling effect that interviewing children about their sessions may have. However, the authors reflect that the children did not appear distressed by the actual interview process and in general seemed pleased to be asked their views. This ‘professional concern’ may be compounded when the child attending therapy is also a disabled, fostered or adopted child (see Morris, 2003; Murray, 2005). Thus, an important task for researchers in this area is to persuade gatekeepers that children have a right to make their views known and that they will not be put at undue emotional risk in the process.
There has been an emphasis on the use of verbal semi-structured interviews in this field (e.g. Carroll, 2000; Green and Christensen, 2006). However, a few studies have emerged that have begun to actively utilise creative methods. These have included picture completion tasks and ‘a bag of feelings’ technique utilising pictorial cards (Davies et al., 2009; Ross and Egan, 2004). Day et al. (2006) used a variety of creative methods, including play in focus groups such as using a magic wand to express wishes for change. Strickland-Clark et al. (2000) utilised video playback.
The play-based techniques developed by the author (Jäger & Ryan, 2007) fully integrate play in the evaluation interview and provide a comprehensive framework for interviewers to explore the complex experience of child therapy. In addition, the format and guidelines for facilitating the evaluation session begin to address some of the concerns raised by gatekeepers regarding children’s emotional well-being.
Play-based evaluation methods
As reported by Jäger and Ryan (2007), three play-based evaluation methods, the ‘Expert Show’, ‘Miniature Playroom’ and the ‘Puppet Interview’, were piloted with 12 children (5½–10 years) in the author’s clinical practice within CAMHS and earlier within a schools-based National Society for the Prevention of Cruelty to Children (NSPCC) therapeutic programme. A brief description of the first two techniques is provided below. The puppet technique follows the same premise as the ‘Miniature Playroom’, utilising large puppets and real toys instead of miniatures. However, it was not used by the play therapists in this follow-up study. There follows a description of the study utilising these play-based methods to facilitate children’s views of individual play therapy. This article reports on the development and refinement of the play-based evaluation methods. In particular, the strengths and weaknesses of each approach and the process issues arising when facilitating a play-based evaluation session are discussed. The views expressed by the children in this study are reported separately (Jäger, 2011).
‘The Expert Show’ – a role-playing technique
This technique is an adaptation of a directive play-therapy technique, ‘Broadcast News’, developed by Kaduson (2001). In the original technique a child is invited to be the expert on a news show and the play therapist pretends to be child callers ringing in to ask advice regarding common childhood problems. In the adaptation of this technique, for this study, the child remains an expert on a TV chat show. However, the therapist invites the child to talk about his/her experiences of therapy. The therapist herself acts as the presenter on the show and pretends to be various children and parents who ring in. Rather than asking the ‘expert’ for advice on solving their problems, the callers ask for the ‘expert’s’ opinion on various aspects of therapy. The therapist follows a semi-structured interview schedule/TV script, asking the child open-ended questions about their general experience of play therapy. The therapist then guides the child through the process of the therapy intervention, beginning with questions about what it will be like when a child first starts therapy, the review meeting(s) held with parents during the therapy, and what it will be like at the end of therapy. This comprises the first phase of the evaluation: the call-in phase. Later children are invited to talk more directly about their own experiences in the chat-show phase. See Jäger and Ryan (2007) for examples illustrating these phases.
‘The Miniature Play Room’ – a projective narrative technique
‘The Miniature Play Room’ technique was inspired by a well-researched projective play assessment technique; Story Stems and Doll’s House Play (see Emde, Wolf, & Oppenheim, 2003; Woolgar, 1999). In the ‘Miniature Play Room’ play-based evaluation technique, the child is provided with Play Mobil figures with which to choose a child protagonist and adult figures to represent the play therapist and any other adult they choose, for example, a parent waiting for the child during therapy. Similar to the ‘doll’s house’ assessments, a miniature building is provided. In this case, instead of a doll’s house, a miniature playroom is used. Doll’s house furniture and miniature toys are provided. The usual toys of a play-therapy room are represented (e.g. sand and water tray; clay; pens and paper; dolls; animals; cars; ball; costumes). In the first part the therapist/interviewer asks the child to tell them and show them what happens in special play times using the ‘Miniature Playroom’. In the second half of the evaluation a more structured approach is taken. Story stems that reflect the child’s actual experience of play therapy are presented by the therapist/interviewer and the child is asked to complete them. Similar to ‘The Expert Show’, the therapist/interviewer follows a semi-structured interview schedule and guides the child through the process of the play-therapy intervention, beginning with stories about the initial meeting, the first therapy session, and so on. The follow-up study reported below details the use of these techniques in play therapists’ clinical practice.
