Play Therapy in Asia 9789882370166, 9882370160

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play therapy in asia

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Play therapy in asia Edited by Angela F. Y. Siu & Alicia K. L. Pon

The Chinese University Press

Play Therapy in Asia   Edited by Angela F. Y. Siu & Alicia K. L. Pon © The Chinese University of Hong Kong 2017 All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from The Chinese University of Hong Kong. ISBN: 978-988-237-016-6 The Chinese University Press The Chinese University of Hong Kong Sha Tin, N.T., Hong Kong Fax: +852 2603 7355 E-mail: [email protected] Website: www.chineseupress.com Printed in Hong Kong

Contents

  About the Editors

vii

  About the Contributors

ix

  Acknowledgements

xvii

  Foreword by Felicia Carroll

xix

  Foreword by Evangeline Munns

xxi

Section I. East Meets West 1  Play Therapy: Development From West to East

1

   Karen Stagnitti and Judi Parson 2  Growing Up in East Asian Cultures

19

   Alicia K. L. Pon 3  Play Therapy Research in Asia    Angela F. Y. Siu

37

Section II. Play Therapy Development in Asia 4  Play Therapy in Mainland China

63

   Hannah Sun-Reid and Donghui Chen 5  Play Therapy in Hong Kong

81

   Angela F. Y. Siu and Alicia K. L. Pon 6  Play Therapy in Indonesia

101

   Astrid Wulan Sari Emeline Napitupulu 7  Play Therapy in Japan

117

   Yumiko Ogawa and Miwa Takai 8  Play Therapy in Malaysia

137

   Andrew C. L. Ng and Linda E. Homeyer 9  Play Therapy in the Philippines

153

   Maria Louise Trivino-Dey, Maria Aurora Assumpta Dela Paz-Catipon, Maria Caridad H. Tarroja and Washington Christopher C. Garcia 10  Play Therapy in Singapore

173

   Sock Kuan Lee 11  Play Therapy in South Korea

203

   Mee Sook Yoo, Mi Kyoung Jin and Rana Hong 12  Play Therapy in Taiwan

219

   Miao-Jung Lin and Ju-An Cheng

Section III. Moving On 13  Moving Forward    Angela F. Y. Siu and Alicia K. L. Pon

237

About the Editors

Angela F. Y. Siu, PhD, RCP, CPsychAssoc, RPT-S, CPT-S, CTT/T Angela F. Y. Siu is a registered clinical psychologist and has credentials in play therapy. She is also a certified Theraplay® Therapist/Trainer, as well as a certified Filial Therapy Instructor. She specializes in strengthening family relationships through play, and conducts play therapy trainings and supervision for various international professional associations. Angela graduated from The Chinese University of Hong Kong (CUHK), with a major in Psychology. She completed postgraduate training in the Institute of Child Study at the University of Toronto, Canada with a specialization in child assessment and counseling. She further received professional training in clinical psychology. She served in various education, social service and clinical settings in Canada and in Hong Kong before she joined CUHK as a faculty staff. She is now Associate Professor at the Department of Educational Psychology, CUHK. One of her research interests is in child assessment and counseling, particularly in using play as an approach for children with special needs and their families. She has served as a consultant for non-government organizations and schools in providing intervention programs for students with various abilities and needs. She has also published book chapters and research studies, and has presented in Asian and international conferences in play therapy.

viii  |  About the Editors

Alicia K. L. Pon, PhD, RSW, RPT-S, SEP Alicia K. L. Pon has been a child psychotherapist and social worker since 1996. Her training is in general psychology, child and adolescent mental health, play therapy, sandplay therapy, Somatic Experiencing®, grief counseling and social work. Alicia’s experiences and specializations include divorce and separation, grief and loss, complex trauma, adoption and attachment, developmental stresses, and parent-child relationship. At present, Alicia is a Senior Lecturer with the Department of Social Work, National University of Singapore. Prior to this, Alicia has been a staff of and served as an Honorary Assistant Professor with the University of Hong Kong and Hong Kong Shue Yan University for six years. She continues to lecture and supervise undergraduate and postgraduate students in the areas of counseling and psychotherapy, grief and loss, child and adolescent mental health, play therapy and social work. In addition, Dr. Pon has been highly involved in the research and training on Somatic Work, play therapy, complex trauma, and end of life.

About the Contributors

Maria Aurora Assumpta Dela Paz-Catipon, MA, has been working with children and adolescents with developmental, emotional (anxiety, depression) and behavioral concerns. A certified Master Solution Focused Practitioner with the International Alliance of Solution Focused Training Institutes since 2013, she was a presenter at the 4th Asia Pacific Solution Focused Approach on “Integrating Solution Focused Brief Therapy into Play and Expressive Therapies with Children and Adolescents.” She also authored a book chapter in Solution Focused Stories of Asia (in press) which described her integration process of Solution Focused Play Therapy in the Philippine context. Donghui Chen, MA, is a registered clinical psychologist of the Chinese Psychological Society. She has eight years of experience in clinical psychotherapy and worked as a psychotherapist in the Center for Psychological Counseling and Psychotherapy at Peking University. She has been well trained in cognition and behavior psychotherapy, play therapy, psychoanalytic psychotherapy, couple therapy, family therapy and hypnotherapy. Her involvement was instrumental in successfully bringing the Child and Play Therapy training program from Canada to China in 2010. The program is the first systematic training program of Child and Play Therapy in Mainland China with its mission of advancing the professional development of play therapy there.

x  |  About the Contributors

Ju-An Cheng, PhD, received his PhD in Counseling Psychology at the National Kaohsiung Normal University. He has many years of teaching experience from elementary school, senior high school and university. He was also the director and clinical supervisor of the Kaohsiung Student Counseling Center. So far, he has already devoted himself to the field of play therapy for more than 20 years, which includes clinical experience, teaching, and supervision in Taiwan. Dr. Cheng developed his own clinical model of structural play therapy, which had already been published both in Taiwan and Malaysia. Washington Christopher C. Garcia, PhD, has been in practice for the last 30 years. With his extensive experience in psychological testing and psychotherapy, he has served in the positions of Guidance Director at the Loyola Schools, Ateneo de Manila University and Clinical Supervisor at the Ateneo Wellness Center and the Creative Child Center in the past. He currently teaches courses in graduate school (Counseling and Educational Psychology Department—De La Salle University Manila), and has contributed articles to the International Journal of Play Therapy (2013) and the book Magic of play: Children heal through play therapy (2009). He is also a board member and officer of the Philippine Association for Child and Play Therapy (Philplay). Linda E. Homeyer, PhD, LPC-S, RPT-S, is Professor of Professional Counseling at Texas State University, where she developed their play therapy program. She served on the Association for Play Therapy (APT) Board of Directors. Linda has numerous publications, including Sandtray therapy: A practical manual (2016, 3rd Ed.), and The handbook of group play therapy (1999). Her publications have been translated into Chinese, Russian, Korean, and Spanish. In Malaysia she assisted a core group of mental health professionals to develop play therapy over the course of several years. Linda is a strong advocate for improving the life of children and families through training others around the globe to provide quality play therapy and sandtray therapy counseling. Rana Hong, PhD, is an Adjunct Professor and field liaison of the School of Social Work at Loyola University Chicago, and teaches clinical social work practice with individuals and families and advanced clinical practice with children for masters students. A seasoned clinician, she has specialized in treating children and their parents with children’s behavioral and emotional issues including but not limited to attachment, anxiety, trauma, and oppositional defiance. As a certified Theraplay® therapist, supervisor, and

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trainer and a registered play therapy supervisor, she has been a frequent lecturer and presenter on topics of play therapy modalities in working with children and their families. Her research and scholarship have focused on improving clinical practice and services for children and parents. Additionally, she maintains a group practice in Des Plaines, IL. Mi Kyoung Jin, PhD, is an Associate Professor in the Department of Child Welfare and Studies, Sookmyung Women’s University in South Korea. She earned a PhD in Human Development and Family Science from the University of Texas at Austin. Her research and scholarship have focused on play therapy, attachment, and cultural issues in developmental psychology. She has published several book chapters on play therapy. She is a current play therapy supervisor at the Korean Association for Play Therapy and is a director of the academic committee of the Korean Association for Play Therapy. Sock Kuan Lee, MSSc, has been practicing in the Wesley Counselling Services after completing her Masters degree in Counselling at Edith Cowan University. Besides taking counselling and psychology courses, she has received specialized training in play therapy, sandplay therapy, gestalt therapy, art facilitation, cognitive behavioural therapy, family therapy and emotional-focused therapy. She is a registered clinical member of the Singapore Association for Counselling as well as a Certified Practitioner in Therapeutic Play Skills with Play Therapy International. She works with children and their families on coping with stress, attachment, challenging behaviour and loss issues. Her clinical work is primarily grounded in Gestalt Therapy as she supports her clients towards better well-being and a better way of being in the world. In addition to her clinical practice, Sock Kuan also supervises and trains therapists, social workers and volunteers. She is currently working towards completing her certification in Gestalt Therapy with Children and Adolescents with West Coast Institute. Miao-Jung Lin, PhD, is an Associate Professor in the Department of Counseling Psychology and Human Resource Development at the National Chi Nan University, Taiwan, R.O.C. She has already taught play therapy and has been a play therapy supervisor for more than ten years in Taiwan. Her research and clinical work specialize in the treatment of traumatized children and their families. She was the chairman of the board of directors of the Association for Taiwan Play Therapy during 2011–2012. She currently serves on the editorial board of the Journal of Taiwan Play Therapy.

xii  |  About the Contributors

Andrew C. L. Ng, MCS, a student of Dr. Garry Landreth, is pioneer and advocate for play therapy in Malaysia since 1997, a practicing play therapist, APT’s approved provider since 2008, founder and consultant of Agape Counselling Centre Malaysia, and founding member and consultant of Selangor Association for Play & Expressive Therapy. He has lectured at Beijing Normal University, Peking University, Qingdao Adult Education Institute, Hangzhou Pediatric Hospital, and Hong Kong Baptist University. He also helped with church mission in northern Thailand. Andrew studied industrial design in New Zealand, and graduated from China Graduate School of Theology, Hong Kong, with a major in counselling. In 1999, he furthered his study in play therapy at the University of North Texas, and expressive arts at the European Graduate School in Switzerland. He has conducted numerous play therapy training and parenting workshops for schools, teachers training colleges, and universities. He is also a columnist, writer, and popular speaker for radio and TV talk show, including the MH370 and MH17 air disasters and bereavement counselling. His recent book Play therapy in Malaysia—Theories, skills, and case studies, coauthored with Dr. Linda E. Homeyer, Professor at Texas State University, USA, was published in August 2015. Andrew is well known for his 50-hour play therapy training and supervision in Malaysia. Yumiko Ogawa, PhD, is an Assistant Professor at the Department of Educational Leadership and Counseling at New Jersey City University. She is a Licensed Professional Counselor, Approved Clinical Supervisor, Registered Play Therapist Supervisor in the US, and Certified Clinical Psychologist in Japan. She has extensive clinical experience in providing therapy to children and their families in a hospital, community based agency, foster care system, school, private practice and crisis intervention settings. Judi Parson, PhD, is a pediatric qualified Registered Nurse, Play Therapist / Supervisor and Lecturer in Mental Health within the School of Health and Social Development at Deakin University, Victoria, Australia. She has experienced a clinically diverse nursing career which has taken her across a number of Australian states and to the United Kingdom. She has practiced in various specialty fields including child and adolescent health, acute pediatrics and transplant care. She enjoyed being a nursing academic in Queensland prior to moving to Tasmania in 2004, where she completed her PhD. Her doctoral thesis was titled “Integration of procedural play for children undergoing cystic fibrosis treatment: A nursing perspective.” The results of Judi’s thesis then lead her to investigate further play therapy

About the Contributors  |  xiii

knowledge and techniques. She completed her MA degree in Play Therapy (with Distinction), at Roehampton University London, to become a fully qualified play therapist and she is actively involved in the development of play therapy in Australia. Judi has presented in Australia, New Zealand, Oman, Hong Kong, South Korea and United Kingdom. Her current position includes teaching and researching in child play therapy and paediatrics and she is the deputy course director for the Master of Child Play Therapy. Karen Stagnitti, PhD, currently works as Professor, Personal Chair at the School of Health and Social Development at Deakin University, Victoria, Australia. She graduated with a bachelor’s degree in Occupational Therapy from the University of Queensland. For over 30 years she has mainly worked in early childhood intervention programs in community-based settings as part of a specialist paediatric multi-disciplinary team. In 2003 she graduated from LaTrobe University with a Doctor of Philosophy. Her area of research is children’s play. Karen has written five books on play. She also has over 80 national and international papers published as well as 20 book chapters. Her norm referenced standardized play assessment, the Child-Initiated Pretend Play Assessment, was published in 2007. Throughout the year, she is invited to present her work on the play ability of children nationally and internationally. Currently she teaches into the Master of Child Play Therapy at Deakin University. Hannah Sun-Reid, MA, MDE, is a Certified Child Psychotherapist and Play Therapist Supervisor, a Certified Theraplay® Therapist, a Certified Trauma Specialist, a Certified Dyadic Developmental Psychotherapist, a SandtrayWorldplay Therapist and an EMDR therapist. She has more than 20 years of experience working with children and families who experience life challenges including trauma and loss. Hannah provides supervision and consultation to therapists and organizations, and conducts training workshops nationally and internationally. She lives and works in Southern Ontario, Canada. Miwa Takai, MA, is a Certified Theraplay® Therapist and Trainer. Miwa received her bachelor’s degree at the University of the Sacred Heart in Tokyo, Japan, in early childhood education and worked as a kindergarten teacher. She received a master’s degree and is completing a doctoral degree in child psychotherapy at Sookmyung Woman’s University in South Korea. Miwa worked at the Theraplay Counseling Center in Seoul, Korea and at a center for children with Autism Spectrum Disorders in Sapporo, Japan. In 2011, Miwa started the Theraplay Counseling Center in Tokyo.

xiv  |  About the Contributors

Maria Caridad H. Tarroja, PhD, is a full-time Associate Professor at the De La Salle University and currently the Director of Social Development Research Center (SDRC). As a practicing clinical psychologist, she has been doing psychological assessment and play therapy with children. She has been actively doing research on various topics in assessment and clinical psychology, family studies, adoption issues, play therapy among others. She has published her work in local and international journals, the most recent of which are on predictors of adjustment of adopted Filipino children in Adoption Quarterly (2015), the challenges of play therapy practice in the Philippines in the International Journal of Play Therapy (2013) and support for children of overseas Filipino workers in the School Psychology International (2013). Dr. Tarroja was the President of the Psychological Association of the Philippines (PAP) from 2010 to August 2012. Currently, she is the Chair of the Philippine Social Science Council (PSSC), Board Member of the Philippine Association of Child and Play Therapy (PhilPlay), member of the CHED Technical Working Committee for Psychology, and President of the ASEAN Regional Union of Psychological Societies (ARUPS). Maria Louise Trivino-Dey, MA, is a registered psychologist and has worked with children with emotional, social and behavioral concerns in the last 20 years. She works as a consultant at the In Touch Community Services and is currently a school counsellor at the British School Manila. She is a registered play therapist with the Association for Play Therapy (USA). She is also working on her certification as a Jungian Sandplay Therapist with the ISST (Switzerland). She was a founding board member and an officer of the Philippine Association of Child and Play Therapy (Philplay). She has contributed articles in the International Journal for Play Therapy (2013) and The Philippine Journal of Psychology (2000), and presented on the cognitive profiles of sexually abused street children in The International Counseling Psychologists’ Conference (Chicago, USA, 2008). Astrid Wulan Sari Emeline Napitupulu, M Psi, is a child psychologist, and lives in Jakarta, Indonesia. She received a bachelor’s degree in psychology from Universitas Padjadjaran in 2006 and then received her professional qualification as a clinical child psychologist from Universitas Indonesia in 2009. Her thesis, “Theraplay Treatment for a Child with Reactive Attachment Disorder” was supervised by Mimi Patmonodewo and Mayke Tedjasaputra, senior psychologists. As leading experts in subject of play, they transmitted their passion to Astrid. Four years later, Astrid took Theraplay® training from

About the Contributors  |  xv

The Theraplay Institute. She then started her practicum and has become the first Theraplay Practitioner in Indonesia. She is now working towards certification as a Theraplay Therapist. With her colleagues, she is promoting Theraplay in Indonesia and building Theraplay Indonesia. She practices in private clinics and in various settings. Mee Sook Yoo, PhD, is a Professor in the Department of Child Welfare and Studies, Sookmyung Women’s University, South Korea and is a current committee member at Central Early Childhood Education, Ministry of Education of the Korean Government. Furthermore, she is a senior play therapy supervisor at the Korean Association for Play Therapy and is a certified counseling psychologist from the Korean Counseling Psychology Association. As a prominent scholar in Korea, Dr. Yoo has a number of publications on play therapy. She was director of the first private play therapy center in Korea, Wonkwang Counseling Clinic for Children, for over 14 years and also served as the past president of the Korean Association for Play Therapy.

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Acknowledgements

We would like to acknowledge and express our appreciation to the many people who saw us through this book; to all those who talked things over, read, wrote, offered comments, and assisted in the editing, proofreading and design. Without their support, this book would not have become a reality. We would like to thank each one of the authors for their contributions. Our sincere gratitude goes to the chapter’s authors who contributed their time and expertise to this book. Finally, we wish to thank our respective spouses and families for believing in us, supporting us and encouraging us through this long but rewarding journey. Professor Angela F. Y. Siu The Chinese University of Hong Kong Hong Kong Dr. Alicia K. L. Pon National University of Singapore Singapore

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Foreword

The reader of this book will soon recognize it as a major contribution to the ongoing consideration of many significant issues in the field of child psychotherapy. Issues such as how we work both to support the individual development of the child and recognize the significance of adapting to the field conditions such as cultural norms and values. The authors of the various chapters provide a depth of scholarship as well as sensitive and thoughtful clinical work with children that reflect these considerations as they are emerging in clinical practice in Asian societies. For the past decade I have had the privilege of joining with many of these authors as a teacher from the West. I have instructed hundreds of clinicians along the Pacific Rim from Singapore, Hong Kong, Japan, and South Korea. As a Western teacher I became a student, learning from my Asian colleagues about what was valuable within my perspective and what was not as they thought about the implications of my teaching to their work. We taught one another by sharing our experiences and our questions. Through dialogue we came to experience our contact as “the appreciation of differences and the recognition of similarities.” This text will be welcomed by professors, clinicians, and parents of all cultures East and West. I have been enriched by reading about the challenges and developments of child psychotherapy within Asia over these past twenty five years. I am honored to participate with the editors and authors who have deepened my understanding of the fundamental cultural

xx  |  Foreword

influences throughout Asian societies and the great diversity that is there. My reading has caused me to reflect upon the assumptions and “unthought knowns” that have shaped my own clinical work. I am certain that clinicians in both the East and the West will find themselves reading and reflecting on what is the purpose of our clinical endeavors as well as how our cultural assumptions inform how we carry out our clinical practice. In addition to an exploration of the contextual background of our clinical work, each author has written from her theoretical perspective a narrative and discussion of therapy with a child. These case narratives with theoretical material will greatly enhance the development of awareness of the variety of approaches to clinical work with children. It is wonderful to read that so many clinicians from various Asian societies recognize the significance of play in the cognitive and emotional development of children. In our contemporary digitalized world which has been guided too often by historical traditions that stress self-improvement through effort and work, we have needed to recover the necessity of unstructured play in the socialization, creativity, and intellectual rigor necessary for healthful growth and development of children. Each of the clinicians writes about the need for play as a therapeutic language and a way that the therapist engages with each child. The discussion that they bring to the importance of play in therapy is filled with warmth and fun, as well as clinical assessment. I commend the editors and authors of this text for their contributions not only to the teaching of West to East, but equally significant, is the teaching of East to West. This collection brings insightful support to our conversations. And those who will benefit the most from our dialogue together are our children. Felicia Carroll, MEd and MA, Licensed Marriage,Family Therapist, Registered Play Therapist-Supervisor, Founder and Advanced Trainer of the West Coast Institute for Gestalt Therapy with Children and Adolescents, California USA

Foreword

This is a book that should be read by most play therapists. Although the focus is on play therapy in Asian countries, this book has many insights that would be helpful for any play therapist. In today’s globalization of human cultures, it is imperative that therapists are aware and sensitive to the different values and practices of varied ethnic groups. In the following pages there is a clear description of many of these differences (and similarities) not only within the Asian countries, but also between the East and West worlds. The authors of each chapter are experienced professionals who are knowledgeable not only about the different models of play therapy that are used in their respective countries, but also about parental attitudes and child rearing practices that need to be considered in modifying therapeutic approaches. For example, in the East, the widespread emphasis on academic excellence from early childhood can contribute to a down valuing of play which can be considered to be just “fun” and frivolous. This can lead to a lack of faith in the value of play therapy and instead, a seeking of medical interventions and medications for their children’s problems. Added to this is a sense of parental “shame” in having a troubled child and a need to “save face” where reputation and prestige are more important than a child’s mental health. As well, in the East, there can be a reluctance to speak candidly about their problems, so the therapist may need to rely on being extra sensitive to nonverbal cues such as eye gaze, body posture, voice tone, etc.

xxii  |  Foreword

The need to modify a treatment approach is frequently cited in this book and the reasons for it are also addressed. In the East, the influence of “collectivism” and a striving for “harmony” has had a profound influence on parental practices of teaching their children self control, emotional restraint, social inhibition and dependence on others. In contrast, western countries encourage individualism, self-determination, independence and expression of feelings. Asian children are brought up in an authoritarian atmosphere where they are expected to be polite, obedient and to wait for adult instruction. When they are confronted with a western style therapeutic approach (such as non-directive or client-centered play therapy), where they are expected to be self-directed, they can be overwhelmed with anxiety and stress. A modification is suggested by several authors, advocating the use of a more structured, directive approach in the beginning sessions. Another modification when working with Asian children is in regards to the selection of toys—for instance, if pigs and dogs are regarded as “unclean,” it might feel offensive to have such toys in the play room or to avoid the presence of guns or knives, to combat the parent’s fears that their child might become more aggressive. These are examples that indicate the strong need to include parents in any play therapy approach and the need for parental psychoeducation. As well as differences between East and West worlds, there are problems common to both. For example, the increasing trend of both parents working and leaving their child from an early age to institutionalized daycares or extended relatives is found in both worlds. This becomes particularly worrisome when parent/child separations are frequent and long-lasting such as the “left behind children” in China. In addition to including many examples for therapists to consider regarding cultural beliefs and child rearing practices, each author has also included the history and present status of play therapy in their respective countries as well as related research. Authors also voice the need for more controlled studies and state that stricter credentialing of play therapists and monitoring of their practices is needed. This book as a whole, gives a clear picture of the part play therapy is playing in Asia today and the hopes and dreams for its future. Evangeline Munns, PhD, CPsych, RPT/S

section i east meets west

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1

Play Therapy: Development from West to East Karen Stagnitti Judi Parson

Playing is an essential ingredient to a child’s positive health and wellbeing. A child who cannot play or who has a disruption in their play ability is a child who has issues in his or her development or a child who has suffered a traumatic or emotional event (Cattanach, 2008; Chazan & Cohen, 2010; Stagnitti & Cooper, 2009). Children who have disruptions to their development benefit from early intervention, and play therapy is one form of therapy that has been shown to bring positive changes to children’s health and well-being (Chazan & Cohen, 2010; Ray, et al., 2015). Many of the play therapies were developed in the West and this chapter navigates the compass from West to East. For the purpose of this chapter, the “West” refers to countries such as the United States of America, Canada, United Kingdom, Europe, Australia, and New Zealand. The “East” refers to East Asia, South Asia, and South East Asia (excluding Australia).

Brief History on Play Therapy Development in the West Play therapy evolved from psychoanalytic approaches, humanistic approaches, developmental psychology, and educational psychology. Figure 1.1 (p. 2) shows the evolvement from theorists across various traditions to the development of the range of play therapies used today in the West. The different levels of the triangles at the base of the diagram represent the time differences in the development of the theories and models, with

2  |  play therapy in asia

Figure 1.1 Summary of the Development of Play Therapy in the West

Play Therapy: Development from West to East  |  3

psychodynamic theories developing first and emerging play therapies being a more recent development. In 1909 the psychoanalytic theorist Sigmund Freud introduced the idea of therapeutic play for children into psychotherapy (Schaefer, 2011a). Freud believed play was important to a child’s emotional development, and also served to promote a freer expression of self, wish fulfilment, and mastery over traumatic events (Mellou, 2006; Schaefer, 2011a). Through play, a child could bring repressed memories to consciousness and relive them with a sense of mastery and control over the experience (called abreaction) as well as have a cathartic experience (i.e., the child plays out and assimilates a negative experience through repetitive play) (Schaefer, 2011a). Melanie Klein and Anna Freud continued to develop the idea of play within child therapy, with Melanie Klein pioneering the use of miniatures as representations of real-world objects or people (Schaefer, 2011a). This concept of using miniatures in play as a means for children to gain a sense of mastery over these objects was developed further by Lowenfeld (Schaefer, 2011a). Lowenfeld developed The World Technique in the early 1900s which included a sand tray, miniatures, and access to water (Schaefer, 2011a). In Lowenfeld’s World Technique, the miniatures are used as a vehicle for a child to express their emotions and communicate their feelings and experiences from their internal and external worlds (Taylor, 2009). Carl Jung encouraged Dora Kalff to study under Lowenfeld to develop play-based analytical techniques for children (Green, 2011). Kalff developed sandplay in the 1950s when Kalff applied Jungian concepts to The World Technique (Green, 2011; Taylor, 2009). While Lowenfeld was verbally involved with the child as the child developed their “world” in the sandtray, in Kalff’s technique the therapist was an observer and focused on the completed work (Taylor, 2009). Both Lowenfeld and Kalff took the view that the purpose of their techniques (World Technique and Sandplay respectively) was to uncover the nonverbal, however Kalff took the view that a series of sand trays provided deeper healing at the level of the unconscious (Taylor, 2009). Jungian child psychotherapy was further refined by John Allan who incorporated techniques from play therapy into child analysis (Green, 2011). The primary goal of Jungian play therapy is to activate the individuation process which is a lifelong development of personality (i.e., for the child to mature and become whole). In Jungian play therapy, the therapist remains at the level of feelings of the child with the therapist interacting with the child regarding the symbols the child places in the play (Green, 2011). The primary avenues for therapists to observe symbol production are artwork,

4  |  play therapy in asia

sandplay, and dreams (Green, 2011). In the 1950s, Erikson extended the view of play held in psychoanalytic theory to examine its contribution to normal personality development (Mellou, 2006). He viewed play as combining the present, the past, and the future. The focus on the individual moved to the recognition that people are socially embedded and this became one of the principles of Adlerian Play Therapy (Kottman, 2011). This play therapy is based on Adler’s work in the 1920s and his belief that people are socially embedded, goal-directed, subjective, and creative (Kottman, 2011). The therapist is active with the child within Adlerian Play Therapy by taking on the roles of partner, encourager, and teacher (Kottman, 2011) and working with children to increase their ability to be socially and positively connected to others. Adlerian Play Therapy also recognizes that all behavior is goal-directed or purposeful. For example, when a child is argumentative with the therapist, the therapist recognizes the child’s behavior goal is striving towards power and thus ensures during play therapy sessions that power is shared (Kottman, 2011). The remaining two principles of Adlerian Play Therapy are that children interpret their own view of the world (subjective) and each child is unique and makes choices (creative) (Kottman, 2011). In therapy, the therapist establishes an egalitarian relationship with the child, then explores the child’s lifestyle in order to gain understanding of the child’s interpersonal and intrapersonal dynamics; assists the child to gain insight into their lifestyle (using directive and nondirective techniques); and reorients the child to more positive attitudes, beliefs, and behaviors (using more directive techniques) (Kottman, 2011). The recognition that the therapist’s engagement with the child through play is therapeutic was an advancement made in the 1970s from the more traditional psychoanalytic approaches that viewed play as a vehicle of the child’s preconscious and unconscious emotions (Levy, 2011). Winnicott viewed play as a creative activity where the internal and external realities of child and therapist join one another (Levy, 2011). Play was viewed by Winnicott as a “transitional phenomena” (Levy) because it allowed children to cocreate more successful ways of experiencing relationships with self and others. The therapist relationship with the child was also recognised by Frederick and Laura Perls who drew on psychoanalytic and humanistic theories and Gestalt psychology in their development of Gestalt Play Therapy (Oaklander, 2011). In Gestalt Play Therapy, therapists bring themselves to the session with a sense of being fully present and congruent

Play Therapy: Development from West to East  |  5

(Oaklander, 2011). They respect the child and must be aware of their own limits and boundaries. The therapist creates a safe place for the child to be and the focus of therapy is on strengthening the self of the child. A variety of techniques is used in Gestalt Play Therapy to engage the child and help the child renew and strengthen aspects of the self that have been suppressed, restricted and lost (Oaklander, 2011). Play activities can include sensory experiences, puppets, clay work, drawing, sandtray, music, storytelling, movement, and fantasy play. How the therapist related to the child during therapy was central to Virginia Axline’s work in her translation of Carl Rogers client-centered counseling to the world of the child. Axline called this therapy NonDirective Play Therapy. In Non-Directive Play Therapy, a play room is set up as a safe space with a variety of toys including messy play materials (water, sand), miniatures and puppets, and so on. The therapist accepts the child unconditionally, creates an atmosphere of permissiveness so the child is free to self-initiate play, respects the child’s capacity to develop, and responds to the child (Axline, 1974). In Axline’s approach, praise of the child is not used as praise shapes behavior which can distort unconditional acceptance of the child. Child-Centered Play Therapy is very closely related to, and builds on, Non-Directive Play Therapy. Child-Centered Play Therapy uses the child-centered approach to therapy where the foundational element is the focus on the relationship between the therapist and the child within the playroom (Sweeney & Landreth, 2011). In Child-Centered Play Therapy, evaluation of the child is not used as this is in conflict with acceptance of the child. Filial play therapy draws strongly on child-centered traditions and is also influenced by family systems, psychodynamic theory, developmental/attachment theory, and community orientations (VanFleet, 2011). Filial therapy was first developed by Bernard and Louise Guerney in the 1950s–1960s and includes the child and parent in the session. ChildParent Relationship Therapy (CPRT) Filial Therapy (Landreth & Bratton, 2006) is a more recent adaption of filial therapy which draws heavily on ChildCentered Play Therapy. It is a psychoeducational program for parents only. The parent is trained by the therapist in how to respond to their child so that the parent becomes a primary change agent for their child (Landreth & Bratton, 2006). In CPRT Filial therapy, the parent is trained, supported, and supervised to understand the inner person of their child (the child’s emotional needs) through changing the parent’s own sense of adequacy. Parents are equipped with skills so that they can develop a therapeutic

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relationship with their child (Landreth & Bratton, 2006). The emphasis in CPRT is on relationship building between the parent and child and not on the parent correcting a child’s behavior (Landreth & Bratton, 2006). Ecosystemic Play Therapy was created to encourage play therapists to think very broadly and to consider all systems (including the family and cultural system) in relation to the child (O’Connor, 2011). This play therapy is influenced by Bronfenbrenner’s ecological model (Bronfenbrenner, 1971) as well as drawing on theories such as attachment, family systems, humanistic, and cognitive behavioral to formulate a prescriptive way of working with the child. Ecosystemic theory considers a child’s development within time which affects and is affected by other systems that are arranged hierarchically, with systems at the top having a wide-ranging and powerful influence over lower systems (O’Connor, 2011). Children are dependent on many systems and do not have much influence within the systems in which they are embedded. Thus, in Ecosystemic Play Therapy, the therapist intervenes directly in a child’s life to affect positive change as systemic problems can impact negatively on a child’s life (O’Connor, 2011). The goal of Ecosystemic Play Therapy is to maximise a child’s enjoyment of their life now and in the future. The role of the therapist is to help the child “break set” (O’Connor, 2011) which means the child comes to redefine their problems. The therapist also recognizes that the child usually does not choose to attend therapy and thus the therapist must establish the therapeutic relationship (O’Connor, 2011). The therapist draws on various techniques and is active in assisting the child to problem solve. A treatment contract may be established with the child, and possibly the parents if this is appropriate for the child. Limits are set in the playroom and the therapist works with caregivers to ensure the child has safe boundaries outside the playroom (O’Connor, 2011). From the psychoanalytic and humanistic traditions together with other theories (such as attachment, cognitive behavioral), there is now a continuum of play therapies from directive to non-directive with varying levels of conscious awareness. This is depicted in Figure 1.1 by the circle above the solid line, near the top of the figure, which symbolizes cross influences of theories informing new practices in play therapy. Yasenik and Gardner (2012) have articulated these continuums (directive-non-directive and conscious-unconscious) in the Play Therapy Dimensions Model which is a model to assist therapists to understand their decision-making process. Such a model is timely as more models of play therapy emerge, such as Theraplay®, Solution-Focused Play Therapy, Cognitive-Behavioral Play

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Therapy, Narrative Play Therapy, Integrative Play Therapy, and Prescriptive Play Therapy (Schaefer, 2011a). Added to this list could also be Learn to Play Therapy (Stagnitti, 1998; 2015) which developed from recognition that many of the play therapies (e.g., Non-Directive Play Therapy and The World Technique) assume that children are able to play, use symbols, and impose meaning within the play. Stagnitti noted that not all children have the ability to play, and developed Learn to Play to facilitate the development of a child’s ability to self-initiate their own play, including using symbols in play. Learn to Play can precede other play therapies if children need to develop their ability to play. Only then, when a child can play, can the therapist engage at a deeper level in the play therapy process. Theraplay® was developed by Ann Jernberg in 1967 and is a structured form of play therapy where the emphasis is on the playful interactions between therapist and child and then parent and child (Munns, 2011). It is strongly underpinned by attachment theory. No toys are used in Theraplay but rather engaging activities such as mirroring, imitation of clapping, sounds, smoothing on lotions and powders, and swinging in a blanket (Munns, 2011). The process in Solution-Focused Play Therapy is driven by dialogue between the therapist and the child (Nims, 2011). A variety of techniques are used to help children change their thinking (Nims, 2011; Taylor, 2009). Cognitive-Behavioral Play Therapy (Drewes, 2009a; Knell, 2011) is similar to more traditional play therapies in that a safe environment is ensured by the therapist, the therapeutic relationship is important between therapist and child, and the child communicates through play. In contrast to more traditional play therapies, there is more verbal interaction between the therapist and child with a focus on directions, goals, choice of play materials, and more conscious connections are made by the therapist to connect the child’s behavior and thoughts (Nims, 2011). Therapy may also occur outside the playroom in Cognitive-Behavioral Play Therapy. Narrative Play Therapy was developed by Ann Cattanach, and the EPR (Embodiment, Projection, and Role Play) developmental model of play informs this play therapy (Taylor de Faoite, 2011). The role of the therapist in Narrative Play Therapy is to mediate the cultural and social world of the child by engaging in play and writing stories (Taylor de Faoite, 2011). The treatment model in Integrative Play Therapy (Drewes, 2011) will vary depending on the needs of the child as this play therapy blends techniques, integrates two or more theories, and identifies common factors between the different therapies. The Play Dimensions Model is a useful decision model for therapists who practice

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Integrative Play Therapy (Yasenik & Gardner, 2012). The core of Prescriptive Play Therapy (Schaefer, 2011b) is concerned with the best outcome for the child and “what treatment procedures administered by which therapist to which children with which specific problems are predicted to yield the best outcomes” (Schaefer, 2011b). This brief history of play therapy tracks the influences of theories that were primarily developed for adults and then adapted for children. There are many play therapies today with more therapists developing expertise across more than one play therapy so that they are able to be more prescriptive in their therapy. Evidence for the effectiveness of play therapy is also building (see Ray et al., 2015). So the question is now, “How do these play therapies translate to non-Western cultures?”

Exporting or Adapting Play Therapy Models: Issues and Challenges In exporting play therapy (as conceptualized in the West) to the East, it is important to acknowledge that all conceptual models are socio-culturally situated and privilege the norms of the contexts from which they [have] emerged (Iwama, Thomson & Macdonald, 2009). The models of play therapy depicted in Figure 1.1 have emerged from Western thought and embody the pervading belief in Western countries that the “self” is central and the individual is responsible for their destiny and well-being (Iwama et al., 2009). This leads to the celebrated values in Western cultures of independence, self-determinism, autonomy, and equality (Iwama et al., 2009). In contrast, the Eastern view is that the “self” is not central, but rather is part of an integrated system with harmony being the celebrated value and one individual is not separate from their physical, social, and spiritual environments (Iwama et al., 2009). Within an Eastern view then, the health professional does not just consider outcomes for the individual but rather considers the context of the individual including their family, beliefs, home, and community and takes into account the interconnectedness of the individual within their world (Iwama et al., 2009). The individual’s wellbeing is dependent on the individual being in harmony with their context and surrounding environment. The East represents a collective society and the West an individualistic society. These positions are opposed. Within a collective society, such as in the East (and many First Nations peoples, such as the Australian Aboriginal and Islander peoples and First Nations peoples of the United States and Canada), belonging

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and interdependence are valued. In Western countries individualistic self-determination is valued. Thus, there is a conflict between the basic assumptions of some play therapy models and the values of non-Western cultural groups. Faced with this conflict, O’Connor (2005) puts forward five conflicts that play therapists need to address when working in diverse cultures. These conflicts are put forward as the key challenges in exporting play therapy from West to East. The first challenge is play therapists need to be aware that the way children play varies from culture to culture and this has implications for the toys available in the playroom (this is addressed further in the next section). Second, many play therapy models encourage children to directly express their emotions in play. For Korean parents, for example, this may be interpreted as the child being disrespectful (O’Connor, 2005). Third, play therapy can appear unstructured and just “playing” (Chang, Ritter & Hays, 2005; O’Connor, 2005). Parents from Eastern cultures may believe that the therapist is wasting time and hence the justification for the value of play needs to be addressed. African-American parents may perceive the casual relationship between the therapist and child as disrespectful and be concerned that their child will become disrespectful to them (O’Connor, 2005). Fourth, play therapy relies on children and parents communicating openly and voluntarily with the therapist. Voluntarily disclosing problems to a relative stranger, who may be regarded as an authority figure, may not be culturally appropriate for some cultural groups. The therapist may need to change their approach to parents and be more active. For families from Eastern backgrounds, a more direct approach may be better interpreted by parents as the therapist demonstrating the degree to which he or she will help the family (O’Connor, 2005). For some families, such as Japanese families, the therapist needs to be aware that the family may feel shame that their child has a problem (O’Connor, 2005). Hence, to enable the play therapist to work effectively and sensitively with families, clarification of the therapeutic relationship and assurances of confidentiality are vital to establish at the beginning of therapy. Fifth, Western thinking is logical and linear, and problem solving and many of the play therapy models reflect this thought pattern. Eastern thought is about interconnecting relationships, and health and wellbeing are not necessarily understood in a linear way (Iwama et al., 2009). With these challenges, some play therapies, such as Child-Centered Play Therapy, filial therapy, Gestalt Play Therapy, group play therapy, and Theraplay® are reported to have been applied to cross-cultural settings

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(Schaefer, 2011a). Within Eastern cultures, group play therapy has been used with Chinese earthquake victims (Shen, 2002), and Wakaba (1983) reported a study where group play therapy was the approach used with Japanese children who had problems with social adjustment and stuttering. A version of filial therapy based on “the Landreth, (1991) 10-week filial therapy training model, which uses both didactic and dynamic components” (Yuen, Landreth & Baggerley, 2002) has been used with Chinese immigrant parents to Canada (Yuen et al., 2002) as well as Korean immigrant parents to the United States (Lee & Landreth, 2003). The Landreth (1991) filial therapy training model has subsequently been published as Child Parent Relationship Therapy (CPRT), a 10 Session Filial Therapy Model by Landreth and Bratton (2006). In this chapter, this version of filial therapy will be referred to as Child Parent Relationship Therapy Filial Therapy.

Experience Sharing: How Play Therapy had been Adapted for Different Cultures In considering the adoption of play therapies from the West to the East, the process of play therapy and the toys used in play therapy are now discussed.

Adaptions to the process of play therapy We will explore four studies which reported the use of play therapies with families and their children who were born into families from a collective society with an Eastern perspective or First Nations perspective. Yuen et al. (2002) offered Child Parent Relationship Therapy Filial Therapy (CRPT Filial Therapy) sessions to Chinese families whose children had not received therapy before, and who had immigrated to Canada. The authors acknowledged that immigrant families from China are confronted with a different culture, and a limitation of critiquing this paper is that the Chinese families were not living in China. The authors did note, however, that principles of Confucius can influence Chinese parent child-rearing practices. For example, negation of conflict, obedience, strict discipline, family obligations, respect for elders, and maintenance of harmony can affect the structure of the family and stresses within the family (Yuen et al., 2002). CPRT Filial Therapy was conducted within a support-group format supported by a therapist. To investigate the effectiveness of CPRT Filial Therapy with a

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group of immigrant Chinese families to Canada, 19 parents were randomly allocated to the experimental group of 10 sessions, which were conducted in Cantonese. Seventeen families were randomly allocated to a non-treatment control group. The results showed that the parents who were in the CPRT Filial Therapy sessions were significantly more empathetic in their relationship with their children (Yuen et al., 2002). Parents were also more tolerant of their child’s self-direction than parents in the control group, indicating that parents in the experimental group were beginning to value individualism (Yuen et al., 2002). Overall, the study found that immigrant Chinese parents in Canada could change their relationship with their child by allowing more self-direction in their children, communicating with and accepting their child’s behavior and feelings, being more involved in their child’s play, and accepting their child as a unique, autonomous person. These changes were in contrast to Confucius thinking in that parents have a high degree of physical control over their children, are protective and make decisions for their children, children obey their parents and do not argue, and intimacy is not shown publically (Yuen et al., 2002). The authors concluded that CPRT Filial therapy with immigrant Chinese families was effective in increasing the parent-child relationships and reducing parental stress. They also argued that CPRT Filial Therapy was culturally sensitive and was a healthy blend of Eastern and Western style approaches to parents, as parents could increase their involvement with their children to improve their relationship and acceptance of their child while maintaining traditional cultural values, beliefs and traditions (Yuen et al., 2002). What was not addressed in this study was the views of the parents about how they reconciled their cultural perspectives with the skills taught in filial therapy. Landreth was also involved in a study exploring the use of CPRT Filial Therapy with Korean families who had immigrated to the United States (Lee & Landreth, 2003). For Korean families who immigrate to a Western country, there is often a conflict between their traditional values of piety and patriarchy and Western values of individualism and self-assertion (Lee & Landreth, 2003). Confucianism is strongly influential, and the Korean mothers take primary responsibility for the psychological well-being of their children (Lee & Landreth, 2003). Korean families also value academic work above play, and children may feel they cannot meet their parent’s expectations. CPRT Filial Therapy was offered over a 10-week period to families in the community; 36 parents consented to be in the study with 18 being randomly assigned to the experimental group of CPRT Filial Therapy

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(Lee & Landreth, 2003). Results showed an increase in parent empathy and acceptance of their children, and a decrease in stress for parents who were in the CPRT Filial Therapy. These results concurred with a study that was carried out in Korea by Jang (2000). The authors concluded that filial therapy was an effective intervention for immigrant Korean parents in the United States as it helped the parents become therapeutic agents for their children (Lee & Landreth, 2003). Again, as in Yuen et al.’s (2002) study, this was a case of the parents being assimilated into the dominant Western culture (see O’Connor, 2005). Shen (2002) reported a study with children who had experienced an earthquake in Taiwan. Thirty children were randomly allocated to an experimental group of Child-Centered Play Therapy (15 children) or a no-therapy control group (15 children). Children were seen in groups of three for 3 to 4 times a week for 4 weeks. The children in the play therapy group reported significantly lower anxiety and Shen argued that the power of Child-Centered Play Therapy helped children to be less anxious in an environment over which they had no control (e.g., earthquakes). Shen (2002) did discuss a culturally significant shift in that the children in the experimental group did openly express joy in playing. In typical Chinese culture in Taiwan, children are not encouraged to play because parents value academic achievement over mental health (Shen, 2002). A few parents did tell their children that if they only played in the therapy sessions, they would not be allowed to continue and some children found it more difficult to enjoy the sessions (Shen, 2002). Shen recommends that Chinese parents and teachers should be educated on the value of mental health interventions, and the value of play within these interventions. A study in Hong Kong on children’s play confirmed Shen’s observations (Chow, Cheung, & Swee Hong, 2008). This editorial, which reported a study on children’s playground play, noted that children in Hong Kong spent very little time playing, which was in contrast to children from Western countries (Chow et al., 2008). They noted that Chinese parents valued work over play and that playing was viewed by parents as being wasteful (Chow et al., 2008). They agreed with Shen that therapists who work with children from cultures that do not value play, need to be able to justify and advocate for the value of play in a child’s life (Chow et al., 2008). Shen (2002) concludes, as did Yuen et al. (2002) and Lee and Landreth (2003), that the well-being of children from an Eastern culture can be increased through a helping Western technique. These studies did not appear

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to change the therapy technique or theoretical orientation of the technique. The only reported change was that therapy was delivered in group sessions, not individual sessions. In the West there is a growing awareness of cultural sensitivity and the need to be culturally appropriate in interacting with families and children. Play therapy approaches such as Ecosystemic Play Therapy (O’Connor, 2011) acknowledge the multiple contexts in which people live. O’Connor (2005) has called on play therapists to address cultural issues in play therapy and for Western therapists to “guard against the tendency of traditional, Western forms of therapy to gradually assimilate the client into a dominant culture.” In his paper he is addressing Western therapists working in Western countries (in this case the United States) to be more aware when working with clients from diverse cultural backgrounds to their own. Boyer (2011) was the only study found that changed the process of the play therapy to account for clients who came from a collective society. Boyer discusses a case study from Canada of how CPRT Filial Therapy was adapted for a grandparent, who was a First Nations Elder, and his grandchild. The therapist took time to establish a power-equal relationship with the First Nations Elder, building trust and communication, while also showing concern for the First Nations’ collective. The goals for therapy that were agreed upon were meaningful to the First Nations Elder. CPRT Filial Therapy was chosen as the therapist could work with this model to help the First Nations Elder use core First Nations values to help his grandson (Boyer, 2011). To be appropriate to the values of clients from a collective society, the process of the CPRT Filial sessions were modified. The 10 sessions of CPRT Filial Therapy were changed to 5 weeks, twice weekly, to suit the family; play activities reflected First Nations culture, including storytelling, dancing, singing, painting, and reenactments. The child and the First Nations Elder were seen in the session together and verbal input was replaced with visual input such as videos, role play exercises, and demonstration. Core First Nations values of “(a) Spirit of Belonging or significance, (b) Spirit of Mastery or competence, (c) Spirit of Independence or power, and (d) Spirit of Generosity or virtue of giving” were incorporated into the sessions (Boyer, 2011).

Adaptions to the toys and play materials in play therapy Toys and play materials make up a large part of the equipment of play therapists. The toys used in play therapy sessions are important considerations

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when adapting play therapy sessions from a Western culture to an Eastern culture or First Nations culture. Stagnitti, an Australian, noted that when working in Japan, children did not recognize the wrench (commonly recognized by Caucasian Australian children) and the children had more domestic play themes in their play than Australian children (O’Connor, 2005). In a study of toy choice for the development of the Indigenous ChildInitiated Pretend Play Assessment, Dender and Stagnitti (2011) found that Australian Indigenous children preferred darker skinned dolls and native animals (as opposed to farm animals). As a principle in adapting play therapy to non-Western cultures, culturally specific toys that reflect the child’s daily life should be supplied in a play room or for a play session (Drewes, 2009b; O’Connor, 2005). Such a selection might consider figures that reflect age, gender, ethnically appropriate dress, skin color and ability, and common objects found in homes such as rugs, bowls, colors, religious symbols, specific play food, dress-ups, and miniatures that reflect a child’s daily life (Chang et al., 2005; O’Connor, 2005). Chang and her colleagues (2005) found that the selection of toys and play materials were changing to reflect the cultural diversity of play therapy clients, however, whether therapists adapt the process of play therapy requires more research.

Reflections as an International Trainer As therapists who come from a Western perspective, we have learned a lot when training in Hong Kong (Parson), and Japan and Singapore (Stagnitti). Our reflections are colored by our cultural heritage and we acknowledge that we still have a lot to learn when working with people from cultures different to our own. We will reflect on children’s play, toys, and the therapeutic process. How children play in a normative way for their culture (see O’Connor, 2005) is something we both find fascinating. When working in Japan, Stagnitti was always interested seeing children play in their home environment. She remembers seeing a child in the driveway to her house making food from the dirt and mud she had combined. Watching her, Stagnitti reflected on similar play scenes that she played when she was young. Another example from Japan is of a young child who had a wonderful time playing with a doll that represented her father when he had drunk too much sake, and she laughed and giggled as she moved her doll

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to sleep, snore, and eat. When working with Aboriginal Australian children, Dender and Stagnitti (2017) observed that children from a collective society did not “own” the toys and so when playing together, the children would easily take a toy from another child to begin their own play, and this was completely acceptable. For Aboriginal Australian children, this resulted in the play being very complex and flexible as children changed toys and play scripts, and played together and then separately. This observation raises the importance of being nonjudgmental when learning about a culture different to our own. The choice of toys has been a careful consideration in our training, with recognition that children’s play themes and scripts reflect their cultural perspective. Parson was cognizant of making sure there was a variety of dolls and puppets that reflected many different skin tones, ages, dress, and gender when she undertook training in Hong Kong. When training in Hong Kong, Parson made changes during the training so that the training was accessible and culturally relevant. Adapting the process in play therapy to be culturally acceptable in non-Western traditions takes a lot more thought than changes in toys and observations of children’s normative play within their culture. When working in Singapore and Hong Kong, we were surprised (pleasantly) by the acceptance of therapists and parents for play therapy. Our expectations had been, like the literature mentioned above, that parents of Eastern background would not value play. However, after play therapy sessions with local therapists, parents reported to their therapist that their children were talking more, were happier, and requested more therapy. In Singapore, Hong Kong, and Japan, it was the local therapists who took the concepts and integrated these concepts into their practice. On reflection, it would be interesting to interview these therapists to ascertain the changes in process, if any, that they made. In conclusion, we have both seen dramatic positive changes in children and their families when they have engaged in play therapy. We are continuously learning to adjust our practice to be culturally sensitive, respectful, and appropriate, and we welcome continued engagement with our colleagues from the East as we travel together to work for the health and well-being of families within their ecosystems.

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References Axline, V. (1974). Play therapy. New York: Ballantine Books. Boyer, W. (2011). Using child parent relationship therapy (CPRT) with our first nations people. International Journal of Play Therapy, 20, 38–49. Bronfenbrenner, U. (1979). The Ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press. Cattanach, A. (2008). Narrative approaches in play with children. London: Jessica Kingsley Publishers. Chang, C., Ritter, K. & Hays, D. (2005). Multicultural trends and toys in play therapy. International Journal of Play Therapy, 14, 69–85. Chazan, S., & Cohen, E. (2010). Adaptive and defensive strategies in posttraumatic play of young children exposed to violent attacks. Journal of Child Psychotherapy, 36, 133–151. Chow, S., Cheung, P., & Swee Hong, C. (2008). Understanding children’s play in Hong Kong: A perspective for therapists. International Journal of Therapy and Rehabilitation, 15, 332. Dender, A., & Stagnitti, K. (2011). The development of the indigenous child initiated pretend play assessment: Selection of play materials and administration. Australian Occupational Therapy Journal, 58, 34–42. Dender, A., & Stagnitti, K. (2017). Content and cultural validity in the development of the Indigenous Play Partner Scale. Australian Occupational Therapy Journal, Early DOI: 10.1111/1440-1630.12355. Drewes, A. (Ed.). (2009a). Blending play therapy with cognitive behavioral therapy. New Jersey: John Wiley & Sons. Drewes, A. (2009b). Cultural considerations. In K. Stagnitti and R. Cooper (Eds.), Play as therapy: Assessment and therapeutic interventions (pp.159– 173). London: Jessica Kingsley Publishers. Drewes, A. (2011). Integrative play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 349–364). New Jersey: John Wiley. Green, E. (2011). Jungian analytical play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 61–85). New Jersey: John Wiley. Iwama, M., Thomson, M., & Macdonald, R. (2009). The Kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation, 31, 1125–1135.

