Setting up Play Therapy Room

Post Graduate Diploma in Play Therapy (PTDipKL22017)

  

PROJECT: SETTING UP A PLAY THERAPY

This paper aims to report a task of setting up a play therapy service for children. Planning to write this report, I was contemplating whether to report on what I have already had now or what I have thought of establishing in the near future, hopefully in one year time. I decided to combine both elements in this report as I thought only that would enable me to answer most of the points recommended in the guidelines of this project.

Hence, this report starts with a general introduction of the location where I am now and describes the rationales of setting up play therapy in this place. Second, it elaborates the existing play room that I established which describes briefly the process I went through, things I have accomplished so far, as well as my success, failures and learning points.  Third, it presents my future plan to set up a new play room service, which is expected to be placed in a slightly different setting. It covers important elements in play therapy setting such as safety issues, crisis management, as well as court skills and management.

Background

I am a senior lecturer in psychology at School of Medical Sciences Universiti Sains Malaysia and a clinical psychologist at the affiliated teaching hospital – Hospital Universiti Sains Malaysia (HUSM), situated in the north east of Peninsular Malaysia – Kelantan. Being the only tertiary hospital in the eastern part of the country, all patients from three nearby states who have medical and health-related problems and wish to seek treatment and services from this hospital need to get referral from a third party. The referrer can be primary health care practitioners such as medical doctor.

HUSM is a semi-governmental organization thus majority of the hospital expenses is funded by the government. Since the last 20 years when the hospital was first opened, the charges to patients is very minimal, such as RM15.00 per visit to see a specialist, or free of charge for common medical procedures such as blood testing procedure in the clinic. However, due to current global economic crisis, Malaysian government has now slowly cutting off the subsidy given to its agencies, and HUSM is no exception. The hospital’s annual budget for example, has been steadily cut for several years that the administrator has planned some drastic interventions such as generating income from hospital services. As such, by early next year, majority of the hospital services and procedures will be charged on the patients. Psychological services is one of various services offered in HUSM. At this time of writing, except for RM15.00 for initial registration, the services is free-off-charge.

The main setting for psychological referral is at out-patient clinics. This involves paediatrics clinic, psychiatry clinic, and very recently, combined psychology and neuroscience clinic. This service however is considered to be limited in capacity (i.e. very restricted number of referrals can be accepted at one particular time) due to very limited number of psychologist available in the hospital. As I am working in this setting, it is very convenience for me to set up a play therapy service, in addition to psychological and counselling services I have been offering since last 8 years.

The main rationale of setting up a play therapy and offering this service in this organisation is because currently no play therapy service is available in the hospital, despite the dire need of such therapeutic option for children. Play therapy is a treatment of choice for various childhood problems and issues whereby most of the time medication is not indicated at all. For instance, I receive approximately 10 to 15 new referrals every month that seek for psychological intervention for children from various parties inside and outside the hospital. Generally, I consider that almost one third of this referral is appropriate for play therapy.

The Current Setting

Since early this year, I set up a play therapy service at my workplace mainly to fulfil my therapeutic play session requirement. This play therapy service is offered under my newly-established psychology clinic which is called as Combined Psychology-Neuroscience Clinic (CPsych-Neuro Clinic), in addition to Paediatrics out-patient clinic that I attend once a week. It appears to me that introducing a new service such as therapeutic play is feasible through this new psychology wing because it is consistent with the existing services arrangement  that include day-care and rehabilitation activities as well as  available resource such appropriate room to be furnished as playroom. A meeting with the Head of Department of Neuroscience, Professor Zamzuri Idris – a clinical neurologist who is in-charge of all clinic services under Department of Neuroscience – including CPsych-Neuro Clinic was held. During the meeting, I discussed my plan, rationales, and needs to offer therapeutic play and play therapy services at the CPsych-Neuro Clinic, upon which he had no objection. I was made responsible to take care of the management of my own service so that it is aligned with the existing hospital system and requirements.