Methodology
The overall purpose of the study was threefold: to record the children’s views of play therapy; to explore the use of play-based evaluations as new methods to gain children’s views; and to explore therapeutic interactions observed during play-based evaluations from an attachment perspective. This paper focuses on the use of play-based evaluations as new methods.
The study received ethical approval from the Multi-site National Health Service Research and Ethics Committee and from the individual research and development committees at seven separate sites.
Recruitment
The recruitment process involved the following four phases.
Initial training day in play-based evaluations – open to qualified play therapists (n = 33).
Submission of a play-based evaluation training tape and individualised feedback given.
Recruitment of therapists (who had completed phases 1 and 2) to the research project (n = 13).
Therapist participants were asked to invite all children who they saw for individual non-directive play therapy to take part in the study, using the author’s invitation letters, leaflets and consent forms. They were explicitly asked to include both ‘successful’ and ‘unsuccessful’ cases. It is not possible to truly know whether this request was met. However, several cases were identified by the therapists as ending prematurely or being incomplete (n = 27).
Over a two and a half year period, twenty-seven children were recruited to this study, seven of whom were not included in the final analysis due to poor recording, and/or missing sections of tape. Thus, the final cohort of children participating in this study was twenty, drawn from seven non-directive play therapists. The settings included two CAMHS teams (one generic Tier 3 service and one looked-after children service), one EBD (emotional and behavioural difficulties) school, two voluntary organisations, Children and Family Court Advisory and Support (CAFCAS) and one therapist in private practice. There were six female therapists and one male therapist. Nine video tapes were drawn from the same therapist. The remaining six therapists provided between one and three tapes.
There were nine girls and eleven boys. The age range was 5–13 years. Fifteen of the children were White British. The other five were recorded by the therapists as follows: mixed race, Italian/Brazilian, Algerian, Black and Black African/Jamaican. Five children had a statement of educational/learning or EBD and one child had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD). Each child chose or was given a pseudonym.
In Table 1 the length of the intervention for each child is documented. This ranged from 8–40 sessions. A limitation of the data is that some therapists documented both the number of sessions the child received and the length of time in months; however, others recorded only one of these. The type of play-based evaluation method used with each child is documented. ‘The Expert Show’ was utilised in 13 cases and ‘The Miniature Playroom’ in 2 cases. A combination of both of these techniques was used in the remaining 5 cases. The children are listed in order of age.
Research dyads: details of intervention.
Data collection
Therapists sent a video tape of each play-based evaluation session to the author. This allowed repeated observation of the interaction between therapist and child and reduced the intrusion on the therapeutic process. Questionnaires were completed by therapists both before and after the play-based evaluation session. These provided information about the child, the intervention and the therapists’ views of the child’s therapy both before and after the evaluation session. The researcher remained blind to the therapists’ views and information regarding the child, such as presenting problems, until completion of analysis of the observational material. Thus, the children’s therapists’ and the researcher’s views were triangulated.
Data analysis
An essential first stage of the analysis involved watching each video tape from beginning to end and ‘experiencing’ the session, recording impressions on a reflection sheet (adapted from Miles & Huberman, 1994). The tapes were then viewed a second time and verbally transcribed. A third and fourth viewing of the tapes was undertaken and corrections made to the verbal transcription. In addition, transcription conventions were inserted to reflect the sub-verbal content, for example whispering, inflections and pauses (adapted from Heath & Hindmarsh, 2002). Play-based evaluations put as much emphasis on the child’s non-verbal communication – facial communications, gestures and body language and their play and actions with the toys – as their verbal communication. Therefore, it seemed essential to capture this information as thoroughly as possible. The tapes were viewed a fifth time in slow motion, at times frame by frame, to add the non-verbal data, including head nods, smiles, eye gaze direction and ‘performance directions’, such as picking up the phone or manipulating a figure.
Atlas-ti (computer-assisted qualitative data analysis software package) was used as a technical device to support the subsequent thematic analysis (Flick, 2007).The analysis followed three different strands, which are interwoven. The first line of inquiry was the children’s views of their play-therapy intervention; essentially a thematic content analysis. The second major line of inquiry was the therapists’ use of, and the child’s response to, play-based evaluations. The third line of inquiry focused on the interaction taking place between the therapist and child during the evaluation session itself. A significant limitation of this stage of the process was a lack of inter-rater reliability of the codes. However, both manual and computer-assisted coding checks were utilised throughout the process to increase internal validity (see Miles & Huberman, 1994). Data displays including time-frame analyses and case summaries were also utilised.