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Jang, M. (2000). Effectiveness of filial therapy for Korean parents. International Journal of Play Therapy, 9, 21–38. Knell, S. (2011). Cognitive-behavioural play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 313–328). New Jersey: John Wiley. Kottman, T. (2011). Adlerian play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 87–104). New Jersey: John Wiley. Landreth, G. & Bratton, S. (2006). Child Parent Relationship Therapy (CPRT): A 10 session filial therapy model. New York: Routledge. Landreth, G. (1991). Play therapy: the art of the relationship. Muncie, IN: Accelerated Development. Lee, M. K., & Landreth, G. (2003). Filial therapy with immigrant Korean parents in the United States. International Journal of Play Therapy, 12, 67–85. Levy, A. (2011). Psychoanalytic approaches to play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 43–59). New Jersey: John Wiley. Mellou, E. (2006). Play theories: a contemporary review. Early Child Development and Care, 102, 91–100. Munns, E. (2011). Theraplay: Attachment-enhancing play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 275–296). New Jersey: John Wiley. Nims, D. (2011). Solution-focused play therapy: Helping children and families find solutions. In C. Schaefer (Ed.), Foundations of play therapy (pp. 297–312). New Jersey: John Wiley. Oaklander, V. (2011). Gestalt play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 171–186). New Jersey: John Wiley. O’Connor, K. (2005). Addressing diversity issues in play therapy. Professional Psychology: Research and Practice, 36 (5), 566–573. O’Connor, K. (2011). Ecosystemic play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 253–272). New Jersey: John Wiley. Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2015). Childcentered play therapy in the schools: Preview and meta-analysis. Psychology in the Schools, 52(2), 107–123. DOI: 10.1002/pits.21798. Schaefer, C. (Ed.). (2011a). Foundations of play therapy (2nd Ed.). New Jersey: John Wiley. Schaefer, C. (2011b). Prescriptive play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 365–374). New Jersey: John Wiley.

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Shen, Y. J. (2002). Short-term play therapy with Chinese earthquake victims: Effects on anxiety, depression and adjustment. International Journal of Play Therapy, 11, 219–220. Stagnitti, K. (1998). Learn to play: A program to develop the imaginative play skills of children. Melbourne: Co-ordinates Publishing. Stagnitti, K. (2015). Play therapy for school-age children with high-functioning autism. In A. Drewes and C. Schaefer (Eds.), Play therapy for middle childhood (pp. 237–255). New York: American Psychological Association. Stagnitti, K., & Cooper, R. (2009). Play as therapy: Assessment and therapeutic approaches. London: Jessica Kingsley Publishers. Sweeney, D., & Landreth, G. (2011). Child-centered play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 129–152). New Jersey: John Wiley. Taylor de Faoite, A. (2011). Narrative play therapy. In C. Schaefer (Ed.), Foundations of play therapy (pp. 329–347). New Jersey: John Wiley. Taylor, E. R. (2009). Sandtray and solution-focused therapy. International Journal of Play Therapy, 18, 56–68. VanFleet, R. (2011). Filial therapy. Strengthening family relationships with the power of play. In C. Schaefer (Ed.), Foundations of play therapy (pp. 153–186). New Jersey: John Wiley. Wakaba, Y. (1983). Group play therapy for Japanese children who stutter. Journal of Fluency Disorders, 8, 93–118. Yasenik, L., & Gardner, K. (2012). Play therapy dimensions model. A decision-making guide for integrative play therapists. (2nd ed.). London: Jessica Kingsley Publishers. Yuen, T., Landreth, G., & Baggerly, J. (2002). Filial therapy with immigrant Chinese parents. International Journal of Play Therapy, 11, 63–90.

2

Growing Up in East Asian Cultures Alicia K. L. Pon

Children born in East Asian countries in the last two decades have witnessed a world evolving at a dizzying speed. The meteoric rise of economic prowess in Asia, notably China; the continuing influence of technologies in the digital age; and the rapid confluences of cultures within the region all contribute to a challenging milieu for educators and parents. They are grappling within a society full of opportunities as well as developmental pitfalls for young individuals. Consequently, there is an increasing demand for psychosocial support that is catered for the unique needs of children. Play therapy is one of the psychological treatment modalities that have been proven beneficial to children facing various problems such as parental divorce (Landreth, 1993), behavioral problems, and adjustment issues (Bratton, Ray, Rhine, & Jones, 2005). Originally conceived in Europe as an extension of Freudian psychoanalysis to children, play therapy as a discipline has developed its theoretical basis in the United States, with pioneering works by, for example, Virginia Axline (1950) and Haim Ginott (1961). Today, the growth of this discipline is evident both in the expanding membership of professional associations (e.g., the Association for Play Therapy [APT] in the United States) and in its wide recognition among mental health professionals in the West. From the start, professionals understand the challenge of working with families from different cultures. The steady rise of the Asian population in the West was what prompted play

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therapists, who are used to serving Caucasian families, to recognize the need of developing culturally sensitive play therapy (Chau & Landreth, 1997; Lee & Landreth, 2003; Webb, 2001; Yuen, Landreth, & Baggerly, 2002). Despite a conscious and steady effort by professional bodies such as APT to promote cultural sensitivity, play therapists often reported running into barriers. For example, many of them found it difficult to incorporate materials, such as toys and board games that were relevant to their culturally diverse clients (Vaughn, 2012; Webb, 2001). Of course, developing culturally relevant and sensitive play therapy for Asian families requires more than materials. Play therapists who work in Asia, in particular, recognize in their day-to-day practice with families, the need to adapt and reinterpret what they have learned in their professional training, often on the fly during a therapy session. Parental expectations, behavioral patterns of children, societal norms, and familial dynamics are but a few areas where therapists see culture exerting its influence on clients, on client-therapist relationships, and even on therapists themselves. But what is it like to grow up in Asia? What are the cultural assumptions that play therapists should be aware of? And ultimately, how can play therapy as a profession contribute to the Asian culture at large? During the preparation of this section, the author is conscious of the many perils that are common when one attempts to provide an overview of a certain culture. First of all, when we talk about an Asian culture, we focus our discussions on a constellation of East Asian countries, chiefly China, Japan, Korea, Taiwan, and parts of Southeast Asia, which share common cultural influences that can be traced back, at least partly, to ancient China. This decision to leave out India and other South Asian cultures is not so much a nod to sinocentrism but an admission of the limited scope of our collective knowledge. Moreover, we recognize the fact that we are living in the globalized age of increasingly fluid cultural identity. Every day we meet Asian families who come to the therapy room with various degrees of exposure to different cultures, both within their countries as well as in the West. This certainly makes the delineation of cultures a more difficult task.

Confucianism in Asian Culture With the previous caveat in mind, the following text provides a cursory overview of the main features in Asian culture that are pertinent to growing up in an Asian household. While East Asian culture is heavily influenced by

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three ancient schools of thoughts and religions, namely Buddhism, Daoism and Confucianism, it is Confucianism that continues to exert the most significant impact on the societal configuration of Chinese, Korean, Japanese and Singaporean communities. The teachings of Confucius (551–479 BC) were compiled by his disciples into the seminal book Analects, in which the Confucian ideal in both moral and social terms are described. The central concept of Confucianism is ren (benevolence), through which the sociopolitical order is manifested and social norms are defined. Nurturing oneself through self-cultivation for the common good is the only means towards becoming a man of ren, or sage. Confucian values have a lasting impact on East Asian societies. While families do not outwardly identify themselves as adherents to Confucianism, many of them prescribe and internalize these values as an implicit form of moral code. In terms of parenting, Asian families are guided, to varying degrees, by three major Confucian themes: (a) collectivism and interdependence, (b) social hierarchy and order, and (c) self-improvement as cardinal virtue.

Collectivism and interdependence It has been observed that East Asian culture places more emphasis, relative to Western countries, on the society as a whole than on the individual. In fact, one of the earliest observations in cross-cultural psychology was that collectivism, an encompassing value in the East, shapes the concept of the self (Markus & Kitayama, 1991). The Confucian self is defined by its relationships with others, and the web of relationships can be considered as an extension of one’s own identity (Rao et al., 2001). According to this interdependent view of self, the source of agency is more closely situated in social groups to which individuals belong, instead of within the individual. At the extreme, communal (or familial) priorities take precedence over individual aspirations. It follows that conformity is a rewarded trait, as well as modesty. Asian people are less inclined to self-enhancement and more predisposed towards self-criticism (Lehman, Chiu, & Schaller, 2004), and they consistently report lower levels of optimism (Lee & Seligman, 1997) and self-esteem (Twenge & Crocker, 2002) than their Western counterparts. That does not mean, however, that Asian people have inherently lower life satisfaction. As Lehman and his associates (2004) observe, Asians vest their

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self-worth in the standing of the group to which they belong, thus rendering self-esteem a less important determinant of their subjective well-being.

Social order If self is partly defined as the relationships with immediate others, maintaining order and harmony with them is a crucial virtue in Confucianism, which defines social order based on patriarchal hierarchy. Confucian scholars in ancient China attempted to create elaborate systems that dictated obligations, shaped roles, and defined acceptable social behaviors. Many of these values have been translated into cultural practices that continue in contemporary Asia. In particular, the rule of filial piety (xiao) demands that the older generation be respected, revered, obeyed, and cared for. Today in many Asian countries, this dictum still shapes patterns of residence, family support, legal frameworks, and family policies (Hashimoto & Ikels, 2005); for example, social welfare policies in Asia are commonly based on the assumption that the immediate offspring should provide financial and material support for their parents, with the state as the backup safety net. Since the web of interdependent relationships in Asian societies is built on kinship and social interactions, Hwang (1987) suggests that the concepts of face (mianzi), favor (renqing), and relationships and connections (guanxi) are core components in the study of interpersonal relationships in Asian communities. Face and favor are regarded as “social capital” one accrues by performing public acts that attract social recognition and private deeds to another person’s benefit. In a study conducted by Tam and Bond (2002), beneficence (favor-doing) and restraint were found to be important traits in sustaining Chinese friendship, reasoning that restraint is interpreted as politeness in the Chinese context.

Self-improvement as doctrine The importance of continuous self-improvement cannot be overstressed in the Confucius ideal. This is in turn based on the belief in meritocracy (to a degree that did not overthrow monarchical power). As a result, Asian students and their parents often view hard work, instead of innate ability, a stronger determinant of academic outcome (Stevenson, Chen & Lee, 1993). In a discussion of Confucian learning style, Tweed and Lehman (2002) describe an approach that is pragmatic and moral in nature, and more

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focused on acquiring existing knowledge from authority figures than on independent inquiry. Chinese students have a more instrumental view of education (e.g., as a means to higher social status or financial gains), a preference of structured tasks over open-ended exploration, and a tendency to refrain from questioning the authority. The pragmatic nature of learning and the focus on finding and correcting one’s own weakness in Asian culture result in a motivational system that is different from other cultures. For example, fear of academic failing is a stronger predictor of learning motivation than expectation of success (Eaton & Dembo, 1997). Where in the West learners who seek external rewards such as approval of others display less intrinsic motivation, for Chinese students parental recognition can be an effective incentive for deep learning (Bao & Lam, 2008).

Parent and Child in Asia The considerable media attention given to the “Tiger Mother” phenomenon is due no less to Amy Chua (2011), the Yale law professor who popularized in her book the cultural stereotype of Asian mothers who are relentlessly bent on making sure their children succeed academically by a highly disciplinarian parenting regime. Caricatured as the phenomenon can be, it nonetheless captures the imagination of the Western audience on the apparently superior academic performance by Asian students (and the implicit question that Western parents ask—what have we done wrong?). In fact, beginning in the 1980s, there has been sustained academic interest in understanding the cultural difference in childrearing practices in Asia, particularly in China following its open-door policy. Here we present a few highlights that come from the three decades of cross-cultural research on child temperament, parenting style, and parenting practices. While many of the studies have been done in China or Chinese populations, these findings can still be, to a considerable degree, extended to parents and children in Japan, Korea, and Singapore.

Child temperament Cross-cultural studies of child temperament began with the observation that Asian infants were less active, more fearful, and in more negative mood, based on parental reports (Hsu et al., 1981). In a comparison study between China and Canada, Chen and associates (1998) observed behavior and found that Chinese toddlers are more inhibited than Canadian counterparts.

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Conversely, there are reports that Asian infants were less irritable than Western counterparts (Kagan et al., 1994); Newth and Corbett (1993) also found that in a UK city 3-year-olds of Asian parentage had fewer sleep problems, although behavioral and emotional disturbances were equally frequent in both Asian and British toddlers. The lower level of activity and higher level of timidity in Asian children was also found in an older cohort (first graders) by Ahadi, Rothbart, and Ye (1993). Chinese parents also reported more antisocial and neurotic behaviors in their 12-year-old children (Ekblad, 1990). It should be noted, however, that parental reports can be subject to bias; it is not difficult to imagine that Asian parents may have a tendency to be more vigilant on any deviant behaviors or symptoms in their children given the emphasis on conforming to social norm (Wu, 1996). On the other hand, there seems to be little cultural difference in the structure of childhood temperament. In a review of data collected from Chinese, Japanese, and US parents, Rothbart and associates (2001) described a similar factor structure of childhood temperament, namely extraversion, negative affect, and effortful control. Nonetheless, some researchers look into how parents describe their children’s characteristics and found interesting differences between Western and Asian parents. For example, in addition to the three dimensions (emotionality, activity, and sociability/shyness) usually found in Western data (Buss & Plomin, 1984), Zhang (1999) identifies an extra factor he calls “intellect.” This factor reflects the way Chinese parents describe their children in terms of their perceived mental performance, a topic which is less prominent in the discourse among Western parents. This likely reflects how much Asian parents emphasize the intellectual prowess of their children even at the early stage of childhood (Stevenson & Lee, 1990).

Parenting styles The study of parenting styles has been heavily influenced by the work of Baumrind (1971), who mapped out two major types, namely authoritative and authoritarian parenting. In authoritative parenting, parents employ inductive and supportive techniques, respond to children’s needs, and facilitate children’s adaptive behaviors with adequate control. They tend to be more child-centric and democratic in decision-making, and encourage children to be more independent. In contrast, parents who adopt

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authoritarian style prefer coercive and punitive techniques in child rearing. Children are expected to follow rigid rules with high levels of obedience. Cross-cultural psychologists looked into Asian parents and found that the Baumrind typology generally applies to them as well; that is, they saw that Asian parents displayed similar patterns of authoritative and authoritarian parenting styles (Hsu, 1985; Steinberg, Dornbusch, & Brown, 1992). On the other hand, another parenting style coined by Baumrind, permissive parenting (describing a laissez-faire attitude to child rearing), was found to be less reliably identifiable among Asian parents (McBride-Chang & Chang, 1998). The cultural emphasis on social order and harmony understandably predisposes Asian parents to more active forms of discipline and more assertive control on children’s behaviors. In fact, there are consistent findings that Asian parents are more authoritarian than Western counterparts (Dornbusch et al., 1987; Lin & Fu, 1990; Vinden, 2001; Wu, 1996; Wu et al., 2002). This tendency is observed in either parental self-reports (Porter et al., 2005), observations in controlled environments (Liu & Guo, 2010) or child’s recollections (Li, Constanzo & Putallaz, 2010). Cultural difference in authoritative parenting is, however, considerably weaker (Porter et al., 2005). The use of authoritarian strategies has been found to associate with child behavioral problems and therefore considered less adaptive in the West (Dornbusch et al., 1987). However, some researchers question whether authoritarian parenting would have the same behavioral outcomes in Asian societies which value cooperation and hierarchy (Chiu, 1987; Ekblad, 1986). For example, authoritarian practices are found to be predictive of socially inhibited behaviors in the West, that is, timidity and reticence (Mills & Rubin, 1993). However, Chen, Dong, and Zhou (1997) surveyed a sample of 8-year-old children and their parents and teachers, and found that contrary to literature in the West, authoritarian parenting was negatively associated with shyness and social inhibition. This may be understood within the cultural context, where shyness and socially restrained behaviors are considered more adaptive. Thus the finding indicates how parenting style and outcomes have to be understood within the culture. To this date, there is still an ongoing debate on whether authoritarian parenting is maladaptive across cultures (Nelson et al., 2006), while many studies replicate findings in the West that link authoritarianism to child’s adjustment problems (Chang et al., 2003; Chen et al., 1997; Zhou et al., 2004). Other studies found neither

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negative outcomes associated with authoritarian parenting of Asian children (Supple, Peterson, & Bush, 2004) nor positive outcomes such as greater academic performance (Leung, Lau & Lam, 1998) and lower depression (Li et al., 2010). There is stronger evidence that authoritative parenting is more culturally universal in promoting better adjustments in children (Chen et al., 1997; Li et al., 2010; Supple et al., 2004). If authoritarian parenting is associated with poor adjustments and if Asian parents are on average more authoritarian, why do Asian children have such academic success at school in general? Chao (1994) attempted to answer this question by postulating the existence of a culturally specific parenting style among Asian parents: training parenting. The concept of training owes much to the Confucian idea of human malleability and supremacy of efforts. Training parenting means taking on an active approach in promoting or coercing desirable behaviors in children, usually in a highly involved mother-child relationship. Parents often offer drive and support to children in order for them to succeed, particularly at school. Stewart and Bond (2002) found that training parenting seems to be beneficial to Asian students but not to American counterparts.

Parenting practice Some researchers insist a distinction between parenting style and parenting practice (Wu et al., 2002). Whereas parenting style encompasses various practices that foster a particular interactional climate, parenting practices may be more cultural and situational specific and are intended to achieve a specific goal (such as better school performance, or more obedient behaviors). Wu and associates further postulate five parenting practices that are emphasized in Asian culture: encouragement of modesty, protection, love withdrawal, directiveness, and maternal involvement. 1. Encouragement of modesty: Parents teach the importance of conformity and humility in order for children to better “fit in” their environment. 2. Protection: Parents strive to provide a protective environment and foster dependence from children. They apply restrictions to the child’s activities and regulate how the child interacts with peers and the world. 3. Love withdrawal: Parents employ overt disapprovals and threats of love withdrawal to promote adherence to social norms. They

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heighten the child’s sensitivity of other people’s opinions and judgments. 4. Directiveness: Parents control and correct children’s behaviors by criticisms and directions. 5. Maternal involvement: Mothers are expected to be heavily involved in the well-being of the child, and they take an outsized and exclusive role in protecting, caring, and guiding the child’s development. In their survey of Chinese and American mothers, Wu and associates (2002) reported Chinese mothers scored significantly higher than American mothers on all parenting practices except maternal involvement, where the biggest difference was found in love withdrawal.

The unique role of mothers In Asian culture, the expectation on mothers is unique and intense; as Chao (1994) noted, Asian mothers are usually responsible for providing a tightly controlled environment for their children, and devoting most time and efforts to their well-being. Historical accounts extolling the virtue of mothers for their extraordinary parenting efforts abound. Similarly, existing literature on Asian parenting is focused more on surveys with mothers. In an attempt to understand how mothers and fathers have different parenting roles in China and in the United States, Porter and associates (2005) conducted a cross-cultural survey on parenting with fathers and mothers in both countries. While American fathers were perceived to be less authoritative, but no less authoritarian than American mothers, Chinese fathers were perceived to be both less authoritative and less authoritarian than Chinese mothers. The authors argued that this finding may explain the unique image of Asian mothers as being both “soft” and coercive as they employ a balance of authoritarian and authoritative strategies.

Beyond cultural differences in parenting In the above discussion of cultural differences in parenting, a number of confounding factors have to be noted. Socioeconomic characteristics have been found to greatly affect parenting styles across cultures (Hoff, Laursen, & Tardif, 2002). In the study of Chinese parents by Chen and associates

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(1997), it was found that parents with higher socioeconomic status were more likely to employ authoritative parenting while parents with lower socioeconomic status were more likely to employ authoritarian parenting. Moreover, the rapid urbanization found in many Asian countries and the continuing trend of globalization result in an accelerating influx of Western values to those communities. Asian families who identify with those values may adapt parenting strategies emphasized in the West.

Utilization of Mental Health Care by Asian Families Apart from parenting styles, there are reported cultural differences in how Asians seek mental health support. In general, the prevalence rate of mental health problems is reported to be lower in Asia, for example depression in metropolitan China (Chen et al., 2004). However, many noted that psychiatric diagnosis may be biased because there is the issue of stigmatization, and people sometimes present their mental problems in somatic complaints (Shen et al., 2006). The utilization of mental health service by Asians is also reportedly lower in a number of comparison studies in the United States. For example, a study showed Asian Americans terminated their treatment earlier than other ethnic groups (Sue & Zane, 1987). Other researchers found Asians present more severe problems in their first consultation with mental health professionals (Durvasula & Sue, 1996; Lin & Cheung, 1999) and are less likely to start with mental health support (Chen & Kazanjian, 2005). Although there is no study that specifically looks into play therapy in Asia, it is expected that Asian families should display this similar pattern of delayed utilization and premature termination in seeking play therapy or other mental health treatment for their children. The barriers to service are multifaceted. A study in the United States (Kazdin, Holland, & Crowley, 1997) identified a number of factors that explain why parents decide to terminate child therapy prematurely, including stressful experience during the treatment, the perception that the treatment is not relevant to the child’s problems, and poor therapist-client rapport. In addition to these factors, Asian families may delay seeking help since discrimination against mental illness is still prevalent in many communities. The fact that Asians tend to report somatic symptoms and associate their problems with a physical illness also alters their help-seeking pathway (Yen, Robins, & Lin, 2000). The cultural disposition to somatization potentially begins at an early age. In a study by Ekblad (1990), he found Chinese boys scored lower on aggression and higher on psychosomatic symptoms

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compared to studies in other countries. And of course, access to affordable mental health treatment is scarce in many Asian communities. During treatment, Asians respond to Western psychotherapies differently than their Western counterparts (Shen, 1996). A number of mental health professionals (e.g. Atkinson & Gim, 1989; Kim, Atkinson, & Umemoto, 2001; Kim et al., 2001; Sue & Sue, 1999) have noted that Asian clients are reluctant to discuss emotional issues in an open and candid way. The researchers attributed this to the cultural preference for self-control and harmony, and the general disinclination for social disruption among Asian clients. Play therapy, in this way, may be well-placed to serve Asian clients than other modalities where less verbal interactions are required; nonetheless, whether it is really the case remains to be studied.

Conclusion This chapter provided a cursory overview of what it is like growing up in Asia. Mindful of the inherent risk of overgeneralizations in discussions of culture, we discussed how Confucianism remains a potent cultural force in Asian families, reviewed existing studies on parenting style and practices in Asia, and briefly described the utilization pattern of mental health service by Asians. This provides a background against which we present play therapy research in this fast-growing region, and the implications we can draw from the findings obtained so far.

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from the mainstream: Problems uncovered while adapting Western research to non-Western cultures. British Journal of Developmental Psychology, 20(3), 379–392. Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd Ed.). New York: Wiley. Sue, S., & Zane, N. G. (1987). The role of culture and cultural techniques in psychotherapy: A critique and reformulation. The American Psychologist, 42(1), 37–45. Supple, A. J., Peterson, G. W., & Bush, K. R. (2004). Assessing the validity of parenting measures in a sample of Chinese adolescents. Journal of Family Psychology, 18(3), 539–544. Tam, B. K., & Bond, M. H. (2002). Interpersonal behaviors and friendship in a Chinese culture. Asian Journal of Social Psychology, 5(1), 63–74. Tweed, R. G., & Lehman, D. R. (2002). Learning considered within a cultural context: Confucian and Socratic approaches. American Psychologist, 57(2), 89. Twenge, J. M., & Crocker, J. (2002). Race and self-esteem: Meta-analyses comparing Whites, Blacks, Hispanics, Asians, and American Indians and comment on Gray-Little and Hafdahl (2002). Psychological Bulletin, 128(3), 371–408. Vaughn, K. M. (2012). Play therapist’s perspectives on culturally sensitive play therapy (PhD Dissertation). University of New Orleans, New Orleans, Louisiana). Vinden, P. G. (2001). Parenting attitudes and children’s understanding of mind: A comparison of Korean American and Anglo-American families. Cognitive Development, 16(3), 793–809. Webb, N. B. (2001). Culturally diverse parent-child and family relationships: A guide for social workers and other practitioners. New York: Columbia University Press. Wu, D. Y. H. (1996) Chinese childhood socialization, In M. H. Bond (Ed.), The handbook of Chinese psychology (pp. 143–154). Hong Kong: Oxford University Press. Wu, P., Robinson, C. C., Yang, C., Hart, C. H., Olsen, S. F., Porter, C. L., & Wu, X. (2002). Similarities and differences in mothers’ parenting of preschoolers in China and the United States. International Journal of Behavioral Development, 26(6), 481–491.

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Yen, S., Robins, C. J., & Lin, N. (2000). A cross-cultural comparison of depressive symptom manifestation: China and the United States. Journal of Consulting and Clinical Psychology, 68(6), 993–999. Yuen, T., Landreth, G., & Baggerly, J. (2002). Filial therapy with immigrant Chinese families. International Journal of Play Therapy, 11(2), 63–90. Zhang, Y. (1999). A study of children’s personality and its development: Based on parents’ perception [in Chinese]. Journal of Chinese Psychology Acta Psychologica Sinica, 31(2), 177–189. Zhou, Q., Eisenberg, N., Wang, Y., & Reiser, M. (2004). Chinese children’s effortful control and dispositional anger/frustration: Relations to parenting styles and children’s social functioning. Developmental Psychology, 40(3), 352–366.

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3

Play Therapy Research in Asia Angela F. Y. Siu

In the West, play therapy has been utilized for many decades as an intervention modality for children and adolescents. It has been recognized as an effective intervention for children with a wide range of psychological, behavioral, and emotional issues. Two ground breaking meta-analytic reviews provided relevant research findings in support of the use of play therapy for children (Bratton, Ray, Rhine, & Jones, 2005; Baggerly, Ray & Bratton, 2010). As reported by Baggerly and colleagues, among the 25 research studies on play therapy during the period from 2000 to 2009, all but one resulted in positive effects, though some results were stronger than others. Indeed, like any other therapeutic interventions in our contemporary societies, one of the challenges is to develop further evidence-based practices to support its effectiveness on different populations (Phillips, 2010; Urquiza, 2010). Kenny-Noziska, Schaefer, and Homeyer (2012) postulated that practitioners of play therapy have to take into consideration many factors in order to customize interventions and strategies that best fit the needs of their clients. Cultural factor is one of them. Although play therapy research continues to show strong evidence to support its use among different populations, Ray and Bratton (2010) stressed that play therapy research on multicultural populations continues to be sparse. A limitation with existing studies that explored the use of various forms of play therapy as a culturally responsive intervention is related to their methodology. For instance, while

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studies have demonstrated the effectiveness of filial therapy with Chinese (Yuen, 2010) and Korean (Lee & Landreth, 2003) families, as well as ChildCentered Play Therapy (CCPT) with Japanese children (Ogawa, 2006), it does not necessarily imply that these effects will also be generalizable to the Asian cultures in other groups due to sampling limitations (e.g., small sample size). As these studies consisted of participants from non-Western cultures residing in the West, the extent to which they could represent their counterparts living in the native land is questionable (e.g., biases concerning factors such as acculturation may exist). As a result of these potential methodological limitations evident in extant studies that examined the cultural sensitivity of play therapy, it is critical for researchers to conduct research within the Asian contexts. While play therapy studies that are conducted with local families do exist in Asian countries, the extent to which they are accessible internationally remains unclear. It is speculated that one major reason is the language and accessibility barriers as much of the research is published in journals of their own languages or within their own universities (e.g., unpublished theses and dissertations). Consequently, findings that delineate the effectiveness of play therapy within different Asian contexts may not be recognized internationally. As an example, the effectiveness of play therapy in the Korean context may not be well-recognized despite how well-researched it is in South Korea (Seo, Kim, & Kim, 2007) because most of the published articles are in Korean (Kim, 2008). The paucity of relevant research and publications in some Asian cultures (e.g., Malaysia) may also be responsible for the lack of publicity concerning the use of play therapy (Ng, 2011; 2013). For instance, a search in the network for local studies in Malaysia listed one article on play therapy, which was an unpublished article from the 6th International Qualitative Research Convention held in Malaysia in 2011. One other reason may be related to the ways help-seeking behaviors are perceived in Asian cultures. For example, due to the fact that the disclosure of personal or family problems to strangers are discouraged in the Chinese culture (Yuen, 2010) and that users of mental health services are stigmatized (Sue & Sue, 2007), it may be difficult to have a desirable sample size suitable for large-scale studies in countries like China. In other words, language barriers and publication issues, as well as cultural perspectives on mental health services, may impede the growth and dissemination of play therapy research conducted in Asian cultures.

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The present chapter will provide readers with an overview on the play therapy research conducted in various Asian countries. The studies referred in this chapter were identified using search engines such as PsycINFO, Social Science Index, Educational Resources Information Centre (ERIC), and other databases used by researchers in the field of psychology to find recent articles on a topic. Manual searches, including unpublished manuscripts and articles cited in local websites (which do not have the English translation), were also completed. Countries and cities that are discussed in this chapter include: Hong Kong, Japan, Malaysia, China, the Philippines, Singapore, South Korea, and Taiwan.

Theoretical Approaches Most Studied To date, play therapy takes on different forms to enhance the functioning of children by working not just with the children themselves, but also with their parents and teachers. This section describes some of the common forms of play therapy used and researched in Asia.

Child-Centered Play Therapy (CCPT)/ Child Parent Relationship Therapy (CPRT) Child-Centered Play Therapy (CCPT) originated from Axline’s (1969) elaboration on Carl Rogers’ person-centered theory that emphasized on the self-actualizing nature of individuals (Ray & Landreth, 2015). Through experiencing unconditional positive regards and empathic understanding from the therapist, the child begins to move towards self-enhancement and healthier functioning (Ray & Landreth, 2015). Since its inception during the 1940s, CCPT has gained incrementing empirical support (Ray & Bratton, 2010). To date, CCPT is practiced in many parts of the world (Ray & Landreth, 2015). Jang (2000) completed a study on using Landreth’s 10-week ChildParent Relationship Therapy, CPRT program (Landreth & Bratton, 2006) for families in Korea. Parents were trained at Namseoul University of Korea. In this study, there was an experimental group and a control group. Measures included the Porter Parental Acceptance Scale (Porter, 1954), the Parenting Stress Index (Abidin, 1995), and the Measurement of Empathy in Adult-Child Interaction (MEACI) (Stover, Guerney & O’Connell, 1971). Results indicated that there were significant changes in parental acceptance and allowance

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of children’s self-direction, as seen in MEACI, for those in the experimental group. There was also no cultural difference in terms of reaching the goal of enhancing parent-child relationships among Eastern and Western families. In the Chinese context, CCPT is widely used in Taiwan and Hong Kong. For instance, a study (Shen, 2010) in Taiwan supported the use of CCPT as a useful tool to help Chinese children suffering from anxiety and suicidal ideation, an important indicator of depression, after a devastating disaster. In this study, children’s physiological anxiety and worry/oversensitivity were significantly reduced after play therapy treatment. Moreover, although children’s general depression, anxiety, self-esteem, sad mood, instrumental helplessness, social introversion, low energy, and pessimism did not show significant improvements after play therapy treatments, children’s suicide risk was significantly reduced (Shen, 2010). With respect to Hong Kong, research studies that examine the effectiveness of CCPT on a local sample have been lacking despite its wide use. Nonetheless, theses and dissertations that support its use are available. For example, Choi (2002) reported the effectiveness of CCPT on two children with emotional difficulties.

Filial Therapy As parents often function as the primary caregivers in the child’s life, Landreth (2002/2012) viewed them as partners in the play therapy process as their involvement often lead to greater therapeutic effects (Bratton, Ray, Rhine, & Jones, 2005). Filial therapy is an intervention that has emerged from the CCPT approach (Ray & Landreth, 2015), emphasizing on enhancing the parent-child relationship through instilling parents with CCPT skills. Guo (2005) looked into the effectiveness of filial therapy as a culturally sensitive intervention for children in Mainland China. As parents of this study had been putting too much focus on academic success and cognitive development, the emphases on child’s playtime and emotional development were ignored. Through filial therapy, parents learned to be the agent of change in their children’s lives. The positive effect of filial therapy is not limited to Asian parents living in their domestic land. For example, Lee and Landreth (2003) found that filial therapy was effective in helping immigrant Korean parents in the United States improve their level of empathic interactions with, and their attitude of acceptance toward their children. These parents also experienced a reduction in parenting stress. In other

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words, filial therapy appears to be an intervention that empowers parents to effect change for their children in both the Western and Eastern cultures. The effectiveness of adapting filial play skills for teachers in enhancing teacher-student relationships in Hong Kong was documented in Siu’s study (2014a). The findings indicated a positive change in teachers’ perceptions of target students’ behavior and an improvement in the relationship between each teacher-student dyad. Themes that emerged from her study included gaining new perspectives, having positive changes in relating to the target students, and acquiring better ideas for managing students in class and at school. Leung (2015) also provided support to the use of a child-centered play training model to enhance child-teacher relationships (particularly through increasing communication of acceptance by allowing children to lead and becoming more involved in play with the child) and consequently leading to a reduction in children’s behavior problems.

Parent Child Interaction Therapy (PCIT) Similar to filial therapy, PCIT focuses on facilitating positive behaviors in children by equipping parents with relevant knowledge and skills (e.g., nondirective play therapy principles); through this approach, a more affectionate parent-child relationship is also established (Leung, Tsang, & Heung, 2009). Studies relating to the effectiveness of PCIT among Chinese families were reported in Hong Kong. For example, Leung and colleagues (2009) conducted a study evaluating the impact of PCIT on children with significant behavioral problems. The participants (divided to either intervention or comparison groups) completed questionnaires on child behavior problems and parenting stress before and after intervention. Results from the post-intervention scores revealed that participants in the intervention group showed fewer child behavior problems and lower parenting stress than those in the comparison group. The observational data depicted a decrease in inappropriate child-management strategies and an increase in positive parenting practices following intervention. The intervention group participants generally maintained the changes within 3 to 6 months after program completion. Positive effects of PCIT were also evident among Taiwanese families. In addition, maladaptive personality characteristic(s) of caregivers was the best predictor of treatment attrition; the results from Chen and Fortson’s (2015) study also suggested that PCIT led to enhancements in positive parenting behavior and child compliance, as well as decreases

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in poor parenting behavior, parental stress, and child disruptive behavioral problems. Further, improvement in child behavioral problems was maintained for over half of the families at 3-months follow-up. These results demonstrated the effectiveness of PCIT for Chinese families in Hong Kong and Taiwan.

Theraplay® Theraplay is a structured form of play therapy whereby very few play materials need to be used; instead, it focuses on replicating the interactions that normally occur between children and their parents by taking four underlying dimensions into account, that include structure, engagement, nurture, and challenge (Munns, 2011). Compared to other play therapy approaches, Theraplay has been studied relatively more extensively in various Asian countries. A possible explanation for its wider use may be related to how Asians perceive their roles in therapy. For instance, Chinese seems to prefer directive approaches in therapy, whereby the therapist acts as the “leader” during therapy (Ng & James, 2013) resulting in more therapists being trained in this approach. In addition, Chinese parents may be more likely to embrace Theraplay as an intervention for their child due to its directive nature. Similar cases may also apply to other Asian cultures, such as Japanese and Koreans. In South Korea, there have been studies conducted on the effectiveness of Theraplay (conducted in a group format) on children with diverse abilities. As suggested by Park and Lee (2014), group Theraplay not only improved peer competence among elementary school children, but also reduced externalizing behavioral problems. Another study also supported that group Theraplay was effective in enhancing mother-child attachment, including positive changes in emotional expression, responsiveness, and eye/physical contact, among multicultural families (i.e., Japanese and Filipino mothers) living in Korea (Park & Yun, 2008). In addition, findings from Kim and Han’s (2013) study illustrated that teacher-led group Theraplay was effective in improving the ego resilience, peer competence, and relationship with teachers of full-day kindergarteners. The effectiveness of Theraplay on children and families has also been evaluated within the Hong Kong context. Siu (2009) reported the effectiveness of using group Theraplay for reducing internalizing problems among primary school children in a randomized controlled study, with a sample size of 46 who were described as at-risk for developing internalizing

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disorders. These children were randomly assigned to either the Theraplay condition or the wait-list control condition. A standardized measure of internalizing symptoms was completed before and after an 8-week intervention. The results revealed that children from the Theraplay condition showed significantly fewer internalizing symptoms compared to the waitlist group as measured using a standardized behavior checklist. The results of this study, together with previous studies (e.g., Franke & Wettig, 2003), indicate that Theraplay is an effective intervention for children. Besides conducting research for Theraplay on the general population, there has been research demonstrating the positive effects of Theraplay on children with special needs. Siu (2008) evaluated the effectiveness of Theraplay in enhancing social responsiveness of Chinese preschoolers with autism. Children in the Theraplay group (experimental condition) were compared to those in the expressive arts group (placebo control condition) in an 8-week summer program for autistic children. The results from preand post-interventions as well at the one-month follow-up were gathered. Results showed that children in the Theraplay group achieved better improvement in reading basic affective signals (as shown in the subscale scores for social awareness, social cognition, and social motivation of Constantino’s [2002] Social Responsiveness Scale), whereas those in the Expressive Arts group performed significantly better in social communication and social motivation at post-intervention assessment. Another study by Siu (2014b) denoted the effectiveness of a Group Theraplay program in a special school for children with developmental disabilities. Twenty-three students, arranged into four groups, participated in a year-long program that used Theraplay principles to enhance their social development. The results were compared to a group of 15 students who served as the comparison control. The results from the Social Responsiveness Scale (Constantino, 2002; Gau, Lin, Wu, Chiu, & Tsai, 2013) showed that students from the Theraplay group had significant improvement on the subscale score of social communication when compared to the control group.

Other Approaches of Play Therapy Based on the literature search available so far, there were play therapy studies on a wider range of approaches. Take Chinese culture as an example. These studies were postgraduate theses and dissertations from universities in Hong Kong, Taiwan, and Mainland China. Some of these studies were

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written in Chinese. Topics that have been studied include sandplay therapy for abandoned children (Chen, 2009), children with communication and social difficulties (Liu, 2011; Mao, 2009), cerebral palsy (Wang, 2013), and insecure attachment (Wei, 2009). There are also studies on cognitivebehavioral play therapy for children with special needs (Chen, 2010; Huang, 2011; Hung, 2011), Adlerian play therapy for children with aggressive tendencies (Hu, 2012) and those with attachment difficulties (Yu, 2012), animal-assisted play therapy for social integration of autistic children (Chiou, 2013; Fung, 2011), and group play therapy for autistic children (Chuang, 2011; Liu, 2012; Su, 2013). All of them indicated positive changes in children after the play therapy approach was used. Although these studies might have received limited attention due to language and publication issues, they nonetheless suggest that play therapy has been getting more common in Asian cultures.

Other Specific Populations Targeted Children nowadays have to face many challenges in their early years. Such challenges include changes in family composition (e.g., parental divorce), trauma brought about by natural disasters, as well as stress stemming from the increasingly competitive school atmosphere. In order to support children who often find it difficult to verbally express their emotions, it is imperative to advocate therapeutic approaches that can best match with children’s developmental needs. Play therapy is one of these approaches.

Children affected by disasters In the past decade alone, a person living in Asia-Pacific was twice as likely to be affected by a natural disaster as a person living in Africa, almost six times as likely as someone from Latin America and the Caribbean, and 30 times more likely to suffer from a disaster than someone living in North America or Europe (United Nations Economic and Social Commission for Asia and the Pacific, 2013). Some of the disasters that occurred in Asia include the 2004 Indian Ocean Tsunami, the earthquake in Sichuan province in southwestern China in 2008, and the Great East Japan Earthquake in 2011. Due to these natural disasters, many children are forced to face sudden changes in their lives. When exposed either directly or vicariously to these disasters, it can have an impact on the children’s

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psychological and emotional well-being. In order to provide assistance to a large number of traumatized children, and given the shortage of manpower, resources, and time that result from disasters, conducting intensive shortterm group therapy in an environment that is most familiar to children may be particularly beneficial (Shen, 2010). Studies related to the effects of play therapy on enhancing the mental health of children who went through trauma in Asian countries are evident. For example, Fu (2012) conducted a comprehensive review on universal intervention programs that were used to improve the mental health of child survivors of the Sichuan earthquake in 2008. Of the 27 studies identified, seven were evidence-based. One of the programs cited in his study was on play and art, whereby children were asked to tell their stories about how they had experienced the earthquake in a safe environment. Results showed that the mean PTSD score was lower in the “play and art” group than those in the control group, and that selfawareness was significantly higher among those in the “play and art” group compared to those in the control group. Ho and colleagues (2016) evaluated the effectiveness of a strength-based arts and play support program for the earthquake survivors (who were grade school children) in Sichuan, China. Although the results indicated that participation in the program was associated with increased general self-efficacy and peer support, the relationship was not significant. Nevertheless, this study provided insights for the development of culturally sound arts and play programs for young disaster victims. Play therapy research that focuses on disaster management has also been conducted in Taiwan. From 2002 to 2012, Shen has several articles looking into the effectiveness of individual and group play therapy programs on those who had experienced disasters. For instance, those who joined a short-term CCPT (held in elementary school settings after experiencing an earthquake in 1999) scored significantly lower on anxiety level and suicide risk than did children in a control group after intervention (Shen, 2002). Despite the effectiveness of play therapy, Shen (2002) reported that there was a low rate of parental consent for children’s participation in post-earthquake play therapy group activities, suggesting that the majority of parents may be reluctant to recognize or are unaware of their children’s psychological needs (e.g., having fun), or are simply unfamiliar with Western interventions (e.g., play therapy). The effects of the treatment support previous studies of play therapy with American children (Ray, 2011). These findings reveal the

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possibility of adopting techniques used in the West to help school children who had experienced disaster in non-Western cultures.

Children with chronic or acute illness In Hong Kong, “therapeutic play” is regarded as a technique to nurse children with chronic illness or those who are in the hospital. In most Asian countries, therapeutic play is used by the Hospital Play Specialists interchangeably with play therapists in other contexts. Social workers and hospital play specialists designed sets of structured activities that are based on children’s social and cognitive development, as well as health-related issues in order to psychologically prepare them for hospitalization. Li (2005) showed that children and parents in a therapeutic play group reported significantly lower state of anxiety scores than did the control group in both the pre- and postoperative periods. Li, Lopez, and Lee (2007) also supported the use of therapeutic play, with the help of parents, to prepare children for surgery. Further work on using virtual reality computer games were also reposted by Li, Chung, Ho and Chiu (2011) and Li, Chung, and Ho (2011). Their studies also showed that it was effective in minimizing anxiety and reducing depressive symptoms in children hospitalized with cancer. While these studies illustrate that play can help children cope with the stress of hospitalization, there remains a strong need for play specialists/play therapists working in hospital settings to offer expert opinion on the play environment in pediatric wards, on the selection of toys, and on training volunteers to help children under medical care.

Children with developmental issues Although China is still in its infancy with regard to the development of play therapy (Xu, 2006), extant studies support the effectiveness of this approach in enhancing the mental health of mainland children. For example, play therapy has been found to be effective in treating maladjustment, aggression, resistance, mental disorder, anxiety, emotional disorder, abnormal self-awareness, and mental disabilities (Gao, 2002). Corroborating these findings, Qiu (2007) reported that play therapy allowed marginalized children to release their anxiety and stress. Research findings from studies involving Japanese children and families living in Japan corroborate the effectiveness of play therapy on typically

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developing children in Asian contexts. One such study was conducted by a group of researchers in Naruto University of Education (Nakatsu et al., 2012), with the leadership of Nakatsu looking into the effectiveness of play therapy in kindergarten as a support measure for young children’s growth potential and child rearing. This study was conducted with the teachers and parents of the children in kindergarten. The data was collected with the parents using questionnaires. Results showed that after play therapy, children became more emotionally stable, had fewer behavior problems, and indicated an improvement in their social development. Children also showed greater interest in relating to their friends, as reported by teachers. Seven out of nine parents perceived that their children had matured, conveying that parents regarded play therapy as an effective child raising support measure. Positive changes that resulted from individual and group play therapy can also be found amongst children suffering from developmental challenges. For instance, a study from Japan described that positive changes took place in two children with high functioning autism as a result of play therapy (Hideo, 2011). Similarly, studies done in Korea also highlight the effectiveness of group play therapy on developmentally impaired children. For example, a study completed at Korea University evaluated the effect of group game play therapy on the improvement of emotional intelligence for children with mental disabilities (Paeng, 2006). The experimental group consisted of 16 children with mental disabilities aged between 10 and 13. They were selected from the special classes of four elementary schools in Incheon Metropolitan City because they had similar scores on the emotional intelligence test that was used as a screening tool. The therapy program was designed to be conducted 3 times per week for 5 weeks. There was also a comparison group with similar emotional intelligence test results that did not enroll in any program. The results showed that the participants in the group play therapy increased significantly in their emotional intelligence, self-recognition, self-regulation, others-recognition, and others-regulation. This provided initial findings on the impact of a play therapy program for mentally disabled children. In support of these findings, a study under Myong Ji University also revealed that group play therapy was effective for mentally disabled children, in terms of reducing their problem behaviors (e.g., hyperactivity) and in providing a way for them to express their unspoken psychological difficulties (Seo, 2007). The 12-session program

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was observed, transcribed, and analyzed together with a standardized questionnaire using the Social Skills Rating System developed by (Gresham & Elliott, 1990). Seo (2007) reported that the play program had a positive effect on reducing children’s behavior problems, especially in the area of hyperactivity. A study by Kim (2010) also suggested that play therapy could help to enhance the self-control ability of elementary school children who were diagnosed with having ADHD (Attention-Deficit/Hyperactivity Disorder).

The Roles of Therapists and Parents Research on play therapy in the Asian context is not limited to exploring the effectiveness of play interventions; the characteristics of therapists and parents have also been studied due to the paramount roles that they play in the therapeutic process. In Japan, studies concerning the roles of play therapists have been conducted at various institutions. For instance, a study published under Ryukoku University considered the therapeutic meaning of nondirective play therapy by discussing two types of limits that were set in child-centered play therapy in order to facilitate the connection between child and therapist, and on the role of toys, which is important for children’s development and learning (Morita, 2010). Another article published in 2010 from Kyoto University delineated the therapeutic use of play therapy as psychological aids for children with pervasive developmental disorders (Yodo, 2010). In this study, there is an emphasis on the importance of a therapist to obtain self-convergence, and to establish a corporal imagery when creating a relationship with others. Furthermore, since children with autistic spectrum disorder have a weak sense of self due to their weak body sensations, they could develop a sense of self along with the feeling of body sensations by building meaningful relationships that offer various sensations (Yodo, 2010). Still another is an article on cultural adaptation of Theraplay practices based on lessons learnt from South Korea (Hoshino, Takai & Kubo, 2013). This article discussed the use of cultural adaptations of Theraplay for Asian (Korean) therapists in the field work of play therapy services by using attachment and relationship-based therapy for increasing parent-child relationships in Japan. A Korean study examined the roles of parents in the play therapy process by exploring the effect of parent’s expectancy on play therapy and parenting stress on the working alliance in play therapy (Kim, 2012). One

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hundred and two parents whose children received play therapy service in the cities of Seoul and Gyeonggi participated in this study. Self-report measures were used, including Parent Expectancies for Therapy (Kazdin & Holland, 1991), Parenting Stress Index (Abidin, 1995), and Working Alliance Inventory (Horvath & Greenberg, 1989). Results of this study illustrated that parenting expectancy for play therapy and parenting stress have major influences on the working alliance in play therapy.

Older Populations Although play therapy is often used with children, adults and elderly can also benefit from participating in play interventions. Take Hong Kong as an example. Pon (2010) created a communication board game to promote positive changes among adult patients diagnosed with advanced cancer. Findings revealed that these patients experienced enhanced positive emotional states, purpose of life, and quality of life and death after play. Similar positive changes for older populations were also documented in Jung’s study (2005) at Pusan National University, which evaluated a folk play program that was implemented for elderly people who were staying in a nursing home. While 15 subjects were in the experimental group that adopted a folk play program developed through this study, 18 were in the control group, which offered a gymnastic and walking program that was generally used in elderly homes. The 40-minute intervention was conducted 5 times a week for 4 weeks. Results indicated that the folk play program not only improved participants’ cognition and adaptive daily living, but also significantly reduced the frequency of problematic behaviors. It was concluded that a folk play program should be applied as an effective and practical intervention program for elderly with dementia. Due to their verbal abilities, adults may not necessarily need toys to express themselves in therapies; nonetheless, an interesting study from Malaysia that looked at challenges faced by counselors with the use of play therapy activities, (such as toys, crayons, objects, clay, and water colors) proposed otherwise (Rais, 2011). Specifically, results illustrated that students undergoing their guidance and counseling practicum were more at ease in sharing their issues when using drawings and creative works (Rais, 2011). Together, these studies conducted with older populations depict that play therapy can also be appropriately employed to promote adults’ well-being and to reduce undesirable outcomes.

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Research Work in its Germinating Stage In some countries, though the practice of play therapy has been used extensively, research work is still limited. In the Philippines, there are very few studies on child counseling and psychotherapy (Melgar, 2013). Some published topics were on the application and evaluation of counseling with children, adolescents, and family, as seen in the Philippine Journal of Psychology and the Philippine Journal of Counseling Psychology. Specifically in relation to play therapy, Tarroja and colleagues (2013) provided a detailed description on the challenges of developing empirically based practices in play therapy in the Philippines. Although play therapy has been applied for over 40 years in the country, there is little recognition of play therapy as an effective intervention by professionals working with children. Thus, there has been advocacy in integrating clinical practice with research in order to advance play therapy as a profession. In Japan, most of the research studies are clinical cases whereby the therapist narrates the process of therapy. As seen from the official journal of the Association of Japanese Clinical Psychology (AJCP), most of the articles are clinical case studies and case presentations (Iwakabe, 2008). In fact, there is no concrete methodological guideline for presenting case studies and this has been the most important problem in play therapy research in Japan (Shimoyama, 2011). Due to its short history, there is a lack of evidence-based research to help inform play-based therapeutic interventions in Singapore. A recent publication by He and colleagues (2015) add on to the limited Singaporean research concerning the use of play therapy. Specifically, findings from the randomized controlled trial study revealed that receiving a one-hour therapeutic play intervention could mitigate not only negative emotional displays prior to anesthesia induction, but also postoperative pain in children undergoing inpatient elective surgery, as compared to those who received only routine care. The study conducted by He and his colleagues (2015) thus convey that it may be beneficial to offer therapeutic play intervention to children who are about to go through inpatient elective surgery. Nonetheless, additional research is needed in order to expand this area of research.

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Future Directions The research findings discussed above suggest the potential of applying the commonly known play therapy approaches practiced in the Western world to children from other parts of the world in order to promote their well-being. While we are supportive of research that identifies what works and with whom, clinicians and researchers are also aware that it is critical to continue to advance the therapeutic practice with different cultural communities. For example, by developing a culturally contextualized play model of practice, Child Directed Play Therapy (CDPT), Carandang (1996; 2002) created positive developmental changes among Filipino children and their families enduring difficult situations such as poverty, prostitution, violence, disaster, and parental absence due to overseas employment. CDPT is probably one of the dominant forms of play therapy in the Philippines. Indeed, interventions that are specifically designed to serve the intended cultural group have been found to be four times more effective than interventions that were implemented with individuals from a variety of cultural groups (Griner & Smith, 2006). Therefore, play therapy practitioners need to demonstrate cultural sensitivity by considering their clients from a holistic perspective, taking factors such as client’s culture, community, religion, race, and ethnicity into account (Pehrsson, 2011). In order to facilitate the use of play therapy in the Asian world, more research needs to be done in areas such as the progress of treatment manualization and description, the focus on specific dependent variables related to mental health issues in children, and designs that accurately explore effective variables related to play therapy. There is also a need for replication of studies with similar populations or outcomes of interest in order to evaluate the evidence-based status of play therapy (Ray, Armstrong, Balkin & Jayne, 2015). Without evidence-based research, it can be difficult for practitioners to recommend play interventions with confidence to parents or other mental health professionals, who may regard it as a “fun” therapy that is ineffective for more complex and serious issues. Play therapists around the world will need to serve not only as practitioners, but also as scientists, to improve the professional standings and advance the development of play therapy around the world.

