Play Therapy — March 2013
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Incorporating Play Therapy Into An Integrated Model Of Care
Julie Blundon Nash, PhD, LP, RPT-S

Community health centers were designed to meet the primary health needs of uninsured and underserved populations with a goal of providing comprehensive health care without creating financial burdens on patients while avoiding overutilization of emergency room visits for preventative conditions (National Association of Community Health Centers, 2012).<br /> <br /> I work with the Community Health Center, Inc. (CHCI) located in Connecticut as a psychologist and play therapist. CHCI has created a model of interdisciplinary care that includes provision of medical, dental, and behavioral health services under the same roof for people of all ages, and has received the highest-level certification as a patient-centered medical home by the National Committee for Quality Assurance. This integrated model of care is intended to provide coordinated services for those who need it, when they need it, and where they need it, including within a number of schools and homeless shelters in the state. These three core disciplines work together with more specialized providers including nutritionists, diabetes educators, prenatal and lactation services, podiatrists, and chiropractors to provide comprehensive treatment to our patients. Providers work closely together, not only through the use of shared electronic medical records, but within an integrated physical workspace where ongoing consultation and discussion is encouraged.<br /> <br /> Within the behavioral health department, providers consist of psychologists, social workers, psychiatrists, psychiatric advanced practice registered nurses, social work interns, and postdoctoral psychology residents. While many providers are capable of treating the entire age range, many specialize their skills; yet across the agency of 75 behavioral health providers, I am the only Registered Play Therapist. However, other child clinicians are extremely supportive of play therapy and have experience with using play therapeutically, while medical and dental providers have little to no knowledge of this specialized field.<br /> <br /> Play therapy is a versatile treatment and has been effectively utilized with clients who are homeless and facing significant economic stressors (Baggerly & Jenkins, 2009), as well as clients who are dealing with significant medical issues (Shapiro, 1995). Play therapy has also been integrated into evidence-based treatments like Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT; Briggs, Runyon, & Deblinger, 2011). As many clients, especially children, who utilize community health centers are facing all of these issues and more, it stands to reason that incorporating play therapy into such a model is important and necessary. One goal I continue to strive for in my daily work is to expand the understanding and use of play therapy within this setting, as well as the community as a whole. The following six points are ways that I strive to introduce play therapy to a variety of health care disciplines, as well as outside community agency workers. Some are quick and easy changes to a regular routine, while others require an ongoing commitment to implement.<br /> <br /> 1. Use your credentials in your title.<br /> <br /> In my setting, the behavioral health staff consists of psychologists, social workers, psychiatrists, and more. Introducing yourself as a behavioral health clinician does not designate your specialty, nor does it provide an easy transition to a conversation about play therapy. In addition to using my title when I introduce myself, I include my Registered Play Therapist designation on my email signature and phone message. This provides my credentials with a great deal of exposure throughout the day as I contact medical providers, dental providers, a variety of staff members at the Department of Children and Families (DCF, Connecticut’s child welfare agency), police officers, resources at outside agencies including schools and treatment centers, and many others who may not have heard about play therapy. In fact, the first day I included my RPT on my email signature I received a number of inquiries about the credential and what that meant I could offer their clients.<br /> <br /> 2. Talk about play therapy and its benefits whenever possible.<br /> <br /> I try to use every opportunity I can find to discuss the benefits and applications of play therapy, particularly because I work with an underserved population who does not always have access to specialized treatments. Many of the children I see are facing multiple significant stressors in their lives that are well above their developmental coping levels, and they can benefit from play to help them sort through their experiences. Our model of care is particularly well suited to real-time consultations with medical and dental providers, and play therapy offers them another option for ongoing care of their patients. We also provide developmental, mental health, medical, and dental evaluations for children who removed from their homes within the past 30 days by DCF. These two aspects of my job allow me to provide recommendations for children across the age range facing a variety of stressors, adjustment issues, and more significant mental health concerns. By simply pointing out how play therapy can provide therapeutic support and facilitate areas of potential growth for a child, I have been able to educate professionals across a wide range of disciplines about the power of play. Through this ongoing exposure, medical and dental providers, DCF workers, and police officers have been learning to ascertain when a play therapy referral may be appropriate. It has been wonderful to see dental providers make referrals for children with anxiety over being in a treatment chair, medical providers identify trauma or abuse histories and recommend play therapy, as well as to see play therapy included in ongoing treatment plans through DCF.<br /> <br /> Another way I have found to introduce play therapy is through seminars and supervision with postdoctoral psychology residents. Many of these residents have had no formal (or even informal) introduction to play therapy concepts, and some mainly focus on work with adults. This is a great opportunity to explain how the benefits of play therapy across the age span and to help them begin to recognize the power of play in all of their work.