Due to the necessity of building up a cohort of play therapists who could deliver the play-based evaluations, the author had created a dual role with the therapist participants of both researcher and trainer. She was also a fellow play therapist and founder of play-based evaluations. The author was aware that this was likely to have an impact on the therapist participants, and in turn their behaviour could lead to biased misinterpretations (Miles & Huberman, 1994). To counteract this limitation, the author aimed to maintain a high level of self-reflexivity and employed a variety of methods to record the process of analytical development (see Marshall & Rossman, 1995; McLeod, 2003; Yin, 2003). Case-analysis meetings with a ‘critical friend’ (see Miles & Huberman, 1994) and member checks with therapist participants (Flick, 2007) were periodically employed to provide alternative perspectives. Consultation with a wide range of professionals outside of the field of play therapy assisted the author in considering the use of play-based evaluations from different perspectives and highlighted her own assumptions. This included the multi-disciplinary CAMHs team 1 in which the author works and academics 2 within her university setting.
Results
Children’s views expressed during play-based evaluations
Children were able to express a wide range of views using play-based evaluations. In particular, they expressed a wide range of feelings. They did this through communicating with callers, discussing memories directly with their therapists, acting and using figures in the miniature playroom and introducing their own unique ways to explore their experiences of play therapy. Importantly, children were able to share positive, as well as more difficult, experiences. Their therapists corroborated that many of the views articulated, and the play enacted, directly represented their experience of play therapy. The views expressed by children in this study are reported elsewhere (see Jäger, 2011).
Specific strengths and weaknesses of the ‘Miniature Playroom’ technique
Five children appeared to greatly enjoy using the miniature playroom and were highly engaged in the technique. Three of these children expressed their delight at the similarity between the miniature playroom and the real therapy room. However, two children appeared more ambivalent. Using the ‘Miniature Playroom’ enabled some children to enact their experiences of therapy without a high reliance on language. An example of this was the demonstration of basic reciprocal play between children and their therapists. Two children enacted a child and therapist figure playing together passing a ball back and forth. One child also enacted, and commented upon, the child driving a toy car to his therapist and his therapist driving it back.
A second advantage of the ‘Miniature Playroom’ was the use of props to stimulate children’s memories. One therapist had made a miniature puppet theatre for use within her ‘Miniature Playroom’ kit that replicated the puppet theatre in her own therapy room. This helped to stimulate children’s memories of seemingly significant play sequences (see below). One child wanted to enact playing with the puppets in this theatre. He noted that there were no puppets in the miniature playroom for him to share his story. He was about to integrate this feature of things being missing into the story itself – arguably creating new elements in his story of play therapy based on the here and now rather than his actual experience of the intervention – when the therapist reminded him that they could pretend the puppets he needed were there or make them out of the Plasticine. The child easily incorporated pretend puppets into his story, which enabled him to elaborate on his real experiences of puppet play.
Triangulation of all the child’s communications, be they play, spoken, sub- or non-verbal, along with the therapists’ views (expressed via three questionnaires, one pre-evaluation session and two post-evaluation sessions, one of which was immediately after the session that the researcher remained blind to until her own analysis was complete; the second was a specific email questionnaire regarding points for clarification after the researcher’s own analysis and reading of the therapists’ first two questionnaires) and, lastly, the author’s own observations (of the communication between the therapist and child during the evaluation session), helped to make sense of the layers of meaning in children’s play during the miniature playroom technique. Therapists specifically highlighted in their questionnaires when something the child enacted did not happen in reality but fitted with the child’s themes in therapy or things they wished had happened. For example, one child enacted a grandmother figure attending a review meeting. This had not happened, but the therapist recognised this as a need for this child who existed in a highly isolated mother–child relationship. In addition, children sometimes made explicit direct links between what they were representing in the miniature playroom and their own experience. For instance, one child enacted the child figure painting. His therapist asked him what the therapist figure was doing. The child replied ‘Watching, like you do’.
Specific strengths and weaknesses of the ‘Expert Show’ technique
Children quickly picked up the TV format of the ‘Expert Show’ and demonstrated that they were the ‘experts of play’ by easily getting into role; sometimes more adeptly than the therapists. Similar to the ‘Miniature Playroom’, one of the strengths of the ‘Expert Show’ was children’s enjoyment of the technique. Most of the children remained engaged in exploring their views using this technique for a significant period of time (mean: 34 minutes). The non-verbal analysis, therapist reports and comments from children themselves all corroborated this finding. The technique seemed to appeal to a wide age range from 8 to 13 years. The two eldest children appeared slightly embarrassed (embarrassed smiles, initial avoidance of eye contact, closed body language and mumbled speech) about engaging in role play initially. However, one therapist in particular managed this sensitively and there were observable changes in the child’s engagement with the technique (open body language, increased eye contact, open smiles and clearer speech). Children made good use of the ground rules set up at the beginning of the show enabling them to take a break or pass. Several children were able to incorporate their own creative ideas to communicate their need to pass or take a break into the ‘Expert Show’ format, for example, asking a caller to ring back next week.