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REFERENCES Abidin, R. R. (1995). Parenting stress index (3rd ed.). Odessa, FL: Psychological Assessment Resources. Axline, V. (1969). Play therapy. Boston: Houghton Mifflin. Baggerly, J., Ray, D., & Bratton, S. (Eds.). (2010). Child-centered play therapy research: The evidence base for effective practice. Hoboken, NJ: Wiley. Bratton, S. C., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36, 376–390. Carandang, M. L. A. (1996). Pakikipagkapwa-damdamin: Accompanying survivors of disaster. Quezon City, Philippines: Ateneo de Manila University Press. Carandang, M. L. A. (Ed.). (2002). Children in pain: Studies on children who are abused, and are living in poverty, prison and prostitution. Quezon City, Philippines: Psychological Association of the Philippines. Chen, M. M. (2010). A study of cognitive-behavioral play therapy on improving the interruptive behaviors of ADHD children [in Chinese] (Master’s Thesis). National Chiayi University, Taiwan. Retrieved from http://ndltd.ncl.edu.tw/cgi-bin/gs32/gsweb.cgi?o=dnclcdr&s=id= %22099NCYU5464028%22.&searchmode=basic. Chen, S. Y. (2009). The effect of sandplay therapy on orphans’ mental health [in Chinese] (Master’s Thesis). Qufu Normal University, Shandong, China. Retrieved from Wan Fang Data (Category No.: B844.1). Chen, Y. C., & Fortson, B. L. (2015). Predictors of treatment attrition and treatment length in parent-child interaction therapy in Taiwanese families. Children and Youth Services Review, 59, 28–37. Chiou, H. Y. (2013). Animal-assisted play therapy (AAPT) for maltreated child: A pilot study [in Chinese] (Master’s Thesis). Tzu Chi University, Hualie, Taiwan. Retrieved from http://ndltd.ncl.edu.tw/cgi-bin/gs32/ gsweb.cgi?o=dnclcdr&s=id=%22101TCU00010002%22.& searchmode=basic. Choi, K. M. (2002). A study of the effects of child-centered play therapy on two emotional deficit children (Master’s Thesis). Retrieved from HKLIS Dissertations and Theses Collections. Chuang, F. C. (2011). A study on group play therapy for elementary school students with aggressive tendencies [in Chinese] [in Chinese] (Master’s Thesis). National Kaohsiung Normal University, Kaohsiung City, Taiwan.

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Ho, R. T. H., Lai, A. H. Y., Lo, P. H. Y., Nan, J. K. M., & Pon, A. K. L. (2016). A strength-based arts and play support program for young survivors in postquake China: Effects on self-efficacy, peer support and anxiety. Journal of Early Adolescence, 1–20. Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Hoshino, M., Takai, M., & Kubo, C. (2013). Cultural adaptation of theraplay practices: Seoul, South Korea: Description of the field work of psychotherapy in Seoul [in Japanese]. Studies in Ikuei Junior College, 30, 23–35. Hu, N. (2012). The curative effect research on the Adler play therapy of high aggressive tendency children [in Chinese] (Master’s Thesis). Suzhou University, Suzhou, China. Huang, C. C. (2011). The effect of cognitive-behavioral play therapy on mental retardation and a child’s social skills [in Chinese] (Master’s Thesis). National Chiayi University, Taiwan. Retrieved from http://ndltd.ncl.edu. tw/cgi-bin/gs32/gsweb.cgi?o=dnclcdr&s=id=%22100NCYU5 464063%22.&searchmode=basic. Hung, Y. W. (2011). The effect of cognitive-behavioral play therapy on elementary school students with interpersonal conflict (Master’s Thesis). National Chiayi University, Chiayi City, Taiwan. Retrieved from http://ndltd.ncl. edu.tw/cgi-bin/gs32/gsweb.cgi?o=dnclcdr&s=id=%22100 NCYU5464067%22.&searchmode=basic. Iwakabe, S. (2008). Psychotherapy integration in Japan. Journal of Psychotherapy Integration, 18, 103–125. Jang, M. (2000). Effectiveness of filial therapy for Korean parents. International Journal of Play Therapy, 9(2), 39–56. Jung, K. J. S. (2005). The effects of a folk play program on cognition, ADL, and problematic behavior in the elderly with dementia. Journal of Korean Academic Nursing, 35, 1153–1162.

Kazdin, A. E., & Holland, L. (1991). Parent expectancies for therapy scale. Yale University, Child Conduct Clinic, New Haven, CT. Kenney-Noziska, S. G., Schaefer, C. E., & Homeyer, L. E. (2012). Beyond directive or nondirective: Moving the conversation forward. International Journal of Play Therapy, 21(4), 244. Kim, J. H. (2012). The effect of parent’s expectancy for play therapy and

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parenting stress on working alliance in play therapy [in Korean] (Master’s Thesis). Seoul Women’s University, Seoul, South Korea. Kim, M. J. (2010). The effects of the play therapy by visiting a therapy of elementary school for the improvement of the self-control ability and the adaptation to school environment, and the play behavior of children with ADHD [in Korean] (Master’s Thesis). Namseoul University, Cheonan, South Korea. Kim, Y. J. (2008). Impact of play-therapy on children’s problem behaviors: Mainly deals with pervasive developmental disorder children raised under parents’ over-protection [in Korea] (Master’s Thesis). Dongguk University, Seoul, South Korea. Kim, K. E., & Han, Y. J. (2013). The effect of teacher-led group theraplay on ego resilience, peer competence and teacher-child relationships among full-day kindergarteners. Korean Journal of Childcare and Education, 9(5), 299–320. Landreth, G. (2002/2012). Play therapy: The art of the relationship. Philadelphia, PA: Brunner-Routledge. Landreth, G. L., & Bratton, S. C. (2006). Child parent relationship therapy: A 10-session filial therapy model. New York: Routledge. Lee, M., & Landreth, G. L. (2003). Filial therapy with immigrant Korean parents in the United States. International Journal of Play Therapy, 12, 67–85. Leung, C. H. (2015). Enhancing social competence and the child-teacher relationship using a child centered play training model in Hong Kong preschools. International Journal of Early Childhood, 47, 135–152. Leung, C., Tsang, S. & Heung, K. (2009). Effectiveness of Parent-Child Interaction Therapy (PCIT) among Chinese families. Research on Social Work Practice, 19, 304–313. Li, H. C. W. (2005). The effect of pre-operative therapeutic play on post-operative outcomes of Hong Kong Chinese children and their parents having surgery in a day surgery unit (PhD Dissertation). The Chinese University of Hong Kong, Hong Kong. Li, H. C. W., Chung, O. K. J., & Ho, K. Y. E. (2011). The effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalized with cancer. Journal of Clinical Nursing, 20, 2135–2143. Li, H. C. W., Chung, O. K. J., Ho, K. Y. E., & Chiu, S. Y. (2011). Effectiveness and feasibility of using the computerized interactive virtual space

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in reducing depressive symptoms of Hong Kong Chinese children hospitalized with cancer. Journal for Specialists in Pediatric Nursing, 16, 190–198. Li, H. C. W., Lopez, V., & Lee, T. L. I. (2007). Psycho-educational preparation of children for surgery: The important of parental involvement. Patient Education and Counseling, 65, 34–41. Liu, Y. M. (2011). The initial sandplays of children of bad interpersonal communication and exploration of their clinical diagnostic measure [in Chinese] (Master’s Thesis). Shandong Normal University, Shandong, China. Liu, Y. (2012). The practical research about group play therapy on children with autism [in Chinese] (Master’s Thesis). East China Normal University, Shanghai, China. Mao, X. (2009). The effectiveness of group sandplay therapy on improving children’s peer relationship [in Chinese] (Master’s Thesis). Hebei University, Hebei, China. doi: 10.7666/d.y1635258. Melgar, M. I. E. (2013). Counseling and psychotherapy in the Philippines. In R. Moodley, U. P. Gielen, & R. Wu. (Eds.), Handbook of counseling and psychotherapy in an international context. New York: Routledge. Morita, Y. (2010). Therapeutic meaning of non-directive play therapy III [in Japanese]. Journal of Ryukoku University, 476, 8–27. Munns, E. (2011). Integration of child-centered play therapy and Theraplay. In A. A. Drewes, S. C. Bratton, & C. E. Schaefer (Eds.), Integrative play therapy (pp. 325–340). Hoboken, NJ: Wiley & Sons. Nakatsu, I., Kume, T., Aihara, R., Inoue, K., Kasai, M., Yoshii, K., & Seuchi, K. (2012). A practice-based study of play therapy: The effectiveness of play therapy in Kindergarten as a support measure for young children’s growth potential and child rearing [in Japanese]. Research Bulletin of Naruto University of Education, 27, 45–53. Ng, W. S. (2011). Development of clinical psychologists in Malaysia. In A. H. Quek (Ed.), Multiple perspectives of psychology: Issues, challenges and future directions (ch 3). Kuala Lumpur, Malaysia: HELP University. Ng, W. S. (2013). Counseling and psychotherapy in Malaysia. In R. Moodley, U. P. Gielen, & R. Wu. (Ed.), Handbook of counseling and psychotherapy in an international context. New York: Routledge. Ng, C. T. C., & James, S. (2013). “Directive approach” for Chinese clients receiving psychotherapy: Is that really a priority? Frontiers in Psychology, 4 (Article 49). 1–13.

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Ogawa, Y. (2006). Effectiveness of child-centered play therapy with Japanese children in the United States. Dissertation Abstracts international, 68(026), 0158. Paeng, H. W. (2006). The effect of group game play therapy on improvement of emotional intelligence for children with mental retardation [in Korean] (Master’s Thesis). Korea University Graduate School of Education, Seoul, South Korea. Park, J. S., & Lee, S. H. (2014). The effects of group theraplay programs on peer competence and problem behaviors of elementary childcare class children [in Korean]. Asian Journal of Child Welfare and Development, 12(4), 59–75. Park, R. K., & Yun, J. Y. (2008). Development and the effects of group theraplay for mother-child of multicultural family [in Korean]. Korean Journal of Child Psychotherapy, 3(2), 61–82. Pehrsson, D. E. (2011). Utilizing bibliotherapy within play therapy for children with anxieties and fears. In A. A. Drewes, S. C. Bratton, & C. E. Schaefer (Eds.), Integrative play therapy (pp. 207–223). Hoboken, NJ: John Wiley & Sons. Philips, R. D. (2010). How firm is our foundation? Current play therapy research. International Journal of Play Therapy, 19, 13–25. Pon, A. K. L. (2010). My wonderful life: a board game for patients with advanced cancer. Illness, Crisis & Loss, 18, 141–161. Porter, B. (1954). Measurement of parental acceptance of children. Journal of Home Economics, 46, 176–182. Qiu, X. Q. (2007). Research on the causes and the play therapy of marginalized children. Journal of Nanjing Normal University (Social Science Edition), 6, 015. Rais, H. (2011). Challenges among Iium counseling practicum counselors: Play therapy as a tool of collecting data. Workshops presented at 6th International Qualitative Research Convention, Malaysia, 13th–15th November, 2011, Putrajaya Marriott. Ray, D. C. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York: Routledge. Ray, D. C., Armstrong, S. A., Balkin, R. S., & Jayne, K. M. (2015). Childcentered play therapy in schools: Review and meta-analysis. Psychology in the Schools, 52(2), 107–123.

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Ray, D. C., & Bratton, S. C. (2010). What the research shows about play therapy: 21st century update. In J. N. Baggerly, D. C. Ray, & S. C. Bratton (Eds.), Child-centered play therapy research: The evidence base for effective practice (pp. 3–33). Hoboken, NJ: John Wiley & Sons. Ray, D. C., & Landreth, G. L. (2015). Child-centered play therapy. In A. L. Stewart & D. A. Crenshaw (Eds.), Play therapy: A comprehensive guide to theory and practice (pp. 3–16). New York: The Guilford Press. Seo, S. S. (2007). The group play therapy decreasing for behavior problem of children mental retardation [in Korean] (Master’s Thesis). Myong Ji University, Seoul, South Korea. Seo, Y. S., Kim, D. M., & Kim, D. I. (2007). Current status and prospects of Korean counseling psychology: Research, clinical training, and job placement. Applied Psychology: An International Review, 56, 107–118. Shen, Y. J. (2002). Short-term play therapy with Chinese earthquake victims: Effects on anxiety, depression, and adjustment. International Journal of Play Therapy, 11, 43–63. Shen, Y. J. (2010). Effects of post earthquake group play therapy with Chinese children. In J. N. Baggerly, D. C. Ray, & S. C. Bratton (Eds.), Child centered play therapy research: The evidence base for effective practice (pp. 85–103). Hoboken, NJ: John Wiley & Sons. Shimoyama, H. (2011). Clinical psychology in Japan: Toward integration inside and recognition from outside. In H. Shimoyama (Ed.), An international comparison of clinical psychology in practice: West meets East (pp. 55–68). Tokyo, Japan: Kazama Publishing. Siu, A. F. Y. (2008). Group theraplay for autistic preschool children in Hong Kong: Some preliminary findings (unpublished manuscript). Siu, A. F. Y. (2009). Theraplay in the Chinese world: An intervention program for Hong Kong children with internalizing problems. International Journal of Play Therapy, 18, 1–12. Siu, A. F. Y. (2014a). A qualitative exploration of filial therapy for enhancing teacher-student relationships. Journal of Asia Pacific Counseling, 4, 15–30. Siu, A. F. Y. (2014b). Effectiveness of a group theraplay program on enhancing social skills among children with developmental disabilities. International Journal of Play Therapy, 23, 187–203. Stover, L., Guerney, B., & O’Connell, M. (1971). Measurements of acceptance, allowing self-direction, involvement, and empathy in adult-child interaction. Journal of Psychology, 77, 261–269.

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Su, S. H. (2013). The impact of group play therapy on children of new immigrants exhibiting interpersonal relationship concerns [in Chinese] (Master’s Thesis). Chinese Culture University, Taipei City, Taiwan. Retrieved from http://ndltd.ncl.edu.tw/cgi-bin/gs32/gsweb.cgi?o=dnclcdr&s=id= %22101PCCU0328018%22.&searchmode=basic. Sue, D. W., & Sue, D. (2007). Counseling the culturally different: Theory and practice (5th ed.). Hoboken, NJ: John Wiley & Sons. Tarroja, M. C. H., Catipon, M. A. A., Dey, M. L. T., & Garcia, W. C. (2013). Advocating for play therapy: A challenge for an empirically-based practice in the Philippines. International Journal of Play Therapy, 22, 207–218. United Nations Economic and Social Commission for Asia and the Pacific. (2013). Global Assessment Report on Disaster Risk Reduction. Geneva, Switzerland: United Nations. Urquiza, A. J. (2010). The future of play therapy: Elevating credibility through play therapy research. International Journal of Play Therapy, 19, 4–12. Wang, T. (2013). The effectiveness of group sandplay therapy on the behavioral problems of children with cerebral palsy [in Chinese] (Master’s Thesis). Chongqing Medical University, Chongqing, China. DOI: R742.3 R473.72 Wei, M. (2009). The sandplay therapy on children with insecure attachments [in Chinese] (Master’s Thesis). Hebei University, Hebei, China. DOI: 10.7666/d.y1635257. Xu, E. (2006). The effect of play therapy group counseling on the life adjustment of shy children [in Chinese] (Master’s Thesis). Zhejiang Normal University, Zhejiang, Hong Kong. Yodo, N. (2010). Understanding play therapy from the perspective of corporeity: Psychological aids for children with pervasive developmental disorders [in Japanese]. Kyoto University Research Studies in Education, 56, 251–264. Yu, H. Y. (2012). The study of Adlerian approach play therapy technique for insecure attachment children [in Chinese] (Master’s Thesis). National Chiayi University, Chaiyi City, Taiwan. Yuen, T. (2010). Filial therapy with Chinese parents. In J. N. Baggerly, D. C. Ray, & S. C. Bratton (Eds.), Child-centered play therapy research—The evidence base for effective practice (pp. 323–337). NJ: John Wiley & Sons.

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section ii play therapy development in asia

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4

Play Therapy in Mainland China Hannah Sun-Reid Donghui Chen

China is a vast country with a population of 1.3 billion people. Even with the one-child policy, there is still a significant number of children who experience distress and stressors in their daily life or may encounter disastrous and traumatic experiences at times. These children require support and intervention from a trained child therapist. However, the field of psychology and psychological intervention is in its infancy stage in China, especially in the area of child therapy. Hence, the needs of these children can be challenging to meet with appropriate support.

DEVELOPMENT OF PLAY THERAPY IN MAINLAND CHINA The history of play therapy in Mainland China can be traced back to the publication of the Chinese version of Axline’s (1947) book on play therapy. It was translated by Fang Guanrong and published in 1990 by Jiangsu Education Publishing House (Fang & Liao, 1990). Fang Guanrong is also the first Chinese practitioner and researcher who introduced play therapy to Mainland China and used play therapy in the field of preschool education. Another pioneer, Cui Guangcheng gave a summary and an introduction of play therapy based on his understanding of Western and Japanese literature on Child-Centered Play Therapy (Cui, & Zhang, 1994). This paper could be the very first introduction of play therapy from the perspective of

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psychological intervention in Mainland China. Since then, many of the books on play therapy from renowned Western scholars have been widely translated into Chinese for use in Chinese speaking countries such as Taiwan and Mainland China. These include classics by Garry L. Landreth, Heidi Kaduson, Charles Schaefer, Karla D. Carmichael and Donna M. Cangelosi. In Mainland China, the development and practice of play therapy pale in comparison to sandplay therapy. This modality is more widely practiced and researched with the mental health practices in Mainland China. One possible reason for the striving of sandplay therapy is that it is not only suited for children but also for adults. In fact, many of the practicing play therapists are also trained in sandplay therapy. There are many experienced and internationally trained sandplay therapists who conduct training and supervision to help practitioners in the country. The volume of research papers on the effectiveness of this approach is also greater than that of play therapy or other expressive arts modalities in Mainland China. There is a wide range of topics being researched such as identifying the themes of sandplay work from individuals with different ages (Zhang & Kou, 2005), the effects of sandplay therapy on adolescent’s aggression (Zhang & Kou, 2007), and sandplay therapy for children with Autistic Spectrum Disorders (Zhang & Du, 2009). In addition, the contribution from Shen’s (2004) published work on sandplay therapy not only focused on the application of sandplay therapy in Mainland China but also in the basic theoretical research at the international level (Shen, 2004).

Play Therapy Training The journey of play therapy training in Mainland China began as a natural human desire to help the families and children who were affected by the devastating earthquake in Sichuan province in 2008. The May 12, 2008 Sichuan earthquake killed 69,195 people and almost 18,392 people were missing and unaccounted for (Jacobs, Wong, & Huang, 2009). The magnitude of the disaster triggered vast support response throughout China and beyond. During the aftermath of the disaster and recovery process, Chinese people across all walks of life acted out of love and compassion to help and support the people who were touched by the tragedy. However, many of them were not prepared or equipped to know how to help, and what to say or do. The first author, Ms. Sun-Reid was one of the first play therapy trainers who arrived in Sichuan to assist the local professionals in

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supporting the affected children and families. Ms. Sun-Reid offered a free two-day training in crisis intervention for children and families. The Beijing Psychological Association organized the training and more than 100 professionals including psychologists, psychotherapists, counselors and medical doctors attended the training. From this training, many volunteers were able to use the skills they learned to help and support the families and children in dire need. Though the training was not only on play therapy skills and techniques, it provided a platform for the mental health professionals to appreciate the therapeutic power of play and how the children cope and communicate the stressors and adversities. Since then, play therapy approaches rose to be recognized in Mainland China as one of the effective tools to help children who experience emotional and mental health difficulties. From the training, two training manuals were developed and translated into Chinese for use—Learning, growing and developing through play: Therapeutic games and Journey of hope: Therapeutic stories. Recognizing the need to have more clinicians trained in Child and Play Therapy in a systematic way, Ms. Sun-Reid and the second author, Ms. Chen decided to collaborate to establish formal and structured play therapy training in Beijing, China's capital. In 2010, the first comprehensive and systematic training program in Child and Play Therapy in Mainland China welcomed its first 26 participants. The training program was designed based on the Canadian Association of Counseling and Psychotherapy (CACPT) certification program model. It consisted of three levels covering both the theoretical models and practice of child and play therapy. The training took place over a two-year period, 6 days in each level totaling 18 days of face to face teaching and studying. The program not only covered the important aspects of child psychotherapy and play therapy, it also included the unique cultural influences of children and families in China. To date, there are 95 graduates from the first four training program and 31 more students are in the midst of completing the third run of the training program. In addition to this training, it was noted that there are also many other private training providers who worked with professionals from Taiwan and Hong Kong to develop trainings and workshops to cater to the different training needs of the professionals in Mainland China. Since Mainland China is geographically huge, it is important to have different providers who can provide training and supervision for the professionals here.

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Quality of Play Therapists Based on the profiles of the participants who had completed the training developed by the two authors, they comprised of professionals from hospitals, universities, government departments, child care centers and psychological clinics. They come from many geographical areas of China. Most of them have a background of psychological training in other theories, methods or interventions, mainly for adult population. Some of them came from education background. Many of them are parents themselves. All of them have keen interests in helping children and families who experience distress and challenges in their lives. Carrying the trait of Chinese culture of being modest and respectful in learning, the participants continued with their connections with each other and attended the regular online supervision group sessions. This is indeed a good start in forming a coalition of trained play therapists who are both committed to developing their skills and helping the children and their families in distress. The long term goal is to be able to form an association to gather other play therapists in training or in practice so as to enhance the quality and the professional standards of the play therapists in Mainland China.

Training and Licensing Currently, there are no licensing regulations for using play therapy or any other therapeutic approaches in helping children and families in need, even though there are licensing requirements for practicing psychotherapy in Mainland China. The second author and the graduates of the program are in the process of establishing a child and play therapy professional association in Mainland China. The sheer size of the number of mental health professionals and maneuvering around the complicated regulations in Mainland China are the possible hurdles that practitioners have to cross will result in this process taking some time to achieve. Recognizing the need to have more clinicians trained in play therapy in a systematic way in Mainland China, both authors decided to collaborate in establishing a child and play therapy program. The primary purpose of this program is to advance the development of child and play therapy by providing professional training that is suitable for Chinese social and family situation. Based on the authors’ best knowledge, this is probably the very first structured child and play therapy training offered in Mainland China.

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One important contribution through this program is the adaptation of the interventions according to the Chinese cultural and social environment. Culture plays an important role in providing therapeutic services. Indeed, the likelihood of a person seeking help, available treatments used by mental health professionals, and the outcomes of treatment are greatly affected by cultural considerations. Depression or other mental health conditions that one culture may view as a reason for therapy may be seen as a matter to be handled by family or religion in another culture. These contributions provide the most innovative healing practices with Chinese characteristics. These contributions broaden the road and the horizon and facilitate the development of child and play therapy in Mainland China.

Research on Play Therapy Though existing research is few in comparison to sandplay therapy and other more conventional therapy like cognitive behavioral therapy, a search on the existing Chinese journals yield a sizable number of research on the effectiveness of the use of play therapy in different populations. In Mainland China, the first documented case describing the use of play therapy is by Xueqing Qiu (2001). She published her work on the treatment of children with autism using child-centered play therapy (CCPT). This paper led Qiu to conclude that child-centered play therapy is more applicable than psychoanalysis play therapy in the treatment of children’s mood disorders. Subsequently, Qiu also published the case studies of treating ten marginalized children using CCPT. The case studies showed that the intervention can help marginalized children in releasing their anxiety and stress, and that the principles of unconditional positive regards of this approach provided these marginalized children the badly needed attachment and engagement with adults (Qiu, 2007). The search for other research yields mostly case studies such as that of Gao (2002) who analyzed his cases on the treatment of children’s mental disorder using play therapy. He concluded that play therapy is effective in treating maladjustment, aggression, resistance, mental disorder, anxiety, emotional disorder, abnormal self-awareness and mental retardation (Gao, 2002). Since play therapy is relatively new in Mainland China, comparison studies of different theoretical models are also found in many of the research on play therapy. These include Wang’s investigation of the characteristics of psychoanalysis child play therapy based on the analysis and comparison of

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the researches of Anna Freud and Melanie Klein (Wang, 2000). In addition, Cao and Jiang (2005) also discussed in depth, the development of play therapy and help readers to classify the main theoretical models including psychoanalytic play therapy, structured play therapy and humanistic play therapy. He also discussed and highlighted differences between directive and non-directive play therapy. Liang (2003) also investigated the orientation of different play therapy theoretical models and combined his practice wisdom to develop some practical and specific play therapy techniques for professionals who are keen to develop their own model in working with children and adolescents. All these comparison studies provided a platform for local practitioners who have yet to have a chance to be exposed to or trained by Western scholars, an entry level understanding and appreciation of the various models of play therapy. In Asia, the other mainly Chinese speaking country, Taiwan, shared many cultural and social similarities. For at least more than a decade, play therapists and scholars in Taiwan had embraced the use of play therapy and developed many culturally sensitive approaches and techniques for their country. In order to develop a culturally relevant child and play therapy approaches in Mainland China, Xu (2008) investigated and highlighted the themes around development of child play therapy between two countries, from the aspects of developmental history, study approach and research objects (Xu, 2008). It is hopeful that with this initiation, more studies would be emerging to provide more insights into the similarities or differences in working with children and their families from these two countries.

Moving Forward To facilitate the development of play therapy in Mainland China, like many of our neighboring countries, it is essential to start a national play therapy association so as to bring all interested parties together to advocate and advance the development of play therapy in the areas of education, research, and application. Though the initial play therapy courses are modeled after the Western frameworks of play therapy in the United States and Canada, like many of the Asian countries, Mainland China has to increase her research, clinical studies and reviews on the unique characteristics and effectiveness of play therapy practice according to Chinese children’s personality, family structure and social situations. Hence, there is a need to strengthen our international exchange and cooperative relationship, not only with the Western

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counterparts, but with the Asian countries like Taiwan and Hong Kong so as to develop more structured training and collaboration in research studies in order to speed up the development and narrow the gap in play therapy with other developed countries. Finally, play and play therapy can be very misunderstood concepts and intervention approach in Asia and similarly in Mainland China. Increasing public education on the importance of play in the healthy development of children and the effective of using play therapy to help children in a variety of life challenges is needed. In Mainland China, both the practice and research on play therapy continued to focus on the basics and the use of play therapy is not yet routinely or extensively practiced in the treatment of children’s mental health difficulties. The professional field of play therapy has not yet fully developed, as there is no professional association of play therapy in Mainland China as there is in the United States, Canada, Japan, Korea and Taiwan. The clinical research, training and supervision for play therapy practice in Mainland China have just only begun and more attention and involvement from the government and other professional organizations are required to make play therapy practice grow and flourish further.

CASE ILLUSTRATION

Special Issues affecting Mainland China Child Left-behind children One social issue that Mainland China faced is the “left-behind children” from migrant workers. This impact on the emotional attachment and security between parent and child, consistencies in parenting as well as the lack of trust and issues with self-concepts for children in this circumstance. The rich and poor income gap between urban and rural areas has forced millions of workers to emigrate from the rural areas to the cities for better and more working opportunities. This is a special social phenomenon. In the last 20 years, many young people from rural China, as soon as they reach adult age, leave their hometown for coastal cities to make a living. They then return home for marriage. After having a baby, the responsibility of raising the baby would be passed on to their older parents or relatives. The young couple would still head for the job in the city. According to the official data statistics, there are nearly 60 million children in this situation. This

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phenomenon has created millions of children left behind in the rural areas under the care of their relatives, mostly grandparents or family friends. Often, these caretakers do not have enough education, ability, and financial means nor possess the knowledge needed to take care of these children. They often either spoil the children or completely ignore their basic parenting needs. In addition, these children are frequently being moved between homes. The results are academic, emotional and behavior problems for these children. As the vulnerable group, these children are easy targets for sexually abuse or victims of violence. Children who grow up in this type of environment have an increased probability of having attachment relationship difficulties.

One-child policy The one-child policy, officially the family planning policy, is the population control policy in China. In order to control the population, China has implemented the one child policy for the last two decades. Over 90% of all urban children and over 60% of rural children have no brothers or sisters. Since there is only one child in the family, the child may be given excessive attention from their parents and grandparents. Unfortunately, working parents often do not have enough time being with their children; so they express their love and care by giving money and materials. In Mainland China, grandparents now play an important role in taking care of children, and they most likely have difficulties disciplining and providing appropriate guidance, that a parent would to their children. Children grown up in a single child family have no siblings to grow up with; therefore, they do not have enough opportunities to learn to make friends, to share and to handle conflicts with others.

Early childhood education Like many Asian countries, Chinese families, particularly for the families who have only one child, view academic achievement to be extremely important. Excessive structure and directive kinds of childhood education has become more common in China. The children are made to attend classes that are deemed to be important by their parents, instead of focusing on their fundamental and natural developmental needs such as free play and independent learning. These forms of learning had resulted in children who are achievement oriented, and lacking in motivation and appreciation for

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fun and independent learning. Even before entering the mainstream primary schools, the Chinese students had already experienced the high pressure and competitive educational environment. The pressure of being a young child who needs to meet many expectations affects their developmental or behavioral issues. These children probably will suffer from issues around self concept, resilience and pent up emotions that need addressing.

Chinese style parenting issues Chinese parents are highly involved in and have a great influence on their children’s upbringing. Chinese parenting style is often described as “controlling,” “authoritative” which also referred to as “tiger parenting” after the book Battle hymn of the tiger mother by Chua (2011) had gained special attention. With the Chinese style parenting, the parents know best and would dictate what the child can or cannot do in their daily routine, leaving little room for the children to decide anything for themselves. These children often have difficulties understanding their parents’ intention and approaches, and are frustrated with their parents’ strict parenting style, potentially creating a more rebellious response to their parents. Additionally, the Chinese style parenting could make the children more dependent on their parents and therefore they would lack the skills for independent living. Many of the problematic transitional issues facing the adolescents in Mainland China can be related to this particular parenting style.

Introduction to Prescriptive Play Therapy Theoretical framework and construct Prescriptive psychotherapy is an approach that integrates different psychological interventions to individual client needs (Schaefer & O’Connor, 1983). The prescriptive approach of play therapy emphasizes the therapist’s responsibility to determine which therapeutic techniques could best address the client’s particular needs or concerns (Schaefer, 2003). The play therapist attempts to incorporate the theories and techniques of the different child psychotherapeutic approaches into a broad framework that facilitates the development of client-specific treatment strategies. The basic constructs and goals of the prescriptive play therapist are the following: a) match the theoretical framework of an approach to the specific diagnostic disorder or needs of the client; b) the prescriptive play therapists

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needs to expand and be familiar with their theoretical frame and repertoire to adapt their strategies to the individual client’s needs; c) the prescriptive approach emphasizes the matching of evidence based approaches with the disorder, instead of focusing on clinical experience of self and others; d) the need to have clear definition of the therapeutic changes of the client. This is a description of what are the therapeutic factors that actually produced changes in the client; e) comprehensive assessment of the symptoms and determinants of a client’s problem; and f) clearly defined treatments plans, and realistic and measurable intervention strategies (Schaefer, 2003).

Case Background Xiaojun, an 8-year-old boy is in Grade 2 at a local elementary school in his hometown Jiangxi. Throughout his childhood, Xiaojun had many changes and transitions such as living in different cities and households due to his parents’ work and Xiaojun’s educational needs. Since birth, he has been taken care of by his grandparents in his home town as the parents could not effort the time and resources to take care of a young child. As mentioned earlier, it is common practice for parents to leave their young infant in the care of a trusted grandparent while they work from a different city. Shortly at age 3, Xiaojun went to live with his parents in another big city, Shanghai and attended school there. He returned to his grandparents for summer vacations during the 2 years while living with his parents. At 6 years old, Xiaojun attended the kindergarten in Shanghai. His parents and teacher had high academic expectations and on a daily basis, he is required to preview Chinese and Math materials that are meant for Grade 1 level. During this period, Xiaojun had little time for play and leisure activities; instead he had to focus on his academic work and suffered corporal punishment for not meeting their expectations. Before entering into the formal school, Xiaojun moved again and this time, he left his parents to attend Grade 1 elementary school in Jiangxi. In the meantime, his parents also left Shanghai for Shenzhen, in the Guangdong Province. At around the same time, after starting his elementary school, Xiaojun began to show some externalizing behaviors that include attacking his classmates and skipping classes. The main caregivers, his grandparents, had difficulties managing his behaviors. Left with no other options, it was decided that Xiaojun moved to Quanzhou, in Fujian Province to live with his aunt. Consequently, Xiaojun had to transfer to a different elementary school in Quanzhou. Though the

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transition was smooth, several months later, Xiaojun refused to attend school again and was home-schooled by his aunt. It was reported that in his elementary school, he disrupted the class routines, attacked classmates after class, refused to complete his homework, and vandalized the school textbooks. Xiaojun was referred for psychological treatment when he publicly urinated in class when the teacher invited him to answer questions in front of the class. Due to the specific phenomena of migrant workers in China, the therapist has little chance to work with the child’s parents directly. Therefore, the therapist involved the child’s aunt in the therapeutic process since she spends the most time with the child and the one who has more capacity to understand the situation, and most likely to carry out the treatment recommendations.

Session Content In adhering with the constructs of the prescriptive play therapy approach, the first stage of the treatment process include a thorough assessment was conducted with both Xiaojun and his aunt in order to understand the situation that the family is facing, as well as to develop empirically based interventions that will meet the needs of Xiaojun and the family. This assessment process also included observing and evaluating Xiaojun through play interactions and during this process, the therapist begin the relationship building with him.

The Initial Phase of Therapy In the first session, it was observed that Xiaojun was vigilant at the initial meeting with the therapist as he expected a similar style as his parents and teachers of criticizing, interrogating, judging and blaming. As the session progressed, he appeared to be pleasantly surprised that the therapist actually invited him to play, and allowed him space and time to feel safe and express without judgment. Xiaojun was able to engage with the therapist and soon a trusting relationship was developed with the therapist.

The Middle Phase of Therapy The second stage included identifying treatment goals and select evidence based intervention to meet the needs of Xiaojun. Based on the

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assessment, specific goals were identified in the attempt to help Xiaojun to develop his self concept, make meanings around his current difficulties, building his safety and security, and also develop appropriate coping mechanisms to manage his anxiety and intense feelings towards his life events, his parents and changes in his life. Xiaojun would also benefit from both Cognitive Behavioral Play Therapy (CBPT) and Child Centered Play Therapy (CCPT). CBPT is derived from the behavioral and cognitive theories of the emotional development and psychopathology (Schaefer, 2003). Knell (1998) highlighted that CBPT, an approach that adapted the Cognitive Behavioral Approaches with play therapy demonstrated to be effective with children who are anxious and angry. Specific activities such as art making, feeling games were designed to help Xiaojun look into adaptive strategies to express himself and also cope with his adverse situation. With Xiaojun’s low self concept and self worth, it is important that he is also supported through the principles of CCPT. With his parents and teachers having high expectations of him and having so many changes and moves in his life, Xiaojun probably did not have the opportunity for self direction and self discovery. The constructs of CCPT stressed that a child can grow and heal when there is an environment that is growth generating and free from agenda and expectations (Landreth, 1991). Hence, the use of CCPT in the engagement with Xiaojun will provide the safety, security and unconditional positive regards that he so badly needed in his interactions with his main caregivers. Since the reality of his parents’ absence is likely to remain, the therapist had to explore all avenues to increase the involvement of his parents. When the parents return every once in a while to visit Xiaojun, the therapist meets with them to give feedback of the treatment progress and offer guidance in their role in the child’s life. The same discussion happened regularly with the Xiaojun’s aunt when she brings him for therapy. Xiaojun usually engaged in sandplay when he can chose what he can play in the playroom. He uses the sandtray, art materials and games to express his experiences of strong conflicting situations. In his art work, he painted his family tree and life experiences. Xiaojun used the art work to express his needs to connect with his parents and also ask questions around his predicament. This expressive arts activity provided Xiaojun with the opportunity to share his concerns and also to try to make sense and accept his situation, which he knows he cannot change. The other play themes that emerge from his play behaviors are his need for power and control. As Xiaojun is living with his aunt, he also had to

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learn to engage with his cousins who are living in the same household. With all the children learning to adjust to each other’s presence at home, Xiaojun finds himself confused and frustrated over his situation. In his therapy sessions, Xiaojun spends a considerable amount of time playing out conflicts with his cousins and learning to defend himself. Reading stories of fighting and drawing powerful weapons gave him some sense of power and control compared to his reality. Learning to express his emotions properly and appropriately is the key point in learning how to communicate with others. For example, learning how to communicate appropriately with his parents, aunt, cousin, teachers and classmates is an important goal in treatment. There were a few incidents where Xiaojun exhibited psychosomatic symptoms when his parents were getting ready to leave home. Initially his parents blamed Xiaojun for lying and they constantly had very intense interactions before the parents left for Shenzhen. With the coaching from the therapist, the parents finally understood that his physiological symptoms are all responses to the anxiety and distress around separating from his parents. Since that dialogue, the adults in his life were much more empathetic towards his situation. The treatment focused on offering more empathy to his situation and responses, and giving him opportunities to express his anxiety and distress through play and art making. The therapist also selected therapeutic activities to change some of Xiaojun’s irrational thinking. One example is the use of storytelling and role play to show Xiaojun that his parents did not reject or abandon him, instead they are working hard to give him a better life. Through the use of mutual storytelling techniques, the therapist demonstrated to Xiaojun that he can continue his bonds with his parents even though they are living apart.

The Final Phase of Therapy During the last few sessions of the therapy, it was noted that Xiaojun moved from playing out his helpless and hopeless feelings to more adjusted kinds of play. Instead of playing out conflicts and struggles, his play themes are mostly on reparations and stability. Toward the end stage of the treatment, Xiaojun used less of his regressive behaviors and instead was able to share with the therapist about his hope one day to live with his parents and have a steady home. However, he understood that his parents are working hard towards this goal as well. He would then do his part by focusing on his studies and demonstrate to

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his parents that he is capable of looking after himself. Like most Chinese children who were raised to embrace the notion of filial piety, Xiaojun wants to repay his parents for their hard work.

Evaluation and Reflections This short-term prescriptive play therapy intervention ended after 11 sessions. The therapist made the decision to close the sessions after she observed that Xiaojun became more adaptable, with noticeably reduced behavior problems at school; had a better attitude and effort in studying; had more desirable ways to communicate with others; and became more tolerant towards separating from his parents. The implications of being a child of migrant workers are varied. It has created many issues around parent-child relationships, behavioral issues around inconsistent parenting and insecurity and attachment issues in China. Most parents sacrifice their relationship with their children to look for better job prospects in the hope of giving their children a better future. These parents often lacked love and attention when they were growing up themselves. They are markedly more concerned about materialistic pursuits for themselves and their children over the bonding and attachment experiences they can give to each other. It is important to include parent education work as a combined effort to help the child in need. In addition, the therapist should also be sensitive and empathetic towards the parents since they probably have the high anxiety and pressure as a result of dealing with the child’s problems as well as their work situations. During the play therapy treatment with the child, the therapist needs to understand and appreciate the parent’s situations and to avoid blaming or shaming parents which might potentially induce further problems into this complex picture. For many of the children from migrant workers’ families, the present problems may be about the child behavioral problems, academic performance, or adaptation problems. However, the underlying issues are mostly about the lack of love, security, and attachment from the parents. The basic need and desire of the children are to be close to their parents. As a young child, they might not understand the situations and hence use inappropriate ways to express their unmet needs. The goals of the therapist are to establish the communication bridge for the effective interaction between the child, the parents and the main caregiver. The therapist had to be mindful of the power of individual play therapy sessions with the child.

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These sessions provided the opportunities for the child to release negative emotions, expressing inner conflicts, thus reducing anxiety and stress. At the same time, it is equally important to work with parents and the extended family members in order to improve the natural environment the child lives in.

Conclusion Play therapy is a useful and effective tool in connecting and working with children. The play therapy process gives children opportunities to connect and understand their own inner world. It also helps them to connect and understand the world they live in, and the relationship between the two worlds and how everyone is connected in them. Through play with or in the company of a trusted therapist, the child is safe to release any distress or emotions that may impede his or her healthy growth and development. Play therapy also helps children learn effective coping strategies to better adapt to the world they live in and in turn find more happiness and peace in themselves and in the world. Due to the complexity of Chinese family systems and culture and society characteristics, it is important to include family treatment as a necessary part of the entire treatment plan.

Implications for practice • Children raised in traditional Chinese culture are educated to be polite and obedient. Additionally, they are frequently evaluated on their daily behavior and performance with the simple standard of right or wrong. Most children are conditioned to simply follow the adult’s instructions and they are concerned about how the adults will view and judge them. In addition, children are not modeled or encouraged to verbally express their feelings. Therapists need to have an attitude of curiosity, acceptance and empathy when working with Chinese children. They will also have to be astute and sensitive to the anxiety and stress that the child might exhibit during the first session. The therapist might have to start with a more directive stance in working with these children initially in order to reduce the stressor. Only when the child is more comfortable and trusting of the person and process can the therapist consider focusing on more child centered approaches. • In a culture that is mostly influenced by the Confucian doctrine, reputation and prestige is very important to the Chinese. Having a perfect child is a sure sign of being blessed and having “face.” Since psychological

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issues and mental disorders are not accepted by society as similar to physical illness, having a psychological issue is regarded as a disgrace and abnormal. The lack of public education in this aspect impacts on the openness of the family to seek help for their children or themselves. In fact, most parents consult with medical practitioners for pharmacological interventions for many psychological issues of their children. Hence many times, the children might be misdiagnosed or receive wrong interventions for them. It is critical for therapists who are working in Mainland China to be very astute to this “face saving” and taboo nature of the emotional and psychological issues of the children and their families. Awareness, empathy and confidentiality are important factors in therapy. • Chinese culture does not confer the same acceptance and respect to children as compared to adults. Many parents might be ignorant of the need to meet their basic development of trust, autonomy, initiative and industry of the children. These concepts are very alien to the parents who believe that children should only be seen and not heard. Some parents may lack respect for their children, and not realize that their parenting styles, involvement and approaches influence the emotional development and mental health on their children’s learning and overall health. For play therapy to be effective for the children, a strong emphasis on involving the main caregivers by providing psycho-education to parents is needed. A therapeutic alliance with parents should be formed in order for the therapy to be effective. Encouraging both parents to participate in therapy is always a good idea; however therapists need to accept whatever the level of participation is available from the parents. Individualized treatment plans are necessary for families. Teaching parents to conduct home play sessions is a great way of maximizing therapeutic effect and including the absent parent in their children’s therapy process. • Chinese tradition has clear roles dividing men and women. Men are expected to play a key role in society, while women are expected to raise children. In therapy, mothers often bear guilt and shame for their child’s problems, and appear to feel that it is their responsibility for the problems. In contrast, the fathers would complain and criticize the mother for not parenting correctly. Therapists need to pay special attention to these imbalanced parenting roles, give support to both parents, and focus on parent-child relationships.

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REFERENCES Axline, V. M. (1947). Play therapy: The inner dynamics of childhood. Boston: Houghton Mifflin. Cao, Z. P., & Jiang, H. (2005). Historical changes and developmental orientation of play therapy. Chinese Journal of Clinical Psychology, 13(4), 489–491 (in Chinese). Chua, A. (2011). Battle hymn of the tiger mother. New York: Penguin Press. Cui, G. C., & Zhang, J. W. (1994). Child Centered Play Therapy. Chinese Mental Health Journal, 5, 234–236 (in Chinese). Fang, G. R., & Liao, G. L. (Ed.) (1990). Translation of Axline, V. (1990). Play therapy. Jiangsu Education Press (in Chinese). Gao, J. L. (2002). Treatment of children’s mental disorder with play therapy. Chinese Journal of Pediatrics (40): 271–273 (in Chinese). Jacobs A., Wong, E. & Huang, Yuanxi. (2009). China reports student toll for quake. The New York Times, May 7. Knell, S. M. (1998). Cognitive-behavioral play therapy. Journal of Clinical Child Psychology 27, 28–33. Landreth, G. (1991). Play therapy: The art of the relationship. New York: Brunner-Routledge. Liang, Peiyong. (2003). Theory and practice of play therapy. World Publishing Corporation (in Chinese). Qiu, Xueqing. (2001). Case study on play therapy with autistic children. Science Research and Teaching Research (1), 36–37 (in Chinese). Qiu, Xueqing. (2007). Play therapy with pre-school children: Case study on 10 marginalized children. First edition. Nanjing Normal University Press (in Chinese). Schaefer, C. E. (2003). Foundations of play therapy. New Jersey: Wiley. Schaefer, C. E., & O’Connor, K. J. (1983). Handbook of play therapy. New York: Wiley. Shen, Heyong. (2004). Sandplay (theory and practice). First edition. Guangdong Education Press (in Chinese). Wang, Guofang (2000). Summary of play therapy in child psychoanalytic psychotherapy. Journal of Developments in Psychology, 4, 29–33 (in Chinese). Xu, E. (2008). Comparison of research on play therapy in Taiwan and Mainland China. Zhongxiaoxue Xili Jiankang Jiaoyu (20), (in Chinese).

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Zhang, R. S., & Du, Y. C. (2009). Characteristics of sandplay products and sandplay therapy of aggressive adolescents. Psychological Science, 32(1), 213–216 (in Chinese). Zhang, R. S., & Kou, Y. (2005). Preliminary study on the basic features of sandplay products of infants. Psychological Science, 28(4), 788–791 (in Chinese). Zhang, R. S., & Kou, Y. (2007). Fundamental research on the sandplay products of infants. Psychological Science, 30(3), 661–665 (in Chinese).

5

Play Therapy in Hong Kong Angela F. Y. Siu Alicia K. L. Pon

In the last decade, play therapy, as an effective intervention approach for working with children, has been getting popular among mental health professionals in Hong Kong. In addition, the general public is more aware of the importance of play in a child’s overall development. However, professional play therapy service is still in its germinating stage as trainings and accreditation are still under way.

DEVELOPMENT OF PLAY THERAPY IN HONG KONG Play therapy was first started in Hong Kong with the use of therapeutic play as a means of engagement and intervention for children with chronic illness. In the 1990s, Playright Children’s Play Association (“Playright”) and the Hong Kong Children’s Cancer Foundation provided young patients in some major government hospitals with therapeutic play services. The objectives of such interventions were to support children and their families as they dealt with hospitalization and surgical treatments, as well as help with developmental issues. Because of the effectiveness of such therapeutic play interventions in reducing the related stresses and anxieties related to hospitalization, Playright, in collaboration with the continuing education sector of The University of Hong Kong, inaugurated a Hospital Play training program. The purpose of this program was to train mental health

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professionals as hospital play specialists. In 1996, the first cohort of students graduated from the program. As the Hospital Play services continued to benefit children in the hospital settings, the use of therapeutic play with other populations began to flourish. In the late 1990s, though there was no formal play therapy training in Hong Kong, many of the practitioners who were interested in this approach went overseas to gain formal training. One of the pioneers is Ms. Lottie Lau. She received her postgraduate training in play therapy at the University of North Texas and studied under Dr. Garry Landreth. On her return in 1998, she began to conduct Child-Centered Play Therapy (CCPT) for professionals such as counselors, psychologists, social workers, and teachers. She provided specialized training on CCPT that included 5-day trainings and group supervision. In the last 5 years, Ms. Lau has focused her efforts in delivering training on Parent-Child Interaction Therapy (PCIT) with parents and caregivers. As of mid-2015, more than 1,000 mental health practitioners have participated in at least one of Lottie’s workshops and trainings conducted at the continuing professional development program at the Department of Social Work of The Chinese University of Hong Kong. Another pioneer in Hong Kong is Dr. Iris Chau who also graduated from the University of North Texas. She has focused her efforts on direct service and has since used play therapy as an intervention approach in supporting children, adolescents, and adults with emotional and psychological problems. Besides, the CCPT approach, another pioneer in the development of play therapy in Hong Kong is Professor Norma Leben. Professor Leben resides in Texas but since the 1984, has returned to Hong Kong annually to conduct a wide range of training for mental health professionals, staff working in residential settings, teachers, and parents on the use of therapistled approaches of play therapy. Professor Leben developed Directive Group Play Therapy for working with children who have special educational needs, those with childhood disorders (such as Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder) as well as children with a history of trauma. In recent years, mental health professionals have been expanding their use of play therapy. This is mainly attributed to the hard work of some local non-government organizations in promoting the importance of play as a preventive measure to children and families, and as an intervention approach to children with behavior problems and special needs. In addition to Playright, The Boys’ and Girls’ Clubs Association (BGCA) was the first Association of Play Therapy (APT) provider in Hong Kong to organize play

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therapy training that are accredited by the APT in the United States. Since their inauguration, they have invited a wide range of trainers who provide training from Beginner’s to Intermediate levels in Play Therapy and Sandplay Therapy, and specialized topics in play therapy intervention such as trauma, divorce, and so forth. In recent years, besides sponsoring international speakers, BGCA also developed culturally specific play therapy training that catered to the local practitioners. Since then, there are other independent trainers from Transformation at Play, and Little Tree Play Therapy House who have developed play therapy trainings that are adapted to the local context. These initiatives have proven to be very helpful to practitioners who need culturally specific skills and techniques. In 2004, the Tung Wah Group of Hospitals (TWGHs), a non-government organization, sponsored a group of social workers to receive training in Parent-Child Interaction Therapy (PCIT) conducted by overseas trainers. During the period from 2008 to 2010, more social workers received qualified training in this area so they could provide effective parenting services to support the local community. Initially, the service was offered to three local districts where child abuse rates were high. With extra funding, the services were expanded to other districts in the New Territories as preventive measures to families that were at risk for child abuse. TWGH has been actively promoting the use of PCIT with families and has been organizing conferences since 2007 to develop public and professional interests in the use of this approach for parents. Within the universities, credit-bearing courses on play therapy have been offered to undergraduate and postgraduate students. These elective courses are very popular with the students as they are keen to expand knowledge and skills in working with children and adolescents. Since 2000, there have been two play therapy-related courses offered at The University of Hong Kong. Dr. Iris Chau focuses her efforts lecturing and offering internships for postgraduate students using the CCPT approach, while Dr. Alicia Pon teaches the use of play therapy in counseling for both the undergraduate and postgraduate students. Dr. Pon also provides play therapy internships for the postgraduate students using group play therapy for elders and children with visual impairment. In 2013, a local private university, Shue Yan University, inaugurated a Masters program in Play Therapy in collaboration with the University of South Wales, UK. This program is the first of its kind to be offered in a government-recognized university in Hong Kong, and its impact on play therapy development in the local setting has yet to be seen.

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With the change in the government policy on inclusive education in Hong Kong, and the expansion of the private sector in doing child-related counseling work, more and more people from school and private settings see the need for play to help young children. In the past few years, there are more organizations (both government-funded and private sectors) that have organized workshops and trainings on different play therapy approaches. The first author (Siu) started the first Theraplay® certification training in Hong Kong in 2012 in response to the need for a variety of play therapy approaches to work with children with special needs. Since then, the number of practitioners in the field who have been trained in using Theraplay principles (to work with children and families, for doing case work, and conducting group sessions) has been increasing. Some international organizations also took initiative to set up play therapy training programs in Hong Kong. One example is the Play Therapy United Kingdom/International (PTUK/PTI). They started their first cohort of programs in 2004 by offering postgraduate certificates in therapeutic play skills (focusing on strategies to alleviate children’s learning, behavior, and emotional difficulties) and their diploma courses in play therapy. PTUK/PTI also set up a professional organization in Hong Kong as a branch under Play Therapy International: Play Therapy Hong Kong.

Challenges Accreditation The progress and development of play therapy in Hong Kong is impacted by the lack of public recognition that this modality is a specialization. In fact, the public is only beginning to be aware of what play therapy is, what play therapists do, and the importance of structured training and supervision for the professionals who will use play therapy competently. With the expansion of play therapy trainings offered from various sources to the local practitioners, there lacks a system for formal accreditation. Like in many Asian countries, many mental health professions are still ignorant of the need for rigorous training, supervision, and experiences in being a certified play therapist. At the present moment, the registered play therapists are either accredited with APT or PTI in the United States and United Kingdom respectively. The local community of play therapists would need to look into setting up an accreditation process to govern professional and ethical practices among the professionals. The setting up of the Hong Kong Association for Play Therapy (HKA4PT) in 2012 was a necessary and

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important step towards banding the play therapists together and improving the professional standing of this approach. With this new professional body established in the local setting, quality training in play therapy is organized in a more structured and systematic way. This way, the process for certification is clearer for mental health professionals who would like to further their training in the area.

