Eliana Gil on Play Therapy and Working with Traumatized Children

Eliana Gil: I think that there are so many misunderstandings about play therapy. I have a very good friend who always says, “I can see where the play is, I just don’t get where the therapy is.” In other words, I think because play is such a generic activity – a worldwide activity – and people are so used to children playing in the parks and the playgrounds, that it is very difficult for them to think that such a spontaneous behavior can have any therapeutic benefit.

So, I always say to people that play inherently has some very curative qualities, as Charlie Schaefer has discussed so well. Play gives kids the ability to solve problems, to pretend, to compensate for feelings that are very difficult to express, to have fun, and to delight in. All of those are really positive things and it’s clear that play tends to release endorphins. You’re also forming bonds with the person that you’re playing with. So, there are all kinds of inherent qualities that a child is engaged in when they’re using play.

When kids come to a therapeutic relationship there’s a relational piece that’s built in where the therapist is viewing the child’s play and interpreting that play in a different way than an untrained person. A therapist is going to look at the child’s play with a different lens and begin to interpret it as the child’s way of releasing emotions or trying to process things that are difficult for them to express because they may be worried about something or they may be feeling conflicted about something.

In other words, I think what ends up happening with kids when they come into that therapeutic environment is that there’s an expression of things that are very internalized that begin to make their way out into the open so that therapists can learn about them. I always trust that whatever is on the child’s mind will come forward – and that if we give them specific kinds of props then there are things that are really going to be much more amenable to symbolic play. What we’re trying to do is gain an understanding of something that’s internalized and that children may not have words for. So, again, the context of a play therapy environment is much more structured than free play, and the therapist is focused on the child’s play in a different way than you would be if you were simply playing with a child.

Free play tends to have very few goals. I think the intent when you’re doing play therapy is to advance certain goals that have to do with a child’s growth, or removing obstacles that they may be experiencing towards development, or helping them deal with traumatic events that they can’t figure out what to do with except they have big feelings or they have thoughts that they can’t really make sense of. So, the therapeutic relationship is intended to help create this environment of trust and comfort so that the child can do some of the things that they will do naturally if given the time, space, and proper context. 

EG: Yes. That’s a really good question. I think that for the most part it has to be somebody who feels really comfortable with children who can find some benefit of their own in the experience of sitting with a child. I think they have to be relationally-oriented and comfortable with connections that are emotional. It’s interesting because you meet so many different kinds of play therapists. Every now and then I say, “Wow. It’s hard to believe that they do play therapy.” When I say that it’s usually because I find a person who is a little bit more rigid in her thinking or looks a little bit physically uncomfortable or shy, and yet that same person with a child could be completely different, you know?

I think many of our play therapy colleagues are by nature very playful, maybe take more risks, and think a little bit more openly. I also think that they are oftentimes well-prepared. I think that play therapists can get a little bit defensive about the potshots that come about “it’s not a credible field,” or it’s “hocus pocus.” I think because of that we tend to be more serious about how we prepare ourselves for the job. Mostly now I see the young people wanting more and more courses, and even more and more certificates in this and that, and they really want to prepare themselves to do the best job that they can do. But the qualities that I seem to think of when I think about the play therapists I know are flexibility, and the ability to be warm, connected, emotionally present, and playful with the child.

EG: Yes. I remember this very clearly. My first internship was at the Children’s Trauma Center in Oakland, California. All of those children had very severe experiences of physical abuse and neglect. One of the first kids that I got was a little boy who had been malnourished. So, he was really small, he didn’t look well, and he had been in the hospital for a few months. He was now going into a foster care placement. I remember feeling like I wanted to do the very best job that I could do. I had no idea really what I was doing or what to expect, I just had read so much about him and already had so much empathy for him. I remember that he walked into the room and just grabbed me around the knees and just wanted to hug me.

I didn’t know what to do, and was just patting him on the back. Then he grabbed my hand right and wanted to walk me around the room. I hadn’t been in the room enough to really see everything and it was interesting to see the things that he was pointing out. But eventually he got over to a little kitchen and he wanted me to sit down. Then he sat in front of that kitchen and started making soup with a spoon and then he wanted me to open my mouth and eat the soup. So, there was I was going, “wow,” I didn’t quite even have enough time to think about what was happening.

I just was so amazed by the fact that he immediately found what he needed to do, and that this was so important to him, and that he was immediately showing me the things that were on his mind and they had to do with the fact that he was malnourished, and he hadn’t been given enough food, and he was completely over-focused on food. So, for the next few months, this was his play. It was about making the food and about feeding me. Eventually, he became the person that would be fed, but it took awhile for him to allow himself to be in the position of showing that he was hungry or wanted to be fed. It was an amazing process to behold – my first experience with being led through this room with this little child who eventually just knew exactly what he needed to do and really was able to show me what he needed from me right away. From then on, I was just completely hooked.