A weakness of the ‘Expert Show’ was the dependence on language. The ‘Expert Show’ was used with one of the youngest children in the study (6.1 years). This child’s understanding of the technique was questionable. He passed a high number of times (10; average 3), often saying he did not know or was unsure. Some of his responses were repetitive. He appeared eager to engage in the session but his comprehension of the task seemed limited. His therapist later reflected that she felt this evaluation had been unhelpful. She had reported that this child engaged in projective symbolic play during the therapy intervention and subsequently realised that the ‘Miniature Playroom’ or using puppets may have been more appropriate for his evaluation session.
The relationship with the camera
Most children appeared to enjoy the filming aspect of the ‘Expert Show’. Some children confidently dramatised their roles or made media references throughout the show. For instance, one child pretended to take the microphone and walk around the ‘studio’ giving a ‘moral message’ to the audience. He encouraged his therapist to cheer for him, akin to popular daytime chat shows. Other children grew in confidence at addressing the audience. The camera appeared to help most children enter the role play and ‘speak to the callers’. However, one child demonstrated ambivalence toward the camera. At first this child seemed anxious and concerned about the camera. She then became highly interested in the camera and enacted several different TV show performances and toward the end of the session demonstrated hostility toward the camera, pretending to punch it. Her therapist responded to this non-verbal communication as an indication that the child wanted to end the session.
Combining the ‘Miniature Playroom’ and the ‘Expert Show’
Remaining flexible regarding which type of play-based evaluation was used seemed helpful. A combination of the two main techniques – the ‘Expert Show’ and the ‘Miniature Playroom’ – was used with five children in this study. One therapist invited one of the children to use the miniature playroom whilst on the ‘Expert Show’. This seemed to work particularly well in terms of this child accessing emotionally important memories. When this child was asked by the therapist (who at this time was playing a child caller on the ‘Expert Show’), ’what happens if a child feels sad in the playroom?’, the child began answering by verbally articulating what would happen. She then turned to the miniature playroom (on the ‘Expert Show’ TV set) to pick up the miniature puppet theatre. This visual representation appeared to help her to provide more detail about this emotion laden memory. She recounted going inside the puppet theatre when she was sad, to have a think, and then enact a puppet show for her therapist.
Therapeutic encounters
As suggested in the pilot research, the play-based evaluation sessions often appeared to be cathartic and provided children with a sense of closure. Distinct therapeutic encounters were coded for 10 children in this study. In a further five cases therapists specifically commented on the play-based evaluation being a positive experience, enabling the child to narrate their experience. Three of the directly observed therapeutic encounters are detailed here as they highlight three different themes.
Cathy was a withdrawn and nervous child at the point of referral. Lucy (therapist) noted the change in Cathy’s ability to ‘speak up’ and demonstrate her increased levels of confidence within the play-based evaluation session. Thus, the evaluation session provided Cathy with an opportunity to demonstrate increased confidence and capabilities within the close relationship she had developed with her therapist.
Lee prepared paper for painting and divided one piece to share between him and his therapist, Judy. He handed the paper to Judy and said: ‘so that you can remember me, and I can remember you’. In this case the evaluation session provided an opportunity to process the loss of a close relationship.
Nick was able to facilitate Martin’s exploration of Nick’s dual role as therapist and social worker. Martin had told one of the callers that his therapist might turn out to be a social worker who might take him away. Nick returned to this comment when they sat at the sofa area at the end of the ‘Expert Show’ and asked Martin if that was something he worried might happen when they had been having play therapy together. Martin affirmed this with a head nod. Nick noted in the post-evaluation questionnaire: ‘His (Martin’s) anxieties about being removed from home again has been a dominant element, and one of the reasons for ending the work. I was astonished about how openly he admitted this in role’. Martin’s session appeared to be empowering for him and enabled him to create a narrative about his experience of play therapy. Nick stated:
I was surprised how much it meant to him to be the expert…also that he made comments about feeling strange about the ending of our work – this is the first time he has made any comments and shown appropriate sadness about the end.
Here the play-based evaluation session provided a unique opportunity for the child to begin processing the loss of a close relationship and the end of therapy, and also to acknowledge and process difficulties he experienced within this close relationship.
