do children need play therapy?

DO CHILDREN NEED PLAY THERAPY? BARNEY KATZ

Norwalk - La Mirada City School District, Norwalk, California

It is my contention that very few emotionally disturbed children need to become involved in therapeutic play to help them overcome their emotional difficulties. This conclusion is drawn after twenty-fi<e years of private practice in the field of clinical child psychology and seventeen years of experience as a consulting clinical psychologist to a school district of approximately twenty-five thousand elementary school children. During this period, I have worked with some thirty-five hundred children in the schools, and some twenty-five hundred children in private practice- a total of about six thousand children.

I a m thoroughly convinced that very f e w emotionally disturbed children need this type of therapy. In fact, I ain convinced that relatively f ew emotionally disturbed children need any type of direct psychotherapy. Rather, parents of emotionally disturbed children need proper child guidance. Let me explain why I believe as I do.

Seventeen years ago, in 1947, I became affiliated with a City School District as their consulting clinical psychologist. A t that time, we established a Guidance Center to hclp parents and teachers solve children’s problems as they related to school and family life. Based on sound psychological principles, the guidance program has developed highly successful techniques and concepts for hclping school children overcome their emotional problems, improve their personal and social relationships, and achieve greater academic success. In essence, the guidance program is designed to help these disturbed children grow into normal, well-adjusted adolescents and adults. Our method in helping children with their social, emotional, and academic problems, is through working primarily with parents. In resolving these problems, we also enlist the cooperative efforts of teachers, principals, and other school personnel. We involve ourselves, however, mainly with parents.

The vast majority of all parents are uninformed, untrained, and undirected in their relationships with children. For the most part, they are confused in rearing, managing, and guiding them. This is not to condemn or blame parents; rather it is an attempt to evaluate and help them. The facts are clearly evident. As children grow up a large number of them become anti-social, alcoholic, suicidal, neurotic, and psychotic. It is well known that these personality disorders have their begin- nings in childhood, primarily in the area of the child’s interpersonal relationships with his parents.

It therefore stands to reason that if parent-child relationships can be improved, children can become more emotionally stable and grow up to be reasonably mature and adjusted adolescents and adults. Our experience in dealing with parents of emotionally disturbed children confirms our contention that parents can be helped to rear emotionally stable children. Counseling the parent (preferably both parents) is the most effective means of helping the emotionally disturbed child. The child, however, does not personally become involved in any type of direct on-going psychotherapy.

When a child is referred to the Guidance Center, usually by the teacher, the case is initiated by the guidance consultant who contacts the parents and apprises them of the special guidance services available. The parents then voluntarily ar-

114 BARNEY KATZ

range for a series of consultations with the clinical psychologist. The special needs of each child determine the frequency of conferences with the parents-most often they are scheduled bi-weekly.

A case study is made on each child referred to the Guidance Center. The guidance consultant meets with the parents in the child’s home (which is preferred), in the consultant’s ofice a t school, or in the Guidance Center. The case history in- cludes health and physical development, social and educational experiences, family background, environmental conditions, and such other factors that may have been significant in influencing the child’s personality development. It is during this initial interview that the consultant endeavors to establish rapport with the parents and gain their joint cooperation in obtaining guidance for their child. At the end of the meeting, the consultant attempts to arrange an appointment for both parents, if possible, with the clinical psychologist at the Guidance Center.

The parent conference with the clinical psychologist is a loosely structured meeting. The immediate objective of the psychologist is to dispel any guilt feelings that the parents might be harboring in regard to the child’s problems. He then explores the nature of parent-child relationships, marital relationships, personality patterns of each parent, health factors, neighborhood conditions, and the child’s previous school experiences and adjustment.

Counseling with the parents is a continuing conferencing process. It is primarily a re-educative program. The counseling sessions are designed to give the parents a better understanding of the ego-needs and emotional structure of their child. Discussions center primarily around improving parent-child relationships, especially in the area of discipline and management. I a m personally convinced that the major single factor causing a young child to become elnotionally disturbed i s f a u l t y parental discipline. Negative and inappropriate measures of discipline cause the child to develop strong feelings of insecurity, inferiority, and guilt. These feelings are the roots of his emotional disturbance.

