A Critical Review Of The Application And Treatment Of Psychotherapeutic Play Therapy In Autism

A Critical Review of the Application and Treatment of Psychotherapeutic Play Therapy in Autism

The world of psychotherapy and its application to autism has been largely influenced by Kanner (1943, as cited in Ruberman, 2002) who coined the term "early infantile autism" for the symptoms associated with autism such as deficits in language, repetitive behaviours and an inability to relate themselves in the ordinary way to people and situations from the beginning of life. Furthermore Kanner noticed similar features in parents including, for example, a tendency towards being over intellectualised and obsessive. This later caused much upset among parents of children classified with autism as they felt they were a cause in the disturbance among their children. Kanner, actually suggested that autism is an inborn disorder, and not caused by psychogenic means.

Other areas of psychotherapy that contribute to autism as well as the element of biological contributions is the fundamentals of development including work by Bowlby (1960) and Spitz (1946) on maternal deprivation and its effects on attachment. They maintained that the absence of the nurturing presence of a caring adult (usually the mother) during a child's early years can damage future development. Psychoanalysis such as work by Mahler (1952, Barnett, 1989) focuses upon these inner workings of children with autism.

Freud expressed some intuition about psychosis and autism, even if he did not elaborate his ideas, he claimed "If it is in the very nature of any neurosis to turn away from the 'other person' and this seems to be one of the characteristics of the states grouped together under the name of dementia praecox - then for that very reason such a state will be incurable by any efforts of ours" (Freud, 1909, as cited in Morra, 2002). Kanner (1943, as cited in Kobayashi, 2000) pointed out a tendency towards obsessions and abstract worries in the families of autistic children, and added that there were very few really warm parents implying yet again that parenting was an attribution towards autism (1944). Mitrani (1956 as cited in Bowbly, 1960) says that 'Too much closeness on a physical level, compensating for a frailty of emotional contact, has impeded the development in such individuals of a safe space in which psychic objects might otherwise be created'. In a sense they adapt themselves to physical dialogue with their mothers.

Klein (1955, as cited in Houzel, 2004) described a normal autistic phase of development at the beginning of life and claims the child could, at any moment, regress to that normal phase of development, giving rise to a pathological autism. In any event, she later changed her opinion completely, stating that autism is an early developmental deviation, not a halt at, or regression to, a normal early infantile stage of autistic unawareness.

In 1919 Klein (1955, as cited in Houzel, 2004) began to implement the theory of autism into the technique by using play as a means of analyzing children under the age of six. She believed that child's play was essentially the same as free association used with adults, and that it was provide access to the child's unconscious. Freud (1946, 1965, as cited in Barrows, 2004) utilized play as a means to facilitate positive attachment to the therapist and gain access to the child's inner life. Furthermore Hermine Hug-Hellmuth (1921, Urwin, 2002) formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyse the child.

The main area of psychoanalytic appliance is "playful" therapy. It is not generally regarded as an appropriate form of treatment and is even, at times, felt to be potentially damaging by some. Howlin (1987, as cited in Barrows, 2004) 'one cannot conclude with certainty that it does not work, nevertheless, there is little evidence...to suggest that it does'. Almost 10 years later, Campbell et al. (1996) concluded that 'psychoanalysis as a treatment for autism has a limited value' anecdotal evidence suggests that unless therapy is combined with direct practical advice on how to deal with problems, the outcome may be disastrous. Simply taking an individual back to his or her early childhood, or focusing on disturbed mother-infant interactions, is more likely to result in obsession ruminations and laying the blame for all current problems on other people, rather than encouraging effective coping strategies. This view seems to be based on a misunderstanding of the way in which child psychotherapists now work with such children. A recent paper by Alvarez (2000, as cited in Houzel, 2004) has sought to address these misconceptions and has described a model of therapy that is informed both by the most recent psychoanalytic models of early development and those provided by developmental psychologists such as Tronick & Weinberg (1986, as cited in Maroni, 2008). Rather than revisiting his or her early childhood, a key feature of this modified approach is the emphasis on making emotional contact with the child, by whatever means seem most likely to engage the child's attention. In working in this way, child psychotherapists come close to offering the kind of therapy that Baron-Cohen & Bolton (1990, as cited in Borrows, 2004) see as being valuable, and which they refer to as 'play therapy'.

This practice is described as valuable in helping children with autism to control anxiety and play more creatively, but it can be counterproductive if the therapist makes interpretations of the child's play that simply confuse the child. The implied distinction between 'psychotherapy' and 'play therapy' would seem to be somewhat misleading. Child psychotherapists are familiar with using play as a means of communicating with non-verbal children whereas Klein (1955, as in Barnett, 1989) also originally developed her play technique as a 'substitute' for the adult patient's free associations. Concerns are also based on if the therapist's comments are pitched so that the child can understand them. Where there may be a difference is in how the work develops if and when the child begins to emerge from their autistic state. One difficulty for either kind of therapist is that "Play" in the sense of symbolic, imaginative play rather than repetitive actions is precisely what autistic children are bad at (Urwin, 2002). It is the absence of this capacity that forms one of the classic triad of impairments described by Wing & Gould (1990, as cited in Urwin, 2002) and the DSM-IV (2000) "impairment of social interaction, repetitive activities in place of imaginative symbolic interests, and impairment