Contra-indicators for the use of play-based evaluations
Whilst in most cases the play-based evaluation session appeared to be a positive experience and enabled children to share their views of therapy, the analysis highlighted particular issues that need to be taken into account when considering whether or not offering a play-based evaluation session is most appropriate. These include premature endings, and the interaction between therapist/interviewer and child factors; specifically, the therapist/interviewer’s skill/experience level in conducting play-based evaluations and the child’s ability to engage in a directive task. These issues are considered below.
Premature endings
Six children in this study were ending their therapy interventions prematurely. In one case the decision to end play therapy was based on the parents’ needing support. A strong sense of sadness was evoked in this child’s evaluation session. On the one hand the evaluation session seemed to compound these feelings for the child, while on the other it seemed that the evaluation session enabled him and his therapist to construct a narrative of the important experience they had shared. Two other children were ending the therapy due to the need to focus on the parent’s or carer’s issues. The sense of sadness for these two children was less intense and they were able to explore the ending in the context of the evaluation (see Martin above). On balance it seemed helpful for these children to be offered an opportunity to express their views and they were contained by their therapists during the play-based evaluation session.
Two children in this study were transferring from individual play-therapy sessions to filial play-therapy sessions. The fact that the therapy was continuing indicates that these children continued to have a relatively high level of therapeutic need. In the research analysis both children were assessed to be difficult to engage. Their therapists had to provide a high level of permissiveness and flexibility to effectively engage these children.
One child was ending prematurely due to funding constraints and being referred onto another service. This child tried to avoid how difficult ending prematurely was for her by being overly positive and cheerful. Later in the evaluation session she was more explicit about her difficult feelings and informed her therapist that she continued to feel unsafe. However, she shared that she felt that if she was a ‘helper’ (on the TV show) she ‘should be happy’. She clearly stated to her therapist that inside she was not happy. The therapist was at first responsive and soft in her tone of voice. However, she quickly told the child that they could discuss those things later. The therapist returned to being a cheerful upbeat presenter. This led the child to return to her previous stance of being overly positive and cheerful.
It is likely that this child’s expression of her views were more positive than her true feelings. It is suggested that her therapist was not able to respond and contain this child’s difficult feelings in the evaluation session itself, possibly due to the therapist’s own difficult feelings about having to end the intervention. The therapist showed awareness of the child’s process in her post-evaluation questionnaire, stating that the child was ‘jollying herself along to make everyone else feel better’. Furthermore, the therapist felt the child ‘had no other choice’ than to ‘manage the ending’ and she expressed her own strong feelings about this child’s continued needs. It is suggested that the therapist may have found it too painful to think about things still being scary for this child. This was likely to be compounded by the therapist feeling that she was powerless and had no control over changing the decision to terminate therapy prematurely. A similar process was evident for two other children. In one case the therapy was ending due to funding constraints, despite the child’s continued clinical needs, and in the second case the child was moving area due to a foster placement breakdown.
Power and consent issues
It was previously argued (Jäger & Ryan, 2007) that play-based evaluations were likely to reduce the power imbalance between researcher and child. The pilot research indicated that creative use of ground rules in play-based evaluations enabled children to participate as much or as little as they wanted. In this follow-up study, power and consent issues were analysed closely.
The child’s need to please
A need to please adults was coded frequently for some children in this study. This was indicated by the children’s comments and/or behaviour. Therapists addressed this need to please in varying degrees. In general, therapists addressed the child’s need to please more frequently than the child indicated this need. There were four exceptions to this.
In one case, the child expressed a need to please more frequently than the therapist addressed it. However, this therapist did appear effective in the interaction. She frequently addressed this issue and explicitly reinforced this child’s choices.
As stated above, the youngest child in this cohort made positive affirmations in response to the therapist’s questions, which seemed driven by his need to please adults rather than conscious thought-out responses. The therapist tried to seek further responses. However, this was largely ineffective.
One child’s comments centred on being ‘good’ and ‘helpful’ to the child callers who rang in, and remaining positive to help them (mentioned above). This child also displayed sexualised body movements. She had an effusive manner and frequently used a pleasing tone of voice. It is suggested that this child’s need to please adults was an established pattern of relating to others. One of the reasons for referral for this child was sexual abuse and reportedly confusing cultural norms and expectations on her as a female to be pleasing to males. As suggested above, the therapist seemed to find it difficult to respond to this child’s need to please. The child’s need to please was coded 12 times and the therapist addressing this need was only coded once during this evaluation session.
In one evaluation interview the therapist became controlling in the session. The therapist was ineffective in addressing the child’s need to please. The child’s expressed views seemed to be negatively influenced by the therapist’s approach to such an extent that his views could not be considered a true reflection of his experiences (this case is reviewed in detail elsewhere, Jäger & Ryan, in preparation). A low level of therapist/interviewer experience and skill in play-based evaluations was noted, along with a difficult-to-engage child who was ending therapy prematurely due to instability in care arrangements. This case example was an exception in the cohort.