<br /> <br /> An easy way to promote play therapy with mental health colleagues is to discuss what you have learned at national and regional play therapy conferences. Often there are workshops specific to the needs of your site, including evidence-based practices, supervision support, techniques, and theoretical applications that usable with your population of interest. I bring back whatever information I can to share with others and talk about ways to incorporate these ideas into our model of care.<br /> <br /> 3. Be clear about what play therapy is and what it is not.<br /> <br /> When introducing play therapy, I inevitably receive the response of “So you just play with kids?” I admit, I was thrown off the first time I heard this, but I have since worked out my own brief definition of play therapy and its benefits. For example, I discuss play as the way that children interact with their world and how they communicate. I mention that play therapists have gained training in learning how to understand these unspoken words, and utilize theoretical models to understand the whole person, much like in traditional talk therapy. Playing with a child can be therapeutic, but it is not what makes play become the therapy. It is necessary to be open and transparent about these issues with anyone you speak to, including referral sources, parents, other agency workers, etc. The “Why Play Therapy?” brochure from APT can be a wonderful resource in this setting, as it gives people something tangible to remind them of the benefits of play therapy.<br /> <br /> 4. Translate what you see and do in sessions.<br /> <br /> I have found this to be one of the more important things that I do to promote play therapy, and one of the easiest to overlook. Parents who are watching your sessions and other providers who are referring clients do not attend to the same things you do when a child plays. By making some of the emotional undertones more overt or commenting on which therapeutic power of play seems to be most utilized or needed during a session, I give the observer a chance to become part of the therapy. Not only are they seeing the play in terms of “real therapy,” they are more able to understand the child and his or her needs. Helping the adults to see what you do also helps spread information about the power of play therapy and the importance of integrating it with other models of care.<br /> <br /> 5. Use play therapy themes and applications in your documentation.<br /> <br /> Our treatment plans need to include measurable goals, so the addition of some play therapy specific outcomes is easy when I include items such as reducing the amount of time spent in repetitive play or using play to show a number of positive coping skills. In terms of documenting my sessions, I can include progress on the treatment goals, observed play themes, current mental status, suicidal and homicidal ideation, play materials used, referrals needed, and many other details outlined in APT’s Play Therapy Best Practices guidelines (Association for Play Therapy, 2009).<br /> <br /> 6. Research or write about your experiences with play therapy with various populations.<br /> <br /> Few references exist that discuss the use of play therapy with populations typically seen within a community health center (i.e., Ginsberg, 1976; Lewis, 1986; Reece, 2008). Articles usually point to theoretical models utilizing play, techniques that could be helpful, or how to incorporate play into evidence-based models like TF-CBT (Briggs et al., 2011). It is then up to therapists to determine the best way to integrate this knowledge into their field of practice. There are multiple benefits to publishing and enhancing the literature about play therapy within a community health center or your setting. Not only do these references enhance the overall understanding of the efficacy of play therapy, but they can also serve to help educate senior leadership about how play therapy should be considered as on the same level as other treatment modalities in terms of necessity and available support.<br /> <br /> Conclusions <br /> <br /> Overall, I believe that introducing play therapy to other providers within the community is important, and as such, I consider incorporating play therapy into an integrated model of care is an important aspect of my work. I see the positive effects it has on children and families throughout my day, and look forward to sharing those effects with other providers. By sharing information about play therapy more clearly, I invite the possibility of more discussion and ongoing referrals, thus having an opportunity to help more families and spread the understanding of play therapy. There are some very easy ways to promote play therapy in our daily work, including simply talking about what we do and being open about sharing our observations, treatment strategies, and play therapy recommendations.<br /> <br /> References <br /> <br /> Association for Play Therapy. (2009). Play Therapy Best Practices. Retrieved from cfm?ID=28051 <br /> <br /> Baggerly, J., & Jenkins, W. W. (2009). The effectiveness of child-centered play therapy on developmental and diagnostic factors in children who are homeless. International Journal of Play Therapy, 18(1), 45–55. Doi: 10. 1037/a0013878. <br /> <br /> Briggs, K. M., Runyon, M. K., & Deblinger, E. (2011). The use of play in trauma-focused cognitive-behavioral therapy. In S. W. Russ & L. N. Niec (Eds.), Play in clinical practice: Evidence-based approaches (pp. 168-200). New York, NY: Guilford Press.<br /> <br /> Ginsberg, B. G. (1976). Parents as therapeutic agents: The usefulness of filial therapy in a community mental health center. American Journal of Community Psychology, 4(1), 47-54. Doi: 10.1007/BF00881001 <br /> <br /> Lewis, K. G. (1986). Systemic play therapy: A tool for social work consultation to inner-city community mental health centers. Journal of Independent Social Work, 1(2), 33-43. Doi: 10.1300/J283v01n02_04 <br /> <br /> National Association of Community Health Centers. (2012). About our health centers [webpage]. Retrieved from http:// <br /> <br /> Reece, S. T. (2008). Sandplay supervision in a community mental health center. In H. S. Friedman & R. R. Mitchell (Eds.), Supervision of sandplay therapy (pp. 113-125). New York, NY: Routledge.<br /> <br /> Shapiro, D. E. (1995). Puppet modeling technique for children undergoing stressful medical procedures: Tips for clinicians. International Journal of Play Therapy, 4(2), 31-39. Doi: 10.1037/h0089146<br /> <br /> About the Author <br /> <br /> Julie Blundon Nash, PhD, LP, RPT-S, is the Foster Care Clinic Coordinator at the Community Health Center, Inc. in Middletown, Connecticut where she helped to develop and coordinate its Psychology Postdoctoral Residency. She has authored play therapy book chapters, serves on the New England APT board of directors, and is a Play Therapy magazine reviewer.