I couldn’t wait to get back in there and started having all of these fantasies about should I bring real food in, or should we make this, or what should happen? It was very interesting because he eventually wanted to be given a bottle. So, there was a baby bottle, and then we were feeding the baby bottle to the babies, and then suddenly he started sucking on the baby bottle, and then he wanted to come into my lap and suck on the baby bottle. I remember having so many questions at that time about should I let this happen, is this okay, or is he getting regressed. It was such an amazing first case for me to have.

Luckily, I had a woman supervising me who wasn’t necessarily a play therapist, but definitely knew a lot about children’s behavior and some of the ways that they acted out some of the traumas that they had endured, and so she was completely willing to follow the child’s lead and to deal with my questions and anxiety about whether this was helping the child. She just kept saying, “Eventually, you’re going to trust that this is going to be helpful to the child.” I was in a program where they let you see the child long enough, so I worked with the child for something like two and a half years. It was so gratifying just to see this child eventually be able to receive the nurturing he needed from his foster parent who eventually adopted him, and to watch him act out all of the changes in the play that he was going through.

It was incredible, but it all came out through the play because he really was very much language-delayed given the fact that he had so much neglect in his early life, so the play was really how he spoke and how he showed me everything that was important to him. The relational aspect of play therapy was in the forefront because it was clear to me that there was a lot of countertransference that was going on. Luckily, as I said, the supervisor was able to help me navigate through all of that. That was my first and my most memorable play therapy experience.

EG: I agree with you that, yes, I think we need to be creative and promote expression in almost any therapy that we do. But I think that it is the utilization of some of the creative arts that some therapists simply don’t choose to do. There are so many. For example, I got my doctorate in family therapy and I saw some of the most creative family therapists in the world. They were verbally creative. I mean, I remember Peggy Papp and some of the family therapy sessions that she would do. She would get people up and she would do family sculpting. There was so much creativity involved in that.

However, if you said to them anything about, “Well, you know, maybe we can do some artwork during the therapy,” there was less of a tendency to want to do that because the emphasis was so much more on verbal communication and people just didn’t feel as comfortable. Oftentimes, they would say, “Well, I don’t know what to do after somebody makes a piece of art.” I would watch, for example, some of those family therapists put the kids – little kids like under six – sort of in a corner, give them a paper and pencil, and ask them to draw something or just kind of be quiet while the therapy took place with the parents. If the kids were older, they were very interested. There’s so much creativity, for example, in circular questioning and different things that family therapists do, but the kids were in the corner making these pictures. I was always interested in pictures they made. You know, let me go through that trashcan and see what they threw out.

So, I think it really is a different focal point. It’s saying I value the artwork that people can create, I value the process of doing it, and I value the product that they come up with. I think it has therapeutic benefits to allow people to engage in those activities and then to process those activities. It’s a different kind of punctuation, as it were.

I love watching movement therapists because they get people off the seats. And then suddenly they access a different kind of energy that’s available when you start doing that. In music therapy now, there’s so much research that’s indicating that it can be really incredibly therapeutic for people. Then there’s the access issue – that a lot of people feel, “Well, I can’t do that because I’m not trained to do that.” So, there’s a little bit of that separatism with each of those fields valuing that modality so much that there’s coursework required and practicums required. For example, to become a drama therapist, which my daughter recently became, you have to really study a lot about the history and development of drama as therapy, and how it is utilized in contemporary circles, and how it is different from psychodrama.

There’s a ton of stuff there that I don’t know anything about, but I watch her do it and it’s just – it takes your breath away because it’s punctuating the therapeutic process a little bit differently and it is valuing an activity or some kind of creative process in a different way. So, we, as play therapists, tend to do that with play. One of my little pet peeves is that almost every person that I know that works with children will have toys, papers and markers in their room, but the purpose of those things in the room is so much different when you’re trained as an art or a play therapist.

So, I really encourage people to decide how they actually even say what they’re doing because I think unless you’ve been really trained to be an art therapist you should say you’re doing art or using art in a therapeutic fashion, which is true. But to be either a trained play therapist or a trained art therapist, you are privileging that activity in a different way and you think of that as where the therapy is happening, not as a mechanism to get to a therapy process. I see so many people – they’ll get kids to start a painting and then as soon as kids are like spreading the paint around, they say, “So, how are you feeling?” 