Research In general, play therapy has been slow in accumulating empirical evidence to test the effectiveness of different play approaches in dealing with children’s problems. The same applies to the Hong Kong context. Very limited local research relating to play therapy has been published. For details about the play therapy research in Hong Kong context, readers can refer to the other chapter on play therapy research in this book. Below is a recap of the key areas that have been studied. Even though child-centered play therapy (CCPT) has been widely used in Hong Kong, very limited local research studies have been published on its effectiveness for children and families. However, there is promising evidence suggesting the adapted use of child-centered play skills for teachers in order to enhance teacher-student relationship and to help teachers generalize these skills to the daily interaction with children who have behavior problems (e.g., Siu, 2014a). Parent Child Interaction Therapy (PCIT) and Theraplay are two play therapy approaches that have research evidence supporting its effectiveness with local children and families. Leung, Tsang and Heung (2009) conducted a study using PCIT for children with significant behavioral problems. The result of this study suggested that PCIT is effective in reducing behavioral problems in Chinese families. In the field of Theraplay, Siu (2009) demonstrated the effectiveness of using Theraplay in a group format to reduce internalizing problems among primary school children in a randomized, controlled study. Siu (2014b) also reported that a Group Theraplay program conducted by teachers using Theraplay principles aided in enhancing the social development of young children with special needs. Other related research has included the use of therapeutic play with an effective measure for psychological preparation in helping children cope with the stress of hospitalization (Li, 2005; Li, Lopez, & Lee, 2007). The use of virtual reality computer games to minimize anxiety and reduce depressive symptoms in children hospitalized with cancer was reported in the works of

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Li, Chung, Ho and Chiu (2011) and Li, Chung and Ho (2011). Indeed, play and hospital play have an important function for children coping with the stress of hospitalization. There is a strong need in hospital settings for play specialists/play therapists to offer expert opinions on the play environment and selection of toys in pediatric wards, as well as for training volunteers to help children going through medical care. In addition to research on the effectiveness of play therapy with children, there are also studies done in relation to the use of play therapy for other populations. For example, the second author (Pon, 2010) reported the effective use of a communication board game for adult patients who were diagnosed with advanced cancer. Her research results indicated an increase in positive emotional states, purpose of life, quality of life, and quality of death. Besides publications in the international journals, there exist many unpublished dissertations and master theses from local universities where students research on the use of play, therapeutic play, play therapy and expressive art therapy on various target populations with mental health issues. Examples include the studying of the effectiveness of animal-assisted play therapy for children with Autism Spectrum Disorder (Fung, 2011), and looking into the effectiveness of expressive arts therapy for elderly with depression and anxiety (Lam, 2015).

Moving Forward To facilitate the expansion of play therapy in the local setting, postgraduate programs in areas such as counseling, education, and psychology in the local universities could include more courses—specifically on play therapy—to equip mental health professionals with the knowledge and skills for selecting and evaluating evidence-based strategies for working with various types of clients. Non-government agencies and play therapy service providers can work together to expand their trainings to professionals who are interested in play therapy, instead of relying on individual organizations to set up internal training for their staff, limiting access to other interested practitioners. Universities and professional associations can also explore collaborating on setting up the professional standard for play therapists. More research on the cross-cultural applications of various play therapy models can be conducted to identify what works for clients in the Hong Kong context.

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CASE ILLUSTRATION Living with a terminal illness poses a serious threat to the psychological and emotional states of the patients. Lo’s (2002) study with 58 Hong Kong patients in the terminal phase reported that more than 60% of the participants attributed existential wellbeing and spirituality as important contributors to their quality of life. There are also mounting evidence to show that these issues including others such as perception of being a burden (McPherson, Wilson & Murray, 2007), sense of suffering (Ganzini, Johnston & Hoffman, 1999), clinical depression (Wilson, Curran & McPherson, 2005) and loss of dignity (Chochinov, et al., 2002) are all related to the request for hastened death amongst the patients with terminal illness. Clearly, palliative intervention must encompass not only the physical realms but also the psychosocial and existential distresses.

Perceptions of illness, dying and death Being brought up in a utilitarian culture, sick Chinese people are usually rendered “useless” as strong work ethic and the importance of contributing to family wellbeing are highly valued (Chan & Chang, 1999). Besides, according to traditional folk beliefs, illness brings bad luck (Chan, Lam & Chow, 2000). Zheng (2000) identified that the notion of illness and death is considered by patients as a punishment for an ancestor’s or one’s evil deeds. Indeed, concerns about being a burden to others has been found to be of significant importance in many studies on good death (Kehl, 2006), quality of life of patients with terminal illness (Vig & Pearlman, 2003), existential distress (Cohen, Mount, Thomas, & Mount, 1996) and loss of dignity (Chochinov, et al., 2002). In the Chinese culture, death and dying are taboo topics, not to be discussed in public (Chan, 2000; Wong & Chan, 1994). The Chinese culture has an abundance of myths surrounding death that are anxiety provoking. Hence, preparing for death or even mentioning the word brings about bad luck and is seen as inviting it or condemning oneself to it (Chan, et al., 1998). However, studies have shown that though the elderly showed some anxiety towards death and would not speak of it for fear of offending others, they have no personal issues with talking about death (Chong & Lang, 1998; Chan, Tse & Chan, 2006). This prevalence regarding avoidance of talks around death may be more of a social taboo rather than a real fear.

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Self-disclosure One characteristic of the way the Chinese communicate is the principle of implicit or indirect communication, han xü (in Mandarin). According to Bond (1991), the characteristics for interaction amongst the Chinese are indirect and gradual. Generally speaking, the Chinese do not prefer the direct and open expression of needs, feelings and opinions. The emphasis on an indirect approach means that the Chinese will also reveal less about themselves, at least in the initial stages of a relationship. This slower revelation of intimate information is necessary in order to establish trust before one makes oneself vulnerable to possible danger through public exposure. Hence the conventional verbal intervention models focusing on openly expressing one’s needs or any negative feelings can be overwhelming for the Chinese.

Emotional expression For many Chinese patients, they mourned in private for fear of upsetting the family (Chow, Koo, Koo & Lam, 2000). This can be related to Chinese beliefs about emotions (Bond, 1993). Klineberg (1938) was one of the first Western scholars to point out that the Chinese consider emotion to be precarious and they value moderation in all manners and emphasize social harmony over personal expression. Children are taught to control their impulses from a young age and a lack of emotional moderation reflects poorly on the individual and his/her parents (Sun, 2008). Although emotional control or moderation is a valued trait in Chinese culture, within the realm of preventive medicine, emotional expressivity would seem to be more beneficial to one’s wellbeing. In Hong Kong, results from the study conducted by Ho, Chan and Ho (2004) showed that emotional control was closely associated with perceived stress, anxiety, depression and negative emotions in coping with cancer.

Self-effacement The I Ching provides wise counsel when it advises that, “Haughtiness invites riot; humility receives benefits.” One of the qualities most valued in a Chinese person is humility or qian xü (in Mandarin) because of the function it serves in enhancing group harmony (Sun, 2008). The virtue of humility,

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forbids one to explicitly show off their achievements and contributions in their community. Many down play their own abilities or speak of group accomplishment rather than individual contributions (Bond, 1991). Humility can be demonstrated by the factors to which people attribute their successes and failures (Mauro, Sato & Tucker, 1992). A humble person usually attribute failures internally such as his lack of competence, and attribute successes externally such as getting help from others or luck. Social scientists observing Chinese verbal behavior often mention their modesty, a tendency to play down one’s own skills or efforts publicly, to flatter the other effusively, and to speak little of individual contributions (Sun, 2008). She also noted that the Chinese tend to associate pride with hubris and are selective in expressing their contributions and achievements. This virtue of humility can impacted on a person’s perception of good death and their death preparation. One of the important components of a good death is for the patients to affirm their own self worth. He or she needs to feel that he has made an impact, have a sense of meaning and purpose in his life. However, on their own, an individual may not be so forthcoming in sharing their life achievements. They may be so overwhelmed by their illness that they fail to look objectively into their contributions as a productive citizen in the world.

Therapeutic Game Loomis (1957) is the first to publish his work on the therapeutic application of games by using checkers in therapy. He regarded game playing as a medium to express the resistance and oppositional attitudes. Beiser (1979) and Meeks (1970) both separately had suggested that game playing is a projection of the relationship between the players. The components of the working relationship including resistance, transference and countertransference can be observed through the interactions between the therapist and client. In play therapy, the use of therapeutic games is a psychotherapeutic method that utilizes a variety of game forms to help relieve client’s emotional distress. This involves not only playing games but also through integrating the therapist’s theoretical orientation with a cluster of therapeutic game materials so as to help an individual develop systematically towards mental health (Schaefer & Reid, 2001). Game play is not being identified as theoretically different from play therapy and cannot be separated from

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traditional play therapy approaches. It is an extension and broadening of play therapy to better meet the developmental needs of the latency age children, adolescents and adults. According to the play therapy literature, games typically referred to board games, fine and gross motor games, card games and street games (Reid, 1993a, 1993b). Games, though focused on rules and sometimes strives towards the goals of winning, are however, similar to free play as they also contain a sense of enjoyment and pretence. Games are supposed to be fun to play and meant to be separate from real life. Games imitate “real life” more when compared to play, which is more open-ended. It also allows free expression of impulses and manipulation of reality (Schaefer & Reid, 2001).

Background Ming was an outpatient under the care of the Clinical Oncology Unit in Princess Margaret Hospital, Hong Kong. He was diagnosed with end stage lung cancer six months ago and was given a prognosis of less than six months. Ming was 52 years old and worked as a bus driver for the past 20 years, until recently. He had been driving the same route, sending passengers from the city to the airport. Ming was married and had a son and daughter, aged 12 and 10 respectively. The second author, Dr. Pon was stationed at the Clinical Oncology Unit in Princess Margaret Hospital when Ming was there for his bimonthly medical checks with his doctor. Besides palliative medicine, there were no other services offered to Ming and his family. He was approached to join this intervention program. By the time the first meeting started, Ming was already bedridden and had to stay at home. The second author then arranged for home visits to conduct the intervention. Together, the second author (Pon) and Ming met for eight sessions. Each session lasted for approximately 90 minutes. The intervention made use of the My Wonderful Life (MWL) board game (Pon, 2010). The MWL game board and its game cards are designed, in consultation with Professor Norma Leben, to facilitate sharing and discussions on the various attributes that constitute end of life preparation such as life review, preparation for end of life and completion of unfinished business (Pon, 2010). The MWL game is typical of most structured games; with a path of different game squares winding from “Start” to “Finish.” A dice toss dictates how far along the path each player may move. A player may land on spaces prescribing extra moves, pick cards or engage in some simple massage and acupressure

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activities. When the player lands on a square that requires him or her to pick a card, he/she will be asked to respond to the questions on the card. The goals of playing this board game is to provide the players with the opportunities to review their lives, acknowledge and appreciate their contributions, and leave important messages and lasting impression for their loved ones (Pon, 2010).

Figure 5.1 MWL Communication Board Game

The Initial Phase of Therapy Ming was introduced to the MWL communication board game during the first meeting. He was obviously surprised with the way the meetings were going to be administered. Instead of talking about his illness and his concerns, we started the sessions by playing the MWL game. The design of the MWL board game is such that the initial phase of the games would have each players answer questions that pertain to factual information about each other. There was no question that was too challenging or emotional. This is a deliberate design of the game so that the client and the therapist could start

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with relationship building first before proceeding to the more in depth, thought provoking and emotional topics. The second author noticed that Ming was at ease at generating responses and was able to provide vital information of himself.

Positive emotions As we proceeded with playing the game, Ming was delighted to know that we were continuing with the game play. During the week, he had some stressful situations. He was informed that his cancer markers had gone up as compared to the last check. Ming shared with the second author that he was glad that they met so that they can focus on more positive emotions. Even though it was only for two sessions, Ming felt joy, contentment, and relaxation by engaging in the game play. Indeed, there are studies from both Western and Eastern populations, which confirmed that enhancing positive coping and positive emotions rather than reducing negative coping and emotions facilitate growth and wellbeing (Ho, Chan & Ho, 2004; Huppert & Whittington, 2003). Ming was physically and emotionally exhausted from the burden of his cancer; hence with the use of play, it provided a non-threatening platform for him to indulge in reflection, and the sharing of personal interests brought some positive and relaxing moods as well as momentary distraction from the ultimate stressor.

The Middle Phase of Therapy During this phase of the MWL game play, the task that was asked of Ming was to reminisce his life and highlight his life events and experiences that gave him meaning and purpose. Since its inauguration some 30 years ago, life review and reminiscence have been used extensively with elderly and terminally ill patients to help them to look back on themselves, learn to know themselves and make a balanced appraisal of their progress in life (Erlen, Mellors, Serieka & Cook, 2001; Haber, 2006). Ming was guided to use the questions from the game cards to enhance his insights into his life, personal contributions, strengths and wisdom. He had a chance to describe in many details, and with the second author as his audience, his personal stories, memories and what all of these contribute to the meaning of his lives. He shared his positive experiences as a bus driver, his role as a father, son and husband, and with these sharing of his life

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experiences, he also created new legacies and through this process, formally passed on much knowledge and experience to his loved ones.

Self awareness and disclosure During this phase of the game, Ming found it more challenging to answer those specific questions that asked about his life values and principles. The second author was also the player of the game and she was comfortable with being open about and disclosing her own experiences and stories. As she shared some intimate details about herself and life values, Ming was able to relate to those stories and started sharing his. Indeed, game play introduces “equality” in the relationship between players. Games usually involve interaction between two players; in this situation the therapist becomes a player that joins the client’s world, not just as a passive observer. From the client’s point of view, the therapistclient boundary become relaxed and is blurred. It also appeared to narrow the interpersonal and power gap between them. This game playing reduced Ming’s anxiety about entering into a dialogue on a serious topic. In addition, Ming simply enjoyed the game playing format which in itself enhanced the development of a relationship with the therapist. It was noted that during this phase, the strong emotional feelings that Ming had been harboring were discharged within the safe confines of the game. As he relaxed and involved himself in the game, he began to feel comfortable talking about feelings and ideas that mattered to him.

Personal legacy During the initial stages of the game, Ming often talked about passing on material items as a way for his children to remember him. Indeed, material legacy such as heirlooms, possessions and material belongings were the legacy that many patients aspired to pass on to their family. However, like many, Ming often said with a hint of regret at not having made enough money, and being unable to provide a more substantial legacy such as valuable artifacts and jewelry to help the family live comfortably once he was gone. During this phase of the MWL game play, Ming was able to share many narratives of themes as the importance of being kind to others, stories of perseverance and growth, and maintaining relationships with friends and loved ones. As a result of sharing his personal values, beliefs and principles,

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and knowing that his legacy will continue through his children, Ming was able to affirm and recognize his self worth and uniqueness. This was important to Ming. The family was surviving on social welfare and the little savings that he had. Through playing this game, he was definitely more positive about what kinds of legacies he can leave for his family.

The Final Phase of Therapy The final phase can be considered to be the most emotional but liberating for Ming. During this phase, which spanned for three sessions, Ming was given the chance to focus on topics that were constantly on his mind, which he could not able to discuss with his family, especially his wife. He had to manage the sensitivities of their reactions around him. His wife was reluctant to acknowledge his impending death and had rejected his wishes to talk about and accept his mortality. In these three sessions, which were recorded, Ming was able to have the chance to direct his special heartwarming messages and specific instructions regarding how he would like his funeral or end of life affairs to be to his wife and children through the game.

Expression of challenging issues and emotions During this final phase of game playing, the questions around Ming’s plans for medical and proprietary issues such as settling his estate and financial affairs, planning, transferring of roles and responsibilities and deciding on one’s funeral or burial spot were openly discussed. He also had an opportunity to resolve unfinished business, remember personal accomplishments and say good bye to important people. These three sessions were indeed very emotional for Ming and the second author. An important concept in game playing is the concept of “points of departure” (Frey, 1986; Gardner, 2002) in which the players would “leave” the game to discuss issues expressed during game play. The key aspect of this and many game designs is managing and guiding discussion back and forth between the safety of the game and the realistic discussion of issues through points of departure. In each of the sessions, the second author would tactfully redirect Ming back and forth into the game and to guide Ming into moving from the game and into discussing the deeply distressing but meaningful issues around his impending death and preparation for this inevitable event.

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Conclusion As Corr (1992) rightly pointed out, when working with a person with terminal illness, they are above all else a person, a living human being. The person lying on the deathbed is a father/mother, a son/daughter, a neighbor, a friend, and a colleague. The pressures of dying had overwhelmed the patients that they underscored many of their self worth and the value of their lives. The end of road should not be solely focusing on the loss and separation; instead, it should also be about the celebration and commemoration of one’s life in this transient world. The significance of this intervention for Ming is that he had a chance to reflect on himself and his life. He experienced joy and relief in knowing that his legacy, no matter how simple and insignificant from his perspective, can be passed on to his wife, and his two children. Ming made good use of the MWL board game to enhance expression, reconciled with himself and his significant others, and finally but most importantly it bolstered a sense of meaning, purpose and dignity in him. Ming had a chance to address issues that matter most to him as well as appreciating that he can transcend death. Ming died before this chapter and book was published. Ming will be glad to know that his legacy lived on through this write up and that we all became better therapists because of Ming’s generosity in sharing of his experiences as a palliative patient and also in teaching not only the second author but his family about living, dying and resilience.

IMPLICATIONS FOR PRACTICE • When dealing with the physical distresses of their illness, besides the usual symptom control treatments, many Chinese resort to distraction coping. They use other activities or thoughts to distract themselves from the stresses related to physical pain and discomfort. Although the excessive use of distraction coping to deal with psychological and emotion distresses are not advisable, this form of coping may be beneficial for the Chinese patients to manage the pain and discomfort. Instead of focusing directly on the distressing situations, the Chinese patients appreciate the more subtle and indirect kinds of engagement and discussion. The therapist would have to make gentle transitions into the issues and be astute to the client’s needs to stop and integrate before moving back to the topic.

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• Chinese people generally do not consider it polite to be overtly arrogant and boastful about their achievements and connections. Humility and modesty or qian xü is a core norm of personal conduct in traditional Chinese culture. Social scientists observing Chinese verbal behavior often mention their modesty, a tendency to play down their own skills and efforts, to flatter others effusively, and to speak little of their own individual contributions. Left to their own devices, Chinese patients may not be forthcoming in sharing their life achievements. They may be so overwhelmed by their illness that they fail to look objectively at their contributions as a productive person. The therapist working with Chinese patients would need to focus on helping them to feel that there is a sense of purpose and meaning in their lives, even though it might not be all materials legacy like family heirlooms or possessions that they can leave behind. With the guidance of the therapist, they can be encouraged to view their intangible achievements as equally important for their family. Through the change of their perceptions, they can be helped to achieve a sense of closure and a good death. • In general, play therapy tended to specialize in working with children, largely because play is every child’s medium for negotiating their inner and outer worlds. One of the reasons adult play therapy has not been as well developed in Asia may be due to a cultural taboo against it, seeing it as childish, frivolous, and contrary to the productive work required of being an adult. This misconception might exist because there is social misperception that adult play is essentially similar to child’s play. However, being playful and using creative means of engaging Chinese adult clients have potential in helping effectively eradicate the anxiety and resistance in entering into a therapeutic relationship and barriers to communication. The therapeutic components of play with children had the same impact with adults and if incorporated into a clinically grounded treatment approach, play therapy can provide an adult with an appropriate avenue to safely examine their thoughts, feelings and issues. Play therapists in Asia must look beyond utilizing play therapy with children. The therapeutic use of play therapy across life span is another area of specialization where the play therapist could be further trained in using play therapy techniques appropriate for creating a sense of safety, overcoming resistance and mastery of specific skills in approaching more threatening problems and topics for adults.

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REFERENCES Beiser, H. R. (1979). Formal games in diagnosis and therapy. Journal of Child Psychology, 18, 480–490. Bond, M. H. (1991). Beyond the Chinese Face: Insights from psychology. Hong Kong: Oxford University Press. Bond, M. H. (1993). Emotions and their expressions in Chinese culture. Journal of Nonverbal Behavior, 17, 245–262. Chan, C. L. W. (2000). Death awareness and palliative care. In R. Fielding & C. L. W. Chan (Eds.), Psychosocial oncology and palliative care in Hong Kong: The first decade (pp. 213–232). Hong Kong: Hong Kong University Press. Chan, C. L. W., Lam, D. O. B., & Chow, A. Y. M. (2000). Holistic care for cancer patients in China and Hong Kong. In J. Kwok & J. Y. S. Cheng (Eds.), Hong Kong and China in transition: Strategies for a better quality of life (pp. 155–171). Chicago: Imprint Publications. Chan, C. W. H., & Chang, A. M. (1999). Stress associated with tasks for family caregivers of patients with cancer in Hong Kong. Cancer Nursing 22, 260–265. Chan, K. S., Lam, Z. R. C., Chun, R. C., Dai, D., & Leung, A. (1998). Chinese patients with terminal cancer. In D. Doyle, G. Hanks, & N. MacDonald (Eds.), Oxford textbook of palliative medicine (pp. 793–795). Oxford, UK: Oxford University Press. Chan, W. C. H., Tse, H. S., & Chan, T. H. Y. (2006). What is good death? Bridging the gap between research and intervention. In C. L. W. Chan & A. Y. M. Chow (Eds.), Death, dying and bereavement: A Hong Kong Chinese experience (pp. 151–167). Hong Kong: Hong Kong University Press. Chochinov, H. M., Hack, T., Hassard, T., Kristjanson, L. J., McClement, S., & Harlos, M. (2002). Dignity in the terminally ill: A cross sectional, cohort study, Lancet, 360, 2026–2030. Chochinov, H. M., Hack, T., McClement, S., Kristjanson, L. J., & Harlos, M. (2002). Dignity in the terminally ill: A developing empirical model. Social Science and Medicine, 54, 433–443. Chong, M. L. A., & Lang, G. S. (1998). Attitudes of Chinese elderly people towards death: Practical implications of social workers. Asia Pacific Journal of Social Work, 8, 50–63.

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Chow, A. Y. M., Koo, B. W. S., Koo, E. W. K., & Lam, A. Y. Y. (2000). Turning grief into good separation: Bereavement services in Hong Kong. In R. Fielding & C. L. W. Chan (Eds.), Psychosocial oncology and palliative care in Hong Kong: The first decade (pp. 233–254). Hong Kong: Hong Kong University Press. Cohen, S. R., Mount, B. M., Thomas, J. N., & Mount, L. F. (1996). Existential well-being is an important determinant of quality of life: Evidence from the McGill quality of life questionnaire. Cancer, 77, 576–586. Corr, C. A. (1992). A task based approach to coping with dying. Omega: Journal of Death and Dying, 24, 81–94. Erlen, J. A., Mellors, M. P., Sereika, S. M., & Cook, C. (2001). The use of life review to enhance quality of life of people living with AIDS: A feasibility study. Quality of Life Research, 10, 453–464. Frey, D. (1986) Communication board games with children. In C. Schaefer & S. Reif (Eds.), Game play: Therapeutic uses of childhood games (pp. 21–40). New York: Wiley. Fung, S. C. (2011). The role of therapy dog in facilitating social integration for autistic children: An experimental study on animal-assisted play therapy (PhD Dissertation). The Chinese University of Hong Kong. Ganzini, L., Johnston, W. S., & Hoffman, W. F. (1999). Correlates of suffering in amyotrophic lateral sclerosis. Neurology, 22, 1434–1440. Gardner, E. (2002). Handbook for recreation leaders. Amsterdam, The Netherlands: Fredonia Books. Haber, D. (2006). Life review: Implementation, theory, research, and therapy. International Journal of Aging and Human Development, 63, 153–171. Ho, R. T. H., Chan, C. L. W., & Ho, S. M. Y. (2004). Emotional control in Chinese female cancer survivors. Psycho-Oncology, 13, 808–817. Huppert, F. A., & Whittington, J. E. (2003). Evidence for the independence of positive and negative wellbeing: Implications for quality of life assessment. British Journal of Health Psychology, 8(1), 107–122. Kehl, K. A. (2006). Moving towards peace: An analysis of the concept of good death. American Journal of Hospice and Palliative Medicine, 23(4), 277–286. Klineberg, O. (1938). Emotional expression in Chinese literature. Journal of Abnormal and Social Psychology, 1, 2–5.

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Lam, H. (2015). Effectiveness of expressive arts therapy for elderly with depression and anxiety (Master’s Thesis). University of Hong Kong. Leung, C., Tsang, S. & Heung, K. (2009). Effectiveness of parent-child interaction therapy (PCIT) among Chinese families. Research on Social Work Practice, 19, 304–313. Li, H. C. W. (2005). The effect of pre-operative therapeutic play on postoperative outcomes of Hong Kong Chinese children and their parents having surgery in a day surgery unit (PhD Dissertation). The Chinese University of Hong Kong. Li, H. C. W., Chung, O. K. J., & Ho, K. Y. E. (2011). The effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalized with cancer. Journal of Clinical Nursing, 20, 2135–2143. Li, H. C. W., Chung, O. K. J., Ho, K. Y. E., & Chiu, S. Y. (2011). Effectiveness and feasibility of using the computerized interactive virtual space in reducing depressive symptoms of Hong Kong Chinese children hospitalized with cancer. Journal for Specialists in Pediatric Nursing, 16, 190–198. Li, H. C. W., Lopez, V., & Lee, T. L. I. (2007). Psycho-educational preparation of children for surgery: The important of parental involvement. Patient Education and Counseling, 65, 34–41. Lo, R. S. K. (2002). Quality of life in palliative care patients: A multi-centre study of profile, determinants and longitudinal changes from inpatients admission to death (PhD Dissertation). The Chinese University of Hong Kong. Loomis, E. A. (1957). The use of checkers in handling certain resistances is child therapy and child analysis. Journal of the American Psychoanalytic Association, 5, 130–135. Mauro, R., Sato, K., & Tucker, J. (1992). The role of appraisal in human emotions: A cross cultural study. Journal of Personality and Social Psychology, 62(2), 301–317. McPherson, C. J., Wilson, K. G., & Murray, M. A. (2007). Feeling like a burden to others: A systematic review focusing on the end of life. Palliative Medicine, 21, 115–128. Meeks, J. E. (1970). Children who cheat at games. Journal of the American Academy of Child Psychiatry, 9(1), 157–174. Pon, A. K. L. (2010). My wonderful life: A board game for patients with advanced cancer. Illness, Crisis and Loss, 18, 141–161.

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Reid, S. E. (1993). Game play. In C. E. Schaefer (Ed.), The therapeutic powers of play. Scranton, NJ: Haddon Craftsmen of Scranton. Reid, S. E. (1993). It’s all in the game: Game play therapy. In T. Kottman & C. Schaefer (Eds.), Play therapy in action: A casebook for practitioners (pp. 527–560). Lanham, MD: Rowman & Littlefield Publishing. Schaefer, C. E., & Reid, S. E. (2001). Game play: Therapeutic use of childhood games (2nd ed.). New York: John Wiley & Sons. Siu, A. F. Y. (2009). Theraplay in the Chinese world: An intervention program for Hong Kong children with internalizing problems. International Journal of Play Therapy, 18, 1–12. Siu, A. F. Y. (2014a). A qualitative exploration of filial therapy for enhancing teacher-student relationships. Journal of Asia Pacific Counseling, 4, 15–30. Siu, A. F. Y. (2014b). Effectiveness of a group theraplay program on enhancing social skills among children with developmental disabilities. International Journal of Play Therapy, 23, 187–203. Sun, C. T. L. (2008). Themes in Chinese psychology. Singapore: Cengage Learning. Vig, E. K., & Pearlman, R. A. (2003). Quality of life while dying: A qualitative study of terminally ill older men. Journal of the American Geriatrics Society 51(11), 1595–1601. Wilson, K. G., Curran, D., & McPherson, C. J. (2005). A burden to others: A common source of distress for the terminally ill. Cognitive Behavioral Therapy, 34(2), 115–123. Wong, D., & Chan, C. L. W. (1994). Advocacy on self help for patients with chronic illness: The Hong Kong experience. Prevention Human Services, 11(1), 117–139. Zheng, X. J. (2000). On the death attitude of Chinese people. Journal of Shangrao Teachers College 20(5), 1–8.

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Play Therapy in Indonesia Astrid Wulan Sari Emeline Napitupulu

Play therapy, as one of the therapeutic interventions to work with children, is perceived as a novelty for parents in Indonesia. It is also a new approach for Indonesian mental health professionals who are working with children and adolescents. The affiliation for play therapists in Indonesia was started in 2014. To date, there is no licensing protocol for play therapists. Even though play therapy has been introduced by the Faculty of Psychology of Universitas Indonesia since the 1980s, few graduate students are willing to take on play therapy as their specialization.

DEVELOPMENT OF PLAY THERAPY IN INDONESIA There are few professionals with formal training in play therapy, art therapy, or other creative and expressive mediums in Indonesia. Based on the author’s knowledge, one of the few known therapists is Dr. Monty Satiadarma Psi, an educational psychologist specializing in music and art therapy. He studied art therapy at the Emporia State University, Kansas and specializes in treating survivors of the Indonesian tsunami on behalf of the International Red Cross and the United Nations. He is also a founder of Asian Psychology Association and presented papers in various international conferences. In addition, Mayke Tedjasaputra, M. Si, a senior psychologist and a lecturer at Universitas Indonesia, is also considered as a pioneer in

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practicing play therapy with children. She presented a paper in a regional conference. Up until 2014, many child therapists who have immersed interests in learning and practising play therapy had difficulties in meeting the criteria for international certification because there are no institutions in Indonesia that could provide the training. Despite the challenges in meeting the international standards to be a registered play therapist, many professionals continued to be interested in play therapy and looked out for opportunities to improve their skills and knowledge in this area. In recent years, parents from big cities in Indonesia are increasingly aware of how their parenting styles can affect the development of their child and want to learn more about how to meet their children’s needs. This led to the increasing need for mental health professionals and greater interest for play therapy intervention in helping the children and family in need. In 1980, the Faculty of Psychology of Universitas Indonesia, a leading university in Indonesia, introduced the topics of play therapy in one of the modules on Introduction to Psychotherapy. One of the books that they used was Play therapy by Virgina Axline. At that time, there was no internet and no books from Indonesia about play therapy. Between 1991 and 1994, a visiting play therapist from The Netherlands, Dr. Jean Lammerst van Bueren Smith, taught Non Directive Play Therapy to the students and faculties from the Faculty of Psychology, Universitas Indonesia. In addition, she also offered supervision to a few lecturers who are also clinical psychologists. In 1995, three lecturers who completed the training and supervision received their certification from Universitas Indonesia. They are Mayke Tedjasaputra, S. R. Retno Pudjiati, and Hanny Savitri, (Pudjiati, personal communication, 2013; Tedjasaputra, personal communication, 2013). Savitri had since moved to New Zealand, while Pudjiati’s specialization is researching and training on child resilience, and Tedjasputra practiced play therapy and placed greater interest in the topic on play. Tedjasaputra was invited to share her knowledge in some universities in Indonesia. In 2005, Tedjasaputra together with Rini Hildayani, a child psychologist and a lecturer at Universitas Indonesia, attended Theraplay® Level One training in Melbourne, Australia. Since then, Theraplay has become a topic for post graduate research and was also included as a module in Introduction to Psychotherapy in the University. Rini and Tedjasaputra introduced Theraplay during parenting seminars or workshops in Indonesia.

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Through Tedjasaputra, this author became familiar with Theraplay and applied Theraplay principles in her thesis. Together with Tedjasaputra, the author introduced Theraplay at a national conference for child and adolescent psychiatry that was held by Indonesian Psychiatric Association in Jakarta in 2013. The author then attended Theraplay Level One in The Netherlands in 2013 and met Bettie Sleeuw and Phyllis Booth in training. Sleeuw was a Theraplay trainer, supervisor, and initiator for developing Theraplay in The Netherlands and she offered to help the author connect with The Theraplay Institute in Chicago. Together they held the Theraplay Level One training in 2014 for the first time in Indonesia. Since then, Theraplay Level One Training is organized once a year in Indonesia. Theraplay Indonesia, an Association for professionals who completed Theraplay Level One and practice in Indonesia, was founded in 2015. To date, there are 44 clinicians registered with the Association. Satiadarma, the Dean of Psychology in Tarumanagara from 1997 to 2005 introduced art therapy and directed numerous art performances in Tarumanagara and supervised the doctoral program on art therapy at Bandung Technology Institute. In addition, since 2007, Tarumanagara University introduced play therapy as one of their modules in Psychotherapy (Naomi Soetikno, personal communication, December 24, 2013). Introducing art and play therapy to the students in their child clinical psychology programs gave these students the option of selecting art or play therapy as their specialization. This is an important platform for introducing play therapy to other child and adolescent practitioners in Indonesia. Since then, the knowledge about play therapy began to emerge. Furthermore, Universitas Padjadjaran, West Java, in collaboration with Rino Groep, The Netherlands, developed a Child and Adolescent Psychotherapy program in 2011 in which Play Psychotherapy become one of the core topics in the program, and the same organization conducted one of the very first play therapy workshops in 2013 where many participants were teaching staff in the Faculty of Psychology. In 2016, the Association of Clinical Psychologists, West Java and the Department of Psychology Universitas Pendidikan Indonesia also invited Diana-Lea Baranovich to give seminars and workshops about play therapy and expressive arts therapy in West Java. With this development and initiative, the knowledge about play therapy as an effective intervention spread amongst clinician-in-training. In 2013, the College of Allied Educators Indonesia, in collaboration with the Academy of Play and Child Psychotherapy (APAC), offered the first

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Postgraduate Certificate in Therapeutic Play Skills (PGCTPS). The trainees from this program can continue to pursue a Postgraduate Diploma in Play Therapy, and Masters of Art in Practice. Under the leadership of Alice Arianto, a certified play therapist from Indonesia, they initiated the formation of the Association of Play Therapists Indonesia, affiliated to Play Therapy International. In October 2016, they organized the first play therapy Asia Conference in Bali. In 2016, the Association of Play Therapists Indonesia and Theraplay Indonesia organized a joint meeting where they agreed to collaborate on educating the public and raising the awareness of the importance of play and play therapy in the society. They have promoted play, play therapy and Theraplay in government agencies, schools, and amongst other professionals and parents.

Adapting Play Therapy in Indonesia Adapting Non Directive Play Therapy In Tedjasaputra’s unpublished thesis, she applied non directive play therapy to a child with Selective Mutism. This research project highlighted the power of play in facilitating change and engagement with the child client. Her study also showed that there is no one child who would not want to engage in play as a therapeutic means. They might need more time to engage with the therapist and to be comfortable to be self directed in their play and communication. Indeed, for some children, they probably did not have much exposure to the kinds of toys that allows for free play (instead of computer games, construction or academic oriented kinds of play). From her study, Tedjasaputra also noted that there was a presumption that certain kinds of animal miniatures like pigs would be avoided due to their Islamic religion, but it turned out that Indonesian children were not adverse to playing with these toys and freely chose the toys. One adaptation during play therapy is to include other culturally specified toys such as Congklak, a traditional game like Mancala that all Indonesian children would know. This helps with the initial engagement. In Tedjasaputra’s experience, it was rarely observed that Indonesian children played with hand puppets or role playing with costumes in play room. This might be because the costumes were influenced by foreign stories not familiar to the upbringing of the Indonesian children.

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Adapting Theraplay In practicing Theraplay, nurturing activities must be done carefully. Rini learnt from her Theraplay training that if the child has an attachment issue, the therapist would facilitate some nurturing activities with the parents such as feeding or massaging by the therapist in the sessions. However, touching the opposite sex, especially in the presence of the spouse is considered inappropriate and disrespectful in Indonesia. The adaptation that can be done is for the therapist to position herself between the mother and the child without sitting next to the father. For Nuratman’s case (2007), he stated that his client was a pre-teen girl and both of them felt uncomfortable doing nurturing activities in Theraplay session. Physical contact is generally a sensitive issue not just for the opposite sexes but also for some tribes in Indonesia. Similarly, Stephani (2012) found in her Theraplay case that the mother predominantly conducts the nurturing activities in most tribal communities. The therapist would have to be sensitive and mindful to the clearly demarcated roles and responsibilities of each parent within the tribes, instead of introducing activities that are not suited to the cultural expectations and norms. Indonesia also has cultural beliefs that appear to be contrary with Theraplay principles. For instance, in some tribes, it is impolite to stare at your parents and look into their eyes, while eye contact is encouraged in Theraplay; or in some tribes it is also considered impolite to give something to a parent after you have touched it with your feet, as the feet is considered “unclean” from some tribes perspective. However, in Theraplay it is acceptable to playfully hold something with one’s feet or to massage or touch the child’s feet. Explaining and discussing with parents the nature of the treatment sessions and the activities involved before the sessions would be helpful to parents and therapists as they engaged in Theraplay activities. During the month of Ramadan where the majority of Indonesians who are Muslims will be prohibited from eating from dawn to sunset, the clients should not be directed to take part in feeding activity for both therapy as well as the Assessment. Even though there are some exceptions for young children on fasting, it would still be considered disrespectful or impolite to direct the parents to feed their children at sessions during the month of Ramadan. Hence the therapist can consider different nurturing activities to replace feeding during this month, out of respect for the religion.

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Major Play Therapy Applications and Approaches in Indonesia Parents who understand the process of play therapy usually will appreciate the use of this therapeutic approach and be patient with the therapeutic process. However, since play therapy approaches are still relatively new in Indonesia, some parents do not understand the therapeutic factors of play and might consider play therapy as ineffective or “only play.” This can be related to how parents view the value of “play” itself. Indeed, many Indonesian parents do not play with their child because they simply do not know how to do it. Giving explanations and knowledge about the benefits of play and therapeutic play would help parents understand the importance of play and play therapy for their children. During Theraplay, the parents are often given some tasks to complete at home. Often, many parents do not complete their homework, at times, trivializing the activities. Farver and Wimbarti (1995) found during informal conversations about children’s play activity, most mothers were not particularly concerned with how or what their children played, nor did they orchestrate or direct play activities. Instead, their primary concern was that their children were quietly occupied indoors or busy outdoors with other children. Like many parents in Asia, Indonesian parents still value academic performance and intelligence more so than creativity and free play. Parents would endorse activities such as finger painting or any play activities that claimed to increase their child’s intelligence. A local study showed that the main reason for mothers to buy a particular toy or game for their children is improve their cognitive abilities (Dwynia, 2013). They buy electronic gadgets for their children because they perceive that these toys can improve their child’s intelligence. The other more popular toys in Indonesia are constructive games like LEGO, puzzles and building blocks. One other challenge in applying play therapy in Indonesia is the technique of reflection of feelings. In general, there are fewer vocabularies in Indonesian for emotions. For example, the word “senang” is used to describe feelings of “happy,” “joy,” “glad,” and “pleased.” Another feeling word like “malu” can encompass the feelings of “embarrassment,” “shame,” and “shyness.” In the Indonesian culture, it is uncommon to reflect or even to have only one word to describe one emotion. In the early years as play therapy entered into the Indonesia’s mental health field, our pioneers, Tedjasaputra and Pudjiati spent considerable time learning the techniques

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of reflecting and identifying feelings to adapt them to the local culture. In reality, it takes much practice for Indonesian parents to be comfortable to label and identify appropriately their child’s affects. Indeed, even during therapy, it is challenging to identify the appropriate feelings as the child engage in expressing him or herself since one feeling word could mean so much more.

Research and Practice The lack of research on the practice of play therapy in Indonesia is due to a lack of scholars who are interested in conducting research on play therapy. Much of the research are written up as unpublished university essays or theses. Based on this author’s knowledge, from 2006 to 2013, there have been 10 theses and final projects completed by clinical child psychology students in Universitas Indonesia. Almost all of the research methodologies are carried out using the single case design. Theraplay is the most researched play therapy intervention in Universitas Indonesia. Indeed, there is a need to have more diversed research methods and topics on the use of play therapy. Besides the plaucity of research, there are also very few clinical workplaces that has a formal play room designated for play therapy. Unfortunately all these initiatives would require substantial budget and investment. Some universities in Indonesia provide play rooms for the study of play development in children but they are generally not a therapeutic space. At the present moment, only the Universitas Indonesia has a designated observation room that can be used for the practice of play therapy or Theraplay. In 2005, an organization called Komunitas Hong (Hong Community) was founded by Mohamad Zaini (TEDxTalksVideo, 2011). This organization developed an inventory of traditional plays in Indonesia, with more than 980 types of games and play activities around Indonesia. This organization aims to avail the traditional games that could meet the needs and spread the Hong community values, especially for the children. Zaini found that by playing with these traditional games like making wood puppets or following the traditional dance steps in group, the children become more active, healthy, confident and happy (Zaini, personal communication, 2015). Zaini highlighted that Indonesia has a rich culture of plays and drama but there are very few research studies in this area. Zaini stated that it is important

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to systematically use these creative and symbolic means that are culturally specific to Indonesia. In Indonesia, traditional games that do not require any play materials such as hand clapping games can be used to build engagement and bonds between players and had been played for centuries. Zaini hoped that by revitalizing the traditional games and play, Indonesian would reconnect with their roots and use these culturally rich games with their children.

Moving Forward Play therapy in Indonesia is in the early developmental stages. Even though psychologists first began to learn about play therapy in the 1980s, the status and the importance of play therapy is only beginning to flourish. In fact, structured play therapy training only started in 2013. Indonesian play therapists need to reach out to the international community to equip themselves with more advanced play therapy techniques and knowledge. Parents in Indonesia are getting more affluent but they may not be more responsive and sensitive to the needs of the children. They seemed to have lost their innnate abilities to parent their child. Hence, professionals working with children and adolescent have an added responsibility to provide guidance and coaching on the importance of play in a child’s development. Indonesia needs more practitioners to come together and form affiliations so as to formally develop and adapt play therapy to meet the needs of a striving and developing nation. For Indonesia, as a country with the fourth largest population in the world, issues like emotional problems, abuse, anxiety, attachment issues, and social problems continue to rise. The professionals need to make concerted efforts to integrate play therapy as a central part of Indonesian psychological intervention used to help children and their families. With more research, training and licensing bodies in Indonesia, play therapy will have a stronger foothold in Indonesia.

CASE ILLUSTRATION

Background of the Issue in Indonesia Based on Indonesia’s Child Protection Commission (KPAI) data, there were 200 cases reported of child sexual abuse from January to April 2014. This is about one and half times more than in 2013. What is reported on the

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media and to the police or KPAI is only the tip of an ice berg. Many of the cases go un-reported and do not bring justice to the victims. The lack of assistance from the law and the police department means there are many unsolved sexual abuse cases and most of victims have to share their stories to their family or the trauma center. Unfortunately, many also keep the abusive experience a secret. There was an increase in the number of reported child sexual abuse cases in 2014 since there was more public awareness. Unfortunately not all experts who are expected to help the victims were well prepared. Some of experts do not have the ncecessary knowledge and skills to support the victims and their families. They gave inappropriate and misguided advice which might in turn have misled the public’s understanding of how best to support the victims and the family. Child victims are violated in every sense: physically, psychologically, emotionally, and spiritually (Wickham & West, 2002). According to Browne and Finkelhor (as cited in Wickham & West, 2002), sexual abuse can lead to traumatic sexualization and stigmatization in a child. Indeed, the children would blame themselves for bringing trouble upon the family and maintaining the secrecy enjoined by the perpetrator. The child’s trust in adults may have been violated, and the experience of powerlessness may also lead to the internalization of a victim-persecutor internal working model for relationships (Wickham & West, 2002).

Theoretical Framework and Construct of Theraplay There are many available psychological interventions in Indonesia for victims of sexual abuse. They range from conventional talk therapy to the use of other modalities such as play therapy, and Eye Movement Desensitization Reprocessing Therapy (EMDR). Others include family therapy and providing psychoeducation for the family about impact of the abuse and trauma. Theraplay is an engaging, playful, and relationship focused treatment method that is interactive, physical, personal, and fun. Theraplay’s principles are based on attachment theory and its model is the healthy, attuned interaction between parents and their children (Booth & Jernberg, 2010). Theraplay has four dimensions: Structure, Engagement, Nurture and Challenge (The Theraplay Institute, 2013). Structure is where parents are trustworthy and predictable, and provide safety, organization, and regulation.

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Engagement is where parents provide attuned, playful experiences that create strong connection, and optimal level of arousal, and shared joy. Nurture is where parents respond empathically to the child’s attachment and regulatory needs by being warm, tender, calming, and comforting. They provide a safe haven and create feelings of self-worth. Challenge is where parents encourage the child to strive a bit, to take risk, to explore, to feel confident, and to enjoy mastery (Booth & Jernberg, 2010). Theraplay can help to repair the attachment between parents and child that was broken because of the abuse/trauma effect. Theraplay can offer the child who has been sexually abused an experience in which he or she is nurtured and unconditionally accepted the way an infant would be in a healthy parent-child relationship (Munns, 2000). Children who have been sexually abused often develop sexualized behavior that can be threatening to adults. It has been suggested that the adult not only limit sexual behavior of the child but also replace the behavior with appropriate touch (Munns, 2000). The adult helps to model appropriate touch and behaviors which might be lacking due to their previous sexual abuse experiences. In Theraplay, when working with a child who has been physically or sexually abused, physical contact is significantly reduced and the process cannot be rushed. The Theraplay sessions focused more on the safety by providing consistent and firm Structure activities, or the confidence building provided by Challenge activities, while using less physical forms of Engagement and Nurture activities until a relationship is developed (The Theraplay Institute, 2013).

Case Background Andi was 5 years old, when he became a victim of sexual abuse in his neighborhood. The perpetrator was a male teenager, a high school student and his neighbor. Andi was sexually abused in his own home. The family did not file a police report as the family of the abuser begged for mercy for their child. Since then, the perpetrator and his family moved to another city and has not been in contact with Andi and his family. Andi’s mother came to the Trauma Center to seek help for Andi. She was also highly traumatized by this event and could be hypervigilant, fearful and worried when Andi is out of her sight. Since the incident, Andi had not been allowed to play outside, and his mother would take him wherever she went. Unfortunately, his father had not been supportive and placed the blame on his mother for the event. After the incident, his mother noticed changes in

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Andi’s behavior. Andi became more emotional and appeared to be more controlling than before. There are also many inappropriate temper tantrum which the mother had difficulties managing. His mother also observed sexualized behaviors from Andi. This behavior caused great alarm and confusion for her, and hence she decided to seek help for him.

The Initial Phase of Therapy The initial therapy focused on providing counselling for the mother. She was also educated on the impact of child sexual abuse and the appropriate parenting and reactions towards Andi’s behavior. Subsequently, Theraplay was introduced to both parents. Though the father had reservations of the effectiveness of such a playful and “unordothdox” intervention, he thought that it would not harm Andi, given that they were feeling helpless with Andi’s emotional outbursts and inappropriate behaviours. Before sending Andi back to their indigenous hometown, the parents decided to give Theraplay a try. Andi’s family comes from a lower social economic strata, and his father works as an Angkot driver. Angkot is a personal old car that is modified for public transport and can carry 10–15 passengers. They live in a boarding house and have financial problems. Both of their children are sent to a free public school and they only have very little money left to pay the transportation fee to the clinic. To get themselves to the clinic also takes about 1.5 to 2 hours by public transport. Therefore, it takes a lot of effort for the family to be compliant to the therapy. The Theraplay treatment was provided to Andi and his mother. They had a Marshack Interaction Method Assessment to determine their attachment and engagement styles. The outcome from MIM showed that his mother constantly have high expectations of Andi and tend to blame Andi when he made a mistake or could not meet her expectations. There appeared to be disconnected engagements between both of them. His mother also had self doubt and instead of taking ownership of her role, she constantly used others to coerce him into compliance. It was also noted from the assessment that his mother seemed awkward with touch and had to work on learning how engage Andi in a nurturing way. Andi, on the hand, needs to feel loved, accepted and secured with a main caregiver. He appeared to have low self concept. The activities in the Challenge domain can help him develop a stronger and more confident self.

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The Middle Phase of Therapy As the sessions moved on, Andi showed ambivalence towards his mother’s effort in nurturing and engaging him. Similarly, his mother seemed to have difficulties giving nurturance as well. They had to have many rounds of practice and modeling from the therapist before they could feel more comfortable with these nurturing and playful activities. However, one common activity that both parent and child loved was singing. As his mother sang to Andi, it brought him back to the times when he felt safe, comfortable and secured, probably during the infancy stage. His mother acknowledged that she sang a lot to him when he was younger. Andi enjoyed his mother singing and sang with her. He even requested his favorite song to be sung by her. For the next few sessions, his mother seemed to enjoy engaging with Andi as they could bond with each other in a safe environment. Besides the nurturing activities, Andi also enjoyed and participated earnestly in activities that could challenge him and make him feel confident and good about himself.

Towards the End of Therapy The Theraplay sessions with Andi and his mother terminated after 5 sessions. Through this short term therapy, there were observable changes especially in the mother’s response to Andi. His mother was more structured and calm in giving instructions and responses to Andi. She was also secure enough to let Andi play with his friends in school. His mother stopped blaming and shaming Andi, and instead adopted a more accepting and non judgmental stance in engaging with Andi. She began to appreciate that Andi was the victim in this incident and was able to express more empathy and positive thinking towards him.

Evaluation and Reflections Though the Theraplay sessions were short, it demonstrated that its effectiveness, specifically on the change towards bonding between Andi and his mother. This is an important goal as Andi needed to feel that he can connect with his caregiver in a loving and secure way. Despite the intensity of the sexual abuse incident, Andi needed to feel that he is still loved and that his secure base will be there to support him as he dealt with this ordeal.

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During the sessions, the parent were taught many parenting skills and techniques applicable to the family’s values and reality. This knowledge helped the parents to learn more about their own parenting styles, the child’s needs and how to engage with each other in a meaningful and loving way. It is important to be mindful of how the engaging and nurturing activities can be administered. Andi was physically violated and hence might feel overwhelmed by touch and being too close in proximity with a stranger. In addition, we need to understand better the usual engagement styles of the parent and child before we decide on the activity since it might impact on the compliancy and effectiveness of the activity both parent and child do not engage usually in this way. Singing is a good substitute for the nurturing activities since it makes Andi feel safe and secure with his mother. It is very common in Indonesia to have short term therapy. The travelling time, the cost and the lack of knowledge of the therapeutic process could have impact on the compliancy of the family to attend longer term therapy. For Andi’s case, he will need continued therapy. This short term Theraplay intervention only set the foundation for other interventions such as psychoeducation therapy for the parents, and traumatic focused play therapy for Andi. In addition, the support from the community is important for the healing process for Andi and his family. His parents need to be encouraged by larger society, not just by professional helpers. They need to feel that they are not stigmatized or blamed for the traumatic experiences of their son.

Conclusion Theraplay is a playful treatment method that provides a secure base for the victims. With the sensitiveness of the therapist, enjoyable moments, and consistency in creating a safe environment, Theraplay can bring positive changes in the child’s self. They can feel loved, valued, and worthy so they can recover from the trauma and develop themselves in a better and healthier way. In addition, psychoeducation about child sexual abuse and parenting is important either as a prevention or as an intervention. People need accurate and objective information about the trauma experiences of their child and to know how best they can support their child.

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IMPLICATIONS FOR PRACTICE • The unique feature of the Indonesian household is that a child is usually raised by his/her extended family. It is very common that a family living in the household includes three generations (grandmother, grandfather, mother, father, and sometimes aunts/uncles are included). Besides the extended family, there will be maids who also live in the house and take care of the child. The maid might spend a considerable time raising the child with the parents and other relatives at home. Babysitting or daycare is the last option whenever the parents need someone else to take care of the child. Therefore, when a therapist needs to understand the child’s caregivers, daily living, attachment, parenting styles and family structure of the child, they need to look beyond the core family system. • Cultures, religion, and tribes play an important role in Indonesia. Indonesia is the biggest archipelago in the world and therefore has hundreds of tribes and thousands of local languages. The composition of the population according to the everyday language used shows that the majority of Indonesia’s population still maintains the social and cultural identity of each tribe. Even for parents who are living in the city, their roots tie them to the indigenous tribes. In addition to the cultural influence, Indonesians are generally religious. There are only six religions that are officially recognized in Indonesia. The composition of the population according to the religious affiliation showed that religion of Islam (87.18%) is still the most widely adopted among Indonesia’s population followed by Christianity (6.96%) and Catholicism (2.91%). Other religions are Buddhism, Hinduism, and Kong Hu Cu (Confucianism). Our ancestral and religious values and beliefs strongly influence our daily living and how we function as a family. Hence, the therapist cannot over simplify the assessment and planning of the intervention for the child and the family. Particularly it is critical for the therapist to understand the culture that applies in that area and the differences in the family. It is also important for rapport building and engagement if the therapist also can learn a few words of the local language. • Cooperation with parents is important. Most Indonesian parents expect the best from the play therapist. However, if they do not think that they have any part to play with the child’s therapeutic process. They expect the therapist to “fix” the child’s problem. Hence, in Indonesia, the play therapists

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have to put more priority on educating and contracting with the parents around learning about the therapeutic process, commitment to therapy, and their role in the therapy. • There were fewer vocabularies in Indonesian for emotions / feelings, for example: the word “senang” is used to describe feelings of “happy,” “joy,” “glad,” and “pleased.” The feeling word like “malu” is to describe feelings of “embarrassment,” “shame,” and “shy.” In the Indonesian culture, it is uncommon to reflect and identify emotions. In reality, it takes much practice for the Indonesian parents to be comfortable to label and identify appropriately their child’s emotion. The therapist needs to be familiar with the language of feelings and emotions in Indonesian language and to identify the appropriate feelings as the child engages in expressing him or herself since one feeling word could mean so much more. • Selection of toys is an important issue in doing play therapy in Indonesia. Due to Islam religion, there was a presumption that certain kinds of animal miniature like pigs would be avoided. However, it turned out that Indonesian children were not affected by it, and freely chose the toys. Still, it is important to note that given the different tribes and cultures in Indonesia, the therapist should consider having some culturally specific toys such as Congklak, a traditional game like mancala that most Indonesian children would know. This helps with the initial engagement. The therapist can also take note that certain Westernized toys and games, such as hand puppets or costumes might not be widely utilized by the Indonesian children and need some cultural adaptations such as changing the customs or appearance of the puppets that are more familiar to Indonesian culture.

