Kawa model case study – non directive play 2

Editor's Notes

• #3: The aims of this case study are consider the theory of occupational therapy and how it can be applied via a case study in play therapy. To achieve this, I have chosen the Kawa Model of occupational therapy. Throughout the case study I will explain why I feel this conceptual model is appropriate in this setting, the parallels that can be made to non directive play therapy.From then I will move through the occupational therapy process, looking at two methods of play that the child involved himself in, and then highlighting how therapy can be evaluated . Lastly I hope to look at some recent studies and how they contribute to the efficacy of play theory, and reflect upon the process and the setting, and summarise with my reflections on the process. Michael Iwama details that conceptual models of practice in occupational therapy describe like occupation or occupational performance, and guide treatment approaches be easily allowing therapists to focus on the right problem areas and help predict outcomes in clinical interventions (Iwama, 2010)
• #4: Firstly I thought it might be helpful to draw on a definition of play. Bundy’s description describes play as being intrinsically motivated, spontaneous, involving non literal behaviour, being free from externally imposed rules. “Occupational therapists once again are concerned with the occupation of play and with the child developing as a life long player “ (Rigby and Rodger,2006)Play has been described as a "universal and inalienable right of childhood“ (Landreth, 2002, p.10). Play as “child’s work” to give some meaning to it, to make a comparison on how play fits into the adult world. Play, however, is the opposite of work. Work has some sort of goal and direction to it such as the completion of a task. In contrast, play is intrinsically motivated and changes to match the child’s view of the world.(Landreth,2002) For example, a child may use a baby bottle as a rocket ship or a block as a car. Child’s play is a way for children to become familiar with their environment. According to Piaget play brings together concrete experiences and abstract thought, and it is the symbolic function of play that is so important. Play is the one thing children have control of, allowing them to feel more secure (Landreth, 2002).It is an essential part of childhood, being considered a fundamental element in growth and development from childhood. Play allows opportunities for physical emotional cognitive and social growth and is often pleasurable, spontaneous and creative. Play can reduce anxiety and tension, and can aid amusement and enjoyment.And focusing on emotional and behavioural growth - through play children learn about the world and relationships, in exploring relationships and roles through play. Play enables children to express aggression and buried feelings. (West,1992)
• #5: I’ve included two definitions, one of play therapy and one of non-directive play therapy. Non-directive play therapy is a unique therapeutic process that allows children to work through circumstances that are scary, confusing, or bothersome to them. Both of these definitions emphasis the role of the play therapist . The play therapist recognizes the child's wants, needs, and feelings, which are expressed through play. But non directive therapy, The role of the therapist is a supportive one, rather than authoritative or interpretive. Summary of Axline’s rules of play therapy allow to child to feel empowered, become more self aware and self accepting and give more understanding of their behaviours. Axline's Basic Rules of play therapy are The therapist: Must develop a warm and friendly relationship with the child.Accepts the child as she or he is.Establishes a feeling of permission in the relationship so that the child feels free to express his or her feelings completely.Is alert to recognise the feelings the child is expressing and reflects these feelings back in such a manner that the child gains insight into his/her behaviour.Maintains a deep respect for the child’s ability to solve his/her problems and gives the child the opportunity to do so. The responsibility to make choices and to institute change is the child’s.Does not attempt to direct the child’s actions or conversations in any manner. The child leads the way, the therapist follows.Does not hurry the therapy along. It is a gradual process and must be recognised as such by the therapist.Only establishes those limitations necessary to anchor the therapy to the world of reality and to make the child aware of his/her responsibility in the relationship.
• #6: With the last slides in mind, I’d like to go on to describe what the Kawa model is, and why it can be considered as relevant within this setting. The Kawa model (which is Japanese for river) offers an alternative way to understand the child in a familiar context ( as in the previous slide, their socialisation and creativity) . The model uses a familiar metaphor of the river. It could be considered as a narrative of the child’s life, to gain a broader view of the child in their situation.Life, as described in the Kawa Model, is like a river; its starting point with the child’s birth,and may meander down an eventful course, towards a distant sea as they grow older. At any point along the child’s life course, the river can be appreciated as a configuration of contextual factors. What is the Occupational Focus of the Kawa?Water in this metaphor symbolises life flow, or occupation, so specifically, in this setting, it can be conceptualised to symbolise and explain play as an occupation. Play perhaps, being a means of allowing the child’s integrating within their environment. As long as there is water( the potential for play) in the river course, there is potential for fuller involvement and potential for the child. River walls which give shape and volume may symbolise factors such as the child’s social and physical environment. Rocks, of different shape, size and number, can appear in the river course affecting the quality of water flow at that location. Rocks symbolise difficulties and challenges. These rocks might have been there since birth or may have, like trauma or bereavement in a child’s life, suddenly appeared. Driftwood, which is considered the child’s attributes, may flow by inconsequently, push structures like rocks and walls aside to create greater flow,or become caught up between rocks, resulting in a slowing down of water flow at that particular point in the life course.