Consequently, I contacted several people to inquire about management of patients’ appointment in the hospital system. Referring to particular minutes in one of the meetings with hospital director, CPsych-Neuro Clinic has been approved to operate but this new clinic had not been registered in the system – which means there is no way I can record in or track my sessions from the system. After several weeks, my request was approved that the hospital system administrator has registered CPsych-Neuro Clinic under day-care clinic services, thus my therapeutic play session can come underneath.  Following this, all referrals and appointments are keyed and maintained in the HUSM clinic system by a nurse in-charge of all clinics on that specific floor. Every child comes for the session needs to be registered as HUSM patient and each appointment is recorded in the clinic system. As for this cohort of children, no formal record is made in their dedicated hospital folder but notes are written and kept in and for my personal record-keeping and training purposes only. Similar to other clinic services, play session is provided free-of-charge for now. As for the current arrangement, referral is obtained from my existing psychological service, whereby most of the referrals are made by medical officers in the hospital. Initial assessment is conducted to indicate if the referring issues and children are suitable for play therapy. 

My Play Room

The current ‘Play Therapy Room’ is located in a hospital day-care building, at level 2. This is a new building with rows of day-care clinics for various medical specialisation, such as rehabilitation, ophthalmology, neurosurgery, psychiatry, internal medicine, obstetrics and gynaecology, to name some. The room I am using now is initially designated for Dance and Movement Therapy, thus we will share this fairly well-equipped room. It is a medium-size room with fully-blinded window and a door with a small window on the top. It has a sound-proof wall, video recording, and one-way mirror facilities. The room is allocated at the very end cornered of the row of the clinics thus it is least likely that the children’s noise during play would distract or disturb other patients or staff members. Figure 1 to 10 illustrate the room and some of the toys available for the time being.

Fig 1: Front Door 'Therapy Room'

Fig 2: Inside the room

This is the second play room that I set-up since I started my training in therapeutic play skills. The first one was set-up in a kindergarten and now closed as I moved back to work place. I would say my room is equipped with adequate materials and toys necessary to start play therapy session. The materials and toys I prepared can be grouped into several categories that would normally serve most important themes or purposes in play therapy. I select some important toys that I have in my room and describe some observations I made on those to illustrate some learning points and issues arose from that.  

First is regards to toys for creative expression and emotional release. A strongly-built, wooden covered sand tray and specially imported natural and hygienic sand have always attracted children to come in my room. Sand is one of the best materials I have that facilitate creativity, emotional release, boundaries setting, and fun, messy play. Whilst I have some reservation about the use of water in the room due to logistic reason, I admit should water is offered, children would have more freedom of expression and fun play opportunities. Compared to my first play setting, I opted not to offer water in the room because of the restriction implied by another party whom I share the room with now. In addition, the sand I have now is adequate for only one tray thus I choose to offer dry sand instead of the other. In the near future, I will find ways to provide wet sand as well as paints, easel with water in view of significant benefits those materials could have on a child, based on my recent readings on play.

Fig 3: Sand Box 

I always have clay in the room too for the same reasons but somehow plenty of natural clay that I have in the room is not appealing for majority of the children – at least those I am seeing now. ‘Play-doh’ instead is desirable by many children but I always have difficulties to maintain ‘adequate’ stock. Based on my experience, whenever a child is in a ‘clay mode’ play, some of them would create so much from clay, want to preserve and keep the clay model until I have very little clay left for other children. It is frustrating to listen to a child asking for more red clay for example, when all of red clay had been preserved and kept by the earlier child. Similar issue goes with flashing colour, sticky marker pens where many children really love to draw with and use up so much that often left little or no ink for the next children. Reflecting this, I wonder it could be about my skill or my own reservation in dealing with children consuming materials in excessive manner or something related to that.

Second, I have some real-life toys such as doll-house, puppets, people figurines, and baby doll that enable a child to play by themselves, as themselves, or act out family members’ activities, emotions, and responses. Baby doll is a favourite toy for girls in particular. Later I would like to add feeding bottle, baby pillow, and blanket in my room as suggested by some authors in play therapy. I found that cooking utensils, doctor kits, and carpenter tools are mostly chosen in the room. Via these toys, I could see many things from the children such as changes in interactions, language-used and communications as well as shift in play patterns and roles. I plan to add cooking shelves, money transaction machine, and wooden doll house if possible as these toys could add up opportunity for the children to role play and directly express their feelings. Moreover I would like to add my role-play materials by adding some recommended materials such as jewelleries, handbag, handphone, shawl, large clothes and hats like policeman’s helmet, fireman’s or soldier’s hat.