Let me present a typical case that was referred to us in October, 1958. George, age 6-1/2, was referred to our Guidance Center by his 1st grade teacher with the following complaint: “George cannot conform in and out of the classroom. He does not follow rules and regulations. He is very aggressive to other children-teases, calls them names, spits and hits them. He is destructive of the furniture in the room and the belongings of others. He has frequent temper tantrums and lies on the floor kicking his feet and screaming a t the top of his lungs.” George had been having a great deal of difficulty in adjusting to the school situation. After six weeks of schooling had shown that George was not going to “settle down,” the teacher suggested to the parents that they seek guidance. The parents accepted her recommendation.

According to the mother, George started school in another district as a Kindergartner a t the age of 5-1/2 years. On the third day of school, the mother was called in for a conference with the principal because of George’s extreme non-conforming behavior. His behavior did not improve and after four weekv of schooling, he was excluded from school. The parents decided then to keep him out of school for the rest of the year hoping that George would “grow out of it.”

The mother gave the guidance consultant the following information: George weighed 7 pounds a t birth. He walked a t 14 months, talked a t 20 months, and was weaned at 15 months. Toilet training was difficult. He obtained bowel control at 3-1/2 years. He was still enuretic-wetting his bed every night. He was a chronic thumb-sucker and blanket-twister (he sucked his left thumb and twisted the fringes of his blanket with his right hand) A sleeping problem developed at age 2-he would not go to sleep at bedtime. They would scold him severely and when that didn’t work, they would spank or shake him. It would be 10 or 11 o’clock before he settled down to sleep. They were still having difficulty in getting him to sleep. Every night he had to take a sleeping pill to get to sleep.

George was a healthy child. He had no serious childhood illnessas. He had a mild case of measles at 3 years and the chicken-pox a t 4 years. A t 4-1/2 years he slipped in the bathroom and hit his head on the tile floor. He suffered a slight concussion but did not lose consciousness. His pediatrician reported that there were no indications of any brain injury. An EEG tracing showed no abnormal signs.

George was very difficult to manage since he was 2 because he was stubborn, demanding, and destructive. On several occasions, his temper outbursts reached violent proportions. He was subject

DO CHILDREN NEED PLAY THERAPY? 115

to mood swings; a t times he was cooperative, congenial, and outwardly happy. Most of the time, however, he was tense, irritable, negative, and hostile. Because of his hostile attitude and aggressive behavior George had a great deal of difficulty in getting along with other children.

The father, a man in his early thirties, was a building contractor. He liked his work and had a good income. He would work long hours, seldom getting home before seven o’clock. He worked every Saturday and occasionally on Sunday. He was represented by the mother as a man who was difficult to satisfy-perfectionistic and self-centered. He was very strict and punitive with George. He was quick to criticize and condemn. 111 his eyes, George was a “brat,” a “nuisance,” and a “delinquent.” He rarely showed any demonstrative affection to George and spent very little time with him.

The mother, a woman in her late twenties, admitted she had been over-indulgent, over-pro- tective, and overly-permissive with George. Hecause of father’s severe attitudes, she would try to compensate by being “good” to George. She had rarely punished him but often threatened to “tell father” on him. She indicated that she had always beeii a very high-st,rung and nervous person. When she would get upset with George, she would often start crying-telling him how “ungrateful” he was to upset her so.

The parents admitted they had beeii unable to agree on how to discipline their children. There were two younger siblings: a girl age 3, and a boy age 1-112. Father believed in “using the belt” and making his children mind. Mother was against corporal punishment but disciplined them by isolating them to their room or depriving them of some privilege. Father was unyielding in his attitude. He would never admit he was wrong and never apologized to any of his children. Mother, on the other hand, was quick to “give in” especially when George threw a severe tantrum. In trying to cope with his misbehavior a t home, the parents had attempt,ed every known method of discipline-punishment, threats, scoldings, bribery, pleadings, and nagging. Nothing worked. They were at a complete loss as to how to handle him.

