International Journal of Play Therapy, 12(1), pp. 31-47

Copyright 2003, APT, Inc.

STRUCTURED PLAY THERAPY: A MODEL FOR CHOOSING TOPICS AND ACTIVITIES Karyn Dayle Jones Montserrat Casado E. H. "Mike" Robinson, III University of Central Florida Abstract: This article presents a model to be used for structured play therapy. Structured play therapy is a form of play therapy that is directive and uses planned, structured activities in almost every session. This model was developed to provide a framework for appropriate timing and sequence of structured activities. This article describes structured play therapy and how it differs from nondirective play, presents a structured play therapy model, presents specific guidelines for choosing appropriate structured activities and exercises, and presents a case study demonstrating application of the model.

The majority of therapists work with children in a variety of settings including schools, mental health agencies, hospitals and private practices. Many therapists use a form of play therapy in which they present specific activities or exercises using various play media to address issues important to the child's therapy. This therapy is known as structured play therapy. Structured play therapy is directive and uses planned, structured activities in virtually every session. Unlike nondirective play therapists, therapists using structured play are both director and facilitator of the therapeutic process and assume the responsibility for choosing session topics and activities. They use structure to create the play situation to lead the child in directions that are seen as beneficial in therapy. Karyn Dayle Jones, Ph.D., is an Assistant Professor in the Department of Child, Family and Community Sciences at the University of Central Florida. Dr. Jones may be reached for questions regarding this article at: Department of Child, Family and Community Sciences, College of Education, University of Central Florida, Orlando, FL 32816-1250, or by e-mail at kiones(a),pegasus.cc.ucf.edu. Montserrat Casado, Ph.D., is an Assistant Professor in the Department of Child, Family and Community Sciences at the University of Central Florida, Orlando, FL. E. H. "Mike" Robinson, III, Ph.D., is a Professor in the Department of Human Services and Wellness at the University of Central Florida, Orlando, FL.

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Therapists who use structured play need to choose activities that are developmentally appropriate to the child, address the child's issues, and focus on the goals of therapy. In addition, a critical yet often overlooked task of the therapist is the sequencing of session topics and structured activities. The timing of topics and activities is essential in helping children address important issues without forcing them to face an issue when they are not ready. Although a wide variety of exercises and activities based on various counseling theories exist for counseling children, little information is found in the literature that provides a model or framework for therapists to follow to choose and sequence session topics and activities for structured play therapy. The purpose of this article is to present such a model. This article will: (a) describe structured play therapy and how it differs from child-centered or nondirective play; (b) present a structured play therapy model; (c) present specific guidelines for choosing stage appropriate structured activities and exercises; and (d) provide a session-by-session example demonstrating the application of the structured play therapy model. STRUCTURED PLAY THERAPY

Structured play therapy is quite different from the prevailing approach of nondirective play therapy, or child-centered play therapy (Sloves & Peterlin, 1994). Child-centered play therapists depend on the skills of tracking, paraphrasing, reflecting feelings, returning responsibility to the child, and setting limits (Landreth, 1991; Landreth & Sweeney, 1997). They avoid skills that involve leading the child in any way, including interpretation, designing therapeutic metaphors, bibliotherapy, and other more directive techniques (Kottman, 1999). In contrast, the structured play therapist's role is both director and facilitator of the therapeutic process. Therapists use structured play to focus attention, stimulate further activity, give approval, gain information, interpret, or set limits. A variety of play media is used to create the play situation, "attempting to elicit, stimulate, and intrude upon the child's unconscious, hidden processes or overt behavior by challenging the child's defense mechanisms and encouraging or leading the child in directions that are seen as beneficial" (Gil, 1991, p. 36).

