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Models of Play Therapy
Play therapy can be divided into two basic types: nondirective and directive. Nondirective play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy. Both modes of play therapy have received at least some empirical support. On average, a child suffering with an emotional or behavioral difficulty that is treated with play therapy will improve functioning at 0.80 standard deviations than children who are not treated with play therapy.

Nondirective Play Therapy
Nondirective play therapy, also called client-centered and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. Thus, nondirective play therapy is regarded as non-intrusive. The hallmark of nondirective play therapy is that it has few boundary conditions and thus can be used at any age. The principles under which this therapy operates originated in Carl Rogers's non-directive psychotherapy and in his characterization of the optimal therapeutic conditions. Virginia Axline adapted Carl Rogers's theories to child therapy in 1946 and is widely considered the founder of this therapy. Different techniques have since been established that fall under the realm of nondirective play therapy, including traditional sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms is covered briefly below.

Traditional sandplay therapy and its development are attributed to Margaret Lowenfeld, who established this technique in 1929. As in traditional nondirective play therapy, the notion is that allowing an individual to freely play with the sand and accompanying objects inside the sandtray will facilitate the healing process and be therapeutic to the unconscious. When constructing the sandtray, little instruction is provided and little to no "talk" therapy on the part of the therapist is give. This protocol emphasizes the importance of the non-verbal free play in this therapy. Upon its completion, the patient may talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may provide guidance. After a number of sessions, the therapist may provide interpretations. This is also often used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also observance by the therapist of a family working together on a sandtray may show evidence of unhealthy alliances, depending on who works with who, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships. Parents may sometimes conduct this nondirective play therapy with their children while a therapist observes. It has been shown that therapy conducted by a parent produces a larger treatment effect than play therapy conducted by a therapist.

Using toys in nondirective play therapy with children is another common method therapists employ, a method which was derived from the creative toys used in Freud's theoretical orientations. The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalization of their feelings. Through these actions, then, children may be able to experience catharsis, gain more or better insight into their consciousness, thoughts, and emotions, and test their own reality. Popular toys used during therapy are animals, dolls, hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to encourage dramatic play or creative associations, both of which are important in expression.

Efficacy of Nondirective Play Therapy
Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years. Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as cognitive behavioral therapy. They also argue that therapists focus more on the institution of play rather than the empirical literature when conducting therapy Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies of play therapy included small sample sizes, which limits the generalizeability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment. Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.

To date, research is lacking on the overall effectiveness of using toys in nondirective play therapy. A study done by Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during nondirective play therapy were not more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checker game. There is also ongoing controversy in choosing toys for use in nondirective play therapy, with choices being largely made through intuition rather than through research. It has been shown, though, that following specific criteria when choosing toys in nondirective play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and leads to play that can be easily interpreted by a therapist.

Several meta analyses have shown promising results toward the efficacy of nondirective play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for nondirective play therapy. This finding is comparable to the effect size of 0.71 found for psychotherapy used with children, indicating that both nondirective play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups. These results are stronger than previous meta-analytic results, which reported effective sizes of 0.71, 0.71, and 0.66. Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with nondirective play therapy. Results from all meta-analyses indicate that nondirective play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.

There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes. Although positive effects can be seen with the average 16 sessions, there is a peak effect when a child can complete 35-40 sessions. An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child. Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behavior problems. Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.

Directive Play Therapy
Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist, then, plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself. Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities. This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy.

Directed sandtray therapy is more commonly used with trauma victims and involves the "talk" therapy to a much greater extent. Because trauma is often debilitating, directed sandplay therapy works to create change in the present, without the lengthy healing process often required in traditional sandplay therapy. This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives.

Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate. Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of Beck's cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy. In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children's verbalizations in these interactions but rather on their actions and their play. Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists in order to change children's maladaptive thinking.

Efficacy of Directive Play Therapy
The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have. Similarly in 2005 meta analysis by authors Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while nondirective play therapy had an effect size of 0.92. Although the effect sizes of directive therapy are statistically significantly lower than those of nondirective play therapy, they are still comparable to the effect sizes for psychotherapy used with children, demonstrated by Casey, Weisz , and LeBlanc. A potential reason for the difference in the effect size may be due to the amount of studies that have been done on nondirective vs. directive play therapy. Approximately 73 studies in each meta analysis examined nondirective play therapy, while there were only 12 studies that looked at directive play therapy. Once more research is done on directive play therapy, there is potential that effect sizes between nondirective and directive play therapy will be more comparable.