The family lived in their own home in an above-average neighborhood. George had a room of his own while the younger siblings shared a bedroom. The home was very tastefully furnished. The guidance consultant who visited in the home had commented “the home was beaut,iful-but the emotional climate was cold.” Although the parents stated that there were no serious difficultim in the marriage, there was much friction and dissention. Father was i1nhapp.y about how mother managed the house, and mother was unliappy about how father treated the children. As a married couple they had very little time to themselves and rarely socialized with other people. Father was wrapped up in his work and mother tied down with her children.

The parents were fairly well educated. Father had completed two years of junior college and mother had one year of business college. They were very interested in their son’s education and were willing to do everything they c:ould to help him with his schooling. In their conference with the guidance coiisiiltant t1ie.v stated that t,hey had started a savings accouut for his college education and had purchased aii expensive encyclopedia for him.

Both parents vame to the first guidance conference. They were congenial, cooperative, and talked freely. The father initiated the discussion by stating he was very appreciative of the help t,he school was giving George. The c:onferenc:e was primarily a “get acquainted session.” I listened to their story of their tlifiiculties with George a t home and how disappointed they were in him. They were worried that there WLLS possiMy something wrong with his brain since he had a rather severe head injury at 4-1/2 years of age. I mentioned to them that George’s behavior patt,erns appeared to be signs of an emotional disturbance rather than of a brain injury. To dispel any doubts, I suggested a neurological examination including ail EEG t,raciiig be done in the near future. On the assumption that George was reacting to an insecure feeling, we explored several possible causes to account for his emotional distrirtxmce. We focused on father’s long working hours and mother’s highly nervous state. A t the dose o f the conference I recommended that they take home a book from our lending library. I suggested a book spec:ific:ally written for parents hy D r . Frank Richardson, a psychologically oriented pediatrician, entitled, “How to Get Along With Children.” An appointment was made for a second conference two weeks later. An appointment was also made for George. Mother was to bring him in for a fifteen-minute period the following day. George arrived a t the appointed time. He entered my office without. hesitation and pulled his chair closer to my desk. He was a personable and attractive yoiingster. He opened the conversation by stating, “You’re the school doctor.” “That’s right,” I k w e r e d . “What hrings you in to see me, George?” “My mother said I had to come because I didn’t mind the teacher and I was fighting with the other children.” We spent the period by casually c:hatting about his behavior in school, his TV programs, and his pets. I closed the session by asking him if he would like to come back to see me again and he said he would. On the way out I gave him several pieces of candy and he was delighted.

Both parerit,s returned for their second conference. They returned the book stating that they had enjoyed it and learned a great deal from it. They wanted to know how George was doing in sc:hool. “Not very well,” I told them. “In fact,” I continued, “I have discussed his behavior with th; teacher aiitl the principal and we all agree that George would benefit from a shortened school day. “What (lo you mean, a shortened school day?” asked the mother. “We want George to come to school only for the morning session,” I answered. “He is always more restless and hyperactive in the after- noon arid has more trouble with the other children. His important subjects are in the morning so he won’t really lose any schooling.” I assured them that his school hours would be extended as soon as he showed some improvement. The parents accepted this recommendation. His limited school program was to start the following day.

A t one point the father stated, “It says in the book that parents shouldn’t punish their children.

116 BARNEY KATZ

How are we to discipline George if we aren’t su posed to punish him?” “There are more effective ways to discipline a child than by punishment,” f stated. “Actually, punishment is the very poorest way to discipline a child. Not only is it the poorest way, but it actually harms a child; punishment makes a child feel anxious and insecure.” “How is that?” he asked. “The remons are these: The purpose and design of punishment are to teach a child to mind and obey the parent through fear and suffering.” I continued, “When you spank a child, send him to his room, or take away his TV for a week, you are teaching him to fear you. What you are actually doiFg is this: You are saying to him, ‘You had better mind me or next time I’ll make you suffer more. As a parent, you are making him afraid of you. And as he becomes afraid of you, he starts to resent you. Here we have the begin- nings of an insecure child. Furthermore, you are not actually teaching the child right from wrong- rather, you are teaching him to fear you-to fear the suffering and pain that you will give him if he does not mind you.”