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One of the first theorists to describe structured play therapy was David Levy (1939). He formulated release therapy, a structured play therapy approach. In release therapy, Levy determined the cause of the child's difficulties through case history, and then he controlled the play by providing selected toys to help work out the child's problem (Frost, Wortham, & Reifel, 2001). Gove Hambridge (1955) further developed structured play therapy. He believed in using the structured approach only in relationships already established through nondirective play therapy. He disapproved of flooding or pushing the child to release strong, negative feelings; rather, he advocated starting slowly with less threatening materials and progressing to more threatening materials. Similar to Hambridge's (1955) work, many therapists use structured activities as an adjunct to nondirective play therapy. For example, after the child has gained safety and trust in the nondirective play environment, the therapist may introduce a structured activity to address a particular issue. Various theories of play therapy, including Adlerian, Gestalt and cognitive-behavioral, subscribe to both directive and nondirective approaches (Knell, 1997; O'Connor & Schaefer, 1994). Often times, therapists are strictly directive and use only structured activities when counseling children and adolescents. Vernon (1999) suggests that structured exercises can be effective with many children and adolescents, but especially with reluctant clients. Structured play is most appropriate for older children and adolescents, approximately 7 years of age and older, who have the cognitive development to focus on and process the structured exercises. Younger children may also lack the attention span and concentration needed to follow through on various directive activities. Since structured play therapy focuses primarily on symptom relief and the central theme that underlies the child's difficulties, the therapist develops a plan for each session, designs specific structured activities, and selects the appropriate play materials that address the child's symptoms or difficulties. Structured activities come from a variety of sources and theoretical orientations. Examples of structured activities include books and stories, drawing, painting, finger painting, collages, arts and crafts, imaginative pretend play, puppets, dolls, role-plays, sand-play, clay, checklists, worksheets, games, self-composed songs, poems and stories. Structured play therapists are responsible for facilitating and accelerating the process of therapy; therefore, they need to choose session

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topics and activities that focus on the theme of therapy without triggering maladaptive defenses, e.g., inappropriate, ineffective or selfdestructive coping behaviors. In fact, one of the primary concerns about using structured play therapy is the therapist focusing on issues that the child is not ready to face. Hambridge (1955) suggested that the types of play activities should be introduced based on a gradient of potential threats to the child. The structured play should start with less threatening material and move slowly to material that would be more threatening to the child. In addition, much thought and consideration is necessary in choosing appropriate activities based on the client's issues and goals of therapy. The therapist does not, simply out of a compulsion for thoroughness or fear of incompleteness, use forms of play media unrelated to the client's problems (Hambridge, 1997). The therapist needs to have a rationale for every activity chosen for the client. STRUCTURED PLAY THERAPY MODEL

In order to plan each session and select appropriate materials, structured play therapists need a model to follow that provides guidelines for the appropriate selecting and sequencing of session topics and activities. The model needs to be based on the process of structured play therapy. Process refers to the client's movement or change that occurs during the course of treatment (James, 1997). Most of the descriptions about play therapy process vary depending on theoretical orientation. To create a model based on the process of structured play therapy, the authors drew upon stages of play therapy developed by Sloves and Peterlin (1994) in their work with time-limited play therapy (a form of structured play therapy) and cognitive-behavioral play therapy (Knell, 1997). The three stages include an opening stage, a workingthrough stage, and a termination stage. This model would be most effective with children ages 7 and older. Using the three-stage process, this model was developed as a means to help therapists choose activities and exercises appropriate to the stage of structured play therapy (See Figure 1). The model consists of two axes with a bell curve design. The Y-axis is labeled as intensity and the X-axis is the number of play therapy sessions. The vertical lines splitting the X-axis in thirds represent the three stages of structured play therapy process. The model demonstrates that as therapy progresses

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from the first few sessions to the halfway point, e.g., from the beginning stage to the middle stage, the intensity of the sessions increases to its highest point. Then, as the therapy aims towards termination, the intensity of the sessions will decrease. Intensity is defined as the extent to which the session topic, structured exercises and techniques do the following: (a) evoke anxiety in the client; (b) challenge the client to self-disclose; (c) increase awareness; (d) focus on feelings; (e) concentrate on the here and now; and (f) focus on threatening issues (Jones & Robinson, 2000). Because of the structure inherent in structured play therapy, the topics and exercises, planned by the therapist, help determine and affect the level of self-exploration or intensity. Thus, therapists must first be able to assess session topics and structured exercises in terms of intensity (e.g., Does the topic or activity evoke anxiety in the client? Does the structured exercise challenge the client to self-disclose?); and second, therapists must develop the sequence or order of the topics and activities. Therapists planning structured play therapy sessions would choose topics and activities that are less intense at the beginning stage, more intense during the middle or working stage, and less intense during the ending stage. During the beginning stage of structured play therapy, the focus of therapy is on developing the client/ therapist relationship. Children entering into therapy may feel uncomfortable and anxious; therefore, the therapist needs to choose topics and structured activities that are less intense. Introductory topics focusing on getting to know the child, the child's likes and dislikes, safety, and trust are appropriate at this point. The therapist needs to assess the child's -readiness to move from the beginning stage to the middle stage of therapy. If the child appears positive about coming to therapy, is more talkative to the therapist, and appears more comfortable during the session, he may be ready for the next stage. As clients move into the middle or working stage, the therapist focuses them on more intense issues and feelings. Having participated in less intense exercises, the therapeutic relationship should be developed and clients should feel more comfortable participating in activities that challenge them to address intense issues with greater depth. Activities in the working stage also focus on the goal of therapy. For example, if a child were in therapy for anger management issues, then anger would be an issue addressed in the working stage of therapy. If a client is not