• #7: Moving on to discussing the child. The Longitudinal aspect of the Kawa river can be used to see the impact of current issues and past events on the child’s life. It can be used like a narrative in placing meaning to these events. The concept of the river can be used as an occupational profile in understanding the course of the child’s life to date and can help us understand how current issues have unfolded. Ben was born in 2005, and is 6 years old. He experienced the death of his mum tragically just before starting school. His behavious are such that he is only attending school for a limited time each day. Contextual factors - His grandparents now have custody of three children. Significant change in roles with added stressor of having to attend school with Ben. Authors like Galligan(2000) that children like Ben are like to have feelings of confusion and bewilderment, insecurity, anger, isolation, loss of identity and self esteem. These can be expressed in a number of ways including angry and difficult behaviour, although these feelings are not thought about at a conscious level.
• #8: Looking at a ‘snapshot’ of Ben’s river at this point in time. In his Environment - Ben’s behaviour is problematic in both his home and school environment. He is now only participating in school for one hour per day. This has significant impact on his grandmother especially, as not only has she taken on custody of three children, she has experienced significant loss herself. However Ben is part of a very loving family, with much support from aunts and cousins. -Driftwood - Ben is a child with many strengths. He is sociable, enthusiastic, conversational with children and adults, and has a very good ability to play. Often traumatic events can impact on a child’s ability to engage in play. Where spaces exist – lies the opportunity play therapy to impact on the ‘rocks’ in Ben’s life. The driftwood, the child’s personal strengths and attributes can be harnessed by the therapist to engage his journey through play. Clinical Reasoning...The indications were that Ben had the capacity to respond to a safe secure child centred environment that the play therapy room would offer. It would not place the demands on him that school did, but would encourage him to be how he needed to be on the day. He also has the added strength of a very loving and supportive extended family.
• #9: A Description of Play Therapy Play therapy is based upon the fact that play is the child’s natural form of self expression. Play therapy has been specifically designed to be developmentally appropriate for children and is based on the idea that children communicate and express inner conflicts and feelings through play (Landreth, 2002).Non directive play therapy was developed from the work of Carl Rodgers and is essentially client centred. It does not attempt to change or control the child’s abilities or behaviours. The importance of the therapist is evident and the relationship is vital. The therapist actively reflects on the child's and feelings, - when these are reflected upon and accepted, the child is free to accept and deal with these feelings. Specific techniques, such as interacting with the child by observing, listening, and making reflective statements of recognition, the therapist conveys a warm and accepting towards the child promoting a comfortable environment, which allows the child to express any emotions they may be experiencing and come to be more understanding and accepting of them. The principles of child therapy re-iterate the child centred nature of play therapy, as the child is effectively in charge, given choice, and the focus is unique and varied according to the child’s developmental needs.
• #10: I’d like to move on to the rationale for using play therapy with Ben.Children express themselves through play and activityDue to the developmental differences between children and adults, children, especially of Ben’s age, need an alternative approach to conventional talking therapy.. Adults communicate through verbalization, whereas a child's natural means of expression is play. Children are not developmentally ready to use expressive language as a primary means of communicating their feelings (Landreth, 2002) and also have difficulty using abstract verbal reasoning, making it difficult for the therapist to use conventional talk therapy to help children work through their problems. Although a child’s method of emotional expression is different than that of an adult, the feelings the child has are similar, such as fear, happiness, guilt, anxiety or sadness. Therefore, “toys are viewed like words by children, and play is their language” Landreth (2002) The basic form of expression for a child s activity" (Landreth, 2002, p. 16). Children use toys to express feelings they may be afraid to talk about. Play reveals several different aspects of a child such as, “what the child has experienced, reactions to what was experienced, feelings about what was experienced, what the child wishes, wants, or needs, and the child’s perception of self" (Landreth, 2002, p. 18). NDPT is particularly appropriate for Ben , especially given his age, as through play he can begin to regain control, and decrease anxiety and aggression. CR. Ben’s initial visit to the psychology and his first visit to play therapy, in which he was relaxed and engrossed in playing creatively, showed that he had a good ability to play and make use of many of the items in the play therapy room and enough grasp to realise there was a difference between that demands that school placed on him and the atmosphere of the play therapy room. He expressed great enthusiasm for the play therapy room and separated easily from his grandmother. Most significantly, the principles of child therapy re-iterate the child centred nature of play therapy, as the child is effectively in charge, given choice, and the focus is unique and varied according to the child’s developmental needs. Miller and Boe(1990) note that the non threatening nature of the playroom is crucial as the child is vulnerable from previous experience and also state the need of these children for consistent attachment to an interactive resonating adult figure. Miller and Boe (1990) note that children in a highly disturbed emotional state can hardly begin to describe the trauma let alone deal with it.