“DO you mean that children should never be made to suffer?” the mother inquired. “Yes and no,” I explained. “k-ou should never deliberately plan to make your child suffer. There are times that he will suffer because of his actions. Let me give you an example. Supposing George rode his bike across a busy boulevard that he had been warned not to cross. In this instance, you could rightfully take away his bike for two days and tell him you hope that denying him his bike will help him learn to be careful where he takes it. He will probably suffer those two days. But this suffering will not make him insecure-it will have no effect on his personality. You were not making him afraid of you. And you did not plan to hurt him or make him suffer. The suffering came as a result of his own actions. We call this-suffering the consequences of his behavior.”

“How does this differ from punishment?” the father asked. “In this way,” I continued, ‘*you would be punishing George if you spanked him or took his TV time away from him. By these measures you would be deliberately planning to make him suffer and fear you. Actually, hitting him or taking away his TV has absolutely nothing to do with his bike riding. There is no connection whatsoever between what he did and what you are doing to him. Mind you, I said to him. When you took his bike away, you were doing something for him. When you spanked him, you were doing something to him.” “I can see the difference, now that you have explained it,” he stated. The remainder of the conference was devoted to an evaluation of the concept of punishment and its very damaging effect on the child’s personality.

Two weeks later both parent8 returned for their third conference. “I’m sure I know another reason for George’s troubles,” was mother’s opening remark. “Go on, I’m interested,” I replied. “It’s my hollering and nagging at him,” she went on. “Since our first discussion with you several weeks ago, I’ve been examining my actions and reactions. This week I have been very much more aware that I do a good deal of hollering and a lot of nagging.” “This could very well be one of the causes,” I countered. We then went on to evaluate the detrimental effect of an angry, nagging parental voice. During the course of the session the father admitted to losing his temper with George, often for trivial matters.

I opened the fourth conference with the parents with a casual question, “Well, how are things progressing with you folks?” “George is showing a more cooperative attitude at home. He now goes to bed willingly. Only once since we were in last has he given us a bad time at bed-time. He also had a dry bed this week. I am sure that George is getting better.” “I feel sure he is improving because I am improving,” chimed in the mother. “There has been no hollering and very little nagging during the past two weeks.” she continued. “I think we are all getting along better,” added the father. “I can see where the children are getting along better with each other. There has been much less fighting and quarreling between them.” The remainder of the session was devoted to Ribling relationships. We discussed sibling rivalry, jealousy, and how children take out on each other the angry feelings they harbor toward the parents.

During the following conference, the matter of consistency was discussed. It was pointed out to the parents that i t was essential for parents not to contradict each other in front of the child. Very often the mother may find it difficult to remain silent when the father is disciplining the child, especially if she believes the discipline is unjustified or too severe. But while the child is present, she must remain silent. She must not undermine his authority and the child’s respect for it by countermanding what he has said to the child or by arguing with him about it. When this is done, it is extremely confusing to the child. If the mother must say something, she should wait until the child is no longer present and then discuss the matter with him. The same holds true with the father if the mother is doing the disciplining. I strongly emphasized that as parents they should always try to be consistent in their rules, regulations, and limits they place on their children.

At the next conference, the parents brought in a medical report from their ediatrician. George had no evidence of any organic disturbance. His EEG was normal, his PBI was aEo within the normal range. The physician’s report concluded with the following statement, “George’s behavior must be stemming from an emotional disturbance. I can see no organic basis for his hyperactive and nervous condition.’’ The parents were relieved by this report and I assured them that George was going to improve. During the conference, the mother mentioned the fact that George had become increasingly more disrespectful in the past weeks. “He tells me I’m stupid, he yells a t me to ‘shut up,’ and he makes faces at me,” she complained. “What am I supposed to do?” “Just grin and bear it,” I replied. “His ability to express himself freely to you is actually a good sign. It is a sign that he is no longer afraid of you. He is now able to express his deep resentments. It is like pus coming out of a sore.’’ “But what am I supposed to do when he talks th3t way?” she asked. I answered with, “Just reflect to him that you understand how he feels. Say to him, ‘George, I know you’re upset, I know how you

“We can see some improvement,” reported the father.


feel. You can say anything you feel like saying. Go ahead and tell me more.’ I’ “But isn’t this being disrespectful to his parents?” interrupted the father. “It appears to be disrespectful,” I continued, “hut it isn’t disrespect a t all. We know he is upset inside. We know he has these mean and hostile feelings locked up inside of him. The more he can expTess these bothersome feelings, the better he will act.” We spent most of the remainder of the session discussing what takes place when a chdd continues to choke down his hostility. At the end of the conference, I recommended an outstanding book that deals with the child’s deepest and innermost feelings; a book that he1 s parents in handling a child’s hostile and aggressive attitudes and behavior-by a clinical psycgologist, Dr. Dorothy Baruch, titled, “New Ways in Discipline.”