Similar to the pilot research, there were many examples of the children appearing to feel empowered through the process of the ‘Expert Show’. The child feeling empowered was coded 50 times across the 20 children. Six children took on roles in which they interacted directly with the audience and took control of the show at times. For example, one child sat upright and organised the papers on the desk whilst telling the callers how much fun play therapy was. He suggested that child callers would be sent a limousine to transport them to the studio. He smiled and pointed to the badge on his chest in a proud fashion, stating that he worked at the helpline service. He chose to put the callers on speaker phone and sat looking down at the phone with an air of authority. He turned to ask his therapist, Judy, if there was another clipboard that he could have. Judy deferred to Charlie and allowed him to take her clipboard. He referred to himself as ‘Mr Charlie Daniels the expert’ on the audience’s ‘favourite show’
Summary of findings
Strengths and weaknesses
children were highly engaged and enjoyed the similarity of props and the real room;
it promoted the ability to enact experiences non-verbally;
the use of props stimulated children’s memories;
there were not exact replicas of every object (although encouraging pretend play or making props from Plasticine mitigated against this).
children were highly engaged and enjoyed the role of expert and camera (one exception);
it appealed to a wide age range (8–13 yrs);
there was a frequent use of ground rules;
the dependence on language was high (although combining techniques mitigated against this);
older children showed initial embarrassment.
therapists’ intimate knowledge of a child’s sessions and life circumstances facilitated deeper exploration and understanding;
the therapeutic benefits of taking part in an evaluation session included increased confidence, an opportunity to process the loss of the therapeutic relationship, to process any difficulties within the relationship and acknowledge unresolved issues.
Contra-indicators
Premature endings are a contra-indicator if the ending has been difficult for the therapist due to an unplanned ending out of the therapist’s control, for example, funding constraints or child moving placement.
However, if the therapist is more flexible and facilitates exploration of difficult feelings and behaviour regarding the ending, the session can be beneficial.
Power and consent issues
Children appeared to feel empowered by the ‘Expert Show’.
The child’s need to please was coded frequently.
Most therapists addressed the child’s need to please each time it was expressed.
There were four exceptions: In one case the child’s views were still facilitated well. In three cases the session was compromised.
Discussion and implications
The ‘Miniature Playroom’
Landreth (1993, p. 52) states that ‘…toys are like words to children in their efforts to communicate their experiences’. The use of toys in the ‘Miniature Playroom’ certainly enabled children to communicate about their experiences of play therapy. However, as Landreth (1993) points out, the meaning of children’s play is at best a difficult process. In this study, triangulating the therapists’ views with the children’s account assisted the meaning-making process. This supports the argument that therapists themselves should undertake the evaluation, or be consulted regarding the potential meanings of a child’s communications within a play-based evaluation.
A weakness of the ‘Miniature Playroom’ technique was the difficulty in distinguishing whether or not some play was just a reflection of the child’s interest in the ‘new’ toys. Playing with certain toys may have been a reflection of their play in the here and now of the evaluation session, rather than a recreation of their play-therapy experience. Therapists were able to intervene and suggest making toys out of the Plasticine or ‘just pretending’ before the absence of important items influenced children’s stories. Whilst this approach compensates for props or toys that children need not being available, it is more difficult to compensate for the potential impact of the presence of ‘new toys’.
However, the findings from this study suggest that props and toys in play-therapy evaluation interviews with children did enhance their accounts. This supports a previous finding by Sälljö (1997, cited in Westcott & Littleton, 2005). In that study a globe was used as a visual referent to prompt children’s discussion of astronomy. Reportedly, this dramatically improved the process of joint meaning making. In this study, the miniaturised puppet theatre, a replication of a specific item in the therapy room, enabled children to share their views more fully. Investigations into doll play assessment techniques have revealed that close replication of the child’s ‘real world’ produced more identificatory themes (Woolgar, 1999). Therefore, it is suggested that the use of props and toys in play-based evaluations, which directly represent objects the child has had direct personal experience of in play-therapy sessions, enhances the process of joint meaning making. It is also likely that closer replication of the real toys reduces the effect of children being interested in the novelty of toys in the ‘Miniature Playroom’ kit. Closer replication of the ‘real playroom’ is now being emphasised in play-based evaluation training and elimination of distracter items is advocated.