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ready for middle stage activities (demonstrated by a reluctance to broach a more intense topic or a lack of willingness to follow through on a more intense activity), therapists can move back into beginning stage activities to work on building safety and trust until the client is ready. The therapist can determine if a child is ready to move into the final stage of therapy by assessing whether the child has adequately addressed and processed issues and feelings related to the presenting problem. However, if therapy is constrained by time limits or a limited number of sessions (often dictated by insurance companies or other outside factors), the child needs to move into the final stage of therapy prior to termination whether the problematic issues have been fully addressed or not. By the ending stage of the therapy process, the client may want to continue to work on more intense issues. Despite the client's readiness, therapists must be mindful about the need to decrease intensity in preparation for termination. Therapists can decrease the intensity of sessions by focusing more on integration of learning, coping skills, and future orientation. This structured play therapy model is helpful to both therapists and clients. For therapists, it provides a framework to follow while choosing session topics and activities. Therapists should be flexible in deviating from the model when necessary. For example, if a middle stage session is planned, yet the client has experienced a particularly stressful or traumatic week, therapists should feel free to use stage one activities for that week. For clients, it provides a meaningful, organized plan of session topics and exercises that respects their readiness for exploring important issues. Clients will not feel thrust into self-disclosure or confronted with threatening personal issues before they are ready. CHOOSING STRUCTURED PLAY ACTIVITIES

Choosing the appropriate structured exercise or activity is a vital part of planning for structured play therapy. This article has described a model that therapists can use in the organization and planning of structured play. Overall, the importance of the timing of activities cannot be overemphasized. Therapists must be cognizant of their clients' readiness to approach certain activities. "To push beyond a client's readiness to move is to violate the client's integrity. To confront defenses without consideration for their importance in maintaining equilibrium is

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to expose a client to possibly serious psychological damage" (Corey, Corey, Callanan, & Russell, 1988, p. 5). In order to choose the appropriate activity with the appropriate timing, understanding the process of therapy is of key importance. The following are step-by-step guidelines to help therapists choose appropriately timed activities in structured play therapy: Step 1: Brainstorm Topics and Activities Appropriate for Client Issues and Goals Brainstorm and list as many topics and activities as possible that are appropriate for the client. The activities can come from a variety of books, journal articles, and other resources. It is appropriate to use activities from a variety of theoretical approaches such as Adlerian, Gestalt, behavioral, and cognitive-behavioral. Step 2: Assess the Intensity of Each Activity Assess the intensity of the activities, including the extent to which activities do the following: (a) evoke anxiety within the client; (b) challenge the client to self-disclose; (c) increase awareness; (d) focus on feelings; (e) concentrate on the here and now; and (f) focus on threatening issues. Step 3: Choosing Activities for the Beginning Stage of the Process of Structured Play Therapy From the brainstorming list, decide which activities are appropriate for the beginning stage of therapy. Choose activities that are less intense. Appropriate activities include creating a trusting climate, establishing the therapeutic alliance and safety, and orienting the client to therapy. An excellent get-acquainted exercise involves asking the child to tell the therapist about himself or herself. Appropriate discussion could focus on things the child enjoys doing, school activities, favorite pets, etc. A variety of play media can be used to facilitate discussion including drawings, games, or worksheets focusing on getting to know the client. The activities in this stage are less intense and do not focus on threatening issues or increase the child's anxiety.