EG: Yes. “How are you and your mom doing this week or weekend?” So, what you do is you interrupt the process that art therapists consider so valuable because it is right hemisphere of the brain activity. So, you’ve actually invited someone to be in that area of their brain where there is symbol language, metaphor, and all this really important stuff going on, and suddenly you crash in with a question and you’re asking them to shift into this cerebral activity of responding to you. Now, you’re not doing either verbal therapy well or art therapy well. The same applies in cases of play therapy.

EG: Exactly.

EG: You’ve got it.

EG: Yes. One of the things that became very clear to me being in the family therapy field before I got into child therapy was this lack of connection between, “hey, we’re here to work with the grown-ups and the older kids,” and the people mostly in the child development field who were seeing kids individually and/or with their parents. It just felt like this real disconnect where the family therapist didn’t feel comfortable with kids and the play therapist often didn’t really want the parents in the room. So, that was one of those bridges that I really felt needed to be built between those two fields. So, I started making a concerted effort to teach family therapists how to do play therapy, how to invite younger kids into their meetings, and vice versa with the individual play therapists to consider the possibility of dyadic work with parents and kids.

I started thinking about activities that could be done in systemic work and family play activities that could be brought in to invite everyone to engage. Thus, family play therapy was one of the things that I felt really was the connecting bridge, and there were simple things that could be taught to family therapists and to play therapists that could actually engage this systemic point of view and/or the expressive point of view. So, I totally see that. In the process of doing that, of course, I always invited everyone who was living in the home and that meant some of the grandparents and other people who happened to be staying with the families. So, I worked with a lot of people that were seniors, as it were.

The one thing I haven’t done which I think would be a wonderful thing to do is to actually go into senior centers. I know that that’s being done. I know that some of the senior programs that I’ve visited with my mom do playful activities, they do bingo, and they have balls that people throw around. I’ve seen video examples of these kinds of things. I think that would be a wonderful thing to interject because laughter is really important, as we now know, for the whole system to kind of get re-energized. I think it was Patch Adams who first started talking about the healing power of laughter and play. So, I think that that’s wonderful to incorporate with seniors.

EG: Yes. Those are really good questions. I have seen an evolution over the last 10 to 15 years about this particular question. I was concerned about was the defensiveness that came with this debate. In other words, those of us who are in art therapy or in the expressive therapies obviously were defensive because the research hadn’t been done and maybe can’t be done as well. I mean, I think CBT, for example, is one of the easiest things to research because it is such an obvious protocol, you apply it, and then you see what the outcomes might be. But art and music? I mean, that’s a little bit more difficult to figure out.

Over the years, though, something interesting has happened. I think that it’s been good for us in the play therapy world because it has prioritized some of us doing research in play therapy, especially trying to figure out a way to do it when you’re not in an academic setting. So, doing some of the smaller research studies is useful and it’s valuable for us as therapists to put on that other hat and say, “We can accumulate some data.” It may not be the gold standard of a research study, but we can do something, and we can contribute something. So, that’s happened. I think there’s been a shift to incorporating the collection of data or data analysis when that is at all humanly possible.

But I think the other thing is that some play therapists really took on this whole notion of trying to get the evidence support that we as a field need. So, I feel really comfortable now that the play therapy research has really advanced a lot. So, that’s all good. I think that’s positive in the end for all of us. For example, Parent-Child Interaction Therapy has a component of psychoanalytic play therapy. Theraplay was just recognized by SAMHSA as being evidence-based and now, filial therapy looks to be evidence-based at this point because people have been doing research for quite a while.

There has been sort of a movement towards “let’s put an external stamp of approval on this,” but it legitimizes everything we do in a way. It has rippling effects into the larger play therapy field. So, I do think that we can all pretty much say now that we’re using evidence-based and practice-informed types of play therapy 

EG: Well, yes. In some of those. Now, in others – I think in Theraplay, obviously play is what it is all about – play and relationship – and I think filial therapy as well. But these other two that are a little bit more recognized outside the play therapy field – the child-parent psychotherapy as a model for working with domestic violence. CBT was originally designed to work with physically abusive parents, as I remember. But those are a little bit less connected to the play therapy world, and yet they are being recognized, valued, and they have a big inclusive piece that is play therapy. So, I think that’s interesting, but here’s where we are at. I think everybody is feeling a little bit settled, a little bit more able to justify what they do, and so I think that’s all good. It worked in the right direction.Then, just as a final comment, trauma-focused cognitive behavioral therapy, which many people were calling the gold standard for working with sexually abused children, is now a hybrid. 