The ‘Expert Show’
Most children were easily able to immerse themselves in imaginative role play in the ‘Expert Show’. Arguably this affords them the emotional distance needed to explore emotionally laden memories. The use of role play is highly accessible for a wide range of children and adolescents, as Forrester (2000, p. 242) states: ‘the techniques of role-playing…are simple and easy to understand, socially accepted and culturally sensitive’. It is likely that several children accessing mental health and therapy services will have experienced dramatic play with their therapists during the intervention itself. Again this argues for children’s own therapists’ undertaking the evaluation session. Helping older children engage in the role play is one of the skills therapists need in order to deliver play-based evaluations effectively. These findings also indicate that for older children adaptations may be needed.
Although the use of role play has been criticised for making it more difficult to extrapolate ‘fantasy from reality’ (Mitchell & West, 1996), the findings from this research demonstrate that triangulation, attention to process issues and children’s non-verbal communication, along with the debriefing stage during the ‘chat-show’ phase, reduce these difficulties. Triangulating the therapists’ views and understanding of the children’s communications with the author’s own observations and analysis and the child’s actual recorded communication enabled the author to explore different possible meanings (see above, and for further discussion Jäger & Ryan, in preparation).
Children displayed a strong relationship and knowledge of media and technology in this study (Jensen Arnett, 2007; Livingstone & Bovill, 2001). Along with the use of play, in the ‘Expert Show’, the link with technology also seems to meet children in ‘their world’ and their culture (see Davis, 1998, for a discussion on the interaction between researcher’s and participant’s cultures). Such techniques have been utilised in therapeutic contexts to connect with children and adolescents (Gallo-Lopez, 2001; Guldner & O’Connor, 1991; Kaduson, 2001; Rose, 1995; Rubin, 2008).
In this study, one child expressed hostility toward the camera and another behaved in a provocative manner toward the camera. In both instances sensitive management of the situation and considered judgement about the potential distress the camera may be causing was needed by the therapists. As Banks (2007) highlights, using video for research purposes can be experienced negatively for some participants and may be met with hostility. Similar to the considerations of video-taping therapy sessions, Banks (2007) points out that some participants may associate filming with danger or control. This is a particularly important consideration in the therapy context (Wilson & Ryan, 2005) and a substitute camera or alternative approach to the ‘Expert Show’ is advocated in such circumstances.
The high reliance on language in the ‘Expert Show’ technique promotes processing that is left-hemisphere dominant. If successful therapy is thought to be a right brain to right brain process (Schore, 2003), then thought is needed on how to incorporate more action-orientated elements into the ‘Expert Show’. This would arguably allow children greater access to their affective states (right hemisphere-dominant activity), as demonstrated by the use of the miniaturised puppet theatre, to further facilitate the child’s expressed view. The findings of this main study, along with the author’s own continued clinical experience of using play-based evaluations, indicate that offering a combination of techniques to children is helpful. Furthermore, integration of other methods during the ‘Expert Show’, such as drawing or photos of the real playroom and toys, is indicated. However, a high level of familiarity and skill in administering both techniques is needed in order for the therapist to manage the differing demands of both techniques. Furthermore, for some children, particularly younger children or those with cognitive impairments, combining both techniques is likely to be overwhelming. For these children the ‘Miniature Playroom’ seems best suited to their needs, certainly in the first instance.
Further research utilising and adapting play-based evaluations in other modalities beyond non-directive play therapy is indicated. The integration of drawing and other ‘real’ items, such as the child’s own artwork, from the therapy process seems particularly important in art therapy, for example. A training manual detailing how to deal with various process issues along with the semi-structured interview schedules has been developed as a result of this research. Ten children who have undertaken a play-based evaluation have been consulted about the methods, including the interview schedules. Their ideas about the wording of questions and further questions to include have been incorporated. Additional schedules adapted to fit a number of other therapeutic interventions have been developed and the author has trained a team of art therapists in their use. The author has also piloted new schedules in ascertaining children’s views of Filial Therapy and The Incredible Years Parenting Programme. Training in play-based evaluations is now being delivered by the author to a multi-professional CAMHS team, including psychologists, and art drama and family therapists, all of whom have prior training in basic non-directive play-therapy skills.
Contra-indicators
Some examples from this study illustrate the need to make a careful assessment of the child’s needs when considering play-based evaluations. It is argued here that it is important to hear and represent the views of all children and not exclude children purely because the therapy has been ‘unsuccessful’ or remains ‘unresolved’ from the therapist’s perspective (as presented by Ryan, 2004). If all children who were finishing their therapy prematurely were excluded, a skewed picture of children’s views would be presented. Furthermore, it is important to hear the views of children who experience their therapeutic intervention being curtailed due to funding issues or other reasons, such as disengagement of the family. Understanding how these processes affect children, and how these can further impact on the children’s views of what they believe may have caused their finishing prematurely or dropping out of therapy, is important to add to our current understanding (see Campbell, Baker, & Bratton, 2000; Kazdin & Mazurick, 1994). As detailed above, providing children with a space to explore this process and narrate their experience when the therapy intervention is ending prematurely can be therapeutic.