REFERENCES Booth, P. B., & Jernberg, A.M. (2010). Theraplay: Helping parents and children build better relationships through attachment-based play (3rd ed.). San Francisco: Jossey-Bass. Dwynia, A. (2013). Differences in maternal affective behavior in interactions of mothers and preschool children when playing games using electronic media and non-electronic. Unpublished essay, Universitas Indonesia.

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Farver, J. & Wimbarti, S. (1995). Indonesian children’s play with their mothers and older siblings. Child Development, 66, 1493–1503. Munns, E. (2000). Theraplay: Innovations in attachment-enhancing play therapy. Northvale: Jason Aranson Inc. Nuratman, A. (2007). Description of theraplay application on a child with low confidence (Master’s Thesis). Universitas Indonesia. Stephani, R. (2012). The application of theraplay on child with parent child relational problems (Master’s Thesis). Universitas Indonesia. TEDxTalksVideo. (2011, Dec 29). Zaini alif—the secret meaning of “hom pim pa.” Retrieved from http://www.youtube.com/watch?v=hRVrm3svaUk. The Theraplay Institute (2013). Touch in theraplay [Training Handout]. The Theraplay Institute, Evanston, IL, USA. Wickham, R. E., & West, J. (2002). Therapeutic work with sexually abused children. London: Sage Publications.

7

Play Therapy in Japan Yumiko Ogawa Miwa Takai

Play therapy appeared to flourish in Japan in the late 1950s and early 1960s as a result of the publication of the Japanese translation of the books Client-centered therapy (1951) by Carl Rogers and Play therapy (1969) by Virginia Axline.

DEVELOPMENT OF PLAY THERAPY IN JAPAN Prior to the introduction of play therapy, common practices for emotionally disturbed children in Japan were limited to offering advice to parents or teachers, or for the severe cases, hospitalization (Hatase, 1957). From the late 1940s, child guidance centers were developed rapidly in Japan. However, the treatments offered at these centers were limited to assessments of children and an investigation of their home environments; no direct treatment was provided to them (Tsuchiya, 1967). In response to the lack of mental health treatment for children in Japan, play therapy was enthusiastically accepted as an innovative, practical, and promising direct approach to children in the late 1950s (Sato and Yamashita, 1978). One of the oldest Japanese articles on therapeutic factors of play is probably the one by Hayasaka (1953). In this article, he noted several healing elements of play including catharsis and enhancement of self-acceptance and sense of self. Although Hayasaka (1953) did not use the word “limits” in his article, he

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discussed the importance of preserving “social discipline” in utilizing play in a therapeutic setting and stating that this could anchor the therapy session to reality. In 1954, a book on psychotherapy that contained a whole chapter dedicated to play therapy was published in Japan (Ikeda, 1954). Along with the awakening of person-centered therapy in Japan, Jungian therapy was introduced in the mid-1960s by Hayao Kawai, one of the most prominent Japanese psychologists (Enns & Kasai, 2003). Kawai, who was taught by Dora Kalff was instrumental in introducing Hakoniwa therapy, which is an integration of sandplay therapy with Japanese cultural practices. “Hakoniwa” means “box garden” in Japanese. Gardening in Japan is considered spiritual work and is based on Zen Buddhism (Enns & Kasai, 2003). Japanese gardens are regarded as microcosms that symbolically depict the larger world outside. They are also viewed as a representation of “human efforts to form an enclosed and protected space in which individuals work through dilemmas as well as cultivate growth and build an orderly productive world” (Enns and Kasai, 2003). The conceptualization of Hakoniwa as a mirror of a person’s sensory and visceral experience of an inner as well as outer world was applied to play therapy, and Jungian play therapy became a part of mainstream methods in counseling children and adolescents in Japan. Another major theoretical orientation in the play therapy field is psychoanalytical play therapy. This approach was brought into Japan by several Japanese psychiatrists such as Keigo Okonogi, Takeo Doi, Kiyoshi Ogura and Kuninao Minakawa around 1960. These Japanese psychiatrists had studied in institutions abroad such as the Menninger Clinic in the United States and the Hampstead Clinic in England. In 1941, Anna Freud established the Hampstead Clinic that served as a war nursery providing residential services for children who demonstrated emotional and behavioral issues. In 1952, the nursery became the Hampstead Child Therapy Course and Clinic and offered clinical services as well as training in therapeutic work with children. Many of the books written by Anna Freud and Melanie Klein were translated and published in Japan. The Society for Child Analytic Therapy in Japan was also established to provide professional development opportunities on psychoanalytic orientation for Japanese psychiatrists and psychologists, and has since been hosting workshops and case consultations for mental health professionals across Japan. In the last two decades, some of the play therapy books written by prominent figures in the field of play therapy in the United States, including

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The healing power of play by Eliana Gil (2006), Play therapy: The art of the relationship by Garry Landreth (2002), and Foundation of play therapy by Charles Schaefer (2003), were enthusiastically translated into Japanese and highly referenced in play therapy education and training. The translations of these books by distinguished Japanese child psychiatrists and psychologists provided more recognition and deeper understanding of play therapy among Japanese mental health professionals as a structured and theoretically sound approach for helping children and their families. Today, play therapy has established its position as the primary approach to children with emotional and behavioral issues in Japan. It is a commonly employed therapeutic modality in a variety of settings, including clinics, hospitals, child guidance centers, group homes and schools. However, there is no easy access in Japan to formal and structured play therapy trainings in which theories in play therapy are introduced. In most graduate programs in Japan, play therapy is introduced briefly in a child psychotherapy class, often limited to a lecture, and there is a lack of experiential and practiced based learning such as role play. It is common that graduate students are expected to learn how to conduct play therapy as they start seeing cases as a part of their internship curriculum.

Play Therapy Research As play therapy became an emerging therapeutic modality for children in 1950s, there was a growing interest in conducting research to elucidate how play therapy works. For instance, Yasuhara and Hatase (1955) reported case studies of 11 of their child clients to examine the effectiveness of Child Centered Play Therapy (CCPT). Sato (1957) investigated the process of establishing an initial relationship between a play therapist and a child. Hatase (1957) examined the effectiveness of play therapy with 11 child client cases by collecting the data from a therapist’s observation, reports from the parent’s therapist and teachers as well as conducting Rorschach tests and a follow up evaluation. Miyama and Tsushima (1960) investigated variables that appeared to be conducive to the successful outcome of play therapy treatment by examining play therapy processes of 64 children. It appeared that the mental health professionals in Japan in the late 50s and 60s were actively and rigorously engaged in conducting research studies to explore the effectiveness of play therapy and in analyzing the process that led to its healing effects.

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Wakaba (1979) conducted a single case study on a group play therapy process with a stuttering child using a nondirective play therapy approach. She conducted pre- and post- assessment of stuttering severity and symptoms in addition to the intensive observation of 19 group play therapy sessions regarding the child’s play behaviors with other group members and the frequency of his aggressive behaviors. The results showed that the child’s stuttering symptoms subsided and his recovery process coincided with the shift from his solitary play to cooperative group play. Currently a majority of Japanese play therapy research methodologies are based on case studies; there is a scarcity of quantitative studies examining the effectiveness of play therapy in Japan. Those case studies mainly conceptualize play therapy using Jungian and psychoanalytic perspectives, such as those of Donald Winnicott and Margaret Mahler, as well as Child-Centered Play Therapy approaches. Among recent articles on play therapy in Japan, the study by Nakatsu et al. (2012) added more credibility to play therapy. She conducted an empirical study to examine the effectiveness of play therapy to facilitate children’s innate ability to grow. Although this research has a small sample size of nine participants, she employed more sophisticated research methodology in this study. As the psychotherapists in Japan are more encouraged to employ evidencebased approaches, there is a growing need to conduct both quantitative and qualitative studies with a well-established research design in order to more precisely examine the effectiveness of play therapy as well as to advance and elevate the importance of this modality in Japan.

Play Therapy Associations in Japan The Japan Association for Play Therapy (JAPT) was established in 2007 by Japanese child psychologists and play therapists with a quest to promote play therapy and advocate the importance of play through trainings, workshops, research and community services such as disaster response work. JAPT has been inviting not only Japanese play therapists but also renowned play therapists from all over the world to provide play therapy trainings on a variety of topics. In addition, in collaboration with Japan UNICEF, JAPT was greatly involved in the disaster response work after the Great East Japan Earthquake from 2011 to 2016. The Japan Theraplay® Alliance was established in 2014 to align the training and professional standards of the Theraplay practitioners with the standards of the international home base of The Theraplay Institute. Even

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though there are only a few professionals conducting Theraplay sessions with supervision in Japan, this intervention approach has deep international roots. For instance, there are many licensed Theraplay therapists in countries that are culturally different from the United States. Theraplay in countries such as Finland and South Korea are adapted and culturally sensitive to the unique features of their own countries. Similarly in Japan, the Alliance aims to develop the Theraplay practice through public education and quality therapy for both the children and their families. It is also very encouraging to note that there is a multidisciplinary team of professionals who are members of the Theraplay Alliance. Some of the directors and advisors are experts in medicine, welfare, psychology and education. They, along with the Theraplay therapists in training, are working to create a situation in Japan where the practice of Theraplay is freely discussed.

Qualification and Certification Despite its recognition and prevalence, the definition and understanding of play therapy appears to vary extensively among Japanese mental health professionals. Although some experienced play therapists in Japan advocate that play therapy is a complex and advanced psychotherapy that requires specific knowledge and skills to be effectively conducted (Azima, 1999), there also is a perception that play therapy is relatively easy to deliver by novice clinicians. When this chapter’s first author was working at an educational consultation center in Japan, it was a common practice that a beginner psychologist was assigned to a play therapy case and an experienced therapist provided psychotherapy or consultation to a child’s caregiver. It appears that this practice, in general, has not changed (Tanaka, 2000). This general misperception and a lack of professional recognition of play therapy as an established discipline is the result of a lack of a governing standard for becoming a play therapist. As a result, any mental health professional with very limited play therapy training can claim to be a play therapist in Japan. In order to elevate the quality of play therapists in Japan, there have been some attempts by local play therapy practitioners to introduce the criteria for Registered Play Therapist by the Association for Play Therapy (APT) in the United States. However, simply importing the criteria developed in a different culture creates some confusion, limitations and adversities since cultural conditions should be considered in the development of such criteria. Developing culturally responsive criteria for

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becoming a certified play therapist in Japan will not only further qualify the play therapists in Japan but also contribute to establishing a base for rigorous well-designed research studies on the efficacy of play therapy.

Current Needs of Families: Beyond an Individual Approach In past years, there has been a resounding call within the United States for child mental health professionals to employ a systemic approach for families with young children in which a caregiver’s involvement is a critical component (U.S. Public Health Service, 2000). As a response to this need, play therapists in the United States have been actively employing play based parent-child therapy and play based parenting trainings. In recent years, the play based systemic treatment methods such as filial therapy (Guerney, 2000), Child Parent Relationship Therapy (Landreth & Bratton, 2006), Theraplay (Booth & Jemberg, 2010) and Floortime (Greenspan, Wieder, & Simons, 1998) became more prevalent approaches and the efficacy of those interventions are also supported by research. To some extent, this approach of working with a child’s system may not be dissonant with Japanese culture, which traditionally values the family unit, particularly the bond between a mother and a child. The relationship between a mother and a child in Japan is often characterized as “interdependent” “or interrelated” in which a mother demonstrates great sensitivity, accurate interpretation and prompt responsiveness to signals from a child in order to foster an emotional connection with the child (Doi, 1973; Fogel, Barratt & Mesinger, 1994; Friedlmeier & Trommsdorff, 1999). In order to implement more evidence based parenting training into places and to provide parents with an easy access to such services, some programs such as “Nobody’s Perfect” and “Positive Parenting Training” have been conducted as a part of the Child Rearing Support Services (Kosodate Sien) in the community (Hiratsuka, 2006). These practical parenting trainings serve the true nature of Child Rearing Support Program, which is to ameliorate and improve parent-child communication and relationship (Tanaka, 2000). In fact, in recent years, some psychologists and researchers in Japan have been creating and implementing assessments and therapeutic services which target the enhancement of parent-child relationship as a part of Child Rearing Support Services (Aoki, 2013; Inagaki, 2013; Sasaki, 2013). It appears that there is an existing culture, demand, and readiness in Japan to accept those systemic interventions. To respond to this need, some Japanese play therapists began to explore a possibility of implementing such systemic

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approaches such as filial therapy (Yuno, 2015) and Theraplay (Hoshino, Takai, & Kubo, 2013). In her article, Yuno (2015) made suggestions on how to adapt the existing filial therapy model that is modeled after the Western parent child principles into a more culturally sensitive format in order to effectively deliver it to Japanese families. It is important for Japanese play therapists to be familiar with existing evidenced based play based parenting training or systemic interventions and also to be culturally sensitive and responsive by modifying the approaches based on the cultural and social context of children and their families in Japan.

Obstacles for Play Therapy Development Yamanaka (2002) and Hironaka (2005) both pointed out that the Japanese translation of the term “play therapy,” “yugi ryoho,” is misleading and invites misconception. Yamanaka (2002) stated that while the meaning of “play” in English is very extensive and can even cover “emotional expression,” in Japanese, “Yugi” implies more recreation or a fun activity. Because of this imperfect translation, the distinction between “play” and “play therapy” became obscure. Consequently, it may have fostered some misunderstanding even among mental health professionals that the main purpose of play therapy is to offer a fun time to children. In addition, the lack of formal play therapy training opportunities exacerbates this misperception. There are very few universities in Japan that offer a semester long graduate level play therapy course. Therefore, it is rare for graduate students to receive in-depth play therapy specific training that covers four specific contents of play therapy (play therapy history, theories, techniques or methods and applications) recommended by the Association for Play Therapy (APT). To fill the training gaps, private organizations such as Japan Association for Play Therapy (JAPT) and Theraplay Alliance have been actively offering training and workshops in order to respond to the intense demands for play therapy education opportunities. Shimoyama (2005) noted that the lack of interest in conducting empirical mental health research in Japan might be partially attributed to a general lack of training in psychotherapy theories. He also mentioned that Japanese mental health professionals tend to practice based on the presumption of the efficacy of their approach. This presumption appears to be prevalent in the field of play therapy in Japan. As it is mentioned in the previous section, in Japan, most of the published journal articles on play therapy are case reports. There are very few play therapy articles, which

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employ the gold standard of research methodology such as quantitative analysis, qualitative methods or mixed methods to examine the efficacy of a play therapy (Ogawa, 2006). Despite the early stage of play therapy development, in 1959, Tatara advocated the need for objective data obtained through the use of the scientific method in order to prove the effectiveness of play therapy (Tatara, 1959). He also argued that employing rating scales that were originally developed for process analysis of adult therapy was not valid for process analysis of play therapy because the former was dependent on the verbal mode of expression whereas the latter treatment consists of child’s play, which is often nonverbal (Tatara, 1959). Although his statement was made almost 60 years ago, little improvement seems to have been made in play therapy research methodology in Japan. The aforementioned issue of lack of formal play therapy training also contributes to stagnation of play therapy research because it creates difficulty in accounting for therapists’ factors such as education and training background, experience and skill level of play therapy. In addition, an issue of confidentiality compounds the strain on conducting play therapy research in Japan. Although the stigma attached to psychotherapy or counseling has been ameliorated in Japan, clients are still sensitive to the issue of confidentiality and they often become concerned that the consent for the research participation may compromise the level of confidentiality. Due to this fear, it is rare that a Japanese client, or a caregiver if a client is a minor, would agree to sign a consent for research participation or to be videotaped for training purposes, which in turn prevents therapists from conducting play therapy research and receiving more thorough play therapy supervision. Mental health professionals including play therapists have an ethical responsibility to practice empirically supported treatments; they must be held accountable for their work in order to protect the public (American Counseling Association [ACA], 2014). Japanese play therapists face a significant challenge to engage in conducting more empirical research studies on play therapy in order to ensure that play therapists are providing the best services to their clients.

Moving Forward Play therapy has established its position as a primary means for mental health professionals to work with children in Japan. However, the gap between the prevalent use of play therapy in the mental health field and the

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paucity of systematic play therapy training opportunities remain great. Yoshida and Itoh (1997) warned that there is too much focus on a “learning from experience practice” approach in play therapy training; that is, a novice play therapist learning solely from conducting an actual session. Although they criticized this trend more than 20 years ago, there still exists much room for improvement in providing more training opportunities that equip graduate students and clinicians with play therapy specific skills and knowledge. Such training opportunities will enhance the quality of play therapy service, elevate its credibility and advance play therapy research opportunities. A most significant development in recent years is that some experienced play therapists in Japan have seen this need and have begun to dedicate their time to help other clinicians and students become effective play therapists. However, an additional task of Japanese play therapy educators is to adopt what is effective in the west in a way that speaks truly in the east. Although there is hard work ahead, it is an exciting time to be a Japanese play therapist. Our field is developing into an important force to uniquely support the well-being of children and their families in Japan.

CASE ILLUSTRATION

Current Status of Theraplay in Japan Theraplay is a structured form of play therapy for building and enhancing attachment, self-esteem, trust in others, and joyful engagement. It is based on the natural patterns of healthy parent-child interaction and is personal, playful, and fun. This approach of play therapy focuses on four essential qualities found in normal, healthy parent-child relationships. These qualities are: Structure, Engagement, Nurture, and Challenge. Theraplay sessions create an emotional bonding between the child and the adult, which resulting in a changed view of the self as worthy and lovable and of relationships as positive and rewarding (Booth & Jernberg, 2010). Theraplay was first introduced to Japan in 1987, when Theraplay: A new treatment using structured play for problem children and their families (Jernberg, 1979) was translated into Japanese. In 2009, Level One Theraplay trainings were held in Japan. The second author was certified as the first Japanese Theraplay Therapist. Local training and the availability of Theraplay services in Japan became powerful factors to introduce Theraplay throughout the country. Theraplay sessions in individual and group settings were provided at a

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facility for children with developmental issues and their family in 2011, and have been provided to children and their family at the second author’s private practice in Tokyo since 2012.

Changes in the Family Structure and Parenting Roles In Japanese society, it is economically difficult to raise families and there are increasing numbers of dual-income parents. Many children suffer the grave consequence of being placed in a child care facility soon after birth and starting their lives separated from their mothers for 8 hours or more. Despite continuous scientific developments around the world proving the importance of parent-child interaction period during infancy, the trend of placing very young children in the care of others continues to increase. This trend in Japan might be creating an environment depriving children of securely bonding with a main caregiver and leading to later emotional and psychological pathologies. In order for mothers to be attachment figures and for children to grow up as who they are, there needs to be an environment where parent and child can spend time bonding. In addition, gaining help and support from their family, friends, and/or community are essential. The genuine wish of parents for the “happiness of children” remains unchanged. However, some parents try everything to get children ready for their unpredictable future; they take their children to piano or ballet lessons or a tutorial prep school at a very young age. As time went by, the heartfelt wish of parents for the happiness of children has somehow derailed into meeting mostly the parents’ own needs. The children grow up burdened with the stressors and expectations being placed on them by their parents and possibly by the society as a whole. Many children try so hard to meet the parents’ expectations and end up refusing to go to school, becoming “hikikomori” (shut-ins), which is an unexpected result for both parents and children. Hikikomori or school refusal is now a grave social issue in the contemporary Japanese society; it is estimated that the number of such individuals and those on the verge of becoming hikikomori is approximately 695,000, according to a government report in 2010. It is extremely painful to think that this is the result of parents trying to take care of their children and children trying to do their best for their parents. In an attempt to bring joy and support for child rearing and to strengthen the parent-child relationship, the Japan Ministry of Health, Labor and Welfare has started putting more focus on child rearing support services and has reinstalled programs supporting the communal approach of child

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rearing. By 2012, approximately 3,300 Child Rearing Support Community Centers were established (Ministry of Health, Labor and Welfare, 2012) where nurses and pre-school teachers provide parenting consultation, resources and workshops. While parents utilize the centers, the report on the survey revealed that both parents and staff desired availability of more specialized services (Japan Childcare Association, 2010). Arimoto and Murashima (2008) reported one of the main motivations for the mothers to utilize community based parenting group services is to learn how to play with and respond to children. In addition, Tanaka (2000) reported that there were young parents who lack the sensitivity and receptivity to physiological responses of young children. As a result, they feel overwhelmed and at times impatient with their attempt to attune and engage with their children. Tanaka (2000) mentioned that with the increasing number of parents who lack understanding and responsiveness for children who are in a pre-verbal developmental stage, there is an increasing need to provide parenting training that emphasizes the enhancement of the parent-child relationship using nonverbal communication.

Theraplay in Japan In the last five years, Japanese trainees have been receiving Theraplay training in their native language and the practice and techniques of Theraplay are adapted mostly to the Japanese culture. As a Theraplay Therapist (hereinafter, therapist), the second author conducts Theraplay sessions with families and their children in her private practice and also provides training for certification as a Theraplay Practitioner. Small group training for the Level 1 training was designed so that the trainer can follow up with trainees closely and the group members can learn and support each other’s process. They used their small group as a peer support group, conducting case consultations together and discussing their challenges in using Theraplay as an intervention. In the initial sessions of Theraplay, it is very common to observe that the parents do not want to be involved in the therapy process. They have the belief that “the subject of therapy is my child, not me.” It often takes time to gain their understanding for the fact that their relationship with their child is built through interactions that affect both parents and their child. It is critical for the therapist to continue to provide information to the parents around the importance of fostering the attachment and engagement as a therapeutic factor that can heal and transform their children. The forte of Theraplay is

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focusing on the family, and as the session progresses, there are times when the whole family participates, even the grandparents. While many therapies in Japan focus on the individual, Theraplay puts more focus on the child’s relationship with his/her surroundings such as family and siblings. Because of this perspective, a ripple effect reaches to other family members and a focus of therapy expands to the intergenerational transmission. In a parent session, the mother sometimes starts talking about herself when she was the same age as her child and becomes aware of herself having similar behaviors or treating her child with the same ways that her parents had treated her. During the course of the Theraplay treatment, the therapist attempts to facilitate awareness of the parent and child through verbal/nonverbal interactions and play.

Client’s Presenting Problem Kenji (pseudonym) was almost five years old when he and his family came to the center. He was diagnosed with Pervasive Developmental Disorder and childhood depression at the age of three. Several days after his admission to the kindergarten, he began having panic attacks after returning from school, spewing violent language and throwing things. After the third day in school, he was hysterical—laughing at one moment, but started crying at the very next. He also hit his head repeatedly on the pole of the swing in the park. Due to his bizarre behaviors, Kenji stopped attending the kindergarten after a week. The teachers and parents felt helpless about managing his behaviors and also how to assist him.

The Initial Phase of Therapy In the interview, the parents narrated their journey of looking for interventions and doctors who could help them with Kenji’s difficulty with social engagement, lack of attachment and bonding with his caregivers, overstimulation in new environments and his inability to follow instructions. The starting point of the Theraplay protocol was to administer the Marschak Interaction Method (MIM) (Booth, Christensen & Lindaman, 2011). A videotaped assessment of parent-child interaction, followed by a discussion between the therapist and parents about the assessment with review of segments of the video were the main domains in the initial phase of the meeting. Then the therapist conducted a few Theraplay activities with the mother to demonstrate the Theraplay activities. Weekly Theraplay sessions

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with the therapist, child and mother were held. These sessions were videotaped and later reviewed with the mother while the therapist explained the process. This phase provided the mother with the first insights into her child’s needs. She was surprised when the assessment video was reviewed as the therapist was making comments about their misunderstanding and miscommunication during their interactions. When the therapist asked the mother if there was anything she could start doing on that day, she insightfully answered that first she needed to take time to really listen to her child. The therapist also conducted some Theraplay activities with the mother first, so that she was able to experience the impact of the Theraplay activities on herself, and the usefulness of those types of activities and interactions with Kenji.

The Middle Phase of Therapy As the sessions progressed, significant breakthroughs happened in the fourth and eighth sessions. In the fourth session, the therapist and the mother observed that Kenji, who had never sought physical or emotional closeness with his mother, naturally sat on her lap, allowing her to hold him while he ate the candy she gave him. Though there was no word of affection from Kenji, this act brought tears to his mother’s eyes. It was the very first time since Kenji was born that he had allowed for such nurturing acts. During the eighth session, both Kenji and the mother faced each other and embraced. Not only did they have fun laughing and playing together, but Kenji was also calm, and the mother was able to wait so that they were able to really listen to each other and have a mutual understanding. Between those sessions, the mother shared with the therapist about the episodes at home and how she understood and responded to his emotional experiences. She gradually became aware of her habit of asking so many questions and talking to Kenji without giving him any chance to respond. She realized that this type of interaction made him even more dysregulated and feeling, “my mother never understands me.”

The Final Phase of Therapy When the therapist and the family decided to end the Theraplay treatment after eight sessions, Kenji was already able to regulate his behaviors and emotions and engage with others in a more appropriate way.

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Most importantly, both mother and child were able to bond and connect with each other. Throughout the process, besides focusing on the engagement and nurturing domains of the intervention, his mother also realized the importance of being the adult who can firmly take the lead so that Kenji can feel secure within play, and have a sense of safety and consistency. The mother began to learn to balance the mother-child relationship while simultaneously being firm with Kenji when he needed to learn self-control and containment. The mother stated that the therapist was like a spokesman for her child’s inner voice; the therapist became Kenji’s advocate and shared with his mother his feelings and needs which prior to the Theraplay sessions, she was unable to hear or understand. The mother also said that she had no confidence before the Theraplay meetings but now she had much more confidence in listening and protecting her child. Three months after the therapy ended, an envelope containing a letter and picture from Kenji was left at the center. In the picture, each family member’s face was drawn, with the face of the therapist at the bottom slightly apart from the others. Lines were drawn coming from each face so that everyone was connected. The message “Daisuki ga tsunagatte iru” (affections are linked)” was written. In addition, he also wrote these words, “I want to be born one more time.” With Kenji’s permission, these words are used as the motto in the Japan Theraplay Alliance. According to the recent update, Kenji is attending a regular class in an elementary school.

IMPLICATIONS FOR PRACTICE • According to Japanese physician Kenichiro Okano (2014), various mental health pathologies in the community stemmed from “shame– narcissistic trauma.” Besides pathologies, a “shame culture” has penetrated into the social atmosphere of the country. Indeed, the Japanese are astute about being seen by others from a perspective of shame. As a result, it is not unusual that when Japanese families first enter a play therapist’s office, they exhibit a sense of shame from their failure and disappointment in addressing their child’s difficulties. It is important for play therapists working with Japanese children and their families to be sensitive to the parents’ needs, especially the need for privacy and showing respect and a non-judgmental stance and to normalize their shame and struggles. • It is important to take note of the subtle ways that Japanese people communicate and engage with each other. It is a feature of the Japanese

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culture that when the Japanese talk, the emphasis is on maintaining a level of harmony with each other. In general, Japanese people do not often communicate to others directly and verbally. The Japanese rarely challenge other’s opinions and will refuse to speak negatively of others. Hence in therapy, for example, when reviewing videotaped sessions of the parentchild interaction, and giving feedback about their communication and interaction between them and their children, it is critical that the therapist not be too direct in highlighting their weaknesses and the therapist’s concerns. The parents might feel overwhelmed and hence affect the working relationship between parents and therapist. • Indirect communication such as inferring and being sensitive to the feeling of others are virtues in Japanese culture. The Japanese tend to value non-verbal communications such as eye gaze, posture, voice intonations and manner of behaviors. The listener tends to agree with the speaker’s opinion. Hence, it is more important to observe the non-verbal cues and focus on the attunement dance, as compared to the words that the child or the parents may say. For the therapist, if play therapy is to work effectively, it is critical to appreciate the distinctive factors and context of the Japanese psyche and process of human connections such as ways of smiling and touching, the way it is considered rude to stare, and the amae culture of expecting someone to understand something without having to say anything. The concept of amae culture conceptualized by Takeo Doi (1973) highlighted the special features of the verbalizations by the Japanese. He explained that the Japanese often verbalize something with two conflicting aspects. For example, it is often seen that Japanese people understand and agree with each other as saying “Yeah, yeah, I know,” even though nothing is shared clearly with others with ambiguous expressions such as “somehow I don’t like him” or “something bothers me.” In addition, a Japanese virtue is to adapt oneself and get along with others. Sometimes they say “yes” in spite of themselves wanting to say “no.” They could rephrase it later, but they would hope that others would understand the message of “no” through non-verbal messages that may communicate subtle hesitation. In Japan, phrases like “read between the lines” and “read the air” are often used, and people expect others to understand. The Japanese often need some time to start talking about their stories, even if they humbly talk about themselves in a self-deprecating way, and while these stories are true, they may not be the core. For those reasons, when the therapist has a Japanese client, it is good to keep in mind that one might need to go along with him and accept any

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current state until he feels safe. One needs to understand that he may not be able to answer directly to your questions and talk in a roundabout way to get to the point. • Lillard (2015) pointed out how Japanese mothers are prone to speak to their infants affect using onomatopoeias. For example, onomatopoeias such as “waku-waku” are used to express excitement, “ira-ira” for frustration, “niko-niko” for smiling and “shiku-shiku” for crying can be a very appropriate response to reflect a child’s feeling. In general, it is said that Japanese don’t express their emotions verbally and overtly. However, knowing those onomatopoeias and implementing them in therapeutic responses will facilitate their emotional expression in a culturally responsive manner. • Working with Japanese culture, it is important to have knowledge of the concept of intergenerational transmission of negative models. In Japanese culture, parents and therapist alike are getting familiar with the terms “Sedaikan Dentatsu” or “Intergenerational Transmission” (Watanabe, 2000, 2008). Watanabe (2000) highlighted how the nature and style of parenting stemmed from a negative chain coming from parents’ memories and experiences in their childhood, like a Japanese saying, “Mitsugo no tamashii hyakumade,” or “a spirit of a three-year child is held until a hundred.” This saying described the challenge of child rearing and parenting when ones’ unresolved issues and psychopathology are brought to this generation and can complicate child rearing and interactions. Hence, in Japan, it is becoming clear that teaching parents’ child-rearing methods is not enough. When parent-child interactions change and the child’s behavior changes for the better, the parents’ thinking about the child, themselves and their situation changes positively as well.

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search?q=cache:x2iDfPc4rhsJ:https://www.counseling.org/docs/ ethics/2014-aca-code-of-ethics.pdf%3Fsfvrsn%3D4+andcd=1andhl= jaandct=clnkandgl=jp. Arimoto, A., & Murashima, S. (2008). Utilization of parenting groups and consultation services as parenting support services by Japanese mothers of 18 month old children. Japan Journal of Nursing Science, 5, 73–82. Axline, V. (1969). Play therapy. Boston: Hough-Mifflin. Azima, T. (1999). Yugi ryoho wo kousei suru mono [The elements of play therapy]. In Japan Association of Play Therapy, Yugi ryoho no kenkyu [Study of play therapy]. Japan: Seisin Shobo. Booth, P., Christensen, G., & Lindaman, S. (2011) Marschak interaction method (MIM): Manual and cards (Revised). The Theraplay Institute, Evanston, IL. Booth, P. B., & Jernberg, A. M. (2010). Theraplay: Helping parents and children build better relationships through attachment-based play. San Francisco: John Wiley and Sons Inc. Doi, T. (1973). The anatomy of dependence. Japan: Kodansha International. Enns, C. A., & Kasai, M. (2003). Hakoniwa: Japanese sand play therapy. The Counseling Psychologist, 31, 93–112. Fogel, A., Barrat, M. S., & Daniel, M. (1994). A comparison of the parent-child relationship in Japan and the United States. In J. L. Roopnaire and D. B. Carter (Eds). Parent-child socialization in diverse cultures. Norwood, NJ: Ablex Publishing Corporation. Friedlmeier, W., & Trommsdorff, G. (1999). Japanese and German mother-child interactions in early childhood. Journal of Cross-Cultural Psychology, 30, 684–711. Gil, E. (2006). Helping abused and traumatized children: Integrating directive and nondirective approaches. New York, NY: Guilford press. Ginsberg, K. R. (2007). The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics, 119, 182–191. Greenspan, S., Wieder, S., & Simons, R. (1998). The child with special needs: Encouraging intellectual and emotional growth. Cambridge, MA: De Cap Press. Guerney, L. (2000). Filial therapy into the 21st century. International Journal of Play Therapy, 9 (2), 1–17.

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Hatase, M. (1957). Yuugi ryouhou nokeiken to sono mondai. [Play therapy and its issues.] Kyoto University Research Studies in Education, 3, 149–166. Hayasaka, S. (1953). Goraku ni yoru sinri ryou hou: Play therapy ni kan ren shite. [Psychotherapy by amuse: in relation with play therapy]. In I. Sakamoto, S. Nakano, K. Hatano, and S. Yorita (Eds.), Seinen sinri [Psychology of adolescent]: Adolescence 3, (pp. 87–92). Tokyo: Kaneko. Hiratsuka, C. (2006). Kosodate sien to “oya ni naru” tame no manabi ni kannsuru kosatsu: Oya no community keisei ni chakumoku shite. [Study on child rearing support and learning to “become a parent”: Focusing on “community for parents”] (Thesis)． Hironaka, M. (2005). Yuugi ryoho to sono yutakana kanousei ni tsuite [Play therapy and its rich potentials]. In H. Kawai, Yuugi ryohou no zissai [Practice of play therapy] ( pp. 1–21). Japan: Seishin Shobo. Hoshino, M., Takai, M., & Kubo, C. (2013). Cultural adaption of theraplay practices: Seoul, South Korea: Description of the fieldwork of psychotherapy in Seoul. Ikuei Tanki Daigaku Kiyo. 30, 23–35. Ikeda, Y. (1954). Sinri ryo ho [Psychotherapy]. In Y. Ikeda, Sinrigaku kou za Vol. 6. Japan: Nakayama. Inagaki, Y. (2013). “Kosodate Hiroba” de kodomo wo mabai, kodomo ni manabi, kodomo to manabou. [Learning on, from and with children at “Child Rearing Space”]. Kosodate Shien to Shinnri Rinsyo, 7, 98–100. Jernberg, A. M. (1979). Theraplay: A new treatment using structured play for problem children and their families. San Francisco: Jossey-Bass. Landreth, G. (2002/2012). Play therapy: The art of the relationship. New York, NY: Routledge. Landreth, G. L., and Bratton, S. C. (2006). Child parent relationship therapy (CPRT): A 10-session filial therapy model. New York, NY: Routledge. Lillard, A. S. (2015). The development of play. In L. S. Liben, U. Muller, and R. M. Lerner (Eds.). Handbook of child psychology and developmental science, Volume 2, Cognitive Process (7th ed) (pp. 425–468). Hoboken, NJ: John Wiley and Sons. Miyama, T., & Tsushima, T. (1960). On the variables significant in terms of the therapeutic results in play therapy (No. 2). Kyoto furitsu daigaku gakuzyutu houkoku, 3 (2), 165–170. Ministry of Health, Labor and Welfare (2012). Chiiki kosoadate sien kyoten

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zigyo zishi hokoku [Report on activities of child rearing support at communities]. Retrieved from http://www.mhlw.go.jp/stf/seisakunitsuite/ bunya/kodomo/kodomo_kosodate/kosodate/index.html. Nakatsu, I., Kume, T., Aihara, R., Inoue, K., Kasai, M., Yoshii, K., Imada,Y., Sugawa, K. Ogura, M., & Sueuchi, K. (2012). A practice-based study of play therapy: The effectiveness of play therapy in kindergarten as a support measure of young children’s growth potential and child rearing. Journal of Naruto University of Education, 27, 45–53. Nihon Hoiku Kyokai (Japan Childcare Association) (2010). Minnnade tsunagaru kosodate sien: Chiiki ni okeru kosodate sien ni kansuru chousa kennkyuuhoukoku syo [Collaborative Child Rearing Support: Report on research on Child Rearing Support in communities]. Retrieved from www.nippo.or.jp/research/pdfs/2010_04/2010_04.pdf. Ogawa, Y. (2006). Effectiveness of child-centered play therapy with Japanese children in the United States. Dissertation Abstracts International, 68 (026), 0158. Okano, Kenichiro. (2014). Haji to jikoai torauma [Shame and NarcissismTrauma].Tokyo. Iwasaki-gakujyutsu publisher. Rogers, C. (1951). Client-centered therapy: Its current practice, implications and theory. London: Constable. Sasaki, M. (2013). Hiroba gata to renkei sita Nakamura gakuen daigaku no gakusyuuteki chiiki kosodate sien [Combining the open space style child rearing support service with learning style service at Nakamura Gakuen University]. Kosodate Shien to Shinnri Rinsyo, 7, 114–117. Sato, M. (1957). Zidou chushin yuugi ryou hou no shoki ni okeru chiryou kannkei no ginnmi. [Examination of therapeutic relationship at the initial stage in child-centered play therapy]. Bunka, 21 (2), 160–171. Sato, S., & Yamashita, T. (1978). Kouza sinri ryou hou 2 [Lecture on psychotherapy 2].Tokyo: Fukumura. Schaefer, C. E. (2003). Foundations of play therapy. NJ: John Wiley & Sons, Inc. Shimoyama, H. (2005). Assessment no susume kata: Ima naze assessment ka. [Application of assessment: Why now assessment.] Japanese Journal of Clinical Psychology, 5(1), 98–105. Tanaka, A. (2000). Hoikuen no kosodate sien: Oyako douzi sien no chosen [Child rearing support in preschools: Challenge for providing simultaneous support for a parent and a child]. Hattatsu, 84, 46–49. Tatara, M. (1959). Yuugi ryouhou ni okeru process research no genzyo to

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mondai [Current status and issues on process research on play therapy]. Kyoto Daigaku Bungakubu Kiyo, 5, 187–197. Tsuchiya, K. (1967). Zidou sinri ryouhou (yugiryouhou) no riron to sono kadai. Yamanashi daigaku Kyoiku Gagkubu Kennkyuu Houkoku, 17, 141–148. U. S. Public Health Service (2000). Report of the surgeon general’s conference on children’s mental health: A national action agenda. Retrieved from http://www.surgeongeneral.gov/topics/cmh/cmhreport.pdf. Wakaba, Y. Y. (1979). Recovering process from stuttering through group play therapy situation. RIECC Report, 28, 1–23. Watanabe, H. (2000). Boshirinsyo to sedaikan dentatsu. [Clinical of mother and child and intergenerational transmission] Japan, Kongo syuppan. Watanabe, H. (2008). Kosodateshien to Sedaikan dentatsu [Support for children and child-rearing and Intergenerational transmission] Japan: Kongo syuppan. Yamanaka, Y. (2002). Yugi ryoho no kotsu [Secrets of play therapy]. Rinsho Sinri Gaku, 2(3), 283–289. Yasuhara, H., & Hatase, M. (1955). Yugi ryou hou no kennkyu (1): Hi shi zi teki yuugi ryou hou no kokoromi [Study on play therapy: attempt of non-directive play therapy]. Zidou sinnsi to seisin eisei, 5(3), 34–42. Yoshida, H., & Itoh, K. (1997). Yuugi ryoho: Futatsu no approach [Play therapy: two approaches]. Japan: Science Press. Yuno, T. (2015). The use of powers of play in child-parent relationship intervention: Clinical implication and application of filial play therapy in Japan. Shizuoka University Clinical Psychology Research, 14, 27–37. [in Japanese]

8

Play Therapy in Malaysia Andrew C. L. Ng Linda E. Homeyer

It all started thirty two years ago after founding Agape Counselling Center (ACCM) in 1985, that the first author began to search for an effective way to help children cope with their pressure of study and traumas in life circumstances. Specifically, he noted that the conventional talk therapy was just inadequate for helping children cope with their problems, especially when they were required to express their complicated thoughts, feelings, emotions or traumas in words (Ng & Homeyer, 2015). In 1997, he had the opportunity to attend the International Christian Counsellors Conference held in Dallas Forth Worth, organized by the American Association of Christian Counsellors (AACC) and chanced on Dr. Daniel Sweeney, a renowned play therapist and the past president of the Association for Play Therapy (APT). Upon returning to Malaysia in 2000, after learning childcentred play therapy from Dr. Garry L. Landreth, and embracing childcentred approach as his philosophy (Landreth, 2002), one of the first play therapy rooms and a department solely for the development of play therapy was formed at ACCM. In 2008, the first author became the first Malaysian to obtain the status as an approved provider granted by the Association for Play Therapy (APT), to teach play therapy and sandtray therapy both locally and in various universities in Hong Kong and China. In 2001, Dr. Gao Shu Zhen from Taiwan, an alumni of the University of North Texas, held a two-day workshop and seminar. It was the first play therapy workshop in Chinese ever held in the country. In the following

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year, Dr. Daniel Sweeney was invited to conduct a play therapy workshop titled, “Enter the World of Children Through Play” for school counsellors and mental health professionals. In order to maintain the professional standards of the trainees in Malaysia, every bi-yearly, visiting scholars such as Dr. Linda E. Homeyer, Dr. Mark Pearson, Ms. Helen Wilson were invited to hold workshops on sandtray, art, and other expressive arts as a continuing education program for the local mental health professionals. All these training sessions were made possible through the joint effort between different organizations such as ACCM and the Selangor Association of Play & Expressive Therapy (SAPET).

DEVELOPMENT OF PLAY THERAPY IN MALAYSIA

The Formation of SAPET Since her first visit to Malaysia in 2004, Dr. Linda E. Homeyer had been encouraging the local play therapy pioneers to consider setting up an overseeing body in order to ensure quality training and accreditation for the training of professional play therapists and other creative therapies in Malaysia. It was not until 2006 that those who had gone through Dr. Homeyer’s continuing education applied for the registration of the Malaysia Association for Play and Expressive Therapy (MAPET). With the leadership of Ms. Lisa Sum, and the sheer hard work of Dr. Tan Kui Chin, Ms. Yong Yuk Yen, Ms. Susan Low, Ms. Nallini Swaminathan, Ms. Elisabeth Phillips, Mr. Koh Jiun Shyong and Mr. Alex Ng, the Selangor Association for Play & Expressive Therapy (SAPET), a non-government organization, was finally formed in 2008. The Association continued to invite scholars and practitioners like Dr. Linda E. Homeyer, Dr. Daniel Sweeney, and Dr. Mark Pearson to conduct training and provide supervision. The diverse range of participants included mental health professionals, psychiatrists, and faculty heads from various universities throughout Malaysia.

The Formation of the Association of Play Therapy Malaysia International Under the leadership of Dr. Ku Suhaila binti Ku Johari, the Association of Play Therapy Malaysia was set up in 2014. Since the setting up of the Association, Dr. Johari has continued the tradition of tapping overseas speakers and scholars to empower and train our local practitioners with

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more evidenced based practices. Other important topics included the need to have multicultural adaptations for culturally sensitive play therapy techniques among the Chinese, Malay, Indian and other ethnic groups in East and West Malaysia. Another key advocate for play therapy and expressive arts therapy is Dr. Azizah Abdullah of Universiti Utara Malaysia, who is also the executive cochair of Asean Creative Arts Therapy Association (ACATA). She is actively involved with ACATA in coordinating and providing training for the mental health professionals in neighbouring countries such as Brunei, Indonesia, Philippines, Thailand and Myamar.

Public Education Great efforts were made to advocate the use of play therapy amongst practitioners and teachers from primary schools, kindergartens, child care centers, NGOs, hospitals, and the governmental institutions. The response was slow in the beginning because like many cerebellum dominant societies in Asia, the mindset of the adults could not see the value in play and its significant connection between the cognitive and emotional functioning of our children’s development. In the beginning, a few teachers and parents were those who first realized the true meaning of play and its benefits of play therapy. It was not until the children’s mental health issues started to increase over time, and more complicated children’s mental and behavioral problems began to emerge, that it finally caught the adults’ attention and urgency for an effective modality for counselling children. In the mid-90’s, parents whose children had been helped through play therapy, as well as pre-school teachers and principals who had attended workshops and parenting seminars organized by ACCM, SAPET, and Play & Expressive Arts, eventually became allies of the use of play therapy, thus helping to advocate play therapy to other parents. As early as 2003, the Hospital Kuala Lumpur was one of the few government hospitals to show interest in the use of play therapy. The first author provided an introduction workshop on the therapeutic power of play at the Paediatric Institute for their mental health professionals. To date, a wide range of approaches such as art therapy, sandtray therapy, and expressive arts therapy for children, adolescents as well as adults have been conducted. Besides the primary schools and government hospitals, the local NGOs have also started to take interest in the use of play therapy and expressive arts therapy in their intervention work with their clients.

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It was also through the support and publicity of the local and overseas multi-media such as the local leading press, radio stations and NGO, that more and more kindergartens, schools, and mental health professionals both in the government hospitals and private settings, began to see the real value of this child-friendly counselling approach through play. At the same time, due to the publicity of this modality, other creative modalities such as sandtray, art, music, dance, drama, storytelling, and other expressive arts, began to surface as other alternative but equally effective therapeutic interventions.

The Challenges Training and continuing education for play therapists In 2008, the first author designed and conducted a professional certificate training with SAPET. The target participants were counsellors and teachers in a special needs child care center. Most training on play therapy was hardly systematic and accredited until 2008 when SAPET was formed. A 50-hour professional course inclusive of a 20-hour group supervision for training and continuing education was developed for play therapists. With more public awareness and demand for skilled play therapists, other professionals in different parts of Malaysia began to develop play therapy programs to meet local needs. Notedly, a three-day play training has been conducted by Dr. Ku Suhaila binti Ku Johari from Universiti Kebangsaan Malaysia in various part of the country. She also conducted a research on the effectiveness of this training. The results of her study demonstrated the critical role in providing a platform for the mental health students and professionals to integrate their skills, techniques and attitudes towards working with children using this modality (Johari, Bruce, & Amat, 2014). Dr. Johari continued to provide training on play therapy, sandtray therapy and other therapeutic play modalities. Other institutions like Universiti Utara Malaysia, Universiti Malaysia Terengganu, Islamic Universiti Malaysia, Universiti Malaya, and NGOs like Agape Johore Bahru Branch, Agape Melaka Branch, Agape Sabah Branch, Agape Penang Branch, and Life Line, have also been actively conducting systematic play therapy or para-professional training to promote the use of play therapy, sandtray therapy and expressive arts therapy.

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Johari, Bruce, and Amat (2014) noted that in recent years, in several public universities in Malaysia, there existed dedicated play therapy rooms that can be used by their students as part of their training work in child and family courses. However, there are still very few play therapy courses in the counselling curricula at the university level. They highlighted the need to develop university programs that can prepare the practitioners to work in various settings for children. In addition, besides play therapy training at the university level, it is critical to incorporate topics on child and adolescent mental health and play based intervention into the curriculum of the Ministry of Education’s 14-week counselling program. Certainly, with these areas of training, the standard and effectiveness of counselling as well as the confidence and fulfillment of the counsellors can also be strengthened and affirmed.

Licensing and credential To date, there are no formal licensing and credential procedures that are professionally or locally recognized for the play therapist. As a result, the level of training and their skills set are not properly regulated. This definitely has an impact on the perceived professionalism of play therapy within the mental health profession.

Lack of skilled school counsellors According to the government statistics in 2010, the ratio of counsellors in the primary school ought to be one counsellor to every 500 pupils. Unfortunately it is not so in reality. It is not surprising to find that many schools, especially in the Chinese primary schools with over a thousand pupils, are without a full-time counsellor. Among most Chinese schools where there is lack of teachers in the first place, the counsellors are often appointed by the headmistresses or headmasters whenever necessary. For those schools who have appointed counsellors, most are required to teach, or are involved in some administrative work or extra curriculum, such that they hardly have the time and energy to focus on their counselling task. At least before 2000, many of the counsellors may not have the necessary training and experience in using therapeutic play or play therapy with their young clients. With the rise in publicity of this approach, the school counsellors and headmistresses or headmasters began to grasp the significance of play therapy and became advocates themselves.

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To the best of the authors’ knowledge, to qualify as a school counsellor, one needed to attend a 14-week training with basic counselling skills and theories, with no internship, or follow up supervision. Obviously, this is insufficient training and guidance for these counsellors. Given the short training stint of the counselling professional, it is unlikely that they will cover specialized areas such as working with children and adolescents, using play therapy or expressive arts therapy. Many of the school counselling approaches remained in the mode of traditional talk therapy with some art facilitation skills. As a result, most children find it hard to express their difficulties or problems because of their limited cognitive development, or their verbal limitation when Bahasa Malaysia (Malay language, the national language in Malaysia) is not their mother tongue. Rather than requiring them to communicate like adults, there is an urgent need for a counselling approach where trained counsellors know how to enter the developmental level of the child.

Moving Forward Pre-school education The Ministry of Education made plans to start early child education at the age of six instead of seven. This will no doubt require thoughtful and careful planning, preparation and training of teachers and child care professionals. As a result, creative play and learning will indeed be crucial for any children at this stage of their early childhood development. We can foresee that there will be a heightened awareness of the use of play in learning and emotional development as the teachers and parents seek alternatives to support their children in the school setting.

Continuing professional training With the complexity and challenges of life that children or adults are not immune to, the need for mental health professionals to keep abreast with their core skills as well as developing new, creative and therapeutic treatments has heightened. Besides becoming advocates in promoting the play and expressive arts modalities to the community, it is important that existing play therapists focus on sharpening their skills and knowledge with continuing education. Like many Asian countries, practicing play therapy is not regulated. There does not yet exist in Malaysia an umbrella body that

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can provide the necessary procedures to look into the professionalism of play therapists. In fact, many practitioners, after attending a short course on play and expressive arts intervention have positioned themselves as play therapists. Some may have only attended a basic course in play therapy and since then, have not looked into further training and supervision in this area. Until the time that there is governmental oversight, it remains the responsibility of the professional organizations like Association for Play Therapy Malaysia and SAPET to provide minimum guidelines for competency.

Relevant parental education In order to be effective parents, adults need to be educated with the knowledge of the importance of play, child development, emotional needs of children, emotion management, handling marital conflicts, parenting skills, and having fun with children through play, art, sand, music, drama, puppetry, storytelling and other creative means to establish early parentchild relationship (attachment and bonding). Due to the stress and demand of work and daily living, parents are finding it challenging to juggle among marriage, family, work, carer, social and religious engagement. Therefore, lacking the necessary information, time, and training to be effective parents, they often feel inadequate, helpless, incompetent, and frustrated. This can be more evident when parents, also facing their own marital problems and emotional upheaval, would start to impact their next generation’s well-being. With the increasing interest and availability of credible local practi tioners, together with the backing of the schools and The Parent Teacher Association, the training and applications of play therapy in school had expanded from Selangor to cities in other states such as Penang, Perak, Melaka, Johore Bahru, Pahang, as well as Sarawak and Sabah in East Malaysia. In addition, there exists a strong cohort of practitioners and scholars in the universities who are involved in evidence-based training and development of counselling curricula with an emphasis on child psychology and play therapy. This is a result of the passion and perseverance of many of the scholars and practitioners who are dedicated to reaching out and advocating for the use of play therapy with child care centers, schools, hospitals, counselling settings and universities in Malaysia.