Third concerns with toys that facilitate releasing of acting-out and aggression in children. It is known that children come in play session usually hold strong emotions for which they do not have words or verbal label to express. I have few materials for this purpose in my room such as gigantic insects and wild, frightening animals such as alligators and snakes. I realise only recently from my reading that toy soldiers could serve the same purpose. Based on my observation, musical instruments that produce loud and high-pitched sound such as drum, xylophone, and even maracas could also function the same. I have seen several children playing those instruments in a very out loud sound and long duration as if they are expressing some emotions from inside. I noticed that I do not have much toys in this category. I consider to add some recommended toys such as pop guns, rubber knives, and swords, as well as big soft pillows, egg cartons, and newspapers.

Majority of the things that I have in my room now is those I have used and still using in my certificate training. Whilst I had planned my first room pretty thoroughly and went to various shops for several weeks looking for toys and materials to be put in my room, and again at the middle phase of the training, added some new materials, I always feel the need to improve the ‘collection’. Almost every time I read on play therapy, and often during the play session, I have some feelings that my room is not adequate, that it can be prepared better for the children to express themselves, or it is not good enough compared to those I viewed in the Youtube. As a result, I always convince myself that for the new session I will have in Diploma training I would plan and shop ‘better’ so that I could have an almost ‘perfect’ collection. Writing this now I sense that the feeling of inadequacy and never good enough is exactly one of the core beliefs that I always carry with me and somehow affect the overall view of myself. I will see if my perception would shift as I give another chance to myself – which is soon after I improvise my play room that will be used for the new children enrolled for diploma training.

One thing I will stop doing when I start my new children is to inform and show them that each has a box to keep the things they made during play. I learned that some children feel the box is more important than the play that they keep finding ways to load the box with everything possible from inside the room. It is a struggle when children constantly negotiate and find ways to get the things they wanted to be kept in the box. In addition, it is hard for some children to wait until the end of the therapy before they can bring the box home and show their achievement’ to their parents and friends. 

Confidentiality and Safety  

Whilst confidentiality and safety are very important elements in all forms of therapeutic relationships, I admit that I could only appreciate their importance and learn the good lesson when issues and crisis happened especially in the play room. For my newly recruited children and parents, I will spend some time and effort to explain about confidentiality, privacy, and sharing of information, as well as examples of specific conditions when these principles can be overruled. With the parents in particular, I need to reach to an agreement the extent of confidentiality to be exercised. I will advise the parents my potential actions should a situation recommends for breach of privacy and confidentiality in putting the best interest of the children. It would be preferable if I could prepare a written document whereby the parents could read some details and sign the document of agreement.

As far as security in the room is concerned, I learnt my lesson that my safety is my sole responsibility, in addition to the safety of the child and the room. Being in the room with an emotionally intense child for example, I need to be well-prepared to remain safe and to prevent any potential harm. For instance, I should wear a practical, proper attire – such as top and pants instead of skirt or long dress. I must not wear any jewelleries to prevent injuries if the child happen to inflict harm on me. Most importantly, I must keep away materials or equipment that may potentially be harmful such as glass table or broken toys with sharp edges.

Child Protection Procedures and Legal Matters

The current setting of play therapy service is directly positioned under Hospital Universiti Sains Malaysia management. On one hand, it is pretty obvious that matters related to child safety and protection should be in agreement to existing policies and procedures applicable to all services under the jurisdiction of the hospital. There is a specific guidelines for hospital management of child abuse and neglect published by Medical Department Division, Ministry of Health Malaysia in June 2009, which is applicable for clinical services in HUSM. Following this guideline, HUSM has developed and enhanced child abuse services within the hospital under the management of SCAN Team. The SCAN Team is a centralised, multidisciplinary team of hospital staff that comprises of paediatricians, gynaecologists, mental health professionals, accident and emergency staff, forensic pathologists, nurses, and medical social workers who work closely with designated Welfare Officers from Division of Community Welfare, Child Protection Team, and police officers in charge of abused and neglected children. The SCAN Team members are trained to evaluate and manage child abuse cases. It is a mandatory requirement of doctors to report suspected child abuse, neglect, and/ or protection needs to the Child Protector (empowered Division of Community Welfare officer) under the Child Act 2001. Under this Act, the identity of the reporter will not be revealed without consent unless ordered by court.