However, when the adults’ need for evaluative information overrides the child’s therapeutic or emotional needs, the child’s best interests are not at the fore. Similar to the legitimate reasons highlighted by professionals for withholding consent for children to take part in research in general (Murray, 2005), there are legitimate reasons for children not to take part in evaluation sessions. Flick (2007) reviews the potential impact of striving for quality in research on ethical standards. She points to examples of narrative and life-story interviews becoming overwhelming for some vulnerable participants. This is particularly the case in asking children to share their views of child therapy.
At times, gatekeepers can make decisions to withhold consent for spurious reasons. Similarly, it is important that therapists do not fall into this trap when assessing the suitability of play-based evaluations. Therapists are familiar with making difficult and complex decisions regarding setting up therapy interventions. As Ryan and Wilson (1995) explore, careful consideration regarding the stability of the child’s home environment needs to be undertaken to ensure that the child can make good enough use of therapy. Similarly, therapists need to employ these assessment skills at the end of the intervention and assess each case on an individual basis. It is suggested that this process should not only take into account child factors, but also the therapist’s level of skill and experience with play-based evaluations.
The data from this study suggests that the demands on therapists’ skills are higher when they first undertake play-based evaluations. At this time they are less likely to be able to adapt the protocol to suit individual needs. If the child is easy to engage, then this small sample suggests that play-based evaluations are beneficial and the therapists provide ‘good enough’ conditions to facilitate the child’s views. However, if the child is highly anxious, demanding and/or controlling, it is less likely that the play-based evaluation will be effective with a therapist who is newly trained in play-based evaluations. It has been argued here and previously (Jäger & Ryan, 2007) that it is beneficial for therapists to undertake evaluations with children on their own caseload as ‘insiders’. However, in some cases, where the therapists’ experience in play-based evaluations is low and/or they have unresolved/strong feelings about the ending of therapy, it is suggested that it would be in the child’s best interests for an ‘outsider’ to undertake the evaluation session. Further analysis of the therapists’ part in facilitating the child’s views and their influence on children in the interaction is explored in greater detail elsewhere (Jäger & Ryan, in preparation). An outcome of this analysis has been additional input during the two-day training programme, and the incorporation of specific prompts in the interview schedules on addressing children’s need to please and power imbalance issues. Further research on this issue is needed.
Conclusion
The findings of this study suggest that play-based evaluations are in themselves therapeutic. Several therapists commented that the session enabled children to narrate their experience of play therapy. Their comments suggested that children were able to put into words or otherwise express feelings and processes that they had not previously been able to or not found an opportunity to do so. The benefits of constructing a narrative of one’s life experiences are well known in both the therapy and research literature (see Cattanach, 1997; Vetere & Dowling, 2005).
It could be argued, from a service point of view, that a disadvantage of using play-based evaluations routinely is their time-consuming nature. However, as Gilroy (2006) asserts, it is important for therapies that incorporate play and creative mediums to develop methods that are appropriate to their discipline. Gilroy argues that narrative description and the client’s voice can expose the ‘interior’ of these therapeutic modalities. Play-based evaluations provide the service with meaningful feedback from children, whilst providing the child with an opportunity to engage in a respectful and empowering experience. Children in this study were enabled to share a whole range of feelings they have regarding their therapy. These mixed and sometimes conflicting feelings are arguably missed or confused when using child-friendly questionnaires. Such questionnaires, based on customer satisfaction, often include questions on how children ‘feel about their therapy sessions’ and utilise smiley faces for a positive score and sad or angry faces for a negative score. However, in therapy children experience and express a whole range of emotions. This complexity was captured by the play-based evaluation techniques and provides services with a more comprehensive understanding of the child’s experiences. Children’s rights to share their views of the service they receive should not be solely the duty of participation workers and child researchers. It is argued here that the interview session should be conceptualised as an integral part of the therapy process rather than seen as an additional time-consuming extra. Creating a coherent narrative of life experiences is one of the key goals in many therapies. It seems important to provide children with this space to reflect upon and make sense of their new life experience: therapy. Play-based evaluations can support children in coherently integrating this experience into their ‘life story’, while, alongside quantitative outcome measures, adding to the evidence base for child therapies.
Footnotes
Declaration of conflicting interests
The authors declare that they do not have any conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.