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CASE ILLUSTRATION

Contributing Factors of Children’s Mental Illness In Malaysia, with a population of more than thirty-one million citizens, children under the age of fourteen takes up 28.8% of the nation’s total population (Index Mundi Demographic Profile, 2014). Like other fast growing countries in Asia, Malaysians are facing severe societal issues, such as a quickly increasing divorce rate, unmarried mothers, abandoned babies, delinquent youth, and suicides, along with increased substance abuse, child abuse, family violence and tragedies. Children and adolescents, under increasing pressure to perform and compete with their peers, coupled with addiction to modern electronic gimmicks, experience increased mental illness issues such as anxiety, fear, panic, nightmares, self-injurious behaviors, eating disorders, depression, and suicide. According to Malaysia’s National Health Morbidity Survey (NHMS), the number of children with poor mental health is rising, with 20% found to be suffering from stress, anxiety, and depression. The survey, conducted in 2011, revealed there were more children aged between 5 and 15 suffering from mental health issues or were prone to mental disorders, compared with the number from the NHMS conducted in 2006. Deputy directorgeneral of Health (Public Health), Datuk Dr. Lokman Hakim Sulaiman told the New Straits Times in Kuala Lumpur, that the NHMS showed the figure of 13% in 1996, had risen to 19.4% in 2006 and then to 20% in 2011. He stated that stress, anxiety, and depression are the common mental health conditions from which students suffer, while others suffered from mental illness such as schizophrenia. Lokman highlighted that poor mental health could be the result of pressure felt by students due to high expectations of their parents and teachers for academic excellence and the need to excel in individual personality, as well as social, family and interpersonal problems. In addition, he pointed out that poor mental health often results in the forms of emotional and behavioral symptoms such as low self-esteem, sadness, restlessness, poor performance in school and relationship problems. This could also be seen in the manifestation of acting out behaviors such as truancy, bullying, vandalism, substance abuse, tendency to self-harm and suicide. Other contributing factors observed by practicing child and family counsellors that affect the increase of mental illness in children are: (a) the

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competition for good grades, (b) parents’ high expectations, (c) pressure from teachers to excel, (d) overly strict parenting, (e) bullying in schools, (f) marital conflicts, (g) inconsistent parenting, and (h) long hours of extra tuition. The above factors have inevitably caused unnecessary anxiety, anguish, frustration, lying, lack of initiative, sense of inadequacy, and low self-esteem for children who are unable to meet their parents’ and teachers’ expectations (National Health Morbidity Survey, 2011).

The challenge of the education system Malaysia, being a multiracial and multilingual country, consists of different racial, economic, educational, political, religion, cultural, and environ-mental issues. One of the issues that the Chinese parents have been facing since the day of independence fifty-nine years ago, is the importance of their children’s education and future. The reason is that the majority of Chinese parents, who value education and their cultural roots highly, are determined to send their children to Chinese schools. As a result, their children are under tremendous pressure to master three languages: Chinese, English, and Malay. Malay, being the national language of Malaysia, is compulsory in all schools. As a result, Chinese parents who are concerned for their children’s education and future, have high expectations and high hopes, thus creating pressure and stress on their children. Chinese school systems are well known for their strict disciplines and good results. Therefore, not only Chinese parents, but Malay, Indian, and other ethnic groups, compete to send their children to prestigious Chinese schools, with the hope that their children would get the best education at the earliest stage of life, especially with the economic rise of China and increasingly popularity of the Chinese language worldwide. For some who cannot afford to do so, they have no choice but to send their children to those schools that use Malay as their only teaching media.

Challenges that parents face Most modern parents have high expectations and hopes for their next generation. Coupled with the modern technology and media influence, our children are highly stressed, anxious, perplexed, and confused. Of course, our current grade-oriented education system and private tuition culture do not help to reduce any of these stressors.

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Living in a highly pressured and high cost environment, life becomes even more complicated and complex. As a result, issues surrounding divorce, single parents and parenthood, gambling, substance abuse, pornography, incest, prostitution, gang fights, unmarried mothers, abandoned babies, and abusive families, just to name a few, are on the rise, not to mention the addiction to modern electronic gimmicks by parents and children alike. These further compound the difficulties of life in which children try to cope, learn, and grow. Therefore, more acute mental, emotional, and behavioral problems resulted. Increased need for professional treatment for counselling children are unquestionably in desperate demand.

The mindset of parents The expectation to achieve good grades in schools, has led most parents to place stronger emphasis on their children’s academic performance rather than emotional well-being. Like many Asian countries, most parents typically do not pay attention to their children’s emotional well being until there is a major breakdown or the child is unable to function in school or at home. Only then will they seek professional help for their affected child or adolescent. This delay for intervention complicates and prolongs the treatment process.

Child-Centered Play Therapy Non-directive play therapy was developed by Virginia Axline (1947), an American clinical psychologist, who applied Carl Roger’s person-centered theory to the psychotherapeutic work of children. Later, practitioners began to refer to Axline’s form of play therapy as child-centered play therapy (CCPT). The following are the eight basic principles developed by Axline for CCPT therapists (Axline as cited in Ray, 2011): 1. The therapist develops a warm, friendly relationship with the child. 2. The therapist accepts the child exactly as she is; not wanting the child to be different in any way. 3. The therapist establishes a sense of permissiveness in the relationship so the child feels free to express feelings and thoughts.

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4. The therapist is attuned to the child’s feelings and reflects those back to the child, to help the child gain insight to her behavior. 5. The therapist respects the child’s ability to solve problems, leaving the child the responsibility to make choices. 6. The therapist does not direct the child’s behavior or conversation. The therapist follows the child’s lead. 7. The therapist does not attempt to rush therapy, understanding the gradual nature of the therapeutic process. 8. The therapist sets limits that anchor the child to reality or makes the child aware of responsibilities in the relationship.

Case Background Jonathan, 12 years old, is the second child of a Chinese couple. The father is 45 years old and the mother is 40 years old. Both of them are professionals. Jonathan has a 16-year-old brother. They live with their grandparents. It all started about a year ago, when the school teachers discovered their water had a peculiar odor in their drinking bottles. Several days later, they caught Jonathan through the CCTV replay. Apparently, he managed to sneak into the teachers’ work place, and secretly added some solution into their drinking bottles. They later found him secretly defecating in the secluded corner of the library. It was not until the headmaster interrogated Jonathan, that he admitted adding his own urine in those bottles, but confessed there was a strange voice that compelled him to such compulsive action. This not only shook the teachers but also put his parents in great shame and anger. They simply could not believe their shy and timid son would have committed such embarrassing, yet bizarre, actions to his teachers whom had nothing against him whatsoever.

Therapy Process Initial assessment During the initial intake, with both parents present, a 15–20 minute family play experience was set up so that the therapist could observe the family’s dynamic; how each member communicated with each other and

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how the family functioned as a whole. In this case, Jonathan’s mother appeared to be embarrassed, saddened and anxious. She appeared to need to do most things “right” and was cautious around how the family engaged in the presence of the therapist. The father appeared to be more laissez faire in his approach towards the children and his interactions with Jonathan and the family. Jonathan was obviously closer to his father during the play session. They laughed and giggled by playing dinosaurs, sharks, and dolphins in the sandtray, while the mother did most of the talking and explaining. Jonathan has an elder brother who did not attend the session because he had to study for his term test. During his first individual play therapy session, Jonathan came across as extremely anxious, and distrusting of the process and the therapist. He showed little affect during his play session and had difficulty expressing his feelings. Jonathan was generally quiet in demeanor and tentative in his actions and speech. He also demonstrated very low self-esteem and confidence, and frequently looked to the therapist for confirmation and suggestions. Overall however, Jonathan was engaging with the process and seemed to appreciate the opportunity to express himself through toys and games. Jonathan would build roads, landscape the sand, make hills and valleys, and plant trees along the roadside, portraying the village from which he came. At the conclusion of the session he explained to the therapist what he portrayed. This theme continued for many sessions.

The Initial Phase of Therapy At the initial phase, the parents and the older brother would accompany Jonathan to his therapy three times a week, mostly in the afternoon or during weekends. The mother would stay behind after each session to get an update with the therapist. After many sessions engaging with the therapist, she began to trust him and the process. With trust established, his mother revealed to the therapist that she had been on anti-depressant medication since giving birth to her first child. She had postpartum depression and was under stress from her heavy responsibility at work. She was also frustrated with the different parenting styles between she and husband and she did not feel supported by him. Jonathan’s mother admitted that she had communication problems with Jonathan, was harsh and demanding, and had high expectations. Jonathan’s elder brother was admitted into a top school in Malaysia and also had excellent academic achievements in his school. She shared that she constantly compared Jonathan to his elder brother.

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The Middle Phase of Therapy Though there were no reports of additional incidents of bizarre behaviors from the school, his mother continued to be concerned that Jonathan has a possible mental illness. Therefore, the therapist recommended psychiatric assessment for Jonathan. The diagnosis indicated that Jonathan showed an early stage of schizophrenic symptoms. He was prescribed medications to manage these symptoms as he continued to attend play therapy, now twice a week. After a couple of months, the parents were relieved to see Jonathan’s anxiety level had reduced and no further bizarre behaviors manifested. After the first three months on his medication, Jonathan was able to more easily engage in play therapy, expressive arts, as well as sand tray. Throughout the process, child centered play therapy principles were adhered to. The therapist focused on giving Jonathan the chance to express himself through play. He was given many opportunities to take responsibilities and find creative means for problem solving in the clinic. Over time, his creative and imaginative abilities also increased with his self-confidence and self-esteem. It was noted that Jonathan appreciated the use of expressive and symbolic means to express his frustrations and difficulties in school and in life. Over time, he would be able to tell the therapist about his experiences and needs instead of using symbolic means to do so. By this time, Jonathan’s mental condition had improved. His anxiety level was reduced and he no longer heard strange voices. He was more focused and able to relate with the therapist in a trusting and meaningful manner. Although his affect was still lacking, he could at times laugh with the therapist while he narrated funny incidents that happened in his class. Sometimes, he could even ask his father to send him for extra therapy sessions when he was feeling anxious or stressed. It was obvious that he was able to conduct good self-care.

The Final Phase of Therapy In October, Jonathan had to sit for the government’s final examination for all the standard six students in primary schools. He managed to pass with the minimum requirement. His parents tried to enroll him to his brother’s prestigious private secondary school but did not succeed. They even made a special arrangement for him to try the school for a period of time. However, the school proved too overwhelming and competitive for Jonathan. Finally, the family accepted that Jonathan would not benefit from his brother’s

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school which is academically driven. Jonathan began attending a private Chinese school that was further away from his house but was able to cater to his special learning needs. Recently, his form teacher reported that Jonathan had assimilated himself into the school’s educational system. He was happy and delighted with his learning progress and his peer relationship.

Termination Jonathan attended a total of sixty therapy sessions during the one year period. Jonathan would not have progressed without his parents’ love and commitment for such a long process of play and sandtray therapy. His mother had to come to terms with herself and altered her attitude to be more caring and accepting of her son. She had to accept that Jonathan is who he is and should not be compared with his brother. She began to understand that play was a process of development for a child (Schaefer, 1980), and came to appreciate the use of a child-centred approach in dealing with Jonathan. She gave up her need to control, and paced and guided Jonathan in achieving his own goals, especially academically. Jonathan, with the appropriate therapeutic support and finding the school that catered to his academic needs, coupled with the peer-oriented relationships in the classroom, was able to have his condition stabilized. By subscribing to the child-centered approach, the therapist provided a platform for Jonathan to vent his fear, anger, and ambivalence towards his mother and also build a safe and trusting relationship with the therapist. The patience and acceptance demonstrated to Jonathan had given him the space to heal and transform. Jonathan sensed from this therapist that he was not judged but respected at his own pace and timing. Indeed the therapist always looked for ways to highlight Jonathan’s goodness and worth and his ability to express feelings of his own.

IMPLICATIONS FOR PRACTICE • In Malaysia, one has to be discerning to each ethnic group because of differences in religious beliefs and cultural background. For instance, it is important to put care in selecting the toys and also engaging with the clients in the play room. For example, in Islam, pigs and dogs are viewed as impure animals, and the therapist might have to be mindful and sensitive about having these symbols in the room. In addition, in Islam, it is disrespectful to touch someone’s head while you engage with them. Due to taboo symbols

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and actions, the therapists must also consider finding toys that represent Malaysian people, skin colors, foods, animals, dress, etc. For example, many toys are imported from Western countries, thus it might be easy to find a baby doll with blond, brown, or grey hair but not one with black hair. • The national and official language of Malaysia is Bahasa Melayu (Malay). As most play therapy training is in English, it is important for the therapist to translate or find words that can be used in the national language of Malaysia. At times the therapist might need to use the nuances of the Malay language for her work. Because Malaysia has three major races, therapists need to consider the uniqueness of each language. Even though Malay is the national language in Malaysia, children below 12 years old may speak their own language or English and the therapist must adapt to individual needs. Hence, it is important for the therapist to recognize that communication with the child during the play therapy session needs to be spontaneous and natural. • Dealing with parents can be challenging but it is necessary to involve them in therapy in this community. Most Malaysian parents, regardless of races, are very concerned with the progress and effectiveness of therapy and need strategies to help themselves while the child works on his inner resources and capacities. For therapists working with Malaysian children and families, it is critical to equip oneself with parenting strategies, and techniques from either filial play techniques or child parent interaction therapy so as to support the parents in Malaysia. In addition, not all parents understand the therapeutic purpose of certain toys included in the play room. For example, a toy gun, sword, or daggers are toys that Malaysian parents do not desire for their children to play with. They have concerns that these kinds of toys may lead their children to behave aggressively. However, this is quite contrary in play therapy—these toys could be beneficial and used to help child clients express their anger, as well as give them a sense of empowerment and self-control that may help them build their self-worth and manage appropriately in their environments. Another media for play about which there may be strong negative perceptions from the parents is sand. While sand is considered a powerful and therapeutic tool in sandtray therapy, for many Malaysian parents, sand is something “dirty” and “messy,” therefore not for their children to play with. We are aware, however, of how critical the tactile quality of the sand and forming scenes in the sand tray assist in neurobiological changes which supports therapy.

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REFERENCES Axline, V. M. (1947). Nondirective play therapy for poor readers. American Journal of Orthopsychiatry, 4, 193–202. Index Mundi Demographic Profile (2014). Retrieved from http://www.indexmundi.com/namibia. Johari, K. S. K., Bruce, M. A., & Amat, M. I. (2014). The effectiveness of child centered play therapy training in Malaysia. Asian Social Science, 10.7, 221–233. Landreth, Garry L. (2002). Play therapy: The art of the relationship (2nd ed). New York: Brunner-Routledge. National Health Morbidity Survey. (2006/2011). Malaysia: Institute of Public Health, Ministry of Health, Malaysia. Ng, A. C. L., & Homeyer, L. E. (2015). Play therapy in Malaysia: Theories, skills & case studies. Kuala Lumpur: Play & Expressive Arts. Ray, D. (2011). Advanced play therapy: Essential conditions, knowledge, and skills for child practice. New York, NY: Taylor & Francis. Schaefer, C. E. (1980). Play therapy. In G. P. Sholevar, R. M. Benson, & B. J. Blinder (Eds.), Emotional disorder in children and adolescents. New York: Spectrum.

9

Play Therapy in the Philippines Maria Louise Trivino-Dey Maria Aurora Assumpta Dela Paz-Catipon Maria Caridad H. Tarroja Washington Christopher C. Garcia

Play therapy may well have entered the Filipino consciousness upon the publication of the book, Filipino children under stress in 1987 by the clinical psychologist, Maria Lourdes Arellano-Carandang, PhD. This publication came years after she started her practice in the Philippines following her special training in Child and Family Therapy at the University of California at Davis in 1978. In this book, she presented cases in her play therapy practice and highlighted the children’s struggles when family challenges occurred at the time of social and political turmoil in the country from the 70’s through the 80’s. This was a groundbreaking book for many reasons. Not only did it make the practice of play therapy known to the local public, the book has likewise revolutionized the way Philippine society regarded and understood children’s behaviors. By emphasizing the importance of acknowledging children’s inner life and innate wisdom, Filipinos started learning to go beyond the use of punishment and rewards to achieve behavior change in children. With rising awareness of children’s inner lives, Filipino families began examining the dynamics of their familial relationships and their spoken and felt communications with each other, which was a significant shift in family relationships. In the decades that followed, play therapy was applied to special populations. The book Making connections (Carandang 1992), featured play therapy work with autistic children. Later that decade, a publication showing play therapy being utilized to facilitate the emotional healing

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of children who had experienced trauma resulting from natural disasters likewise came out in print (Carandang & Nisperos, 1996). In 2009, the book Magic of play: Children heal through play therapy was published. This book largely touched on the method of play therapy practice that the authors have effectively espoused and their training and formation as individuals and as play therapists.

DEVELOPMENT OF PLAY THERAPY IN THE PHILLIPPINES In the book Magic of play (Carandang, 2009), a Filipino flavor to play therapy was discussed. Child Directed Play Therapy (CDPT) evolved from over three decades of Dr. Lourdes Arellano-Carandang’s clinical practice in the Philippines. It is an integrated approach rooted primarily on the humanistic framework of having mindful trust and respect for the child’s wisdom and innate capacity to direct his or her own healing process. Its focus is on self-direction, self-exploration, and self-growth, as initiated by the child (Carandang, 2009). The process usually starts out with the classic non-directive approach of Virginia Axline, and may integrate some other approach depending on the needs of the child as it is presented in the session. This may include Behaviorist, Cognitive-Behavioral and other creative-expressive arts strategies. In time, however, as more and more of Filipino children with varying ages and needs experienced play therapy, CDPT gradually developed as an approach suited to the nature and needs of children and their families in the Philippine setting and culture. Thus, CDPT may employ both nondirective and directive interventions but with the conscious and utmost respect for the child’s own process and pace as the primary consideration. While Axline believes that the therapist should only reflect feelings back to the child and does not attempt to direct the child’s actions in any manner (Axline, 1969), CDPT allows the use of facilitative and reinforcement responses (such as use of compliments, child-initiated safe touch, hosting, setting of clear and firm limits, engaging in play with the child, etc.) to establish and maintain a connection with the child. As CDPT integrates the use of other modalities such as art, music, and other creative expressive art therapies materials for these activities are likewise provided. CDPT as a framework resonates with Filipino sensibilities. These include the Filipinos’ non-confrontational communication style, which makes the generally non-directive stance of CDPT reflective of our value for pakikiramdam (translated as feeling one’s way around, intuitively reading

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other people’s sentiments and being guided by it, waiting for an opportune time before saying anything or taking action). At the same time, because Filipinos tend to take personal responsibility for other people’s emotional well-being and physical safety (pag-aaruga), we set rules when we have to, even as we strive to show empathy and solidarity with the children both on a personal (damayan) and community level (pakikipagkapwa-damdamin). It is in the same spirit of interpersonal cooperation and team effort that family members and caregivers are educated on the essence of the CDPT framework and coached accordingly on how to deal with children exhibiting problematic behaviors. Most of the time, Filipino play therapists tend to be considered as relatives or part of the family. Filipino practitioners find themselves being assigned a title by the children or their family defining the closeness or significance of the practitioner’s relationship with them. Most of the time, practitioners are called “Tita” or “Tito,” which means aunt or uncle. Other times, play therapists are also called “Teacher.” Filipinos value elders. Children are not usually raised to call people older than them by their first names. But although relationships need to be clearly defined in Filipino culture, it is just arbitrarily stratified and does not in any way diminish the benevolence expressed between the therapist and child. The first few sessions usually begin with a process of tuning in to the inner world of the child (pakikiramdam) facilitated by a nondirective stance. The session ends with a ritual of goodbye for the child, and then followed by a process of reflection and analysis by the therapist. Such reflection ends in a plan for future sessions based on a mindful selection of activities and expressive modalities that may range from nondirective to directive (with specific theme prompts). The process of reflecting makes use of a multidimensional perspective to address the child’s needs in the context of his/her status in the different developmental aspects as well as his/her challenges in the context of family, school and community life. A critical part of this reflection includes the therapist’s assessment of how his/ her engagement in the therapeutic process with the child has affected the therapist personally.

CDPT Therapists’ Training Due to the Filipinos’ strong collective culture, the preference is for working in pairs or as a team with a group of children. While therapists also

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have to frequently work individually with a child, they continue to do “clinic-ing” with a team to ensure a balanced perspective of the child and promote self-care for the therapists. Clinic-ing is a term that has been used to refer to an in-depth discussion process where the therapists’ experiences conducting the play therapy intervention with a child are discussed and analyzed in a group. Although these discussions are done professionally quite similar to group supervision, the context of safety is strongly present and social and emotional support between and among therapists and supervisor is felt. In so doing, therapists can openly reflect on their personal growth and learning within the play therapy intervention. Clinic-ing with a team ensures that the therapist’s need for self care is not overlooked. This is an important, if not critical component of therapist training as CDPT recognizes and emphasizes the person of the therapist as an important tool in the therapeutic process. It is believed that working with children forces one to be authentic (Carandang, 2009). The willingness and ability to allow children to unfold at their own pace and to determine the path to their own healing can only come from therapists who have a strong faith in children and respect their wisdom, who can look beyond their own needs and keep their own issues from interfering with what the children need to do for themselves, who can manage or regulate their emotions, are comfortable with and accepting of themselves even as they remain open to new learning.

Research and Practice on the National Level The CDPT framework which takes the phenomenological approach or subjective viewpoint of the child has also influenced numerous research and intervention projects for Filipino children and families in difficult situations such as poverty, prostitution, violence, disaster, and parental absence due to overseas employment (Carandang, 2002; Carandang & Sison, 2004; Carandang, Sison, & Carandang, 2007).

Other Play Therapy Applications and Approaches in the Philippines Other forms of play therapy practices or play-based interventions flourished and have also gradually spread to other settings in the Philippines. A number school counselors or child psychologists in non-government organizations make use of play therapy in their primary work areas. While a good number of educational institutions and centers offering services to

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children have provisions for toys, it is the trained counselor or psychologist who recognizes the value of play to the emotional well-being of children and puts up a playroom not as a place where children can just kill time or serve a “time out” (as is the usual case with guidance offices) but a place where they can freely express themselves, engage in meaningful activities, and explore their internal and external environment safely. Such counselors and center psychologists choose to do play sessions as an alternative to the traditional talk therapy when they feel that conversations are easier to facilitate in the context of play. This practice is also beginning to be adopted in the university level, where some counselors experiment with the use of sand tray or art materials in their routine interview sessions as a way of helping college students identify their strengths/resources and articulate their future plans. Play therapy in the corporate setting has likewise been done in an effort to help career professionals manage their day-to-day stresses and achieve a better work-life balance. Play therapists in private clinical practice as individuals or in groups, may work collaboratively with allied professionals (psychiatrists, social workers, other clinicians trained abroad). Their techniques and perspectives were enriched and often times integrated with other therapeutic methods i.e. Jungian Sandplay Therapy, Solution-Focused Brief Therapy, ChildCentered Play Therapy, Structured Behavioral approaches are already seen to be enforced by various individuals in different settings. One practitioner who trained abroad makes use of a play-based activity called Floor Time (Greenspan, & Wielder, 2006), which is geared towards strengthening the relationship between the child and his guardian by engaging them in joint play. Floor Time is currently being used to address cases of Opposition Defiant Disorder with anger management for boys, as well as anxiety and depression for girls. Another group of practitioners also trained abroad integrates D. W. Winnicot’s object-relations and attachment-based theories together with the classic child-centered approach in the conduct of their play therapy. This particular eclectic approach has been used to address cases of abuse, neglect, trauma as well as social withdrawal, inattention and hyperkinesias. Some child and adolescent psychiatrists in the local setting make use of play activities or materials such as puppets for Cognitive Behavior Therapy (CBT) intervention. Of late, play therapy is beginning to be more widely pursued in psychiatric practice as a prime intervention for children and teenagers. And those who have utilized play therapy with their clients look at play also as a method of free association and a venue for catharsis.

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The Philippine Association of Child and Play Therapy (Philplay) and other Training Venues Through the initiative of Dr. Carandang, the Philippine Association for Child and Play Therapy (or Philplay) was established in 2009. The association was instituted in order to organize play therapists and to advocate for children by linking up with other play therapy practitioners, as well as allied professionals working with children. Its mission is to create a culture that respects the dignity of children and nurtures their well being through play. It also aims to foster the competent and ethical practice of play therapy in the Philippines and provide a community of support for self care of play therapists. Its vision is to help “create a world where each child can play, blossom and flourish.” To date, the membership is comprised mostly of psychologists, many of whom have multiple roles as therapist, guidance (school) counselors. There are sprinkles of other professions such as social workers, occupational therapists, nurses, doctors, as well as parents. There is also an HR practitioner and individuals interested in the usefulness of play therapy. The association also welcomes free exploration of any approach and technique that is consciously integrated with a clear therapeutic philosophy about the child and his/her process. Dr. Cornelio Banaag, Sr. considered the father of child and adolescent psychiatry in the Philippines has been accredited internationally to supervise play therapists in training. Now he continues to teach, train and supervise in play therapy to different professionals working with children, including schoolteachers, doctors and mental health professionals. At the moment, professionals holding active practice in play therapy trained both here and abroad are being identified. The Filipino play therapy practitioners are looking into ways to comply with international standards and regulations, while also integrating cultural sensitivities and needs of the Filipinos into their professional work.

The Filipino Play Therapists In 2011, an in-depth study that looked into the Filipino play therapists’ training and supervision, their practice and the challenges they encounter in the profession was conducted with Philplay’s initiative and support. This study was patterned after Phillips and Landreth’s (1995, 1998)

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comprehensive survey questionnaire given to play therapists in the United States. Members of Philplay were purposively selected to participate in the study. Thirty-five psychologists who make up approximately 50% of the roster of membership at the time of the study completed the on-line survey. The survey shows that practitioners are mostly females, with master’s degree in psychology or education. They are employed primarily in other jobs i.e. teaching, counseling, or social work that may or may not involve young children. The exposure to and training in handling emotional issues of childhood come either from fulfilling their course requirements in graduate school or from actual work supervision in a clinic for children, or in some instances both. Though largely humanistic in orientation, Filipino play therapists generally blend in a variety of therapeutic techniques i.e. Sandplay, Creative Expressive Therapies (i.e. Art, Music, Dance and Drama) and to some extent, cognitive and behavior techniques. Filipino play therapists have handled children from pre-school years to late adolescents, with the latter responding more to creative-expressive modalities. The survey responses show that the boys seen in therapy outnumber the girls by 14%. Problems related to abuse and neglect tops the list of cases handled in play therapy by the respondents. Relational problems both at home and school were handled by 75% of the play therapists. Half of the time, Filipino play therapists encounter cases of conduct disorder, adjustment disorder, post-traumatic stress, separation anxiety disorder, mood disorders, attention deficit /hyperactivity disorder, oppositional defiant disorder, as well as autism spectrum disorder. They have also encountered cases of children with selective mutism, learning disorders, and in a few instances reactive attachment, sexual and gender identity issues, feeding/ eating and elimination disorders, and motor control problems in play therapy.

Challenges, Strategies and Opportunities Through the years of play therapy practice in the Philippines, the primary challenge remains: for parents and other professionals to recognize play therapy as an effective intervention for children. This challenge of advocating for play therapy is highlighted by Tarroja, Catipon, Dey and Garcia (2013) and presents an opportunity to respond to the call for an evidence-based practice. In that article, two types of challenges faced by some Filipino play therapists are reported, the first of

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which is categorized under personal challenges. These include the therapists’ dealing with difficult clients, their issues of competency as well as financial constraints. The second category of challenges faced by Filipino therapists is of a collaborative nature, where the participants identified their difficulty working with parents and allied professionals. On their own however, the Filipino play therapists have tried to address these challenges primarily through seeking continuous professional education. This may mean reading books and professional journals related to their cases or seeking further training both in the Philippines and/or abroad. Seeking supervision from one’s mentor or peers is another strategy the practitioners have employed. Consciously doing a variety of self-care and support from peers is also considered helpful in dealing with the personal challenges. On the other hand, beefing up communication, coordination and consultation appears to be the prime strategy to address collaborative challenges. Although Filipino play therapists have found ways to meet the challenges they face, there is still a need to document empirical evidence to support the efficacy of play therapy in the Philippines. In this regard, local research efforts can be seen as instrumental in advocating for play therapy as a legitimate and effective method to address serious mental health issues among children. Moreover, standardizing education, training and supervision of students in the university graduate level, as well as carefully planning and executing the credentialing process will greatly help ensure that the quality of play therapy services will remain acceptable both locally and internationally. These may very well be the directions the local practice needs to take. As in the past, there remains a multitude of opportunities for play therapy practice to thrive in the Philippines. While most play therapists are private practitioners in clinic settings, there are a few who have been practicing in other settings although these are not reported and documented at times. Some Filipino play therapists are practicing in child institutions (orphanages, homes for abused and street children), schools, hospital settings, and even non-psychological therapy centers i.e. speech therapy, occupational therapy or even educational therapy as an allied professional.

Moving Forward Play therapy in the Philippines began with the use of the Axline’s non-directive process largely anchored in the humanistic philosophy. Through the years the practice has grown to integrate other theoretical

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orientations and techniques. At this point, to advocate the play therapy practice in the Philippines entails the documentation of effective and best practices with various populations, and in standardizing training, supervision and credentialing of practitioners.

CASE ILLUSTRATION This case is about Miguel. The information about this case is culled from the child’s intake records and play therapy progress reports for which the authors have been granted permission to publish. Likewise, the child, who is now a young adult, verbally consented to having his story told for this book. Miguel’s father had a drinking problem. This had led to marital conflicts and an underlying atmosphere of tension and hostility in the family. The situation was compounded by the undue involvement of his grandmother in the family affairs. An angry older sibling had been in therapy before Miguel. Miguel himself started to display intense episodes of anger. He would get into frequent fights with his older sibling. He had been heard to say how “very difficult (it was) for (him) to forgive” people he perceived to have wronged him. He felt unfairly treated in the family when he would compare himself to his siblings. Feeling sorry for himself as a result, he was at one point heard to have expressed suicidal thoughts. He would engage in obsessive behaviors. He would play computer games excessively and read the medical encyclopedia many times over. The latter consequently unsettled him as he felt he was afflicted with all the sickness enumerated therein. In school, he was seen as smart and creative. However, his actual performance in academic tasks was inconsistent. Though generally regarded as outgoing and sociable, he was known to have brushed his peers the wrong way. The school authorities were concerned about his emotional reactivity and impulse management. In play sessions prior to the workshop, Miguel could be described as a pert little boy. His bursts of energy and outward confidence would easily bring a quiet room to life. He was always filled with creative ideas, inventing things and concocting many new ways to use familiar materials. However, he showed short-lived enthusiasm for tasks especially when he would get frustrated or disappointed with the process or result. He also tended to resort to fantasy play and far-out ideas to deal with difficulties rather than think of simpler and more realistic solutions.

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Miguel needed to learn to deal with his classmates and handle academic tasks better. For him, these things were not always easy, pleasant or simple to do. He complained about being bullied in school. Yet, he had also been observed to mouth foul words every now and then though he would refrain from doing so when prompted. Furthermore, he was observed to be rather emotional, showing swings in his behaviors and moods. Discord, hostility and aggression were prominent themes in his drawings and fantasy play. He also preferred to play by himself rather than join other children in their games. Around this time, sibling alliances were in flux. The older sibling whom he was having frequent fights with was actually someone he was very close to previously. But the older sibling had entered the adolescent years and started developing different interests. Miguel, who regarded this sibling as a friend, felt “lost.” He however, started to see a younger sibling, who was once his rival, as his new ally. Addressing these concerns had become quite difficult especially since Miguel could only come twice a month for oneon-one play therapy. Thus, it was strongly recommended that he join the Summer Play Therapy workshop for closer supervision.

The Summer Play Therapy Workshop In the Philippines, a special form of group play therapy has been practiced for decades. The “multi-interactional group (play) therapy” (Carandang, 1992) is a set up where a therapist conducts play therapy with a child amidst other therapists conducting therapy with other children. The multi-interactional group play therapy is sometimes done intensively over a several successive days that are closely spaced. Though it may total 20 hours of therapy altogether, the combined effect of the intensive nature of the intervention, the therapeutic interactions of a group experience, as well as the carefully selected activities allows for a rich therapeutic experience. This intensive group play therapy usually happens in the summer or term breaks where both children and therapists can set aside an extended period of time for such an endeavor. Hence, it is called the “Summer Play Therapy Workshop” (Carandang, 2009). The summer play therapy workshop is quite different as it operates with a basic structure of activities each day that were carefully designed to help children connect with their self-concept, competencies, family and peer relationships. Through these activities too, the children are given room to express and work out issues in these areas as

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they arise. The highlight of the summer play therapy workshop is the “awards” given to each child at the end of the workshop. The awards are not about their skills, talents or achievements, but about validation of the children’s unique path of inner growth or the breakthrough the children experienced during the workshop. This may entail issues the children may have resolved or the new emotional resource that surfaced. Positive changes are often observed and verbally reported by parents and teachers of the child-participants in the Summer Play Therapy workshops. Behavioral symptoms are generally reduced, and better social interactions are seen to develop henceforth.

The Initial Phase of Therapy On the first day of the workshop, Miguel asked demandingly, “Why doesn’t Tito Wash want to take care of me anymore?” (Staff psychologist Washington Garcia, called Tito or Uncle Wash, who previously took care of his play sessions, was initially assigned a different child for the workshop.) Gauging from the way Miguel stated his request, his vulnerability and apprehension over a possible rejection seemed to surface. This was surprising as these emotional needs were not as apparent before. Miguel would tend to be more pert, alert, witty and confident. At times, he would even be irreverent, sarcastic and acerbic. He would call other children names—i.e. “Dennis dambuhala” (gigantic) or “Teroy taba” (fat). Needless to say, his usual interaction with other children tended to be hostile. He would only be nice to others when he needed something from them. So, it was difficult to see the pain and insecurity that resided within him. He would mask his sadness with outward show of adequacy and intellectual aloofness. His snide remarks and side comments seemed to reflect the brokenness he felt inside. Bearing his need in mind, arrangements were made to accommodate Miguel’s need so Tito Wash was reassigned to him. Later that day, the children were asked to make a nametag for themselves, which they were free to design however they wish. Here, Miguel was observed to lack focus, and kept changing his work, judging every attempt to be “ugly”—an apparent referral to the dissatisfaction he felt about himself. His fears, in fact, seemed to have reached panic proportions that his therapist had to step in and structure him. Tito Wash had to stop and ask him to first think, then decide on what he wanted to do and finalize his plans on the nametag before he proceeded. In doing so, Miguel felt more control over the situation and saw that things could be influenced and not get out of hand.

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The following day, the morning’s swimming activity gave another opportunity for Miguel to learn to emotionally settle and trust his external situation. He suddenly turned frantic about not having his lifesaver inflated. Treating oversight as if it was a catastrophe, he anxiously remarked, “It will take us five hours to put air into this. How can I ever use it?” His vulnerability and shaky faith in himself pushed him once again to get overwhelmed by the situation. The other therapists stepped in to help. They took turns inflating his lifesaver. In 10 minutes, the solution was in front of Miguel. His assigned therapist verbalized that it did not take five hours but just 10 minutes to address the problem. His therapist further emphasized that with patience and hard work, anything could be managed, putting him in a more realistic frame of mind. The effort to put order into his world, plus the unexpected support from the other therapists apparently touched Miguel. After this, his verbal assaults on the other children became less and he seemed more aware of and gracious to the other therapists. The children were given the “Me & My family” activity, where they were to make arts and craft works about them and their family. Though initially distracted, Miguel responded well to his therapist’s structure where he was made to think first, then decide which materials he would want to use and what exactly he wanted to do. He buckled down to work nicely after that. He produced an intricately made house with shoe boxes, popsicle sticks and play dough, showing the different members of his family having a good time. The house itself spoke much of Miguel’s dream for his family, of his wish to have a good life for all of them. It was also interesting to note that he made a figure of his older sibling first—the one he supposedly have frequent fights with at that time. This possibly indicated his inward concern and affection for this sibling. Overall, Miguel seemed protective of his family. In fact, when he misunderstood his therapist’s question of why the head of a younger sibling in his figures was made of red playdough, he seriously said, “Please do not call my (sibling) a red head. I don’t want people to call my (sibling) names.” This came about apparently as a result of his perception that his family was threatened, beset by problems and difficulties, ready to break apart. He also carried with him this feeling in other situations, seeing himself as besieged by his classmates who tease him and compete with him thereby making him react in an aggressive and defensive manner. Yet underlying such behavior was the realization that he was a helpless child. For this reason, the affection of his family seemed very important. Miguel verbalized that he liked his mother the most. He perceived her as the one who would make the effort and try to hold the family together.

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Such support was very important to him during the time of his therapy. At times, he felt unsettled because he could see that she was also human and it was not beyond her to lose her temper with him once in a while. When he presented his work to the group, Miguel’s feelings of uncertainty were again evident. He said to his therapist, “I don’t know if you like it, but at least I tried my best.” His deep need for affection and reassurance manifested itself during the entire workshop in the way he would initiate holding his therapist’s hand while they walked, sit on his lap while doing his arts and craft activities.

The Middle Phase of Therapy In the middle of the workshop, his therapist called his attention to his harsh dealing with another child. He initially responded by changing the topic, and rattled about how his therapist looked handsome underwater. It was as if he was actually admitting he behaved badly, but also needed his therapist to accept him just the same. Reassured by his therapist’s continued acceptance, he thereafter seemed more open about receiving unfavorable feedback about his behavior. By the third day, Miguel’s process had deepened and his insight into his inner process had surfaced. With little prompting from his therapist during the activity hour, he was focused, efficient and reflective. His drawing and conception of “Captain Henyo” captured the previous days’ basic findings of a loving and sensitive boy who was also sad, lonely and insecure. The verbal aggression, the often times rowdy behavior had now been unveiled as defenses that he had to put up to keep himself from getting overwhelmed. Like Captain Henyo, he had “an armor to protect his heart; the heart is the source of power and at the same time a weak spot.” Along with this realization, came some improvement in the way he related with the other children in the group. By this time, he would begin looking for them; play races with them in the pool and started taking genuine interest in what they were doing. It was also this time when he displayed a clearer grasp of his strengths and competencies, i.e., swimming, drawing, a sense of humor and a quick mind that could easily grasp concepts and theories with which to express his feelings. The following day, Miguel’s insight continued to weave its magic. During the puppet-making activity, he elaborated on Captain Henyo, saying that his secret weapon was to help the lonely children. At this point, he appeared to be more proud of his creations, thinking of himself as a genius who could

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invent a lot of things. In his fantasy play, he tried to identify himself with people who were strong and competent and labeled his superhero group of friends as “M. O. S. T.,” which signified masterful, outstanding, skillful and topnotch. At the same time, he was more open about the limitations of his superheroes saying that everything about them could be a weak spot. “Although they have magical powers, they are also human,” he said of them. Apparently, he was now becoming more aware of his vulnerability and could inwardly acknowledge his need for help and affirmation despite his outer façade of competence, spontaneity and inventiveness. In the face of his progress, caution was still exercised so that he would not overstep his boundaries. At one point during the day, he reacted strongly when after all the attention given to him, he was barred by the therapist from playing handheld computer games. Confused, he asked, “Why are you not allowing me anymore?” His therapist, with empathy, patience and understanding firmly and clearly stated the limits saying, “I feel bad turning you down. I know just how much you enjoy playing computer games. But this is not the time to do it. We have agreed to follow the workshop schedule of activities and you know we are not supposed to play computer games during the workshop.” He grumbled in reaction at first though he eventually understood and was pacified.

The Final Phase of Therapy On the last day, the “awards-giving” activity culminated the therapeutic process of the group. While this was in progress, Miguel found another child getting restless waiting for her award. He reached out to her and tried pacifying her saying “Ako nga wala pa; Siguro nga, okay na rin kahit wala ako” (I also have not received an award myself. Perhaps I won’t get any but it’s okay). He appeared to be trying to reassure himself as much as he was trying to help out the other child. The insecurity, sense of helplessness and effort to cope by rationalizing had apparently been part of his character. Yet when he finally got his award, he was almost delirious with happiness. While he might not say it, show it or ask for it, the affirmation that came his way through the award was something he needed, secretly hoped for and thoroughly appreciated when it finally came. “I have a loving heart and a sharp mind… So I can be weak and strong.” This special award encapsulated Miguel’s journey from the first day of the workshop to the last. Where he used to show only the cerebral and tough part of himself—the part of him

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that was pert, sharp and witty yet by turns also hostile, sarcastic and selfserving—he had also learned to uncover his emotions, his insecurity and vulnerability. And, it was that openness that he mastered in play therapy that allowed the therapist to understand, appreciate and help him. For all his gifts, he was still a growing child, looking for affection, affirmation and security within the family. And it was precisely because he was smart that he was able to perceive and become sensitive to what was happening around him; ironically this was also what made him so vulnerable. He ended the workshop with a new friend and a deeper bond with the therapists who have come to know, understand and appreciate him more.

Evaluation and Reflections Miguel’s tough and aggressive exterior, hostile verbalizations, paranoid actuations and non-sensible talk might well be his message: that he was starting to get overwhelmed by problems and was concerned about his family. He was thoroughly affected because he cared, and could only move forward with his family behind him. He needed his parents to be strong for him, and to give him hope and security. Miguel was looking for love and affirmation, just as he was asking for structure and direction. The two needed to go hand-in-hand. He was not likely to respond to limits without perceived affection from others while expressions of love and support would likewise be meaningless without concrete goals and results to look forward to. With the above in mind, continuing sessions with Miguel was recommended. Counseling and coaching the mother on how to relate with Miguel and deal with his problematic behaviors was deemed important and critical to his healing. Psychotherapy with his other siblings was likewise advised. Some salient points of the multi-interactional group play therapy technique were at work in Miguel’s process. Firstly, the design and therapeutic structure of the Summer Play Therapy workshop maximizes the possibility of reaching desired outcomes in fewer, but longer sessions. Miguel’s intra-psychic needs became more apparent and his interpersonal skills better improved through the week-long intensive format compared to his previous bi-monthly hourly sessions. The “award” given at the end of the workshop that articulates the growth of the child is a validation, which also serves as a reinforcement of desired behaviors for the child. Secondly, specific therapist responses were helpful in Miguel’s process. “Prompting” can also be done when a child may be at a loss on how to

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respond to the setting, or to gently steer the child in accomplishing a task when he becomes distracted. Additionally, “structuring,” or setting the limits and conditions can also be done to help him behave in a manner that enables him to respect others. Such is done after “validating” the child’s feelings (i.e., “I also feel bad turning you down. I know just how much you enjoy playing computer games. But this is not the time to do it. We have agreed to follow the workshop schedule of activities and you know we are not supposed to play computer games during the workshop”). One will note also the authenticity of the therapist’s stance as he also models expression of his own feelings, at the same time remaining grounded on what is expected behavior at a given time and place. In so doing, Miguel was notably pacified and able to comply after this intervention. In addressing Miguel’s case, some final notes need to be highlighted. Despite the acknowledged complexity of the problem of alcoholism and extended family issues, the case was still focused on Miguel’s internal process. Little attempt was made to zero in right away on the father’s drinking problem or the grandmother’s active influence in the family affairs. Although the therapists did take note of the mother’s concerns (referral problems), these problematic behaviors of the child were not immediately or directly targeted from the beginning of the therapy. Instead, when the therapist met the child, all of the above-mentioned considerations took a backseat to what the child was personally experiencing, what the child perceived as problems, what the child felt he needed. This was the very essence of play therapy: tuning in to the child’s inner world, accepting the child’s thoughts and feelings about what was happening around him, and suspending judgment on what or who might be stressing him. Indeed, as the play therapy workshop progressed, it became apparent that Miguel’s problematic behaviors as reported by the mother were symptomatic of more unmet basic needs, i.e., of a child’s need for a sense of self-worth as well as a sense of belonging and acceptance in the family—regardless of family circumstances. It was also apparent that, at that point in time, Miguel was not aware of his father’s drinking problem, his parents’ conflicts or his grandmother’s strong influence on the family affairs. These were not the child’s concerns then although he might be experiencing their effects on the quality of his family life.

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Conclusion The integrative approach to play therapy appears to have brought about enduring changes to Miguel. The specific behaviors reported as problematic were (as could be seen in the workshop as well) eventually addressed in the follow-up sessions but the critical work was in understanding Miguel’s needs, accepting his person, and guiding him in exploring his interests and skills with the end in mind of helping him build a strong sense of competence. It was important in the therapy sessions to provide him with positive adult role models and an environment that was supportive of him (even as social limits were acknowledged and respected) and appreciative of his emerging talents. It was in this context that continuing improvements in Miguel’s social behavior and academic performance were observed and reported by his mother over the years. As a young adult looking back at his childhood, Miguel confirmed that he felt isolated in the family. (Follow-up sessions after the workshop revealed that he became close to and identified himself closely with his father, taking note of his father’s strong drive to succeed but perhaps also unconsciously absorbing his father’s struggle to deal with the influence of his mother-inlaw.) Miguel also said that it was the appreciation of his skills and creativity that significantly started during play therapy, which allowed him to cope with his difficult family situation. He considered that as play therapy’s lasting gift to him and for that he was truly grateful.

IMPLICATIONS FOR PRACTICE • Filipino Family System. It will be very helpful for a play therapist in the Philippines to acknowledge the style of collectivism which is most felt in how the Filipinos define what and who is “family” to them. To the Filipinos, the family is an extended system where the parent(s) and children are at the core and includes relatives, i.e. grandparents, uncles, aunts, cousins and sometimes even the household helpers. Basically, everyone who lives under the same roof or spends a good deal of time with the family or supports the family financially or emotionally is treated with closeness and affection, just as family. Having said this, it will be wise that the play therapist notes what roles people play in this extended system, what alliances might there be among the members, who might be the power or accepted authority in the system, how one yields this power and authority and finally how autonomous

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or enmeshed their relationships are to each other. In doing this, the play therapist does not only get a clear picture of the child’s social context but also allow him/her to work the system in order to help meet the needs of the child. • The play therapist practicing in the Philippines likewise needs to note that in as much as children who are often referred for assessment and therapy may likely have a highly sensitive nature, they may tend be overwhelmed by the family system that might be too big, too stressed or dysfunctional altogether. Referred children may behave in either a role that acts out the problem or rescues the family system. The child who acts out is easy to identify. However, the one who emotionally rescues an ailing family system through their overt obedience, extreme agreeableness or a “takecharge” and overly mature attitude, or what Carandang (1987) calls “tagasalo” may not be readily obvious. It is essential for the play therapist in the Philippines to reach out to both types of vulnerable children who might be acting out and more compliant. • Filipino Communication Style. One must also note that the manner in which he/she communicates with the child’s family is as important as being able to competently conduct a play therapy session with the child. The art of being able to clearly convey a difficult point without being confrontational is a needed learning. Furthermore, Filipinos tend to take things mostly personally. The presence of a play therapist in their family’s life means the therapist is privy to their vulnerabilities and thus, will be considered sooner or later as part of the family. The play therapist in the Philippines must be ready to be called “uncle” or “aunt” and even acknowledge invitations to birthday parties. They value the therapist’s help, look up to his/her expertise and profession and thus the Filipino Family may likely owe the therapist a “debt of gratitude” making them feel both respect and affection for the therapist. • The ability of being able to feel one’s way through, or what is referred to locally as “pakikiramdam” (Carandang, 1987) is also a very helpful tool in communicating with the parents and in the conduct of therapy with the child here in the Philippines. Non-directive approach especially in the beginning of contact with the child and his/her family seems to come across as gentle and respectful, thus highly appreciated by the stakeholders. Doing so, rapport can readily be built with them and therapeutic outcomes would most likely be positive.

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• Touch. Personal and affectionate in nature, the Filipino child, once acknowledged and affirmed by the play therapist, may likely physically reach out and express this feeling of closeness to his/her therapist through touch—standing or sitting closely to the therapist, holding of hands, embracing or kissing the therapist on the cheek. When the child initiates touch in this manner, it is culturally acceptable for someone like the play therapist to welcome these physical expressions of affection as part of the child’s positive transference in his/her healing process. The play therapist, however, must be mindful of his/her own level of comfort about touch. To remain authentic all through out, the therapist must have a way of also carefully setting limits should she/he feel discomfort about this physical show of affection from the child. After all, the therapists’ ability to keep his/ her self-respect in the therapeutic relationship is a necessary foundation of the respect she is able to genuinely regard the child in therapy with. However, even while touch is culturally acceptable, there remains the need to ensure ethical compliance through continuing supervision.

REFERENCES Axline, V. (1969). Play therapy. New York: Ballantine Books. Carandang, M. L. A. (1987). Filipino children under stress: Family dynamics and therapy. Quezon City: Ateneo de Manila University Press. Carandang, M. L. A. (1992). Making connections: A group therapy program for autistic children. Quezon City: Ateneo de Manila University Press. Carandang, M. L. A. (2002). Children in pain: Studies on children who are abused and are living in poverty, prison and prostitution. Psychological Association of the Philippines. Quezon City, Philippines. Carandang, M. L. A. (2009). Magic of play: Children heal through play therapy. Pasig City: Anvil Publishing, Inc. Carandang, M. L. A., & Nisperos, M. K. B. (1996). Pakikipagkapwadamdamin: Accompanying survivors of disaster. Makati: Bookmark. Carandang, M. L. A. & Sison, A. B. L. (2004). The path to healing: A primer on family violence. Pasig City: Anvil Publishing, Inc. Carandang, M. L. A., Sison, A. B. L., & Carandang, C. A. (2007). Kapag nawala ang Ilaw ng Tahanan: Case Studies of families left behind by overseas Filipino workers. Pasig City: Anvil Publishing, Inc.

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Greenspan, S. I. & Wielder, S. (2006). Engaging autism: Using the Floortime approach to help children relate, communicate and think. Philadelphia: DaCapo Press Books. Phillips, R. D., & Landreth, G. (1995). Play therapists on play therapy: I. A report of methods, demographics and professional practices. International Journal of Play Therapy, 4, 1–26. Phillips, R. D., & Landreth, G. (1998). Play therapists on play therapy: II. Clinical issues in play therapy. International Journal of Play Therapy, 7, 1–24. Tarroja, C., Catipon, M. A. A., Dey, M. L. & Garcia, W. C. (2013). Advocating for play therapy: A challenge for an empirically based practice in the Philippines. International Journal of Play Therapy, 22, 207–218.

10

Play Therapy in Singapore Sock Kuan Lee

In Singapore, the development and utilization of play therapy pales in comparison to that of art therapy. Before play therapy reached Singapore, experts from overseas first introduced the mental health profession to expressive and creative arts therapy. The first wave of development comes from Mr. Mark Pearson. In 2001, Mark Pearson, an Australian, Expressive Art Therapist and Trainer offered one of the first structured certification training in Expressive Therapies for children and adolescents in Singapore. Mr. Pearson’s workshop and that of the use of symbolism and expressive arts brought a bout of fresh air to the community that was dominated by talk therapies—the traditional method of exchange and therapy. The expressive art and creative approaches attracted a steady group of practitioners who are keen to focus more on different expressive styles and interventions. To date, Mr. Pearson continued to be involved in the trainings and development of other expressive arts approaches such as Expressive Arts, Sandtray Therapy and Symbol Works. Another important milestone is the inauguration of a post-graduate program in Art Therapy. In 2005, LaSalle College of the Arts received their first intake for their Master program in Art Therapy approved by the Australia and New Zealand Arts Therapy Association, making it the first formalized training in art therapy towards certification and registration in Singapore.

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Development of Play Therapy in Singapore It was not until 2010, in part from the initiatives of local private service providers such as Creative and Experiential Therapy Institute (CRAETI) and Bridging Talents (BT) that the practice and development of play therapy began to gain some momentum. These organizations invited overseas trainers who can offer Association for Play Therapy (APT) approved workshops. APT was then one of the overseas societies that offer formal processes for registration of play therapists. This offered local practitioners the opportunity to attend workshops locally, instead of going overseas, and used these continuing educational hours to work towards getting their certification with APT. BT collaborated with Professor Karen Stagnitti and Dr. Alicia Pon to train local practitioners in their Learn to Play program and certification courses such as Foundations, Intermediate and Advanced training in Play Therapy. These trainings provided local practitioners with the relevant and experiential learning opportunities in child and play therapy. As a result, practitioners who are working with young clients are exposed to more specialized child therapy approaches to meet their needs. In the span of 6 years, more play therapy specific trainings and practices began to develop. CRAETI in collaboration with Ms. Felicia Carroll, from West Coast Institute for Gestalt Therapy conducted structured training in Gestalt Play Therapy, and Play Therapy International Singapore was also set up to meet the needs of practitioners who are keen to take up structured and specialized training in play therapy. It is not surprising that there were many other inhouse play therapy trainings that were not publicized but were offered to practitioners who were working with young clients. Indeed, the influx of training opportunities had given local practitioners more choices to upgrade and update their skills and techniques in child and play therapy. However, it is important to note that some of these workshops can be on an ad-hoc basis and gave local practitioners little visibility on their long term, ongoing training, supervision, and certification process. The use of play therapy as an intervention modality first started with the use of therapeutic play as a means of engagement and intervention for children with chronic illness. The medical social workers have been providing young patients in some major government hospitals with therapeutic play services as they deal with their medical conditions and procedures. In recent years, besides the expansion of educational

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opportunities for practitioners, there is also an expansion of both the private and public sectors engaging child-related counseling work. As a result, more and more people from the family service centers, volunteer welfare organizations, schools and private settings see the need for play and therapeutic play to support their child clients. Notably, many of the hospitals use a range of holistic approaches when working with children including play therapy and art therapy. In big local hospitals such as KK Women’s and Children’s Hospital, play specialists continued to be actively involved in the care and support of children during hospitalization. The Child Guidance Clinic with Institute of Mental Health and Khoo Teck PuatNational University Children’s Medical Institute had also begun to offer a multidisciplinary approach including play therapy to treat and support children and adolescents under their care. It is heartening to note that since 2010, Children Cancer Foundation hired two Certified Play Therapists to support affected children in their care. In addition, the organization continued to offer regular case consultation and continuing education for exiting social workers and play therapists to keep up their skills. The organization also offers internship opportunities for play therapists-intraining. With these new initiatives, mental health professionals who are curious and interested in learning and practicing the play therapy modality can finally have some solid platform for development.