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Step 4: Choosing Activities for the Middle Stage of Therapy From the brainstorming list, choose activities that fit the goals of the middle or working stage of therapy, which are higher in intensity. The goals of this stage include clients' recognition and expression of a range of feelings and a willingness to risk exposure to and disclosure of threatening material. Activities during this stage can be more intense and focus on the theme of therapy, focus on threatening issues, encourage client self-disclosure, focus on here and now, and increase awareness. For example, for a child dealing with anger management issues, an appropriate middle stage activity would be addressing the anger. The therapist could provide blown-up balloons for the child to break in order to release suppressed anger (Hambridge, 1997). The child could use puppets to role-play ways that anger is sometimes displayed by others, or ways that the child sometimes displays anger. It is important to establish the difference between feeling angry (which is OK) and hurting others with anger (which is not OK). Step 5: Choosing Activities for the Ending Stage of Therapy During this stage, clients deal with their feelings about termination. They prepare for generalizing their learning to the outside world. The importance of preparing for termination cannot be overemphasized - children need the opportunity to prepare for the imminent ending of therapy. In addition, it would be inappropriate to abruptly end therapy after engaging in a middle-stage, intensive session with the child. From the brainstorming list, use activities that are less intense in nature. Appropriate closing topics building up to termination include coping skills, future orientation, and preparation for closure, all with the goal of preparing the client to end therapy and the therapeutic relationship. The last session is devoted either in part or entirely to termination issues like reviewing and summarizing the client's experience in therapy and processing the feelings around saying goodbye (Jacobs, Masson & Harvill, 1998). As an example of an appropriate closure exercise, the child can write a short letter to say good-bye to the therapist or choose to draw a good-bye picture for the therapist. The therapist may also write a letter for the child, providing the child with positive feedback about his/her participation and progress. Once the letters are completed, the child is given his or her letter, which is read aloud in the session.

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APPLICATION OF THE MODEL

To demonstrate the application of the structured play therapy model, a session-by-session account of structured play therapy with a child is presented. The therapy consists of nine sessions with a 10-yearold girl whose parents have divorced. Each session is identified by the session topic followed by a description of the structured exercises/activities planned for the session. Session I: Introduction The child is encouraged to play a game with the therapist, "Getting to know you". Both players can ask questions to each other about likes, dislikes, hobbies, and interests. The therapist reflects on the content of the answers. (Note: The activities are of low intensity requiring less self-disclosure, less self-awareness, and elicit less anxiety). Session II: Feelings An adjective checklist and pleasant and unpleasant feeling words are processed so that the child can feel more comfortable about self-disclosing and discussing feelings. The child may be asked to identify feelings in drawings of faces. Discussion about "How do you feel today?" or questions such as "When did you feel sad, happy, or scared?" can help the child explore the meaning of feelings and identify those in relationship to present events in her life. (Note: The activities address the beginning stage issues of learning about and exploring feelings. Session topic and exercise are increasing in intensity). Session III: Bibliotherapy on Divorce A story is read about parents getting a divorce. The child is asked to discuss her feelings and thoughts about the character's feelings and behaviors in regard to the divorce. The child may even be asked to draw a picture of how she thinks the storybook character felt when her parents got a divorce. (Note: Activity increases in intensity; requires selfdisclosure about thoughts and feelings on divorce, although not about personal experience; may generate some anxiety and self-awareness in the child; appropriate for entering into the middle stage of the therapy).

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Session IV: Divorce-Related Self-Disclosure The child draws a shield and divides it into four parts. She is asked to draw a picture of a good time she had with her family in one block, an unpleasant time in another block, why she thinks her parents got a divorce in the third block, and what she would like to happen to her family during the upcoming year in the fourth block. The child will then discuss her shield with the therapist. (Note: Activity focuses on the theme of therapy, is higher in intensity; focuses on the middle stage goal of exposure to more threatening material; requires self-disclosure and self-awareness about personal experiences; may elicit anxiety from the child). Session V: Divorce-Related Feelings The therapist provides the child with a number of colored balloons of assorted sizes and shapes. The therapist blows up a balloon and ties the end. The child is encouraged to break the balloon anyway she wishes - stamping and jumping are very common. This structured activity allows inhibited children an opportunity to release suppressed anger or hostility about the divorce. Afterward, the therapist and the child process the experience. (Note: The activity is higher in intensity; requires work in the "here and now"; may generate self-disclosure and self-awareness; appropriate for middle stage of therapy). Session VI: Coping with Parents' Divorce Ways of coping are introduced to the child. The therapist and child use dolls to role-play potential family conflict situations, and using the dolls, act out various coping strategies. Through this structured activity, the child can learn deep breathing, pillow punching, journal writing and other coping skills. (Note: Activities focusing on coping skills are appropriate to use toward the ending stage of therapy. Session topic and exercises work within the here and now, yet focus on reducing anxiety). Session VII: Positive Aspects of Divorce The child discusses things that have turned out pleasantly, or for the better, because of the divorce. The child completes a personal collage that reflects the pleasant experiences and shares them with the therapist (Note: The activities in this session reflect the issues of the middle to late