EG: I’ve heard TFCBT people say that it’s a hybrid model. So, they use art, play, narratives, etc. to make the whole program a little bit more accessible to children. I think that’s interesting, too, that you can field test something, you can research it, and there’s a protocol that was researched. I think we’re very far away from using that rigid of a protocol anymore. I think that most people who use TFCBT are using it in ways that they have found is more accessible to the clients that they work with. But nevertheless, insurance companies and counties want to pay for is anything that is evidence-based, so there has been a financial push towards getting these evidence-based programs into effect as well.

EG: Well, it’s funny that you use the word free because I think by definition a traumatic event sort of traps the person. The person experiences helplessness, no options, and vulnerability, and young children really don’t have the cognitive ability to sort out what just happened, what meaning does it have, and what does it explain about that person, or me, or whatever it is that’s going on. Language is problematic for young children in terms of being able to both perceive and then report out what just happened sometimes because they don’t have the language skills, but other times because they sense that this isn’t something you speak about – that there’s something about it that remains sort of in secrecy and they may be encouraged or threatened to keep something secret.

So, for all of those reasons, they’re really not free. They don’t feel free to come forward to knock on someone’s door and say, “Hey, you know what just happened to me?” It’s a very complicated kind of situation, especially when it is interpersonal trauma in the family. Now, we’ve got to add to all of the things I just said the relational issues with the person you love, or the person that takes cares of you, or the person that you’re dependent on. It gets extremely complicated. So, I think what play does is allow a child to come forward to take whatever that big feeling, or that big thought, or whatever that language might be and somehow externalize it so that it’s out here and he or she can look at it and the therapist also can at least take in what the child is showing.

So, for example, one of the phrases I always use with kids is “You can tell me, or you can show me in whatever way you want.” That’s a really important little thing that goes a long way because if you just say to kids things like, “Yes, and then I’m going to just ask you some questions,” or, “And then you get to talk to me about that,” that’s inconsistent with what they’re in a position to do at that moment in time. So, to say instead, “You can just show me in whatever you want – you can draw about it, you can play about it, or any way that you want to show me,” doesn’t feel like so much pressure on the child. Just being able to give them that message that you can work at your own pace, I’m not going to ask you a bunch of questions in here, and you can show me what’s going on inside of you – that is it.

Then I honestly do believe, as I said earlier, that they’ll bring to you whatever is on their mind or whatever big question or big feeling they have. I have a little kid who came in – this is just a little example, but I must have hundreds of little miniatures on shelves for doing sandtray work. This little girl had just been removed from her mother and she for some reason she zoned in on a mother kangaroo that had a joey in her pouch. What she did in the therapy – and this was a little four-year-old – what she did immediately was she took the little joey out and buried it. The rest of the session she was walking this mother kangaroo around the room going, “Where’s my baby? Where’s my baby?”

I just thought, “Oh, my gosh, this is exactly what’s on her mind.” Is she going to be found? Will her mother find her? Is her mother looking for her? How’s her mother doing? All of that separation stuff was immediate. That was this remarkable ability that toys have to speak to children and for them to speak with the toys. So, I’m just absolutely a believer that given this environment of calm and inviting kids to look around and see what they want to see – that eventually they’re going to show you whatever it is they need. I trust them to do that. 

EG: Yep.

EG: It’s funny that you say that about that initial case. I now trust that process a whole lot more because I’ve seen it so many more times, but even then there was a little quality that I was trusting that something good was happening. So, I think that that’s part of it – you’ve got to believe in the value of the things that you’re offering. I take a child into a play therapy office and I feel like, “Okay, I’m doing the very best thing that I know for this child right now. I know this will be in some way beneficial. Whether he can start doing it immediately or it’ll take him some time to do it, I believe that he will pace himself, and that he needs to slowly walk towards the things that he fears, and that sometimes we push him too hard.”

Some of the programs that involve psycho-education for kids in the first few meetings to me seem like…

EG: Yes, they’re not really taking it in, and they’re probably just nodding their head, but I don’t know that they’re really getting it. I also really believe in that neuro-sequential model of therapy – the thing that Bruce Perry does where he says, “You know, you have to really think about the functioning of the brain. When you meet a kid for the first time, what are the parts of the brain that are most activated at that point?” If you’ve got a kid who is scared to death, it’s the brain stem, right? So, it wouldn’t make any sense for me to start talking to that child. I have to first make sure that they can self-soothe or that they can somehow comfort themselves. So, I might be more willing to blow bubbles with that child than to sit there and say, “Let me tell you what we’re going to do,” because as Bruce says, “I mean, cognitive behavioral therapy is great, but you’ve got to wait until that part of their brain is online and that’s usually later.” They’re not usually online immediately.