• #11: GOALS OF PLAY THERAPY Objectives for play therapyreflect a broadly defined generalised approach, rather than individualised prescriptive goals. As play is non-directive, is SMART goals, for example, were set for Ben it might be that the therapist to drift into the trap of encouraging the child to work on objectives related to the identified problems – and will restrict their opportunity to work these things out through play. An overriding premise is to provide Ben with a positive growth experience in the presence of a supporting adult so he is able to discover his own strengths. One of the most important things about child therapy , particularly for children who have experienced much disruption to their early lives, is the presence of a ‘resonating adult’ . Through acting out issues through play and the reflections of the therapist, the child works on their own goals, possibly not consciously but in the process of therapy. The focus is on the child not the problem so the emphasis is on facilitating the child’s ability efforts to develop a positive self concept and cope with current and future issues that may affect his life. (Dods, 1987; Landreth;2002)
• #12: Sandplay, as a creative medium us particularly adaptive to many different populations and setting. Sand play can provide a place for expression, within safe containment. ( ) The play element of sand in allowing children to create, for example forming the sand can allow children to drop their defences, opening up communication. .....notes that children automatically filter some experiences that they cannot make sense of, so discussing and exchanging feelings is more likely, as the child becomes more emotionally relaxed and more comfortable in trusting. Unpleasant or negative experiences that Ben needs to resolve could include blocked feelings, unresolved conflicts with significant people in his earlier life, negativity towards his schoolmates, sadness and disconnection. On meeting Ben though, it was obvious that he had many positive qualities, such as sociability enthusiasm and motivation to engage in play and with adults, Sandplay uses the benefits of free play, It is an effective intervention for Ben as it allows his unconscious feelings to emerge at their own speed, and when Ben is ready. The sensory tactile aspect of the sandplay also may have compensated for early play, which Ben may possibly have lost out on. Sand construction can be a way of empowering children – a way of reflecting strength, autonomy . Sandplay can help children with self esteem as the children are actively engaged in creating the picture . It can reinforce a positive sense of self as the power is with the child, rather than the treatment being done to them. As with the principles of child centred practice and non directive play therapy, the child’s own strengths can emerge. The therapist can play the role of supporting emotional regulation as well as two way engagement by enhancing and expanding on sensory exploration and functional play by connecting to the child’s experience. Lowenfield saw the sand as a way of expressing feelings and thoughts that might not make sense to children in the ordinary world. It is a way in which the children can describe themselves to the therapist and talk about the nature of their experiences. Ben also engaged in some imaginative symbolic play with pirates. When Ben developed stories in the sand tray, he used it as a medium for expression - his play incorporated themes, of people sinking, falling etc, but. Ben would initiate intriguing role plays between the characters, including the animals. Prior to therapy ending Ben was asked to He also used weapons – typically and balanced, as a child of his age may but could have been a way of defending threats or ridding himself of feelings. What was significant was asked to finish the story – as a means of self completion and containment. Although some of his play might have suggested insecurity – although West notes that some themes of play are only evident after many sessions of play therapy, when asking questions (but not making interpretations) the people in the stories always were rescued. He also notes that these toys can be used positively , suggesting building and regrowth. . In the last session of play therapy I experienced with Ben, his play consisted of school play which suggested how difficult school was for Ben , and in role reversal I experienced a difficult time at school not understanding the writing on the blackboard which was largely in symbols. Building and creating can be positive as it can show the child is in a positive state of mind. Ben did understand that at school he would be allowed to play once all his work was done, and despite insecurities about attending school, he shows a good reciprocal relationship with staff in the therapy room. Perhaps once the insecurity about school subsided, these positive attributes would allow for easier transition back to school.