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stages of the therapeutic process. Session topic and exercise decreasing in intensity; still requires self-disclosure, but will generate less anxiety because the focus is on positives). Session VIII: Building Self-esteem Using a sentence completion form, the client is instructed to complete each sentence. Some sample sentences are "One thing I really like about myself is ...", "People tell me that I'm good at...", "Something I'm changing about myself that makes me feel proud is ...". (Note: Activity again less in intensity; less anxiety elicited; appropriate for ending stage of the therapeutic process). Session IX: Termination A summary of the sessions is conducted. The child writes a good-bye letter to the therapist and the therapist writes one to the child. The letters are exchanged and read out loud. The therapist focuses on the feelings about therapy ending and on the child's growth during therapy. (Session topic is lower in intensity; appropriate for last session in the closing stage of the therapeutic process). CONCLUSION This article presented an overview of the basic concepts of the structured play therapy model for use with adolescents and children ages 7 and above. Many therapists ascribing to diverse theories of counseling use a variety of activities derived from various sources (e.g., books, articles) when counseling children. Although a multitude of structured activities and exercises exist, little has been written addressing the appropriate timing or sequencing of these activities. The primary aim of this article is to help therapists conceptualize and formulate a plan for choosing specific activities in therapy when working with children. One common concern about the use of structured play therapy is pressuring the child to focus on issues when they are not ready. This model provides a flexible framework for therapists to use to help children deal with specific issues, yet only when the child is ready. The ultimate aim is to help children master new skills and express feelings, while acknowledging defenses, in a safe environment as they deal with painful situations in the context of their lives. The primary importance of

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this model is to help therapists determine the best sequencing of session topics and structured activities that does not assault the child's defenses. Although structured play therapists choose structured activities and directly facilitate the therapeutic process, this model helps therapists focus on what to do based on the child's needs. Assessing the intensity of activities based on their effect on the child provides a respectful approach to the use of structured play therapy. This model provides a framework for a thoughtful, intentional approach to using structured activities with children.

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REFERENCES Corey, G., Corey, M.S., Callanan, P., & Russell, J.M. (1988). Group techniques (2nd ed.). Pacific Grove, CA: Brooks/Cole. Frost, J. L, Wortham, S., & Reifel, S. (2001). Play and child development. Upper Saddle River, NJ: Merrill/Prentice Hall. Gil, E. (1991). The healing power of play: Working with abused children. New York: Guilford. Hambridge, G. (1997). Structured play therapy. In C. E. Schaefer & D. M. Cangelosi (Eds.), Play therapy techniques (pp. 45-61). Northvale, NJ: Jason Aronson. Hambridge, G. (1955). Structured play therapy. American Journal of Orthopsychiatry, 25, 601-617. Jacobs, E. E., Masson, R. L., & Harville, R. L. (1998). Group counseling: Strategies and skills. Pacific Grove, CA: Brooks/Cole. James, O. O. (1997). Play therapy: A comprehensive guide. Northvale, NJ: Jason Aronson. Jones, K. D., & Robinson, E. H. (2000). Psychoeducational groups: A model for conceptualization. Journal for Specialists in Group Work, 25(4), 356-365. Knell, S. M. (1997). Cognitive-behavioral play therapy. In K. J. O'Connor & L. M. Braverman (Eds.), Play therapy theory and practice: A comparative presentation (pp. 79-99). New York: John Wiley & Sons. Kottman, T. (1999). Play therapy. In A. Vernon (Ed.), Counseling Children and Adolescents (2 nd ed.) (pp. 97-120). Denver, CO: Love Publishing. Landreth, G. L., (1991). Play therapy: The art of the relationship. Levittown, PA: Accelerated Development. Landreth, G. L. & Sweeney, D. S. (1997). Child-centered play therapy. In K. J. O'Connor & L. M. Braverman (Eds.), Play therapy theory and practice: A comparative presentation (pp. 17-45). New York: John Wiley & Sons. Levy, D. M. (1939). Trends in therapy III: Release therapy. American Journal of Orthopsychiatry, 9, 713-736.

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O'Connor, K. J., & Schaefer, C. E. (Eds.). (1994). Handbook of play therapy: advances and innovations. New York: John Wiley & Sons. Sloves, R. E., & Peterlin, K. B. (1994). Time-limited play therapy. In K. J. O'Connor & C. E. Schaefer (Eds.), Handbook of play therapy: advances and innovations (pp. 27-60). New York: John Wiley & Sons. Vernon, A. (1999). Counseling children and adolescents (2 nd ed.). Denver, CO: Love Publishing.

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Figure 1. Structured Play Therapy Model

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