Current Challenges Professional recognition Like most Asian countries, play therapy in Singapore is not recognized as a specialized mental health discipline (Siu, 2010) and there is no local registration requirement for practitioners or a governing body to ensure a consistent standard of service provided. Practitioners who wanted to be recognized professionally can only do so with overseas regulatory bodies such as Association for Play Therapy (APT), Play Therapy International (PTI) or British Association of Play Therapists (BAPT). Registration with these international bodies is a rigorous process demanding a high level of professional discipline and practice. Whilst it upholds professional standards, the process also created a conundrum as part of the requirements for registration is currently not obtainable in Singapore and in many Asian countries. For example, APT requires applicants to submit a current and active mental health license issued by the state. The “APT only accepts

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licenses that are issued by an authority that promulgates mental health standards and practices and that investigates and penalizes violations of such standards and practices.” To date, there is no regulatory body in Singapore to regulate the mental health professions except for social workers, similar to the standards of other Western countries. Hence there are many of the mental health practitioners such as counselors and psychologists who might have received all the necessary trainings but do not meet the licensure requirement for APT, creating a unique challenge for practitioners working towards establishing professional recognition.

Professional development Prior to the courses being offered by the various local private organizations in 2010, practitioners wanting to acquire more skills and training in play therapy have limited options. Unlike in the United States and the United Kingdom or even in Hong Kong where training is readily available, practitioners here are limited to visiting trainers or what are most popular and not necessarily what are most relevant in the Singapore context. Hence, development path is unstructured and ad-hoc. As training efforts are mostly self-funded and pathways to being a play therapist hazy, many practitioners limit play therapy to an extension of their therapeutic repertoire rather than a separate discipline requiring the rigors of practice and supervision. This unfortunately hampers the professional development of play therapy as an evidence-based adjunct qualification in Singapore. In addition, with ad-hoc exposure, therapists-in-training might have limited understanding or appreciation of the holistic process and depth of work involved. There is also a clear shortage of well-trained and experienced supervisors based in Singapore. As child and play therapy is still at its beginning stages, many of the practitioners are still in the process of getting trained and certified. There are only a handful of local practitioners sufficiently trained and experienced to supervise practitioner in training, specifically on child and adolescent mental health and play therapy. Fortunately, advances in technology allow practitioners to be supervised across geographical barriers via programs like online video conferencing such as FaceTime and Skype. In spite of the high quality overseas supervision available, this format creates cross-cultural issues. Penn and Post (2012) focused on the importance of practitioners being familiar with the cultural identities of the communities they are working with. They found that being a culturally

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sensitive supervisor, instead of having multicultural training, is predictive of the multicultural awareness of the supervisor. If play therapists in training are supervised by external supervisors unfamiliar with the local culture, they might overlook cultural issues or dynamics affecting the therapeutic work resulting in a less optimized supervisory experience. The progress and development of play therapy in Singapore is impacted by the lack of public recognition that this modality is a specialization or, rather, an extension of mental health training. In fact, the general public and the professionals are only beginning to be aware of what play therapy is, what play therapists do, and the importance of training and supervision for the professionals who will use play therapy competently. With the expansion of play therapy trainings offered from various sources to the local practitioners, there lacks a system for formal accreditation. Many mental health professions are still ignorant of the need for rigorous training, supervision, and experiences in being a registered play therapist.

Research and practice In addition, the applicability and relevance of available research, which tends to be Western centric, is questionable in the Asian context. In Singapore, play therapy and its application has been slow in accumulating empirical evidence to test the effectiveness of different play approaches in dealing with children’s problems. There is scant local research relating to play therapy published; a search of online databases yielded very limited offering. Though some may be non-published theses in universities, there are still probably very few scholars and practitioners in Singapore who has researched the effectiveness of play therapy. Pon’s (2011) research on the effective use of a communication board game for adult patients who were diagnosed with advanced cancer was probably one of few researched papers. However, she was then based in Hong Kong when she conducted her research. Indeed, more research on the cross-cultural applications of various play therapy models needed to be conducted to identify what works for clients in Singapore and Asia. The challenges extend beyond therapy in the playroom. Kenny-Noziska, Schaefer and Homeyer (2012) postulated that practitioners needed to consider many factors and to customize interventions and strategies to fit the needs of our individual clients. Of course, developing culturally relevant and sensitive play therapy for Singaporean families requires more than research. Play therapists who work in Singapore, in particular, recognize in their day-

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to-day practice with families, the need to adapt and reinterpret what they have learned in their professional training, often on the fly during a therapy session. To facilitate the expansion of play therapy in the local setting, the play therapy programs design should not only align with the international levels but equally important is the training of play therapy modalities such as Child-Centered Play Therapy, filial therapy, Gestalt Play Therapy, and Theraplay® to be adapted and applied to cross-cultural settings. The local practitioners must be equipped with culturally specific knowledge and skills for selecting and evaluating evidence-based strategies that work with various types of clients in Singapore. In this aspect, it is exciting to note that organizations such as Good Pathways and Tembusu Training & Therapy have been set up by local practitioners and trainers who can adapt their training to the local context, providing more avenues for more cross cultural exchanges and discussions. Finally, Catipon, Dey and Garcia (2013) reiterated this when they highlighted that a key challenge of working with parents was varying expectations resulting from limited understanding of play therapy. To the untrained, play therapy appears fun and simple. Parents who are more familiar with traditional interventions could conclude prematurely that play therapy is lightweight. Indeed, without evidence based research, culturally relevant training and professional accreditation, parents and professionals might continue to languish where play therapy is seen as being a “fun” therapy not effective for serious issues.

Adapting Play Therapy in Singapore Snapshots of the Singaporean child According to the academic performances, the average Singaporean child is very successful. In the 2012 “Programme for International Student Assessment” (PISA) report by the Organization for Economic Co-operation and Development (OECD), the Singaporean child ranked number second in mathematics and in the top five positions for both reading and science. It is quite a feat considering that he was up against 28 million 15-year-olds in the schools of the 65 participating countries and economies. However, the success might have come at a cost. Shum-Cheung et al (2008) found that 10% of the children in his study felt sad and had worries with about 6.4% reported having problems making friends. TODAY, quoting a 2007 Institute

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of Mental Health study highlighted that of the 2,139 primary school children who participated in the study, 12.5% had emotional and behavioral problems. It was also noted that cases involving children aged 6–9 increased by 16% from 2006 to 2009. Channel NewsAsia also reported in 2010 that 1 in 10 children aged 6–16 have mental health disorders which translated to an estimated 50,000 children having mental health disorders and 5,000 needing psychiatric care. The statistics highlighted a fast growing group of children struggling to cope with increasing stress and anxiety. Independent research offered possible reasons for the growing trend. Ebbeck and Warrier (2008) noted that the Singaporean child was valued much in the country and a lot of resources were allocated for his growth and development. However, like many Asian countries, significant emphasis was found to be placed in his academic achievements and hence creating a pressuring environment in school and the unrealistic expectations for their children to excel in this area. Ebbeck and Warrier (2008), quoting statistics from the government, found that the two main causes of stress and unhappiness amongst the children were fear of failing in exams and not being able to perform to expectations of parents and schools. Concerned observers have noted the limited room for free and spontaneous play as “parents use that time to send their children to enrichment classes and pay tuition to improve their children’s performance,” driving an estimate of S$1.1 billion a year spent by families. This created a worrying trend as Ho (2009) observed how socialemotional development might be de-emphasized in the pursuit of acquiring knowledge and academic excellence in schools. The Education Minister at the time, Heng Swee Keat, reiterated this growing concern that Singaporean students were lacking drive and confidence to venture out of their comfort zone to try new things (Ong, 2012). The implications were quickly felt in the clinical setting as the author observed that first sessions were often wrought with anxiety and tentativeness in her child clients. Facing a playroom filled with options and possibilities, many felt overwhelmed and would seek, and sometimes plead for instructions. In the absence of direction, many grew increasingly anxious and bewildered. There is a place for a flexible and adaptable therapist directed approach in the initial stage to help child clients co-construct their first experiences in the play room.

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The Singapore culture Singapore started as an immigrant nation with different cultures and traditions drawn from many races. Over the next five decades of nation building, Singapore gained developed country status in 2013. With increasing numbers of multinational companies setting up regional offices here, Singapore has become a cosmopolitan city. Singaporeans are lauded for having an international outlook and are generally open to foreign cultures and practices. Lu (2014) however, noted that cosmopolitan Singaporeans though not immune to new influences, make discriminatory choices resulting in a “mix-and-match” culture where some Western practices were deemed more valuable than Asian ones and vice versa. Shum-Cheung et al (2008) found that children in their study acknowledged that scolding and punishments by their parents were just and that they seldom argued with their parents. About 98% of the parents interviewed felt that they taught their children good manners and politeness that was commended and validated by the researcher. This highlighted the significance of Asian values—politeness and deference—that were inculcated from childhood. Woo and colleagues (2007) examined differences between Western and Asian cultures and found that there were higher rates of internalizing problems amongst Singapore children compared to the studies in the West where Caucasian American children show more under-controlled or externalizing behaviours. The implication is that expressions of aggression could be discouraged while self-control, emotional restraint and social inhibition were encouraged. This cultural dichotomy has significant implications for practitioners. Kao and Landreth (2001) postulated that whilst the tenets of play therapy might be universal, clients and therapists are “culturally encapsulated.” It is best practice for practitioners to develop awareness of cultural knowledge, identity as well as developing culturally appropriate practices. Hence, play materials need to be in step with popular influences such as Disney characters, superheroes from blockbuster movies and Legos instead of culturally sensitive toys. In spite of the clear Western influences, practitioners need to be discerning and sensitive in using Western standards to assess child clients. With politeness, deference, self-control and emotional restraints upheld as virtues, one has to question the relevance and applicability of Western standards of assessments and interventions to Singapore. Against this yardstick, cultures where silence instead of being verbally active is encouraged, a silent child might be inaccurately assessed

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as being anxious, dependent and non-assertive when he could be trying to be cooperative and obedient (Kao & Landreth, 2001). In addition, because of deference to authority figure and expectations from school and structure, clients’ early experiences in the playroom could benefit from an approach that moves flexibly between being therapist directed and child led.

Evolving Needs, Growing Opportunities Play gaining ground in Singapore In his 2012 National Day Rally speech, Singapore Prime Minister Lee Hsien Loong addressed growing concerns of the stressed out Singapore child. He said, “It is good for young children to play and to learn through play.” Although cognitive and skills based learning are still traditionally more valued, his comment reflected a growing interest and recognition of the intrinsic value of play in the lives of children. It is heartening that in the same year, the Ministry of Education incorporated play-based learning as a main teaching element in its refreshed Kindergarten Curriculum Framework. The framework spelled out the iTEACH principles, which are used to guide pre-schools in designing and implementing a quality kindergarten curriculum for children aged four to six. Identified as one of the pillars of the framework—“E: Engaging children in learning through purposeful play”— play is acknowledged as a primary and critical conduit to facilitate learning and development in children. This growing acceptance of play creates an opportunity for growth and development of play therapy. Furthermore, Woo and his colleagues (2007) also found that both parents and teachers were better in identifying externalized problems such as delinquency or aggressive behavior compared to internalized problems such as depression and anxiety. With more Singapore children likely to internalize rather than externalize problems, early signs of problems could be overlooked, missing the opportunities for early interventions. Therefore, in a culturally diverse Singapore, it is imperative for practitioners to be aware of the cultural issues so that they can best apply the training they have acquired to be relevant to the population they work with.

Changing family structure As discussed earlier, in spite of modern and cosmopolitan influences, Singapore retained many traditional values. The 2009 State of Family Report

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revealed that a majority of the families enjoyed close-knitted familial relationships. They continued to hold traditional father-mother roles where mothers were more involved in parenting and discipline whilst fathers focused on being the breadwinners (Shum-Cheung et al, 2008). However over the years, more mothers are returning to the workforce leaving much of the child-rearing to extended support systems such as grandparents, domestic helpers and after school care centres. With divorce rates rising from 25.9% in 2012 to 28.6% in 2013, there were also growing concerns of psychological impact in single or blended households (Ho, 2009). With such changes in family structure, there is a pressing need for structured support and intervention to help affected children in need. In addition to direct intervention by play therapists, there is a huge opportunity for play therapy to be relevant by working with “therapeutic agents” (Siu, 2010). Key caregivers like parents and grandparents can be trained through kinder or filial therapy to provide continuous support to children in need. Therapeutic play elements can also be incorporated into pre-schools, schools and after school care to ensure children with needs can be adequately supported.

Increased immigration In the last decade, to combat an aging population, the Singapore government’s immigration policy pushed the proportion of non-citizens to the total Singapore population from 25% at the beginning of previous decade to 36% (Yeoh & Lin, 2013) creating an inter-cultural challenge. The fast growing non-citizen segment creates an increasing number of emigrant children with emotional, adjustment and behavioral issues. Vaughn (2012) predicated that children of first generation immigrants might experience two cultures—a social and a home culture—resulting in acclimatization difficulties. This brings new challenges and opportunities for practitioners. Apart from being culturally sensitive to the varied backgrounds of naturalized Singaporeans, practitioners now also need to be aware of new cultural issues brought in by non-citizens. There is a pressing need for practitioners to be trained to work with the immigrant population to help assimilation in Singapore and also offer options in the playroom that are relevant to this new growing population. The wide variety also offers opportunities for practitioners to focus on a specific population. Such specialization allows for more in-depth understanding of the unique challenges faced by each sub-group as well as the offering of nuanced play options used to optimize the therapeutic process.

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Governing body With entry of PTI into Singapore in 2012, Play Therapy Singapore was established to provide training and supervision to the growing number of play therapists trained with them. However, it is primarily still PTI and UK centric. This Association is a closed group for the graduates of PTI, excluding those trained by approved trainers from APT or other recognized overseas trainers. There is yet to be an association of play therapy for Singaporeans, by Singaporeans. There is pressing need to establish a governing body to address many of the issues articulated previously. Apart from being able to setup critical infrastructure relating to training and supervision, this body can police the standards of practitioners and maintain the integrity of play therapy in Singapore. This body can also begin the process of conducting evidence-based research that is contextually relevant for Singapore.

Crisis relief efforts in the region In the last few years, Asia Pacific has seen an increasing number of natural disasters bringing terrible devastation to human lives and properties. According to Eco-Business, Asia Pacific is the victim of up to 70% of the global natural disasters with about two thirds of the victims coming from Asia. Singapore is a unique country located in this disaster plagued region (Lai, He, Tan & Phua, 2009). In addition to her strategic location, the Asian Disaster Preparedness Center quoting the United Nations Development Programme, has also classified Singapore as a “high income country” in a region where many other countries are plagued with poverty and poor infrastructure. Amply equipped, Singapore regularly sends out crisis relief teams to disaster affected areas but the focus is largely on the provision of basic needs and medical care. There is limited attention to helping victims, especially children, cope with the psychological trauma. There is an urgent need to include psychological aid in these crisis relief efforts. Play therapy would be an ideal form of intervention as it allows practitioners to transcend above the language barriers of working with children of different background and nationalities.

Moving Forward Play therapy in Singapore is still in its infancy stages and hence, is experiencing challenges as well as exciting opportunities. The challenges in training, professional development, research and professional accreditation, when adequately addressed albeit arduous, would provide a nurturing and

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fertile ground for growth. But with growing pressures on the Singaporean child, changing family structures, increased immigration and crises in the region, there are bountiful opportunities for growth. With hope and in time, play therapy in Singapore will come into its own strength and continue to meet children and their families’ need for healing and restoration.

CASE ILLUSTRATION

Gestalt Play Therapy First developed by Fritz and Laura Perls in 1948, Gestalt Therapy is a process-oriented, experiential therapy that focuses on the holistic functioning of a person. Violet Oaklander later extended the Gestalt approach to the therapeutic treatment of children, which is documented in her book Windows to Our Children. Drawing from Gestalt Therapy principles, she explained that Gestalt Play Therapy is a “dynamic, present-centered, humanistic and process oriented mode of therapy that focuses on the healthy integrated functioning of the total organism, comprised of the senses, the body, the emotions and the intellect” (Oaklander, 2001). The symptoms that arise and present in the therapy room are the child’s way of finding that organismic balance. And the process of therapy is to help her regain homeostasis and balance within the self and with the environment. Blom (2006) further explained that Gestalt Play Therapy is a process of facilitating the child’s emotional expression, whether verbally or non-verbally. In doing so, the child “will learn to know and will channel his or her own emotions more effectively, will learn to enter into a relationship of trust with another person and that devious behavior will consequently be normalized” (Blom, 2006).

Key Principles Theory of self Osbourne (1996) described the concept of self as the beliefs of self that included abilities, attitudes and values. He explained that it starts from selfefficacy which is the awareness of one’s own ability to move to action and consequences. Similar to Gestalt’s view of the self, it is understood as a process of organismic functioning that emerges from interwoven relatedness. From the time a toddler discovers her own mobility and the ability to make choices separate from her caregivers, her sense of self is shaped by the

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multiple interactions to her choices and activities. Depending on the environment and responses from the significant caregivers, she incorporates different opinions and preferences, forming a stable sense of self.

Contact and boundary disturbances The interaction with the environment and others is known as contact. Good contact involves one’s ability to be fully present in all aspects—senses, body, emotional expression and intellect—to respond healthily to one’s needs (Oaklander, 1997). Polster & Polster (1978) clarified that contact was not just a sense of self but also what would impinge on the boundary, the separation between people for them to retain their identities. Blom (2006) defined these two kinds of contact boundary as intrapersonal, contact between the child and aspects of her self and interpersonal, contact between self and environment. However, contact involves unpredictability and risks of identity loss. When the child’s environment is challenging or difficult in cases of family dysfunction, trauma, stresses or losses, she could struggle to maintain good contact—awareness could be desensitized, emotional expression constricted or feelings disavowed. Such boundary disturbances, if chronic, could affect her ability to regain homeostasis.

Organismic self-regulation Central to Gestalt Therapy is the process of organismic self-regulation which postulated that the organism is constantly seeking homeostasis (Oaklander, 2001). With good contact and contact boundary, a healthy functioning child is able to fulfill her needs to regain homeostasis and continue in her journey of development. In seeking homeostasis in an unsupportive or toxic environment, the child would divert her energy to manipulating self or environment to get needs met.

Introjections Lacking the ability to self-regulate, the child would have flawed experiences of self and the environment, giving rise to introjections. Explained as “a message we hear about ourselves and make part of who we are” (Oaklander, 2006), introjections pressure one into passively relinquishing own opinions or preferences and incorporating others’ points of views without awareness and questions.

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As the child constructs her concept of self through introjections, whether positive, negative, accurate or misguided, she learns to act in a certain way in specific situations and to grow up accordingly. Through such misguided lenses, introjections become fixed constructs that could result in emotional, physical and psychological difficulties we often see in therapy (Blom, 2006; Carroll, 2009).

Process of Therapy I/Thou relationship Oaklander (2006) emphasized the I/Thou relationship as being the foundation of the therapeutic process where “the therapist who is authentic and genuine and does not manipulate, patronize or judge” (Oaklander, 2001) and will accept the child as he is. Many children enter into therapy unable to maintain a healthy contact as they are operating from their introjections. In the presence of an accepting, the authentic and respectful therapist, the child can regain the process of organismic self-regulation. Hence, one of therapist’s key responsibilities is to create a permissive, growth promoting climate for healing and change.

Building the sense of self Oaklander (2001) also believed that what brings children to counselling is a poor sense of self. With multiple opportunities offered in therapy to increase awareness of self and maintain good contact, the children can regain their organismic self-regulation and strengthen their sense of self. The final vital aspect of the therapeutic process is to support them in becoming more accepting of themselves.

Case Background Sue was a 12 year old girl and the eldest of four children. Her parents described Sue as being a sociable, bubbly and popular child during her pre-school and kindergarten years. She started losing self-confidence as she struggled with studies in primary school. In the last two years, Sue became increasingly prone to “emotional outbursts.” She was lethargic and was disinterested in most things especially her studies. Her parents and school teacher observed that she was in a state of ennui. To re-ignite her interest,

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Sue’s parents relied extensively on rewards to motivate but to limited success. In the final primary school year, Sue’s parents became increasingly anxious about her academic disinterest. In Singapore, all Primary Six children sit for a national exam—Primary School Leaving Examinations (PSLE). As the results determine the secondary schools the children are eligible for, there is immense pressure to be adequately prepared. Like schools nationwide, Sue’s school prepared through extra lessons and homework. Feeling tremendous pressure to push Sue, her father started to coach her but admitted to being very tough and harsh as he hoped that fear and threats, alternative to rewards, could effect a change. Unfortunately, Sue became more listless and unmotivated, and even started picking at her hair resulting in two bald patches that she tried to hide from her parents. Her parents understood that the trichotillomania was the result of overwhelming school stress but felt helpless in the face of the impeding PSLE.

Case Formulation Like most children in therapy, Sue struggled to maintain good contact which impaired her sense of self. Singapore’s focus on academic excellence and the pressurizing school environment formed the social milieu Sue was mired in. Functioning as “a monitor, or sociometer, of social acceptance-rejection” (Heatherton & Wyland, 2003), the environment perpetuated introjections like “I’m not good in studies” or “I’m a disappointment to my parents.”Although loving and caring, her parents’ anxiety about Sue’s academic performance led them to an ineffective system of rewards and fears that reinforced a misguided notion that she was only valued if she succeeded academically. With the organismic self-regulation process disrupted, Sue diverted her energy to maintain her unmotivated and lackadaisical persona to regain homeostasis resulting in constricted awareness, energy and emotional expression. Without the emotional and cognitive maturity to filter messages, Sue was locked in a vicious cycle that diminished her sense of self and selfefficacy, critical for supporting healthy development (Oaklander 2006).

Therapeutic Goals Carroll (2009) postulated that the process of therapy was to facilitate the child’s ability to increase experiences of self and regain her organismic self regulation. Within a safe and supportive environment, Sue can deepen her

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awareness, maintain healthy contact, learn to be self supporting and accept personal responsibilities (Blom, 2006). As she regains organismic functioning and begins to integrate disavowed thoughts, feelings and beliefs, she would be on the rightful path of growth (Oaklander, 2001).

The Initial Phase of Therapy Establishing I-Thou relationship and contact-making Sue’s interactions with the authority figures were fraught by expectations and anxiety. Like many Singaporean children (Shum-Cheung et al, 2008), her relationships with her parents and teachers embodied deference and passivity. With each push forward to motivate, Sue withdrew further, accepting their directions without critique or opinions. This pattern of interaction is described as confluence, a boundary disturbance when one wants to limit the difference between self and others to moderate the destabilizing experience of maintaining distinction (Polster et al, 1978). Confluence often results in a loss in identity for children in such relationships as they lack self-awareness to respond to their real needs. Instead, they would “try increasingly to involve other people to tell them how they must be” (Blom, 2006). This was evident from the initial moments in therapy as the therapist observed Sue feeling tense and uneasy when invited to explore the play room. Facing many options with growing anxiety, she repeatedly requested for more directions and even for the therapist to decide for her. It was hypothesized that Sue was used to having choices made for her and the therapist represented another authority figure to take instructions from. Hence, it was an unusual and bewildering experience when instructions were not forthcoming. Blom (2006) also found in her practice that children in confluence struggled to make choices and needed the therapist to choose for them. The focus of this stage of therapy is to establish the I/Thou relationship where the therapist meets Sue as separate individuals fully present and accepting. As the therapist engaged her in dialogue marked by mutuality and personal responsibility, a healing relationship can flourish as Sue would have a different experience than the top-down one she was used to. Though not wanting to replicate Sue’s confluent relationship with her authority figures, it was observed that she was increasingly distressed with the lack of instructions. Blom (2006) highlighted the importance of being sensitive to the child’s non verbal communication which often could be more accurate. To balance her confluence and her increasing anxiety, the

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therapist suggested an activity graded down to encourage contact-making. With lowered anxiety, Sue was able to make a choice. By recognizing and responding to Sue’s anxiety and yet creating sufficient space for her to make choices, the therapist offered an alternative but supportive relationship that focused on her needs rather than what was expected. In the process, Sue discovered an important new experience—the discomfort of making her own choice is tolerable. In subsequent sessions, graded up activities and experiments were offered. Each with greater space for Sue’s own preferences and opinions allowed her to take more personal responsibility and to expect less support from the environment (Blom, 2006). She progressively became more willing to explore sand, clay and art.

Awareness as agent of change Gestalt Therapy’s theory of change is grounded in the notion that awareness of sensorimotor, emotional and cognitive states enables healthy contact, which in turn facilitates change. Yontef (1993) explained, “self-rejection and full awareness are mutually exclusive. Rejection of self is a distortion of awareness because it is a denial of who one is.” Hence the therapeutic process of increasing awareness in our clients helps promote change. Though Sue was sustaining better contact built on a strengthening I/ Thou relationship, she would still be plagued by self-doubts of “doing or playing wrong,” frequently making self-loathing or disparaging remarks as she wistfully compared her creative works with those by friends who were “better artists.” During a session on clay, Sue was incredulous that the therapist guessed accurately what she was making as she could not conceive the possibility that her work was good enough to be recognizable. As discussed earlier, Sue’s academic struggles and her parents’ motivational system of rewards and fears could have reinforced negative introjections that kept Sue in a state of ennui, constricting her contact, awareness and energy. To move towards an integrated view of self, Sue needed to engage with her environment in a more expansive way. In an art activity called “Body Scan” in Session 5, Sue was asked to tune into her inner state, identifying where negative and positive emotions were experienced somatically. Despite initial tentativeness, Sue allowed the therapist to guide her through slowly and became progressively engaged as she described her experiences. At one point, Sue identified “irritation” as a feeling that was somatically experienced on the top of her head

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which incidentally were in the same areas as the same bald patches on her head. That significant moment descended into a quiet shared connection between that emotional stillness and Sue’s awareness of her trichotillomania.

Figure 10.1 “Body Scan” activity in Session 5 Yontef (1993) believed that it was important to understand how feelings and sensations fit into the greater scheme of one’s experience. As a room is created for such exploration, our clients would have “a means of integrating the various details of their lives” (Yontef, 1993). With sufficient support, Sue was able to engage in a dialogic exploration of her “bad” feelings—how she felt when “things became boring or stressful.” She realized that she often felt irritated and frustrated when things were repetitive or without variation like homework and worksheets. Yontef (1993) asserted that “once this cycle has been completed, the individual is uncluttered and ready to move on to new cycles of awareness-expression. It is the perpetually renewing fluidity of this process that constitutes an important quality of good function.” As Sue made better sense of her inner states, she could find new insights and resources to explore more adaptive ways of coping.

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The Middle Phase of Therapy Unlike previous sessions, Sue decided to work with sand without much prompting in Session 6. She was fully engaged as she manipulated the sand, enjoying the sensation of sand on her skin. But after a while, she suddenly stopped and struggled to continue. After a long pause, she moved on to play with musical instruments. Like with the sand, her initial energy quickly melted into self doubt and hesitancy, repeatedly lamenting “I don’t know what to do.” Oaklander (1997) described this disrupted pattern of engaging and disengaging as resistance. She explained that when children have experienced or divulged more than they can handle, they could resist, shift or even inhibit contact as a form of self protection. Therapists, by expecting, respecting and valuing these resistances can help create a safe environment for the self to grow (Oaklander, 1997, 2001, 2006; Blom, 2006). It was postulated that whilst the awareness gained in Session 5 was the precursor to change, it challenged Sue’s introjections. Resistance to possible new experiences and insights through the sand or musical instruments might be Sue’s way of maintaining equilibrium. In respecting the resistance, the therapist had to wait for Sue to feel safe again and for her resistance to soften to enable further exploration (Oaklander, 2001). As the therapist acknowledged her struggles and assured that she could reconnect on her terms, Sue was visibly relieved. She was finally able to restore contact with the therapist by talking about her recent holidays, a safer topic.

Self-definition and emotional expression A child’s sense of self is central to her development—a strong sense of self enables differentiation from others, discerning others’ points of views without relinquishing her own opinions and preferences. On the flipside, a poor sense of self renders a child vulnerable to introjections. Oaklander (2001, 2006) believed that the therapist’s role is to provide children with a poor sense of self the opportunities to make choices, gain mastery and control. As they develop a stronger sense of self, they are better able to express suppressed emotions. Blom (2006) quoting Perls believed that children, when encouraged to make “I” language, are learning to take responsibility for their thoughts, emotions and behaviors. As the child gets to know the self, she is empowered to respond healthily and appropriately. To promote Sue’s sense of self, the therapist initiated an art activity titled “The Shield” in Session 9. In medieval times, shields with the knights’

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house crest embodied their dignity and identity. As a powerful symbol of the self, “The Shield” was designed to encourage I-statements where different questions were asked, each requiring a statement of personal opinion and preference: “What is the most important thing to me” “If I’m the President, I would...” “If I’m an animal, I would be...” “Draw a symbol for your family” “If I’m a superhero, I would be...” “If there’s one thing I can change, I would …” When working through the questions, Sue’s energy shifted noticeably as she declared “If I’m the President, I would cancel the PSLE.” She drew a sign with the acronyms PSLE and then emphatically crossed them out with a satisfied grin. She spoke dramatically about how children suffered under “it” and that “it” had to be dealt with severely. Evidently PSLE represented an oppressive and suffocating juggernaut that Sue did not feel that she had any defense against. However, the activity offered Sue a unique opportunity to express her buried feelings of frustration, agitation and helplessness. In the projective fantasy, Sue reclaimed some control of her circumstance by “cancelling it.” As more of such opportunities were offered to Sue, she could take greater responsibilities for her own feelings and thoughts and learn to respond more confidently.

Mastery and aggressive energy Experiences of mastery are essential for a developing sense of self. Blom (2006) explained that mastery is an inner sense of control and understanding of the world. As a child struggles through important milestones, she gains a clearer view of her self and abilities; miss out on them and her sense of self will remain vague. As children have limited control in their lives and are normally happy to hand over power, parents shoulder the important responsibility of promoting the need to struggle for mastery. However, parents sometimes could do too much or too little by being overly rigid and not creating space for exploration or by being neglectful and unsupportive.

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Sue’s parents frequently directed her on how to study and prepare for tests. Her father also relied on tough and harsh tactics when coaching her on schoolwork, believing it would help Sue learn better. Oaklander (1997) highlighted that the crux of supporting mastery lies in being sensitive to the delicate difference between struggle and frustration, further emphasizing that tasks are not learnt through frustration. Whilst her parents were concerned and involved, their efforts could have inadvertently frustrated Sue’s opportunities for exploration and experimentation to gain mastery in schoolwork. To promote mastery and control, games were made available in therapy. Structured play is appropriately appealing to latency age children as it provides a safe structure for exploration and mastery (Bellison, 2002). By encouraging focus, challenge and skills, Matorin and McNamara (1996) also believed that games could be ego enhancing. In Session 7 and Session 8, Sue played “Pictureka,” a commercial game that required players to identify items described in the game cards. She usually started tentatively, frequently remarking that she was bad at learning new games. Sue was spurred to persevere and with support, stuck to the game and progressively displayed more signs of enjoyment. From Session 10 to Session 13, Sue played with increasing confidence and mastery, revealing a competitiveness that surprised both herself and the therapist. She soon started exploring new games every session, each time more determined than the previous to win. This competitiveness that propelled Sue to seek out new games is known as aggressive energy. Described as a vital life force that a child needs to move her to action, whether to reach out to make friends, ask for help or to respond to her needs. Children with a poor sense of self, troubled or maladjusted lack this aggressive energy and will restrict, cut off or inhibit healthy expression (Blom, 2006; Oaklander, 2006; Carroll, 2009). While she lacked aggressive energy at the initial stages of therapy, Sue became progressively more confident and vocal. She explored different games, challenging game rules and even sometimes arguing to defend a game point. A significant shift was noted in Session 12 when Sue was once again stuck in deciding on an activity at the start of the session. She paused momentarily before remarking casually that she was being indecisive again. Then without any fanfare, she decided and proceeded to invite the therapist to join in the chosen activity. This fleeting moment is imbued with significance as it revealed Sue’s growing ability to accept herself. As Sue gained greater mastery and control, she reclaimed her aggressive energy to act and respond to her real needs. With strengthened sense of

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self, she can find the inner strength to even nurture aspects of herself that was previously rejected. In doing so, Sue can begin to integrate into a fuller sense of self, promoting healthier homeostasis (Carroll, 2006).

Parental involvement Parent education is an essential part of the therapeutic process. An established working relationship with parents creates opportunities to address the issue of their interactions with their children. As they change their ways of relating to them, the children can learn to be self-accepting and nurturing (Oaklander 2006). Sue’s parents’ motivational system of rewards and fears could indirectly communicate that acceptance was conditional on academic success. Assor and Tal (2012) found that perceived parental conditional regard or failure to meet parental expectations could lead to feelings of being worthless and unaccepted. The therapist met with Sue’s parents regularly to encourage a more supportive approach. They were urged to communicate acceptance in spite of academic struggles and failures and were also challenged to move away from a rewards and punishment system. Together with the therapist, they explored ways to avail opportunities for Sue to have more control over her study schedule as well as to promote the struggle for mastery in a variety of activities such as baking and art. Shortly after Session 11, parents reported a shift in Sue’s motivation and attitude towards school and homework. Ironically, after being more nurturing and less focused on academics, they observed greater willingness by Sue to attempt difficult schoolwork and had less emotional outbursts. With parental involvement, Sue’s therapeutic journey was better supported.

The Final Phase of Therapy Oaklander (2006) acknowledged that whilst the length of therapy varies from case to case, observable changes—needs being met, new masteries achieved, blocked feelings expressed or period of homeostasis and stability— could indicate closure to allow the child to continue her development independently. Through the opportunities presented in therapy, Sue was coping significantly better both in school and at home. After discussing with Sue and her parents, it was agreed that closure would occur over two sessions. To support Sue’s integrative process as well as to honor the journey that she has taken, the therapist wrote a metaphorical story of a young princess

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who overcame her self-doubts to save her kingdom through perseverance. The story paralleled Sue’s own therapeutic journey and by weaving in different experiential events that had happened, it helped Sue organize and make meaning of her journey.

Figure 10.2 Drawing by Sue As the therapist read the story to her, it was evident that it resonated with Sue. The story was intentionally left untitled to allow Sue to name and to design the book cover for greater ownership. She took to the task with gusto, brainstorming and sketching the cover design. It was especially poignant when she drew the door to the therapy room on the back cover as she wistfully commented that she would remember her time in therapy. The door was a stirring and heartfelt metaphor that represented the closing of this chapter of Sue’s journey.

Conclusion Under the pressure for academic excellence and of changing family structures, Singaporean children often cope by redirecting their energies from organismic self-regulation to poor contact, limited awareness and unhealthy introjections that assault their sense of self. Although fragmented

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and constricted, well-regarded traditional values of deference and passivity could lure one to think otherwise. Gestalt Play Therapy is an effective modality to help children in Singapore as illustrated by Sue’s example. Through the I/Thou relationship, the longstanding imbalanced dynamics between a child and an adult could be readjusted, offering refreshing opportunities to re-experience and be reacquainted with the self and the environment. In the process, inaccurate introjections could be reviewed and integration could occur. As therapy focuses on defining, strengthening and nurturing the self, it sets a firm foundation for growth and development that would continue throughout the lifespan. With greater confidence and a strengthened self, children like Sue, can find a better way of being in the world.

IMPLICATIONS FOR PRACTICE • Significant emphasis is placed on the Singaporean child’s academic achievements creating a pressurizing school environment. Although they have achieved much academically, a regimented education system conditioned the children to expect structured and directed instructions. In initial sessions, they could look to the therapists for directions without which the children might experience confusion and tension. There is a need for the therapist to focus on co-constructing their first experiences in the playroom. The therapist would have to be flexible and adaptable in maneuvering between child lead and therapist directed approaches before providing more opportunities towards more self exploration and creativity. • The pursuit of academic excellence often leaves Singapore children with limited room for free and spontaneous play so they tend to gravitate towards familiar play materials and scripts. Given their cosmopolitan exposure, they might gravitate towards popular culture influences such as Disney characters, superheroes from blockbuster movies, Legos and board games instead of culturally sensitive toys. Some might even shy away from expressive and creative media such as art or clay, without structures or “instructions.” These children are fearful of being judged and/ or being wrong. Therapists will need to be astute to the child’s needs and gradually move the child to newer and unfamiliar experiences to strengthen their ability to step outside of their comfort zone.

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• Despite a cosmopolitan outlook, Singaporeans remain deeply rooted in their Confucian roots where politeness and deference is highly valued. Thus, the expression of aggression by children is discouraged while self-control, emotional restraint and social inhibition are encouraged. Hence, therapists need to be careful in applying western standards of assessments and intervention; a restrained quiet child might not be a reflection of a diminished self-concept but possibly of a deferential nature or cooperation and compliance might be inaccurately assessed as being dependent and non-assertive. Understanding the cultural influences on the dynamics between therapist and child would result in more accurate assessment. • Whilst politeness and deference to authority could be the expression of cultural influences, it could also mask possible internalized problems in the child clients. Therapists need to differentiate the two by taking more time to assess and tease out the nuanced difference between the two. • The academic excellence climate drives a unique Singaporean experience known as the tuition/enrichment culture. Parents and children alike are familiar in how additional lessons are structured to enrich or help children do better academically. Parents familiar with this would tend to expect a structured approach to helping children focused on assessment and behavioral changes. As play therapy is relatively new in Singapore, parents would need more education on the process of play therapy so that they would be committed to and support their child’s therapeutic experience. • Like their parents, many children come into therapy expecting to be helped with their academic challenges whether to concentrate better or behave better in class. They too need a flexible and adaptable therapist to help co-construct their therapeutic experiences as well as to understand their goals for therapy. • As the majority of the Singaporean families enjoyed close-knitted familial relationships, there is a huge opportunity for play therapy to be relevant by working with “therapeutic agents” (Siu, 2010). Therapists can work more effectively with key caregivers like parents and grandparents through filial therapy to provide continuous support to children in need.

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REFERENCES Asia-Pacific suffers 70 percent of global natural disaster. (2013). Eco-Business. Retrieved from http://www.eco-business.com/news/asia-pacific-suffers– 70-pct-global-natural-disaster. Association for Play Therapy. (2009). Play therapy best practices. Retrieved from http://www.a4pt.org/download.cfm?ID=28051. Assor, A., & Roth, G. (2005). The harmful effects of parental conditional regard. Scientific Annals of the Psychological Society of Northern Greece, 7, 17–34. Assor, A., & Tal, K. (2012). When parents’ affection depends on child’s achievement: Parental conditional positive regard, self-aggrandizement, shame and coping in adolescents. Journal of Adolescence, 35(2), 249–260. doi:10.1016/j.adolescence.2011.10.004. Bildan, L. (2003). Disaster management in southeast asia: An overview. Asian Disaster Preparedness Center. Retrieved from http://www.adpc.net/ pdr-sea/publications/11-DMSEA.pdf. Blom, R. (2006). The handbook of gestalt play therapy (1st ed.). London: J. Kingsley. Carroll, F. (2007). Every child’s life is worth a story. Workshop presentation. September, 2007. Koln Institut fur Kindertherapie. Koln, Germany. Carroll, F. (2009). Gestalt play therapy. In K. O’Connor & L. Braverman, Play therapy theory and practice (2nd ed.). Hoboken, New Jersey: John Wiley & Sons Inc. Channel NewsAsia. (n.d.). Channel NewsAsia. Retrieved from http://www. channelnewsasia.com/stories/singaporelocalnews/view/1092048/1/.html. Department of Statistics Singapore. (2012). Statistics on marriages and divorce. Retrieved from http://www.singstat.gov.sg/publications/publications_and_ papers/marriages_and_divorces/smd2012.pdf. Department of Statistics Singapore. (2013). Population in brief 2013. Retrieved from http://www.singstat.gov.sg/statistics/browse_by_theme/population/ statistical_tables/popinbrief2013.pdf. Ebbeck, M. & Warrier, S. (2008). Image of the Singapore child. Early Childhood Education Journal, 36, 247–251. Ebrahim, C., Steen, R. L. & Paradise, L. (2012). Overcoming school

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counsellors’ barriers to play therapy. International Journal of Play Therapy, 21(4), 202–214. Gan, E. (2010). Young and stressed out. TODAY, August 17, p.14. Heatherton, T., & Wyland, C. (2003). Assessing self-esteem. Positive psychological assessment: A handbook of models and measures, 219–233. doi:10.1037/10612–014. Ho, L. Y. (2009). Raising children in Singapore: A paediatrician’s perspective, Annals Academy of Medicine, 38(2), 158–162. Homeyer, L. E., & Morrison, M. O. (2008). Play therapy—Practice, issues and trends. American Journal of Play, 1(2), 210–228. Retrieved from http:// www.journalofplay.org/sites/www.journalofplay.org/files/pdf-articles/1–2-article-play-therapy.pdf. Kao, S. C. & Landreth, G. L. (2001). Play therapy with Chinese children: Needed modifications. In G. L. Landreth (Ed.), Innovations in play therapy. Philadelphia, PA: Taylor & Francis, 43–49. Kenny-Noziska, S. G., Schaefer, C. E. & Homeyer, L. E. (2012). Beyond directive and nondirective: Moving the conversation forward. International Journal of Play Therapy, 21(4), 244–252. Kindergarten Curriculum Framework. (2012). Ministry of education. Retrieved from http://www.moe.gov.sg/education/preschool/files/kindergarten-curriculum-framework.pdf. LaBauve, B., Watts, R., & Kottman, T. (2001). Approaches to play therapy: A tabular overview. TCA Journal, 29(1), 104. Lai, A. Y., He, J. A., Tan, T. B. & Phua, K. H. (2009). A proposed ASEAN disaster response, training and logistic centre enhancing regional governance. Disaster Management Transition Studies Review. June (16), Issue 2, 299–315. Landreth, G. L. (2002). Play therapy: The art of the relationship (2nd ed.). New York: Brunner-Routledge. Landreth, G. L. (2002). Play therapy (1st ed.). New York: Brunner-Routledge. Leary, M. (1999). Making sense of self-esteem. Current Directions in Psychological Science, 8(1), 32–35. Lee, H. L. (2012, August 26). Prime Minister Lee Hsien Loong’s national day rally 2012 (Speech In English). National Day Rally. Lecture conducted from Prime Minister Office, Singapore. Retrieved from http://www.pmo.

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gov.sg/content/pmosite/mediacentre/speechesninterviews/primeminister/2012/August/prime_minister_leehsienloongsnationaldayrally2012speechinenglish.html#.UvJMYmKSxPc. Lu, L. (2014). Singapore and the cosmopolitan ideal. TODAY. Retrieved from http://www.todayonline.com/commentary/singapore-and-cosmopolitanideal?singlepage=true. Matorin, A., & McNamara, J. (1996). Using board games in therapy with children. International Journal of Play Therapy, 5, 3. Ministry of Social and Family Development. (2005). Protecting children in Singapore. Retrieved from http://app.msf.gov.sg/Portals/0/Summary/ research/Materials_Protect_Children_in_Spore.pdf. Ministry of Social and Family Development. (2009). State of family report. Retrieved from http://app.msf.gov.sg/Portals/0/Summary/research/ NFC-StateoftheFamilyReport2009.pdf. Oaklander, V. (1988). Windows to our children (1st ed.). Moab, Utah: Real People Press. Oaklander, V. (1997). The therapeutic process with children and adolescents. Gestalt Review, 1(4), 292–317. Oaklander, V. (2001). Gestalt play therapy. International Journal of Play Therapy, 10, 45. Oaklander, V. (2011). Violet Oaklander on gestalt therapy with children. (Interview). Oaklander, V. (2006). Hidden treasure (3rd ed.). London: Karnac. Organization for economic co-operation and development. (2012). PISA 2012 Results in Focus. Retrieved from http://www.oecd.org/pisa/keyfindings/ pisa–2012-results-overview.pdf. Ong, A. (2012). Lack of drive in Singaporean students a worry. The Straits Times, p. A10. Osbourne, R. (1996). Self: An eclectic approach (1st ed.). Needham Heights, Massachusetts: A Simon & Schuster Company. Penn, A. L. & Post, P. B. (2012). Investigating the various dimensions of play therapists’ self reported multicultural counselling competence. International Journal of Play Therapy, 21,14–29. Polster, E., & Polster, M. (1978). Gestalt therapy integrated: Contours of theory and practice. New York: Vintage Books.

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Pon, A. K. L. (2010). My wonderful life: A board game for patients with advanced cancer. Illness, Crisis & Loss, 18, 141–161. Shum-Cheung, H. S., Tan, A., Chua, Y. S., Russell, H., Lee, K. B., Shiu, M. & Fung, D. (2008). Children’s social and emotional well-being in Singapore. Research Monograph No. 7. Retrieved from http://www.childrensociety. org.sg/images/stories/OurServices/singapore.pdf. Siegel, D. (2001). The developing mind (1st ed.). New York: Guilford. Singapore: response, early assessment and intervention in community mental health (reach)—A community partnership program. Retrieved from http:// aamh.edu.au/__data/assets/pdf_file/0006/510792/Singapore_pp79–84.pdf. Siu, A. F. Y. (2010). Play therapy in Hong Kong: Opportunities and challenges. International Journal of Play Therapy, 19, 235–343. Swank, J. (2008). The use of games: A therapeutic tool with children and families. International Journal of Play Therapy, 17(2), 154. Tan, T. (2014). $1 billion spent on tuition in one year. The Straits Times. Retrieved from http://news.asiaone.com/news/education/1-billionspent-tuition-one-year. Tarroja, M. C. H., Catipon, M. A. A. D., Dey, M. L. T., & Garcia, W. C. (2013). Advocating for play therapy: A challenge for an empirically-based practice in the Philippines. International Journal of Play Therapy, Vol. 22, No. 4, 207–218. Retrieved from http://www.apa.org/pubs/journals/features/ pla-a0034167.pdf. Tsao, L. L. (2002). How much do we know about the importance of play in child development? Childhood Education International. Retrieved from http://www.thefreelibrary.com/How+much+do+we+know+about+the+ importance+of+play+in+child+development%3F-a085481210. Vaughn, K. M. (2012). Play therapist’s perspectives on culturally sensitive play therapy. University of New Orleans Theses and Dissertations. Paper 1491. Woo, B. S. C., Ng, T. P., Fung, D. S. S., Chan, Y. H., Lee, Y. P., Koh, J. B. K. & Cai, Y. (2007). Emotional and behavioural problems in Singaporean children based on parent, teacher and child reports. Singapore Medical Journal 2007; 48(12), 1100–1106. Yeoh, B. S. A. & Lin, W. (2013). Chinese migration to Singapore: Discourses and discontents in a globalizing nation-state. Asian and Pacific Migration Journal, Vol. 22, No.1, 2013. Retrieved from http://www.smc.org.ph/ administrator/uploads/apmj_pdf/APMJ2013V22N1ART2.pdf.

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Yeoh, B. S. A. & Lin, W. (n.d.). Migration information source—rapid growth in Singapore’s immigrant population brings policy challenges. The Migration Information Source. Retrieved from http://www.migrationinformation.org/ feature/display.cfm?ID=887. Yontef, G. (1993). Awareness, dialogue and process. Highland, NY: Gestalt Journal Press.

11

Play Therapy in South Korea Mee Sook Yoo Mi Kyoung Jin Rana Hong

In South Korea, play therapy is a publicly recognized intervention and has been actively practiced in many settings including but not limited to hospitals, counseling centers, day-care centers, shelters, community centers, and schools. With the big shifts in societal, cultural, family values, and economic growth in Korea, more children than ever might require therapeutic interventions in the coming years. Apparently, the high demands of treatment for children have resulted in the expansion and widespread acceptance of play therapy in Korea.

DEVELOPMENT OF PLAY THERAPY IN SOUTH KOREA Attention to child counseling in Korea emerged along with economic development, women’s participation in society, and increased women’s rights between the 1970s and 1980s (Kim, 2006). While women entered the workforce, people not only began to access institutionalized child-care services but also became educated for seeking counseling services for their children. Although there existed a government-accredited child therapy institute called the Municipal Child Counseling Center, its primary services were limited to retaining, protecting, and controlling juvenile delinquents (Kim, 2006). In the 1970s, two professional groups were devoted to the development of child counseling in Korea: The Korea Behavioral Science

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Research used a behavioral approach while Sookmyung Women’s University took a play therapy approach. Both groups developed their child counseling approach through research efforts and have continued to expand their perspective since then. The development of play therapy in Korea truly started with the translation of Virginia Axline’s book, Dibs (Park & Lee, 2005), introduced by Jung-Il Joo, a pioneer in the field of play therapy. Joo (1976) initiated the first clinical and academic attention to play therapy in the early 1970s by establishing play therapy courses and a play therapy office at Sookymyung Women’s University, Seoul, Korea. Furthermore, Joo founded the first private play therapy center for children called WonKwang Children Counseling Center in Seoul, Korea in 1987. Since the 1990s, play therapy has gradually gained in popularity and use due to societal and political changes, rapid economic growth and increased governmental support for child welfare. With the paradigm of parenting in modern Korea shifting from individual care to institutional care, many Korean parents have begun to utilize and rely on the institutional childcare system for very young age children voluntarily (Kim, & Lee, 2012). The confusion and sudden changes in cultural, societal, and family values in Korea inevitably created a demand for more clinical services for children. And in response to clinical needs, more systematic academic efforts in play therapy began at Sookmyung Women’s University in 1995. At that same time, some child therapists in Korea began to explore different clinical modalities to meet the needs of children. Three creative and expressive art modalities that were introduced in the late 1990s were Art therapy, Sandplay therapy, and Theraplay®. In recent years, most contemporary and classic play therapy modalities in the United States have been introduced to Korea. The general public is aware of play therapy as an effective treatment model for children. With the growth in Korea’s economy, adults are working longer hours and having fewer children, and parents are relying on professional help more than ever, which has led to increased popularity of play therapy among the general public and professionals. However, unclear governmental licensing and legislation protocols in clinical practices seem to have negatively impacted the quality and rigor on play therapy practice in Korea. Because therapists do not need a license to practice in Korea, people without rigorous and structured training started providing play therapy to the general public regardless of their academic disciplines or qualifications. Government

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approved licenses in psychiatry, psychology, adolescent counseling, and social work are available in Korea, but the government has not fully enforced the regulation for treatment providers to have a license to establish the clinical competency. In addition, there is no continuing education for professionals’ primary disciplines. For instance, once a social work license is obtained, it is valid for life, with no continuing education credits required to maintain the license. Therefore, the rigor of a professional’s academic background and of affiliated academic associations literally determines his or her quality and competency in the field of play therapy. Indeed, the competency of play therapists in Korea varies widely. According to a recent steering committee meeting conducted by the Korea Institute of Child Care and Education in the spring of 2013, the institute has on file 576 applications for certifications related to child and adolescent therapy to obtain government funded therapy sessions (K. W. Kim, Personal communication, July 14, 2014). Moreover, due to the cultural factor of academic associations providing their own training to and certification of clinicians, the quality of many play therapy certifications remains questionable.

Research Trend Relating to Play Therapy The research into play therapy begun in 1997, when Sookmyung Women’s University’s Department of Child Study and Welfare established the Korean Association of Play Therapy (KAPT) under the leadership of Kwang-Woong Kim. Since its establishment of KAPT, the association has published play therapy articles in the Korean Journal of Play Therapy three times per year in Seoul, Korea. Another academic association, the Korean Association of Psychological Rehabilitation for Children, began to publish the Journal of Play Therapy in 1998, in Daegu, Korea. With these associations’ journals, the number of published research studies on play therapy has increased each year (Park & Lee, 2005; Kim & Lee, 2012). Park and Lee (2005) reported that case study (40%) was the most frequently used research method to show the effectiveness of play therapy. A recent systematic review of 271 Korean play therapy studies published between 2000 and 2010 reported that researchers’ use of case study has slightly decreased (33.6%), while their use of experimental study has increased (30.6%) (Kim & Lee, 2012). These studies expanded awareness of play therapy and increased different kinds of play therapy research in various

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disciplines. Among the play therapy modalities, Theraplay (17%) was the most common in published research, followed by sandplay therapy (15.1%), play therapy (11%), and parent-child play therapy (10%) (Kim & Lee, 2012). In Korea, many academic associations endeavor not only to provide clinical training but also to research and publish articles on clinical modality of focus. Therefore it is not surprising to see a growing body of play therapy research in Korea. For instance, after Theraplay gains public and professional recognition, the Korean Alliance of Theraplay sponsored the Korean Academic Association of Theraplay in 2012; under KAT’s guidance the new academic association publishes research studies twice per year and has held two Asian Theraplay conferences (2012, 2014) to create greater academic rigor in the Theraplay field.