• #13: EVALUATION OF THE PROCESS OF THERAPY Finlay (2004) notes that our integrity, effectiveness and confidence as practitioners derive from our ability to evaluate what we do, however notes how measuring progress in psychosocial occupational therapy can have its problems. Evaluation of occupational therapy is often thought to occur at the end of therapy, however, in reality play therapy is being constantly evaluated. Dodds (1987) discusses how evaluating change in therapy can be difficult, but typically the three major sources of evaluation data are firstly report from the child, Through general discussion or by using more specific questions such as on a scale of 1/10 how happy are you. Perceptions of the child’s progress by teachers and carers will also give a guide of the progress of play therapy and other events happening in Ben’s life which suggest a positive looking focus. More objectives measures such as the frequency of behaviours at home and or school can be obtained, along with improved school reports and school/social integration, including more integration within the social environment. None of these sources of information will be without their limits– They may be biased, due to some emotional involvement, or vested interest, however one of the strengths of these measures are that they attend to the child’s perspectives. Objective measures may not reflect the child’s improved or worsened feelings, or could be attributed to a wide range of external factors. Improvement at school for example, may not reflect that the child is still desperately low because of family stressors. It is important to gain information from a wide variety of sources as Finlay (2004 notes to obtain data from several sources, so as not to be mislead by one source of possibly skewed data. Also outcome measurement is often thought as something which is done after completion of a treatment plan, however in reality, its therapists will systematically evaluate progress as the child progresses through therapy. However, in the following slide I will focus on Ben again and relate improvements specifically to him.
• #14: in evaluating the process of therapy, we should always return back to the initial issue that brought Ben to play therapy. (Dods, 1987)There are four key factors that could signify a change that could signify a positive outcome of the therapeutic process, and these could be summarised as followsChange might evolve through the issues in Ben’s play. If Ben showed any aspects of what might be considered maladjusted play, with disturbing themes, then more balanced play would be seen as appropriate. This is not to say that themes of disaster, people dying etc are not acceptable as such, as toy fighting etc is a natural part of development ( ) but there should be more balanced play with good and bad elements, such as a disaster scene – but the people survive, with the themes not being so driven and focused. As many authors, including Ryan and Wilson (2004) and West (1992) discuss, creating a trusting environment for children in play therapy might be more difficult because of previous disturbed relationships with adults . It was always positive that Ben was able to engage with therapists , as this would suggest that the relationship between Ben and his teacher or other significant people in his life could improve, even though this was not being directly worked on in the play therapy room. Once Ben had developed a relationship with the play therapist, he would be better able to accept himself , and as such his behaviours would be more integrated and age appropriate . It is unrealistic that Ben’s issues will be cured forever, as difficulties may recur at a later developmental stage or if the child’s life circumstances deteriorate. But through the process of therapy, the child may be better placed to cope with situations . .
• #16: EVIDENCE BASED PRACTICE IN PLAY THERAPY There are lots of studies that suggest non-directive play therapy is a beneficial therapeutic technique for children, however, Carrol(2000) identified a need for more rigorous, quantitative research. However she notes that it is impossible to accumulate groups of children who have exactly the same symptoms, so although studies with a greater number of children would suggest greater reliability, there are many challenges that this would bring. Outcomes Wilson and Ryan (2001) note that most of the research in the field of play therapy to date is American led. A metanalysis undertaken by them found positive outcomes across many different groups, including traumatised and bereaved children . It was most effective when parents could become involved and where there was an optimal number of sessions. (Ray et al 2001) The studies included involved cases with asd, adhd, trauma, abuse and bereavement. Parents PerspectivesA small process and outcomes found that the approach was effective on a range of measures, including having a positive impact on parental relationships with their children. (Wilson & Ryan 2001). The benefits of play therapy could also be enhanced by the support the parents were given, or the ‘reframing’ of the family issues, leading to greater understanding of all those concerned. Other, unpublished, research into the effectiveness of non-directive play therapy in addressing specific problems, as well as more global problems such as identity problems, have been reported in the States (Brattan et al, 2005) These studies, which reportedly incorporate designs which address shortcomings of earlier research for example using control groups suggest that play therapy does have a positive effect on self-concept. A number of other studies have been undertaken which show the effectiveness of the method in reducing physical and verbal aggression improvement in self-esteem, academic performance, social relationships and impulse controlCarrol notes that first and foremost we should be asking children their views on the play therapy and in a study of 26 children, the majority of them could identify the value of the relationship with the therapist, all of whom felt that play therapy had helped overcome various difficult feelings.