So, that part has really kind of helped support some of what intuitively I was doing without really understanding why. It’s wonderful when work comes out that really supports everything you’ve been doing. Bruce of course values TFCBT or any kind of cognitive behavioral work. He just says that it has to be done at the right time. He says that he never starts with that. That’s something that I would say, too – that that is not my go-to. It could be a long-term goal or certainly a goal in the third phase of treatment, but not necessarily where I would start.

EG: Yeah. I think over the years what we’ve been able to identify is that children who have traumatic experiences oftentimes have this resource available to them which is called post-traumatic play, which is a literal acting out of the things that have occurred in a very miniaturized way. It has some very distinct features. Oftentimes, it is incredibly repetitive, so the child is initiating and completing the play in the same fashion over, and over, and over again. Sometimes you see differences in how kids are interacting in that play. There’s very little joy or spontaneity and it almost looks very structured and very rigid. Again, I think that this is the child’s desire to bring this experience out, and then to be able to start seeing it gradually, and eventually be able to feel things associated to it in a safe environment, and be able to use what is more typical in play therapy like pretend play, to incorporate some changes into the play and some new options and possibilities.

This process ends up unfreezing some of the play and helping that child move beyond the rigid memory of what happened into maybe what they wished would have happened or seeing a part of what they did as resilient or fighting back. But there’s some real opportunities here for movement for the children in this miniaturized and externalized play where they’re really projecting stuff and eventually showing that they can go beyond what happened into what is more normal for kids, which is compensatory play, or pretend play, or something where they change the end of the story just because they can and that begins then to free the child up.
So, it’s a beautiful process to behold and it is very much self-initiated. There are times in therapy where you might want to “tickle the defenses,” as Carl Whitaker used to say, and provide kids with some of the literal symbols if they’ve had a specific traumatic experience. That sometimes helps them initiate the play. I’m pretty sure there are some kids who can’t access this play for a long time, so they may look very different in a play therapy situation. They may look unresponsive or as if there’s “not much going on,” and then they may eventually be able to do post-traumatic play. So, one of my goals with kids who have been traumatized is always to facilitate the environment of the relationship so that they can eventually start doing post-traumatic play because I think it can be such a release for them. 

EG: Yes, exactly.

EG: Most of the kids who do get into the door with an interpersonal trauma – boy, have they been already interviewed by people, asked a million questions, and had to meet four or five new people. So, that’s why if you can do child-centered play therapy initially, if you can take all of that pressure off and alleviate the sense that the child has to provide immediate information, then I think then the child can begin to relax a little bit and eventually access their own healing resources.

I’m really interested how people self-repair in any catastrophe or tragedy. I’ve been interested to see how in different cultures, people pray and sometimes sing together. I remember in the streets of New York after 9/11 they started these drama therapy programs where people would come together and do these little plays. After the tsunami in Sri Lanka, I was really struck that some of the children would actually go pick the rubble up and create little villages. So, that reconstructive task of putting together that which was destroyed, I mean, that’s one of the benefits of play, right? There were the kids doing that and then sometimes they would destroy it and put it back because that was what had happened. But it’s beautiful to behold prayer meetings and just all of the different ways that people came together to draw pictures and paint things after tragedies, to both acknowledge and express all of the different ways that things had affected them and then how they had responded to it.

EG: There you go. There you go.

EG: I completely agree with that and understand that. That’s why with kids we have this great ability to just invite them into lots of different kinds of things. We just recently got our first animal assisted therapist and I can’t wait. We had been doing an equine program and to watch the kids with the horses was amazing. There’s a lot of research that shows that these are mechanisms for healing. There are going to be a lot of therapists who are going to say, “What? How is that different from having a dog at home?” I know there’s skepticism for almost everything, but we have to keep inviting people in lots of different ways because you don’t know what their way is going to be.

EG: Yes, absolutely. My structured play activity is tennis and I play a lot of it. But I just pick up things. Like my new thing is stone art. So, I’ve been going on walks with the dog and I pick up stones and now I’m making this art with the stones and I’m really, really, really enjoying that. So, I would say, yes, playfulness and – gosh, you should see me with my grandchildren. 

EG: That’s a treat for me. Then a lot of the Theraplay activities I love with the kids. Whenever I have groups of people in the house I’m always wanting to do something Theraplay-based because I just think it is so much fun. So, I love charades. I’m really good at charades. We do a lot of stuff like that when we get groups together. My kids are great that way, too. They know they are coming to play.