Therefore, if I suspect any form of sexual and physical abuse, harm, or neglect in children, or should I see evidence of abuse emerges during therapy, I am obliged to refer the child to the hospital SCAN team for thorough assessment and further management. In such a situation, I would need to bring the child One-Stop Crisis Centre (OSCC) – a 24-hour one-stop crisis center that is located at the hospital emergency unit that serves as the entry point of child abuse cases in the hospital. There is a private area where the child and family members will be interviewed by health personnel, welfare officer or police, medical social worker, and counsellor. Initial medical examination might be performed and the child could be admitted to the hospital for further assessment, treatment of any physical injury, and counselling.

On the other hand, applying or using those guidelines when a situation arises is not a straightforward action. First and foremost, to make a decision whether or not a condition we suspect is genuine, harmful, and worth reporting is not an easy task. Guidance and advises from clinical supervisor is essential. Second, informing and getting parental as well as children’s permission to bring the suspected problem forward to be managed by responsible party such as SCAN Team could be problematic. In addition, getting multidisciplinary team members to work collaboratively on a case is complicated and this might take long-duration effort.

A final thing to be considered is my limited role as therapist, and possible involvement with legal matters such as become the subject of court proceeding as an expert witness. Ideally, at the outset of therapy, I would clarify and clearly negotiate that my level of involvement in a child’s case, to the parents, referrers, or any parties related with the child’s referral, is limited to what I have agreed to commit at one particular time. For instance, I may agree to undertake an assessment of a child’s needs for therapy rather than becoming expert witness to recommend for placement or specific conviction.

My Future Plan

Currently, there is no dedicated budget from the hospital for my play therapy service, as well as no income is generated from the service either. As for now, all service expenses, such as purchasing toys and maintaining the room, as well as training and supervision fees are at my own cost. It is indispensable to plan for sustainability of the services in the near future so that play therapy which is started this year in this hospital will be available for the benefits of the children. There are at least two ways by which I will work out to ensure play therapy to sustain in this setting.  

My first plan is to bring play therapy into USAINS Executive Health Services Polyclinic and Ward HUSM (USAINS) under USAINS Holding Sdn. Bhd. The USAINS is wholly owned by Universiti Sains Malaysia – a corporate entity that markets and promotes the intellectual property of the university, in particular qualified professional and clinical consultants from both health and allied health fields. Via executive clinics and wards, medical and health services are offered by highly qualified and professional consultants at particular fees. The main advantages of USAINS services are that the patient will definitely be seen by consultant and at a shorter waiting period, compared to the regular, governmental subsidised clinics. The service provider and consultant on the other hand, will receive consultation fees with some deduction made to USAINS for administration and service promotion charges. In order to establish a play therapy service at USAINS, the first step is to submit a proposal to offer play therapy in this private wing and then conduct a presentation to the director. Next I will need to set up a new room for play at USAINS out-patient clinic area. Then the service promotion will take place, followed by assessment of potential clients and arrangement for appointments. Should this arrangement happen, I would receive some fees from my play therapy session and hopefully I would be able to use some of them to sustain the service.

My second plan is to stay at the existing set-up, which is for now receiving no income but rather need to spend money to sustain the room. If I need to be here for longer period, I will plan to generate funds from authorities and relevant organisations. For instance, I could write a proposal asking for funds from the hospital or non-governmental organisations that focusing on helping children to furnish the room with toys for the sake of children who are mostly of disadvantages. I could also apply for research grant that proposes interesting and important study related to play therapy and specific children, such as children with learning difficulties.

In short, setting up play therapy service at a hospital setting like this, for the first time, by a single person who is under training and supervision, is a challenging but exciting experience. I would consider this is a work in progress as I am sure there is so much I will learn both from my formal training as well as my clinical experiences with children in the playroom.