• #17: Key messages of GIRFEC Through the GIRFEC approach, promote opportunities and value diversity, put safety first and consider the whole child: a developmental-ecological approachPromote well-being of individual children and young peopleBuild on strengths and promote resilienceHelp should be appropriate, proportionate and timely, co-ordinated as necessarySupport informed choice, working in partnership with familiesInformation sharing with consent or when necessary without consent for reasons of safety Shared values across professions Connected workforce development and service inspectionIt’s about how services work together to support any child Starts in the universal services for all children – health and educationEarly identification of problems and early intervention Immediate response to protecting children in cases of serious riskBuild on strengths, support family solutions when safely possibleShared framework for assessment and planningStreamlining processes when possibleLead professional to co-ordinate complex services On service contexts, reduced funding, mergers (CAMHS) and new models of care have changes the way services are delivered. A reduced number of qualified posts combined with more generic working perhaps causes a conflict in maintaining our occupational role while working more flexibly within a mdt. There lies a potential to focus the important role the OT can provide in the MDT. Occupational Therapy is described as a research emergent profession, who have not easily implemented evidence based practice, and the focus mostly on their own tuition from clinical practice. Yet one of the issues for Ot research is in developing evidence that meant the standards of level1 EBP namely RCTs which are difficult to perform unless due to the diverse and unique nature of our services. ‘Cultural expectation – childhood being a time of innocent to inspire our children's curiosity, creativity, and imagination. nd special rights – protected and nurtured. (UNICEF,2002) We are denying them opportunities to tinker, discover, and explore -- in short, to play.
• #18: When we talk about play therapy, we imply a holistic approach, using play as a means of helping, in a non invasive way, taking into account the past, present and future of the “whole child “ (West,1992). This was a new experience, as I had done some work with children and ASD, with a mainly behavioural approach, whereas Play therapy is concerned also with children’s feelings, not just their behaviours. Influences on Ben’s participation originate from various sources, for example his social environments, past experiences, his family’s positive attitudes and beliefs and his attachments in younger life. Kawa Model acknowledges and captures this and encourages us not only to focus on Ben as a client, but on his family too – who have also undergone tremendous trauma, and a shift in roles. (Iwama,2010) Other models can be mechanistic and focus on the performance of activities. We must consider the situation holistically and see that engagement is about being.Appropriateness of the model Using the Kawa model and the metaphor of a river helps us visualise why play therapy would be appropriate. The river is dynamic, and ever changing. It’s interdependent – the relationship between the child, the therapist, their carers and their environment is vital and it helps us visualise the child’s past, present – while looking forward to the future. It also allows us to reflect on the abstract less obvious issues that are going on in a child’s life. For example thinking of where the driftwood originated – was this immediate or past events Add quote about play and social environment. Aided Clinical Reasoning Perception of the River , which is longitudinal in space and time allows us to see the process of therapy, and reflect back on other theories such as attachment theories or developmental theories that might have impact on Ben now. . The cross sectional aspects provides a framework for intervention in the here an now. Identified areas for future intervention – such as attending school meetings for Ben, or if compounded family issues resulted, where family work or additional services might be more appropriate. Occupation Focused interventions Thinking of the river again, as I mentioned there has also been a resurgence of interest in occupation at the core of occupational therapy. This has led a move away from the medical model drive to make occupation as the defining feature of our profession and practice. The meaning of occupation, ie play for children, its importance for health and well-being (and play is seen as important way for children to identity themselves within relevant social and cultural contexts.Benefits of Play TherapyUsing Kawa helped identify the benefits of play and play therapy. Changes can be due to a combination of play therapy , and the therapeutic process, the attention given to supporting the family and other significant people in Ben’s life, such as involvement in school meetings. This is not to say that Ben will be free from any problems surrounding his traumatic early life, but perhaps as West(1992) notes, he “was given a springboard to bounce into the future” As the kawa model allows us to focus on Ben’s future life flow, hopefully he will be able to cope with adverse circumstances in the future.