Opportunities and Challenges Although play therapy in Korea is rapidly growing, the field faces a number of challenges. The first and foremost challenge is to assure the quality of play therapy. Due to its widespread popularity with limited and somewhat liberal credentialing process in some academic associations, the quality of play therapy varies (K. W. Kim, Personal Communication, July 14, 2014). Some people who do not have basic clinical experiences or understanding of child psychotherapy or mental health issues can work as play therapists with minimal training. Thus, establishing consistent and high standards across certification issuing associations seems to be an important future task. More importantly, ethical concerns in practice are another challenge because people who are not majoring in mental-health-related disciplines can easily practice with limited training and certifications provided by the academic societies. It is possible that these paraprofessionals are not aware of ethical standards in providing play therapy because they are not part of the academic disciplines. Furthermore, play therapist paraprofessionals are not certain what kinds of ethical standards they need to follow since almost all play therapy certifications over the past two decades have been offered by numerous academic societies and universities without consistent ethical standards. Despite the limitations, there are positive attempts to reduce the concerns in the field of play therapy. Current governmental activity to screen the quality of many clinical modalities may positively impact the quality control in play therapy. The Korean government is planning to set the standards of approving qualified certifications to enforce voucher approval

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for governmental reimbursements. K. W. Kim reported that in the spring of 2013, a steering committee met to discuss and embark on this project with the sponsorship of the Korea Institute of Child Care and Education (K. W. Kim, personal communication, July 14, 2014). Although the screening process has been debated among representatives in the committee, it seemed to be the first step to setting up the standards of play therapy in Korea. Despite the differing certifications and licenses for play therapists in Korea, there are some recognizable play therapy associations such as Korea Association of Play Therapy (KAPT), Korean Academic Association of Sandplay (KAAS), and Korean Alliance of Theraplay (KAT). These associations require at least a master’s degree for membership and set high standards for members to be certified by their associations. Furthermore, KAT and Sandplay are internationally affiliated play therapy associations and follow the rigorous standards set by their respective international boards.

CASE ILLUSTRATION Anxiety disorder is one of the most prevalent disorders among Korean children. Although there are no exact statistics in Korea, Won Kwang Children Counseling Center, one of the most prestigious counseling centers for children, reported that anxiety is one of commonly recognized problems among children who seek counseling followed by Attention Deficit Hyperactivity Disorder. Considering that the onset of anxious behavior happens before age 15 (Miller, Boyer, & Redoletz, 1990) and that untreated worries in childhood often lead to serious mental issues in adults (Waldron, 1976), treating childhood anxiety not only helps the healthy development of children, but ultimately becomes a preventive measure to ensure healthy growth throughout their life. In Korea, integrative play therapy is a preferred treatment model in dealing with anxiety issues among children. The following case will present the treatment progress of integrative play therapy with theoretical underpinnings on cognitive behavioral therapy and childcentered play therapy.

Presenting Problems The child was at first referred for play therapy due to adjustment difficulties at a kindergarten. It was reported that the child presented immense fear in encountering movement of an object. For instance, she

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became easily reactive if an object around her was moving. It was reported that the child felt danger whenever an object was moving. Her fear often resulted in experiencing rapid heartbeats and shortness of breath. It was apparent that her irrational thought of impending danger caused the manifestations of anxious symptoms. Furthermore, concerned parents seemed to fail to provide clear set limits and were permissive in parenting the child, which seemed to cause separation anxiety. Additionally, like many Korean parents, her mother had higher expectations on her child’s learning so that she improperly pushed the child to pursue toddler education, which also contributed to the current excessive anxious behavior.

Clinical Observation The child was at first unable to part from her mother at the waiting room, but after seeing the play therapy room, she was parted from the mother and went into the play therapy room with the therapist. The therapist conducted the HTP assessment (projective drawing assessment by asking the child to draw House, Tree, and Person). During the assessment, the child needed constant reminders to be on task because she tended to skip many relevant details and to switch the topic of discussion. Major stories retrieved from HPT assessment are: “House”—the people in the house are cleaning the house all day; “Tree”—this is an 8-year-old pine tree, the season is summer, and the tree is worried about how it could grow taller; and “Person”—the child drew a 6 year old boy who lives with his father, mother and brother. The boy wanted to go to the Moon with his mother. In the family drawing, she was the only one cleaning her room and did not draw other family members stating that other family members were gone. One of the interesting stories came out when the child was asked about the boy’s three wishes. She responded that the boy wanted to be an adult, and then she switched it to a different topic by saying that “second, I don’t have a golden stone, because my mom said that I can’t have it.” Also, she sadly said that the boy wanted many toys, but his mother refused to buy toys for him because she does not have enough money. She further elaborated the story by adding a 6 year old girl who listened to his talks. When she was asked to give three wishes for the girl, the child said that “the girl wants to be a teacher but everyone is copying her attitude, so please tell the other kids not to be copycats.” She also added that “why does the swing make me so scared by swinging?”

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Therapeutic Goals in Play Therapy Based on collateral information from the parents and HPT observation, the child seemed to experience not only anxiety but also feelings of isolation from her family and peers. She also seemed to have conflicted feelings towards mother as evidenced by her statement of wanting to be with mother and of having upsetting emotions on disapprovals. Therefore, the first goal was established to decrease anxious behavior of the child by utilizing the cognitive behavioral play therapy approach. The second goal is to improve attachment relationship with her parents by applying child-parent relationship therapy.

Session Content The therapist followed the models of Moustakas (1955) and Hendricks (1971), dividing the therapy process into three phases: Initial, middle, and final phase. The first eight sessions were regarded as the initial phase; the 9th to 19th sessions were the middle phase; and the final phase consisted of the 20th to 25th sessions. Each session implemented coping skills based on cognitive behavioral play therapy to decrease the anxiety while maintaining and following overall principles of child-centered play therapy of Axline (1947, 1949, 1955, and 1969) and of Landreth (1991).

The Initial Phase of Therapy The therapist focused on listening carefully to whatever the child said and was attuned to the child’s needs verbally or non-verbally by being fully present to the child. This seemed to mitigate the child’s anxiety level and helped the child “join play.” In particular, when the child repeated her questions due to her anxiety, the therapist answered in a consistent manner because the child often projected her anxiety into the questions. The core content of sessions is as follows: Session 1. The child played for 30 minutes by connecting a wooden railroad and letting the train pass carefully. She made a farm right next to the railroad and placed chicks and hens, and scattered many different birds around it. Session 2. While the child was decorating the sand play box, she said, “I want to make a wide ocean.” As a result, the therapist helped the child

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make the sea bigger by pushing the sand to the edge of the box. While she was putting fish in the sand box, she thoroughly hid little ants in the sand so that they would not be seen. When she was looking at the toy shelf, she wasn’t able to touch a dragonfly and made a remark saying, “I’m scared of the dragonflies. Dragonflies, spiders, and snakes are the things that I fear the most.” Thus, the therapist took the dragonfly out and placed it where the child wanted it to be. The therapist asked the child, “What features of a dragonfly scare you? Is it because it flies, or is it the shape?” The child answered that “the shape” of the dragonfly scares her. When the therapist asked the details in what “shape” of the dragonfly scared her, the child answered, “the eyes, because they look weird.” When the child wanted to get a swing, she wasn’t able to touch it so the therapist took the swing out instead of her. The therapist shook the swing after taking it out. The child was looking at what the therapist was doing quietly and soon imitated what the therapist did, shaking the swing. When the child told the therapist that the web made out of rubber bands were disgusting, the therapist held the web and told the child to punch it. The child was punching it carefully in the beginning, but soon she began to punch it harder and repeatedly punched it. The child played a fishing game using a magnet, and selling the fish in the market. When she called a pump “a bunch of faucets,” the therapist corrected it by saying “this is a pump,” the child called it “a pump” as well. Session 3. The child said “there is something that I couldn’t see” and took butterflies and flowers. She decorated the lake by saying “it has become the flower shop!” She also made a crosswalk and made a child and an adult standing at the crosswalk. When asked how the adult and the child were related, the child told the therapist that a mother and a daughter were waiting for the traffic light to change so that they could walk across. A traffic light was near the building where the play therapy room was. When the traffic light turned green, there was a sound signal for the hearing impaired. The child was showing a sensitive reaction when she heard a walking signal for the hearing impaired. Session 4. When the therapist asked the child how she was doing, she told the therapist that she was well but something sad had happened. She wasn’t able to explain what made her sad. Soon, she organized a doll box after pouring all of the dolls on the ground by turning the box upside down. She made a book by gluing many pieces of the colored paper together, and wrote “math” on the front of the book. She was also coloring a paper on top of the prepared canvass and explained the picture as, “blue cliff, a leaf

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and handle—a picking handle.” As she was coloring, she gave extra care when the watercolor ran on the paper. After she finished the picture, she added another explanation, saying that “a poop, a chick is eating something delicious.” Session 5 & 6. She put water in a wide container and put some fishes and divers so that they could swim. She was delighted, saying “the sea is completely filled up!” Also, she boasted that, “I can catch a dragonfly now!” When she was coloring with watercolor, she didn’t seem to care as if the color was running like before, which was a different reaction from the prior session. Session 7. The child connected railroads and the trains were running, but were repeatedly stopping to watch the train. When 30 minutes had elapsed, she looked at the clock and showed a very relaxed attitude saying “I can still have some more fun!” The child made some food with the therapist and shared the food together. Session 8. According to the parents’ report that the child was scared of a balloon, and so the therapist had put a huge, blown balloon in the room. When the child arrived, she said, “I’m afraid that it would burst.” While the therapist continued blowing air into the balloon and inflating it, the child continuously watched the therapist. When she approached the canvass, she painted using a black watercolor and explained it as “blue water tide in a dark night.”

The Middle Phase of Therapy The therapist encouraged the child to focus on playing games with social interactions and expanded the “play” to develop a genuine relationship. Whenever the child requested the therapist to play with her, the therapist was readily available for the child. When there was a feeling of anger expressed during the play, which the child had difficulty with explaining, the therapist encouraged the child to express the anger verbally, and aided the child to successfully encounter various challenges. The core content of sessions is as follows: Sessions 9–10. In session 9, the child colored the canvas with brown and yellow watercolors, and told the therapist that it is “tree and yellow watercolor flowing” and muttered “it is okay to flow down.” In session 10, she played a game attacking the therapist, saying that a fish was trying to bite the therapist.

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Sessions 11–15. In session 11, the child asked the therapist to inflate the balloon while she was blocking her ear, because she was scared of the air in the balloon. In this session, the child led the game play. In a pairing game, when the therapist took the pair which the child was continuously flipping back and forth, she expressed her displeasure by saying “I wanted to take the fish!” and even yelled “I’m so angry now!” with teary, angry eyes. Then, she played with a Young Play mobile doll wearing clothing that had a fish drawn on it. In session 12, the child enjoyed a hospital role play and other games. From the 13th session, the child mainly played games, and she was able to endure considerably better when he lost in the game. Sessions 17–19. During the 17th session, she was singing happily holding a microphone. She also mentioned that she wanted to raise a shellfish. She told the therapist that she was sad because her mother wouldn’t let her raise it because it would die soon. The child also asked the therapist to put the scorpion away. When the therapist asked the reason, she said that “because scorpion has poison, I don’t like things with poison.” Soon after, the child attacked the scorpion and she became happy for “beating” the scorpion.

The Final Phase of Therapy The therapist helped the child to actively lead the interactive play. The child explored, expressed and verified herself through the interactive play. In order to determine the termination, the therapist examined not only the child’s participating behavior in the therapy room but assessed the child’s degree of adjustment at her kindergarten. The core content of session is as follows: Sessions 20–22. From the 20th session, there were more games available, and the child drew pictures in a short time period. The child was happy doing a hand-printing; she dipped her hand into the watercolor paint and stamped her hand on a paper. In the 21st session, there were two balloons placed in the tent. However, the child was able to get the balloons out of the tent and showed no sign of anxiety while playing by hitting the balloons. In the 22nd session, the child and the therapist played games. Whenever she won or lost, she was able to express her emotions appropriately. Sessions 23–25: During the 23rd session, the child placed a huge dinosaur doll in a tent and played with it inside the tent. The child spent most of the time playing games. It was noticeable that she was able to purely enjoy the game, even though she lost sometimes. In the 24th session, the

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therapist had a discussion about the final party on the 25th session with the child. The child requested a white cream cake with fresh fruit, except for kiwifruit. Also, the child requested a doll as a “graduation” gift. During the last session (the 25th), every family member participated in the session together. When the child was asked of “the anxiety of shaking things,” she answered that the anxiety was now gone. Also, the family told the therapist that the child participated in more programs in the educational center for gifted children. They also reported that the child followed the instruction well and enjoyed the time at the program.

Progress Analysis in Play Therapy Function of play therapy. The child had an opportunity to actively express and explore the child’s inner conflict and the stimuli which caused the anxiety through “imaginative play.” Also, through the role play, the therapist helped the child master the stimulus that made the child anxious. When the anxiety improved, the child was prompted to do the task by herself, which led to further mastery of feelings over her anxiety. During the sand play, the child hid what she could not handle in the sand. While progressing, there was an opportunity to search for the things that she hid in the sand. This process helped the child to overcome the problem by herself, and gave an opportunity for her to experience self-mastery and self-strength. Play Themes. Detailed situations which caused anxiety in the initial phase appeared to be the theme for overcoming the anxiety. In the middle phase, it was noted that the child searched for her limits to improve selfawareness and chose many activities that she felt confident in doing. She also induced the reaction of the therapist while trying to overcome her anxiety by herself. Her competency in the play and expression of happiness were apparent in the final phase. She appeared to be confident in interpersonal interactions as well. The attitude of the child during the therapy. In the initial phase of the therapy, the child was too eager to direct the reactions of the therapist, but she showed much cooperative attitude while trying to observe the therapist’s reaction in the middle phase. In final phase, she was able to look at herself more positively, and showed a significant change in attitude that she put more emphasis on the happiness from interacting with others than winning the game. In sum, she seemed to be transformed from the state of selfabsorption to a person who could be considerate people around her with improvement of interpersonal relationships.

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Therapeutic Interventions. In the initial phase, the therapist intervened for the child to recognize a detailed stimulus which triggered the anxiety, and reduced the child’s anxiety by seeing what the therapist did as a countermeasure of the factor causing anxiety. In order to help the child recognize her feeling, the therapist utilized the child-centered approach while incorporating cognitive behavioral approach in order to recognize anxiety driven stimuli and shifted her thinking patterns. Furthermore, additional parental education was provided. In the Middle Phase, game play was utilized for making the child be accustomed with the anxiety in variety of situations, and allowed the child to explore and to endure the anxiety driven stimuli. The self-awareness increased with the child-centered approach. In the Final Phase, the therapist intervened in the “gladiator game play,” so that the child actively searched for her problem and accepted the “Finale” of the program. The therapist maintained the fundamental position of child-centered play therapist, but also utilized a cognitive-action method in order to develop coping repertoire in managing anxiety.

Follow-Up Session Six months later, a follow-up session was held. The child was adjusting well and continued to attend the educational center for gifted children as well as a mainstream kindergarten. The child was much more eager to learn new things and made frequent requests to learn new things. The parents reported the cessation of anxious behavior since termination.

Clinical Reflection By integrating cognitive behavioral play therapy in the realm of childcentered play therapy, the therapist flexibly and appropriately created the therapeutic setting to address the child’s concerns. The fact that the therapist maintained her attitude of unconditional positive regards, having an emphasis on acceptance and respect helped the child became comfortable and safe in sessions. Once the child felt accepted, she appeared to increase concentration span in playing .The increased concentration span indicated that the child found peace in the relationship with the therapist. By finding peace, the child appeared to form trusted relationship with the therapist, which immensely contributed to the increased concentration span and at the same time decreased anxious moments. The therapist found that integrative

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play therapy was well suited to Korean children because it helped the child develop a sense of independence and provided an opportunity to dealing with concerned issues. In this case, the child’s many requests (or demands) in the early phase turned into independent work as the treatment progressed. Instead of asking the therapist to do something for her, she became selfsufficient in taking care of herself independently. The therapist’s probing questions to her thinking patterns apparently helped her be aware of her feelings and thinking. Once progress was made, the subjects of play gradually changed and became more closely related to the child’s real-life which made it easier for the therapist to continue to deal with the child’s issues. Excitingly, the child presented development of emotional literacy as sessions progressed. While anxiety and upsetting feelings towards her mother’s disapprovals were the only emotions in the early phase, a variety of emotions were expressed in the play in the last phase in treatment.

Moving Forward Play therapy in Korea has come a long way since the translation of Virginia Axline’s book by Jung-Il Joo in 1976. Play therapy’s increased popularity in Korea as a therapeutic tool in supporting children means that there is a pressing need for regulating and licensing the use of play therapy and to uphold its ethical and professional standards. It is important that professionals in play therapy harness themselves not only with gaining quality play therapy knowledge but also with being bounded to an academic discipline which has clear ethical standards in clinical practice in order to avoid inadvertently occurring egregious ethical issues in the inherent clinical practice with no governmental regulations in Korea. Taking steps to ensure play therapists are provided with rigorous practice regulations from certification producing associations is another suggestion in this respect. We anticipate a bright future for the field of play therapy in Korea. In pursuit of being competent play therapists in Korea, local practitioners are making efforts to align their qualifications and training requirements with the Association for Play Therapy in the United States. As of today, Korea has six registered play therapist supervisors; these individuals take leadership roles in the field of play therapy. Furthermore, the emphasis on research in play therapy seems to predict a more rigorous and evidence based practice of play therapy in Korea. Many Korean academic associations are dedicated to finding evidence to evaluate and improve play therapy. The greater increase

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of experimental studies (30.6%) (Kim and Lee, 2012) indicates this academic trend in Korea. The increased research efforts on play therapy, the high number of play therapists, and the approach’s current popularity among the general public and clinicians should contribute further to the development of play therapy in Korea.

Implications For Practice • The first and foremost important aspect in working with children in Korea is to understand the values and parenting styles in the child’s family system. Although Koreans traditionally hold the collective family style system, play therapists need to understand that current Korean society is undergoing rapid changes moving from traditional collectivism to westernized individualism in the family system. This shift from being deeply embedded in traditional collectivism towards a more modernized individualism in child rearing seems to create somewhat unstable and confused parenting values. Thus, it is of necessity that play therapists explore the characteristics of family style in child rearing in order to properly assess the contextual needs of the child and determine ways of interacting with his or her parents in play therapy. • Korean play therapists tend to have an additional role as supportive resources to parents while working with the child. Due to a paradigm shift in parenting in Korean society, young generation parents seek professional guidance for child rearing instead of practicing traditional authoritarian parenting of the older generation. Play therapists often become a linkage that weaves the traditional values into modern parenting practice. • As a transient phenomenon, modern Korean parents tend to develop a peer role in parenting. Economic affluence and a low birth rate (ranked first among OECD countries with 1.2 births per couple), means that many Korean parents attempt to raise their children well in a respectful and supportive way. However, the positive gesture of providing love and respect to their child could result in this phenomenon of developing a peer role in parenting. Play therapists commonly encounter parents who are not strong on setting limits to their child when needed. Therefore, an intervention like Theraplay is well accepted to Korean parents because it helps them not only attune to the needs of their child but also set up a healthy parental role in the dyad with their child.

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• Lastly, it is important to mention the use of touch in play therapy practice in Korea. Touch is represented as closeness, friendliness, and care to Korean children. If there is a good therapeutic alliance, a play therapist and a child client will exchange physical touch such as holding hands, gentle hugs, or sitting closely as culturally acceptable demeanor. Reserved touch from a child client can possibly be an indicator of discomfort, lack of trust, or dislike. Yet, play therapy contains important aspects of touch that is universally acceptable to Korean families because of its use of natural touch to nurture children.

REFERENCES Axline, V. (1947). Nondirective play therapy for poor readers. Journal of Consulting Psychology, 11, 61–69. Axline, V. (1949). Play therapy: A way of understanding and helping reading problems. Childhood Education, 26, 156–161. Axline, V. (1955). Play therapy procedures and results. American Journal of Orthopsychiatry, 25, 618–626. Axline, V. (1969). Play therapy. Boston: Hough-Mifflin. Hendricks, S. (1971). A descriptive analysis of the process of child-centered play therapy. (PhD Dissertation, North Texas State University, 1971). Dissertation Abstracts International, 32, 3638A. Kim, K. W. (2006). The past, current, and future directions of child counseling in Korea. Korean Journal of Christian Counseling, Fall Special Issues, 1–15. Kim, Y. J., & Lee, Y. J. (2012). Research trends of play therapy in Korea: Focused on published papers in domestic journals (2000–2010). Korean Journal of Play Therapy,15, 329–343. Joo, J. I. (1976). Play therapy case study 1. Child study, 1, 29–39. Landreth, G. L. (1991). Play therapy: The art of relationship. Bristol, PA: Accelerated Development. Miller, S. M., Boyer, B. A., & Redoletz, M. (1990). Anxiety in children: Nature and development. In M. Lewis and S. W. Moller (Eds.). Handbook of developmental psychopathology (pp. 191–208). New York: Plenum. Moustakas. C. (1955). Emotional adjustment and the play therapy process, Journal of Genetic Psychology, 86, 79–99.

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Park, S. Y., & Lee, J. Y. (2005). Analysis of research in the Korean Journal of Play Therapy (1997–2003). Korean Living Science Association, 14, 47–57. Waldron, S. (1976). The significance of childhood neuroses for adult mental health. A follow-up study. American Journal of Psychiatry, 133, 532–53.

12

Play Therapy in Taiwan Miao-Jung Lin Ju-An Cheng

Similar to many of our neighboring Asian regions, such as Hong Kong and South Korea, therapists, counselors and individuals in Taiwan who strive to enhance the well-being and development of children alike are turning to play therapy as an effective therapeutic option to support children.

DEVELOPMENT OF PLAY THERAPY IN TAIWAN In Taiwan, the first services that utilize play therapy to facilitate the wellbeing of children and their families can be traced back to the 1980s. The pioneering organizations that offered these services included the Yeou-Yuan Foundation and the Christian Cosmic Light Holistic Care Organization, all located in the northern part of Taiwan. At the time, the services included mostly therapeutic play as a means to engage with and support the child clients and their families. In addition to local organizations, individual efforts have also been made to promote the use of play therapy. In the 1990s, Dr. Liang Pei-Yong, who is self-taught in play therapy knowledge and techniques, delivered numerous play-based services for children and their families based on his clinical experience with children and his knowledge in play therapy. He also provided the very first 2-day workshop on play therapy for elementary school teachers in Taipei. Through the workshop, many

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teachers from elementary schools were introduced to the therapeutic power of play and play therapy. In the southern area of Taiwan, Dr. Liao Feng-Tsu also provided counseling services for children and families through the establishments of the Children Counseling Center at the National Tainan Teachers College in 1993 and the Kaohsiung Children, Youth and Family Counseling Center in 1999. In addition to supporting the children and families, both of the above centers provided training for counselors and students to become play therapists. These are possibly the very few systematic localized training centers that make use of play in therapy. Major historical events also contributed more awareness and application of play therapy as an intervention for children in Taiwan. For instance, the “921 earthquake” in 1999 resulted in many individuals and children suffering from shock and exhibiting post-traumatic stress symptoms. Due to this massive disaster, there was a critical need for therapeutic support, not only for the children, but also for the caregivers and teachers who engaged with these children. Consequently, the Taiwan Fund for Children and Families founded a center called the “Rainbow House” that provided play therapy for affected children in Taichung. Through the government’s support, many elementary schools also created playrooms for their students who might need therapeutic respite and support. At the same time, many of the teachers also took up basic training to deliver play therapy to children. Together, these events set the stage for the development and practice of play therapy in Taiwan.

Development of the Association of Taiwan Play Therapy The Association of Taiwan Play Therapy (ATPT) was established in 2005 with the guidance of Dr. Kao, Shu-Chen and her doctoral students. Since then, the ATPT has been playing an important role in promoting play therapy development in Taiwan. The Association has been proactive in spearheading many play therapy related projects include developing and delivering culturally related play therapy training, rewards for setting up play therapy services in agencies, sponsorships for research and publications on play therapy approaches, and establishing a rigorous licensing process for Taiwan. There are now more than 200 members registered with the ATPT, which just celebrated their 10-year anniversary in 2015.

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Training In Taiwan, there are several ways for individuals to receive professional training in play therapy, including training from university programs, the ATPT and other agencies. The ATPT developed and provided a series of basic and advance level play therapy training sessions each year, and have since been the authority in all areas pertaining to the development of skills and techniques for new and existing play therapists. Besides the local play therapists, ATPT also invited overseas key pioneers, scholars and practitioners in the play therapy field to share their experience and knowledge. These world-renowned speakers included Garry Landreth, Geri Glover, Linda Homeyer, Dee Ray, Terry Kottman, Athena Drewes, and Kevin O’Connor. All of them respectively covered topics on Child Centered, Adlerian, Prescriptive, Ecosystemic Play Therapy approaches, and many more. With respect to training within a university, there are over 25 programs in psychology, counseling, social work, and early childhood that provide introductory play therapy courses. Many of these courses not only use Landreth’s book (2002) Play therapy: The art of the relationship as the first textbook, but also focus on Child-Centered Play Therapy (CCPT) as a key approach of play therapy. As advance courses in play therapy are very limited, many play therapists-in-training and students are mainly trained in CCPT; consequently, CCPT is the most commonly practiced approach in Taiwan. Nonetheless, other approaches, such as Adlerian play therapy, are also a popular option amongst play therapists in Taiwan. Despite available training opportunities, there remains a need to offer more support in the form of specialized topics on play therapy and supervision to those who are interested in adopting the play therapy approach when working with children. There is a huge demand for school counselors who are equipped to use play therapy approaches to support and engage elementary and junior high school students.

Research and Publications Apart from developing the practice arm in play therapy, the Association also set up funding to encourage students to conduct research in play therapy. Post-graduate students from the local universities are encouraged to submit their theses and dissertations to the Association to be considered for

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the annual best theses and dissertations in play therapy. In 2011, the Association set up the Journal of Taiwan Play Therapy to encourage more evidence-based play therapy research in Taiwan. Although the practice of play therapy in Taiwan may not be as established as it is in Western countries such as in the United States and the United Kingdom, published works in Chinese on its use and effectiveness in Taiwan are evident. More than 30 books concerning play therapy have been translated into Chinese by Taiwanese scholars and practitioners. The translated books cover a wide range of topics including play therapy theories, skills, approaches, special issues and treatments. In addition to translated works, more than 15 books on the practice of play therapy have also been written by Chinese authors in Taiwan. Other relevant play therapyrelated materials, such as games and tools were also designed and developed by play therapy experts in Taiwan. They include communication board games such as “Explore the Heart” by Kao, Lo, Tzeng, Lien and Chen (2004). In addition, Kao and her team also designed and produced play therapy materials such as “Variety of Emotional Card” (Kao, Chen & Wu, 2007), “Childhood Play Card” (Kao, 2013), and the “Good Character Card” (Kao, 2015). All of these are used frequently as additional tools by local play therapists. Research efforts to examine the application of play therapy in Taiwan have been made since 1986 (Chen & Li, 2004). An example is a metaanalysis that included 65 research papers on the effectiveness of play therapy in Taiwan by Wang, Chang, Lien and Wang (2006). This metaanalysis concluded that play therapy has been practiced more often with a varied range of issues and mostly with children. Most research studies on play therapy are on child centered play therapy approaches. Tsai (2013) also reviewed 86 master’s theses and doctoral dissertations on play therapy from 2002–2011 in Taiwan and found that the study designs in play therapy research were mainly qualitative, followed by mixed methods and quantitative research. Although available research supports the effectiveness of play therapy in Taiwan, more evidence-based research is needed to advance its use. For instance, research that supports the effectiveness of the four Taiwanese-based play approaches such as Structural Play Therapy and Eclectic Play Therapy (see description in the following section) described in the previous section may promote their applications, thereby benefitting children within Taiwan through their cultural sensitivity.

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Formal Licensing Prior to 2015, there were no clear rules and regulations as to how play therapy practitioners could be officially certified in Taiwan. According to the ATPT, there are more than 200 mental health professionals in Taiwan who registered as members of ATPT and claimed that they practiced play therapy. However, only a limited number of them are formally certified with an overseas regulation board for play therapy. Such a low number could be due to the lack of formal channel for professional registration in Taiwan. In addition, the main language of instruction in Taiwan is Chinese. Many of the practicing professionals are mainly fluent in Chinese and might not have the resources or language capacities to attend training overseas, so as to accumulate the continuing education hours in the US or UK. Since 2015, the ATPT established a set of licensing criteria and procedures for Taiwanese play therapists that aimed to get their licenses to practice play therapy in Taiwan. These criteria included academic qualification and the attendance of courses related to child development as well as on play therapy approaches. There is also a need to have a specific number of supervised hours for conducting play therapy sessions. With these guidelines, all practicing play therapists need to adhere to these criteria for licensing to practice play therapy in Taiwan. This results in standardizations and credibility for the profession.

Adapting Play Therapy In 2015, the ATPT awarded the first Certificate for “Excellence Agency/ Organization for Play Therapy” to the Southern Kaohsiung City Branch Office, Taiwan Fund for Children and Families for their efforts in using and adapting play therapy with their clients. Indeed, with an increasing number of children nowadays who are forced to face a myriad of developmental problems and environmental challenges, it is essential for play therapists to be knowledgeable in different play therapy approaches so as to address various needs from individual children. Specifically, approaches that are sensitive to the client’s cultural background may facilitate greater treatment success. Based on the extensive experiences our existing play therapist had with the local population, four culturally responsive approaches were developed to better meet the needs of the local community. These four approaches are field play therapy, eclectic play therapy, structural play therapy, and authoritative play guidance.

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Field play therapy In 1995, Dr. Liang, Pei-Yung developed an integrative approach using the core principles of psychoanalytic, behavioral and person-centered theories. This approach, Field Play Therapy, was based on his clinical experiences with a wide spectrum of clients and issues. This circular model emphasized the framework of assessment, diagnosis and treatment. Liang (2006) acknowledged the importance of finding the root cause of the issues presented. The assessment process is ongoing throughout the intervention phase. In addition, with his extensive experiences with working with Asian families, Liang (2006) also emphasized the importance of supporting the clients with behavioral strategies so as to deal with some of the presenting problems before we can move the therapy towards more internalizing in-depth psychoanalytical frameworks. Throughout the process, the therapist is also mindful of building strong relationships with the client and the family.

Eclectic play therapy Dr. Ho, Chang-Chu developed an eclectic approach towards the use of play therapy theory and practices in 2005. Similar to Prescriptive Play Therapy (Schaefer, 2003), Eclectic Play Therapy emphasized the selection of suitable theory and skills from different systems to work with clients’ issues. Ho and Yeh (2005) stressed the importance of a holistic integration of the individual’s cognition, affect and behavior in dealing with the issues presented. As a result, the Eclectic Play Therapists would focus on psychoanalytic/dynamic, child centered principles and the cognitive approach as they work with their clients.

Structural play therapy Unlike the classical Structure Play Therapy proposed by Hambidge (1955), this Structural Play Therapy proposed by Dr. Cheng, Ju-An (2008) blended the principles of play therapy, narrative therapy, attachment theory, and interpersonal process theory. Based on the clinical experiences and difficulties of applying long-term play therapy with the local context, Cheng developed this time-limited therapeutic model that uses a more directive and activity based approach. To enhance the effectiveness of this approach, Dr. Cheng, Ju-An also developed communication game cards such as the “facial-emotion cards,” “energetic-language cards” and “family-play cards”

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to help with communications between the client and therapist, and within the family.

Authoritative play guidance This approach was first developed by Dr. Yeh, Chen-Ping (2014) as she worked with families who needed more knowledge and techniques on parenting. With her experience in pastoral care and working with parents, Yeh (2014) blended the principles of child centered play therapy, developmental psychology and positive parenting to support parent-child relationship. This is a more directive approach with more emphasis on the use of solution-focused pastoral counseling with parents and child-centered play therapy with children.

Moving Forward The ATPT used 10 years to reach this major milestone of setting up the criteria for play therapist certification in Taiwan. The next step will be to engage in more public education and publicity around the need for certification so that the professional identity and standards of a play therapist can be acknowledged. Through such public acknowledgement, our clients— the children and their parents may be more likely to have play therapy as an alternative intervention. There is always a high need for mental health professionals who are trained in play therapy approaches. It is hopeful with the licensing process, there will be more potential individuals entering this field. With more play therapists-in-training, there is a need to continue to build the skills of the existing play therapists that can provide further specialized training and supervision. As mentioned earlier, most students are training only in one play therapy modality of child centered play therapy. Though CCPT has its strengths, the students do need to expand on their repertoire of other play therapy approaches and models so as to support more varied kinds of issues and clients. There is a need to encourage more evidence-based research in play therapy in Taiwan so as to increase its credibility as an effective therapy for use in Taiwan. In order to better satisfy the needs of Taiwanese children and their families, creating more play therapy models and culturally sensitive materials in Taiwan will be worthwhile. With the continuing efforts of the ATPT, local service organizations and play therapy training programs, the development of play therapy is sure to grow steadily in Taiwan.

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CASE ILLUSTRATION

Child Abuse in Taiwan Since 2000, the crude birth rate of Taiwan has fallen from 41.7% in 1958 to 8.86% in 2016 (Ministry of The Interior, 2017). However, news of child abuse is still often heard. According to a survey conducted by the Child Welfare League Foundation (CWLF) in Taiwan (2015), approximately 20–30% of elementary and junior high school students in Taiwan have been reportedly been physically abused by family members, and around 20% have experienced some forms of verbal abuse ranging from intimidation, insults, or ridicule. In addition, according to the Ministry of Health and Welfare (2017), there were a significant number of cases of domestic abuse that resulted in severe injury or death. However, only a third of the cases were reported to authorities before the victim’s hospitalization or death. Official registration data revealed 57% of the cases reported were physical emotional abuses, and almost 38% of the cases reported were physical abuse.

Symptoms and reactions to trauma Children might have emotional reactions after traumatic experiences, such as nervousness, agitation, sadness, withdrawal, fear and anxiety (Terr, 1991). Further, it is likely that physical problems will be generated. For instance, one might become aggressive, often feeling angry, withdrawing from the outside world, displaying signs of developmental regression, and experiencing sleeping problems, such as not able to sleep at night and having nightmares. If these emotional and behavioral problems are not properly attended to or treated, they might lead to even more serious and long term emotional and behavioral problems. According to Terr (1991), there are four characteristics that are very common among children who have experienced trauma. First, most of the children have vivid memories regarding the trauma and these memories might flashback most frequently during their free or spare time (Terr, 1991). In other words, the children often re-experience the trauma in the sense of seeing and feeling it again. They might then play out these memories during play. Second, the children often exhibit behaviors in a repetitive manner while playing (Terr, 1991). They tend to reenact the experiences behaviorally. Further, children, as young as 12 years old are able to reenact the experiences in play. Third, children who

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experienced trauma often display fears that are specific to the trauma (Terr, 1991). For instance, they will possess fear towards specific items or things that are related to the trauma. Fourth, these children will change in how they view others, their life and the future; more specifically, they tend to view others, their life, and the future negatively (Terr, 1991). That means children might lack of ideas regarding his or her future; not trust anyone, and perceive others or others’ actions in a negative way.

Structural Play Therapy (SPT) The second author, Cheng, Ju-An (2008) established a culturally relevant approach called Structural Play Therapy (SPT) based on his extensive experiences of practicing play therapy in Taiwan. The framework of SPT includes the following components discussed below.

Time-Limited Therapy In Asia, the applicability and compliance to play therapy is highly contingent on the family and the child knowing how long the therapy will last. In many cases, the therapy is also conducted in schools, social welfare institutions or residential organizations where the therapist gives a predetermined number of therapeutic sessions. While time constraints may hinder treatment progress in some cases, for others, it is actually an advantage in play therapy because children may benefit more from having a clear idea of the beginning and the end of therapy. Hence, having a specific time limit and time structure are two important aspects of the SPT.

Structural strategies for autonomy and intimacy The actual practice of SPT makes use of two structural strategies to satisfy children’s needs for autonomy and intimacy within the predetermined time frame. The first involves the construction of an object, which can be a doll, a puppet, or a model figure that is endearing to children. This object helps lower the tension of anxiety and establish relations. In the beginning of every session of Structural Play Therapy, the play therapist uses this doll, puppet, or model figure to introduce the child to the therapeutic session. Throughout therapy, this object will also be present to function as a friend of the child, thereby allowing him/her to feel a sense of intimacy. The second strategy is for the play therapist to photograph and document the child’s

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works throughout the sessions. These records will then be presented to the child at the closing of the case as a review of the whole therapeutic process. Through this review, the child will experience autonomy because he/she now has a more holistic understanding towards the self.

Use of therapeutic tools for emotional expression In order to address the concern that Chinese children may not be culturally adapt at expressing emotions, SPT leverages on culturally specific communication game cards such as facial-emotion cards, energeticlanguage cards and family-play cards to help them express their emotions or any underlying concerns as opposed to forcing verbal expressions. The second author designed and created these game cards to facilitate expression during the SPT.

Directive in engaging the client Similar to many of the children in Asia, children in Taiwan are used to being lead and directed by adults. This is probably due to respect or that children are conditioned to be passive. They are generally expecting the presence of an adult who can guide them in the playroom. In keeping to the reality that most Chinese may be more comfortable with a directive approach in mind, a SPT therapist would initiate and encourage the client to complete particular tasks. For example, the SPT therapist would be instructing the client to identify and recognize one’s emotions with the use of games or tools such as the facial-emotion cards or prompting the client to answer questions so as to help him become more aware of his underlying emotions and beliefs.

Background When Xiao Yun was 3 months old, she was sent to a foster family because she was physically abused and neglected by her alcoholic mother. At the age of 8, Xiao Yun went back to live with her mother. For two years, she was repeatedly assaulted by her mother. As a result, when Xiao Yun was 10 years old, she was permanently removed from her biological mother and returned to her foster family. Since returning to her foster family, it was reported that Xiao Yun had difficulties in maintaining stable relationships with her classmates. She was emotionally unstable, got into fights regularly

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and also stole from her classmates. As a result, Xiao Yun was unwelcomed by her peers and the school.

The Initial Phase of Therapy Although SPT subscribes to a mostly directive approach, the therapist is mindful of the need to pace the child and allow for freedom to explore the room. In the case of Xiao Yun, the therapist allowed her the freedom to explore the room at her own will, giving her the acceptance that she so lacked in her reality. In order to build a pleasant and positive experience in our space, the therapist invited Xiao Yun to choose an object so as to establish the relationship and as an extension of the therapist’s presence. She picked a stuffed teddy and named it Pudding. From then on, Pudding became an object that can address her needs for intimacy and dependency. Pudding accompanied Xiao Yun as her companion and confidante in the playroom.

Saying “Child, I See You” through photography “I am here” is the indispensable message when therapists work with children as well as a determinative factor for successful therapeutic sessions. “I am here” is also an attitude of focused companionship that consists of concentrating, observing, and listening. How does one conduct concentrating, observing, and listening with Xiao Yun? It can be done during the session by stopping everything at hand, looking at her and listening to what she has to say. The therapist can also cultivate the effect of “I am here” by photography. Children tend to enjoy being photographed and considered it a sign that they are noticed and cherished, and this is also the case with Xiao Yun. Photographs taken during the therapy session can be reviewed at the closing of the case. It is thus highly recommended that practitioners of play therapy include photography in therapeutic sessions.

The Middle Phase of Therapy In the middle phase of the therapy process, a crisis between Xiao Yun and her classmate occurred. A crisis often proves to be a turning point in therapeutic sessions. Instead of fearing it, the therapist could consider it as an opportunity to engage deeply with Xiao Yun. This is a good opportunity to help her confront her emotions, to fathom how she evaluates situations, and to observe her responses.

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Encounter and expression of emotion and consolation Xiao Yun was able to process her tense relationships with her classmates when using the facial-emotion cards. It was obvious from her expressions during the session as she was narrating the incident that she was extremely frustrated and angry. With these cards, Xiao Yun was able to express an array of feelings, not only towards her classmates but also towards her life and her predicament. With this revelation, we then proceeded to use the energeticlanguage cards on the table to help her to build her strength and capacity. The energetic-language cards used symbols and pictures to depict strengths. A child can choose any number of cards as their strengths. Depending on the language abilities and age of the child, the child and the therapist can engage in a dialogue around the images selected. Xiao Yun chose many images, including a Sword, Shield, Bow and Arrow, Gun, Bandage, Invisibility Cloak, Star Gate, Wings, Time Machine, Transformation Solution, and Crystal Ball. Xiao Yun is obviously more mature and astute to her own emotions and needs than her peers. She was able to articulate her need for protection, attachment, love and self-regulation. It must have been very overwhelming for a young child like Xiao Yun to experience abandonment, hurt and pain for such a long time, without any redress. The therapist came to recognize her solitude and agony. Her fighting and stealing are just her ways to get attention and to meet her basic needs for safety and security, and love and belonging. Overall, it is the responsibility of the therapist to provide empathic understanding towards Xiao Yun, as opposed to passing judgments, towards her emotional expression. Through empathy, the therapist is more capable of helping her in terms of identifying emotions that need to be confronted. In this instance, the use of the facial-emotion cards helped Xiao Yun to express her emotions. The cards also calmed her down and assisted her in being in touch with her inner self, where feelings of solitude, despair, grievance, and melancholy were buried under anger, rage and outrage. Energetic-language cards, on the other hand, consoled Xiao Yun and excavated her inner longings. Drawing from energetic-language cards not only enabled Xiao Yun to manage her traumatic experiences but also allow her to feel empowered through their metaphoric and symbolic values. This process is particularly effective in healing and in familiarizing Xiao Yun with the experiences of being understood and loved, upon which lay the basis for the transformation of the relationship between the client and her immediate environment.

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The Final Phase of Therapy During the last phase of her therapy, Xiao Yun built enough trust with the therapist to be able to use those sessions to process her basic needs. Xiao Yun reenacted through her playing with the feeding bottle and the dollhouse as her way to get the nurturing and care that she did not have when she was living with her biological mother. The SPT therapist needed to pace the client and adapt the session accordingly. For this case, it was important to adopt a non directive stance since Xiao Yun appeared to have the capacity to work on meeting her basic needs through the use of symbolic play and projections.

Case reviewing booklet and termination As SPT is time-limited, Xiao Yun is well aware of when the last session will be. For her, the last session is designed to be a review session. It is important to plan the last session in advance. As Xiao Yun enjoyed being photographed, the therapist had earlier compiled photos taken during the sessions and her works into a photo album and a booklet. This present is presented to Xiao Yun during the last session as a parting gift. A celebration is held to honor her healing and transformation journey. The therapist focused on her merits, recounted each of the therapeutic sessions and described the improvements that she had made over the course of the therapy. At the end of the session, Xiao Yun took with her the gift, the toy Pudding, and the photo album with all of the therapist’s blessings, and memories of their therapeutic sessions, with the hope they would continue to accompany her and satisfy her needs throughout her life journey.

IMPLICATIONS FOR PRACTICE • Generally, parents in Taiwan needed to feel involved in the therapeutic process. Besides providing strategies to manage some of the presenting problems for the parents, they would like to understand what the child is doing in the session and the goals of the sessions. A thorough explanation of the process and goals of the sessions as well as having regular meetings with the parents will facilitate a smoother cooperation between the counselor and parents and/or teachers.

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• Not every child from a Chinese cultural background can work well with using a non-directive or child centered approach like CCPT. Some Chinese children may need more directive interventions in order to manage their anxiety around making decisions on their own. Based on our experience in Taiwan, play therapists that employ a directive approach can utilize culturally appropriate materials, such as facial-emotions cards, to assist children in identifying and resolving their inner problems. • Culturally sensitive games and play materials can be developed for use in Taiwan. Many of the games from the West might not be appropriate in a Chinese speaking country with different cultural influences. Specifically, certain Chinese feeling words have different intensities and meanings as compared to the West. In the making of the facial-emotions cards, extensive research on the appropriate use of specific feeling words were undertaken so as to adhere to the needs of the Taiwanese and other Chinese speaking countries.

REFERENCES Chen, C. F., & Li, Y. Z. (2004). Introduction to play therapy. Taipei, Taiwan: Yeh-Yeh. Cheng, J. A. (2008). Play therapy practice in schools: Contact, play and processes review—The introduction to three-stage play. Kaohsiung, Taiwan: Wunan. Hambidge, G. R. (1955). Structured play therapy. American Journal of Orthopsychiatry, 25, 601–617. Ho, C. C. and Yeh, S. P. (2005). Theory and practice of eclectic play therapy. Taipei, Taiwan: Wunan. Kao, S. C. (2013). Childhood card. Changhua, Taiwan: Er-hsin. Kao, S. C. (2015). Character card. Changhua, Taiwan: Er-hsin. Kao, S. C., Chen, S. P., & Wu, Y. C. (2007). Variety of emotional card. Changhua, Taiwan: Xin Xing. Kao, S. C., Lo, M. H., Tzeng, R. M., Lien, T. K., & Chen, S. P. (2004). Explore the heart of board game. Changhua, Taiwan: Pin-Kao. Landreth, G. (2002). Play therapy: The art of the relationship (2nd ed.). NY: Brunner-Routledge.

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Liang, P. Y. (2006). Play therapy: Theory and practice. Taipei, Taiwan: Psychology. Ministry of Health and Welfare (2017). Number and type of abused child and youth. Retrieved from http://www.mohw.gov.tw/CHT/DOPS/DM1. aspx?f_list_no=806&fod_list_no=4624. Ministry of the Interior (2017). Monthly bulletin of interior statistics. Retrieved from http://www.mohw.gov.tw/cht/DOPS/DM1.aspx?f_list_no= 806&fod_list_no=4624. Schaefer, C. E. (2003). Foundations of play therapy. Hoboken, NJ: John Wiley and Sons. Terr, L. (1991). Childhood trauma: An outline and overview. American Journal of Psychiatry 148, 10–20. The Child Welfare League Foundation (2015). Investigation reports and the child protect press conference about violence on children and youth life in Taiwan. Retrieved from http://www.children.org.tw/news/advocacy_ detail/1482. Tsai, M. H. (2013). Research in play therapy: A 10-year review in Taiwan. Children and Youth Services Review, 35(1), 25–32. Wang, C. C., Chang, K. P., Lien, T. C. & Wang, W. H. (2006). A meta-analysis on the effectiveness of play therapy in Taiwan. Paper presented at the 2006 Association for Taiwan Play Therapy Annual Conference and Seminar. Hsinchu, Taiwan. Yeh, C. P. (2014). Authoritative play guidance: The faith, hope and love through play. Taipei, Taiwan: Cosmic-light.

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section iii moving on

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13

Moving Forward Angela F. Y. Siu Alicia K. L. Pon

Play has been consistently described as universal, pleasurable, and natural for all children (e.g., Landreth, 2012). As highlighted throughout the chapters in this book, this assertion is not necessarily true in our Asian cultures. It is obvious that how “play” is understood can be very different across cultures. In fact, cultural attitudes and beliefs have an important role in shaping and guiding children’s play activities and interactions (Chen & Eisenberg, 2012; Holmes, 2012). Indeed, the culture where each child is brought up, also shaped many of the therapeutic processes in play therapy: how the family understands, reacts and engages in therapy, the initial engagement with the child, the intricate balance between being directive and non-directive in approaching the client, the selection of toys and play materials and how to adapt the processes to meet the needs and expectations of the family, amongst many others. The insights and practice wisdom from the knowledgeable and experienced professionals in this book has demonstrated the need and importance for play therapy practitioners to be astute and understand the complexity and dynamics of each and every culture they work with. By doing so, the therapist can better develop relationships, build alliance and formulate therapeutic processes that can meet the children and their families of that specific culture.

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Development of Play Therapy—Achievements In each chapter, the authors highlighted the need for adaptation of the play therapy approaches that were originally developed in the West. Each culture has to design and create approaches that integrate the intricacies of the cultural fabrics and dynamics to develop play therapy models and processes that can meet the needs of their clients within their cultures. As described by the authors in their respective chapters, there are universal appreciation and usage of many of the toys and play materials used by our Western counterparts. However, there are also deliberate adaptation and selection of toys and play materials that is culturally and/or religiously influenced. Specifically, more secular countries such as Taiwan, Japan, Korea, Indonesia and the Philippines adapted not only the toys but also play activities to meet the needs of their clients. For example in Theraplay®, the games and activities, practitioners from Hong Kong, Japan and the Korea had been extensively modified to include cultural characteristics, songs and practices, and traditional games of these countries. The therapeutic processes have also been successfully adapted for use with extended family members, which is an important and common consideration among various cultures in Asia. The adaptations go beyond the selection of toys and play materials. Traditional play therapy models such as Child Centered Play Therapy (CCPT) have been developed into culturally specific ones such as Child Directed Play Therapy (CDPT) in the Philippines. This adapted approach was developed from years of work among local experts that reflected the cultural beliefs and communication styles among the Filipinos. Similarly, in Taiwan, different Western inspired play therapy approaches have been integrated and adapted to work with their client groups. It was noted that culturally specific play therapy models such as structural play therapy, field play therapy and authoritative play guidance were developed to better meet the needs and expectations of Taiwanese children and parents, while integrating with the characteristics of CCPT. Indeed, contributors of this book describe their intervention approaches with their clients had highlighted the importance of either integrating, adapting and in general, being astute to what works and what does not, and how they can meet the special characteristics of Asian families.

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Play Therapy Development in Asia—Moving Forward The professional practice of play therapy in Asia has been flourishing. There is an upsurge of appreciation for how play therapy can be a powerful and effective intervention modality for children and families. However, despite this development, the recognition and professionalism of play therapy with the mainstream mental health field and the public have yet to be fully developed. Despite these limitations, in some parts of Asia, such as Taiwan and the Philippines, professional bodies who are led by dedicated and trained play therapy practitioners are set up to regulate practices, streamline professional ethnics and research, and coordinate specialized training on the use of play therapy. Each author has highlighted the need for more regulated training and research in their respective country. Hence, there are opportunities for experts from all over the world to collaborate and contribute to the development of play therapy in Asia. This collaboration can include training and supervision, development of professional allies for licensing purposes and to share ideas and strategies to further enhance the development of play therapy among Asian cultures. The first Play Therapy Asia Conference held in Bali in late 2016 was an impressive initiative for promoting the use of play and expressive arts in working with Asian families. Among Asian countries that were presented in this book, there is a common issue about public understanding on the importance of play and the acceptance on the use of play as a therapeutic approach in working with children. In general, although there is a good understanding on what play therapy is, many countries like Indonesia, Japan and Singapore had similar issues where there is a lack of public recognition on play therapy as a specialization, misunderstanding of the importance of play in child development, and the therapeutic factors of play. Hence the promotion of play and play therapy is a priority for the further expansion of the application of play therapy in Asia. In 2006, Drs. Eliana Gil and Athena Drewes co-edited a book titled Cultural issues in play therapy. Then and until now, the book is an important addition to the practice of play therapy as it is an essential reminder of the need to be culturally competent to the needs of the clients we served. Their book provided professionals with knowledge about different cultures as well as specific practice principles when working with African American, Latino, Native American, and Asian American children. We hope that our book, like

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that of Drs. Gil and Drewes’s, can be an essential and welcoming addition to professionals who are living and practicing play therapy in Asia. We hope that this book can be an informative resource in the play therapy literature, specifically when clinicians from each country contribute their practice and knowledge wisdom about their own country, culture, and religious influences in adapting and developing play therapy models, processes and play materials. Indeed, the understanding of the development of play therapy in the East can create a positive impact on training culturally competent play therapists in the West. We look forward to more collaboration between researchers and practitioners, fellow practitioners in Asia, and East and West, so as to further enhance the promotion and development of play therapy for children and families globally.

REFERENCES Chen, X., & Eisenberg, N. (2012). Understanding cultural issues in child development: Introduction. Child Development Perspectives, 6, 1–4. Gil, E., & Drewes, A. A. (Eds.) (2004). Cultural issues in play therapy. New York: Guilford Press. Holmes, R. (2012). Children’s play preferences in the Pacific Rim: Then and now. In L. Cohen & S. Waite-Stupiansky (Eds.), Play: A polyphony of research, theories and issues (pp. 27–66). Lanham, MD: University Press of America. Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York: Routledge.