At, the sixth conference, two months after the case waa initiated, the parents reported that George was considerably improved. He waa much more cooperativehe was going to bed without balking, and he hadn’t wet the bed in two weeks. I informed them that we had received a favorable report from his teacher yesterday. George was more attentive, more conforming to school rules, and relating better to the other children. She recommended that he be placed on a full sch 01 program the following week. They made an appointment for George so that I could tell him he wosd be starting a full school day again. The conference was mainly devoted to reviewing and evaluating some of the important changes in interpersonal relationships at home. Because of the steady improvement, the parents were to come in for their next conference in three weeks. This arrangement, conferences every third week, continued for the remainder of the school year. George continued to improve emotionally and socially at home and in school. In their last conference (June) the parents reported that George was no longer a serious problem a t home. He was more cooperative, had milder temper flareups, had made a few friends in the neighborhood, and had stopped wetting the bed. I offered them further guidance conferences in the fall if they wished to continue with counseling.

On returning to the Guidance Center in September, 1959, I learned that the mother had arranged for a conference. Both parents came to the conference and reported that George had greatly improved through the summer. The mother complained that they were having a marital problem. The father was considering having his widowed mother come to live with them. Most of the conference waa devoted to a discussion of this problem. In light of the progress George was making, another conference for the parents was scheduled in a month. Regular monthly conferences were arranged for the remainder of that year. A report from the teacher preceded each parent conference. These reports continued to be more and more satisfactory. The teacher’s final report stated that all of his academic work was at grade level. Behavior-wise, he needed to make better use of his time, participate more in group activities, and refrain from teasing the girls. She did not consider George a serious problem. He was promoted to the third grade.

The following school year (1960-61) saw the parents arrange three visits with me. George continued to improve in the clas?.room, on the playground, and at home. His report card a t the end of the school year showed satisfactory grades in conduct and above grade level in academic subjects. For the next three years, the parents conferenced with me twice a year-after the first parent-teacher conference in November, and again after the spring parent-teacher conference. Their laat conference with me was held last April. The parents were very pleased with the way George had progressed. He was cooperative and considerate; he had a paper route; he was on a little league team; and he wm a leader in his Boy Scout troop. The report from his sixth grade teacher waa equally good. He related well to the other students; was elected to the Safety Council; was one of the top students in clys. George is ready for the intermediate school. There is every indication that he will make a very s a t w factory adjustment.

For the past seventeen years, I have worked with hundreds of similar cases. In nine out of ten cases, the child eventually makes a reasonably good personal and social adjustment in and out of school. There are reasons for this improvement. These emotionally disturbed children readily respond to changes in parental attitudes, disciplinary techniques, and marital relationships. As a rule, it takes most parents from three to six months to make some basic changes in their attitudes toward their children and in the methods and techniques of managing and guiding them. Some substantial improvement in the child’s emotional stability and behavior patterns can be observed in from three to nine months. For example, a first grade child who is unable to conform to school rules and procedures is appreciably improved in the second grade; an aggressive third grader who cannot get along with his peers is noticeably improved in the fourth grade; a school phobic child in Sep- tember, is attending school regularly in February. Most of these parents report similar improvement a t home. The non-conforming child is abiding better to the limits set at home; the aggressive child is more cooperative and friendly at home; the school phobic child is eager to go to school and unafraid to leave home.

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As parents improve in their interpersonal relationships a t home and as their children become more emotionally stable, the Guidance Center conferences are spread further and further apart. Parents are scheduled for conferences once a month, once in six weeks, and once in two months. Eventually, most parents “graduate” from the Guidance Center. They acquire sufficient “insights” and apply their “new learning” so effectively that they are no longer in need of our services. In some instances, parents are counsclcd for several years. They have access to the Guidance Center as long as their child is in school in this school district.

Emotionally disturbed children of every type and nature have been referred to our Guidance Center through the years. We estimate that about ninety per cent of the children referred to us become sufficiently emotionally stable to make a reasonably good personal and social adjustment in and out of school. With improvement of interpersonal relationships a t home, sometimes assisted by changes in teacher-pupil relationships, and occasionally aided by environmental changes, the child responds by a change in his feelings, attitudes, and behavior patterns. As a result, the non-conforming child becomes more cooperative, the hostile child more friendly, the anxious child more confident, and the quiet child more sociable. Sim- ilarly, the tense child bccomes more relaxed and such tension symptoms as thumb- sucking, nailbiting, bcdwetting, and facial and bodily tics disappear.

I have attempted to point out that parents of emotionally disturbed children can, through guidance and counseling, help their children become reasonably well- adjusted individuals. Essentially, these parents are helped to understand the emotional make-up of their child. They learn what will make him feel insecure, what will make him feel inadequate, and what mill make him feel guilty. The conferencing process is designed to help them change their interpersonal relationships with their child, or children. They are encouraged to acquire certain attitudes, practice certain techniques, and relationships, and urged to avoid others. In the main, parents are encouraged to:

Accept the child as he is Express demonstrative affection Give individual time to each child Remove excessive pressures and unrealistic demands Practice firmness and avoid strictness Express friendly caution and avoid harsh threats Permit suffering from logical consequences and avoid punitive measures Correct the child in regard to his actions and avoid criticizing him as a person Upgrade and praise the child when possible; avoid downgrading and de-

Set reasonable limits, that is, rules, regulations, and boundaries; avoid being

Avoid unfavorable comparison with siblings and other children Avoid overprotection and oversolicitousness Avoid nagging Encourage the child to verbalize his hostile feelings; but do not permit him

preciating him

overly-permissive

to injure others or be destructive of property

At times a child’s emotionally disturbed state is due primarily to the parents’


marital discord. When the climate in the home is charged with friction and resentments, or with open hostility, of one or both parents, the child will react with tension and anxiety-often with hostility. Children are very sensitive to the feelings and attitudes that their parents express to each other. A large number of parents who consult us have marital difficulties and many of them openly discuss them in our conference sessions. Most of them can be readily helped by brief marriage counseling. In some instances the marriage problems are so severe that they are in need of long-term intensive marriage counseling. These couples are referred out to clinical psychologists and psychiatrists trained in marital counseling.

After a quarter of a century of extensive clinical experience with all types and degrees of emotionally disturbed children, my strong convictions are that: (a) few emotionally disturbed children need any type of personal, direct, or individual psychotherapy; (b) only the severely disturbed children, usually those with character disorders or pre-psychotic conditions, are in need of personal, direct, or intensive psychotherapy; (c) emotionally disturbed children can benefit from, but do not necessarily need, play therapy; and (d) nearly all emotionally disturbed children can best be helped by parent education and guidance in regard to their interpersonal relationships with their children.

EDUCATION AND BEHAVIOR PROBLEM CHILDREN: SOME TRENDS AND SOME PROBLEMS’

ROGER REGER

Wayne Community Schools, Wayne, Michigan

There is an urgent need for clarification of issues in the education of children with behavior problems. While public school programs for them are rapidly expand- ing at the present time there has not been an adequate discussion of curriculum and goals appropriate for the public school setting.

The term behavior problem children refers to those children who present management problems, either because of excessively active and uncontrollable behavior or because of excessively withdrawn or “nonparticipating” behavior. These children frequently are “diagnosed” as being emotionally disturbed, socially maladjusted, neurotic, delinquent, and so on.

RECENT TRENDS There appear to be at least four major trends in conceptions and programing

for behavior problem children at the present time:

1. Permissive-SentimentaE School First is the trend which perhaps has the longest history, dating back to G.

Stanley Hall’s development of the child-centered approach to education in the late 1800s and early 1900s. As president of Clark University from 1889 to 1920, Hall

‘Chapter in School Psychology b y Roger Reger. Springfield, Ill.: Charles C Thomas, 1965.

do children need play therapy?

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