Topics in Psychotherapy and Psychology

 © Dr Elaine Bing | 2 Dec '17








Cognitive Behavioural Therapy

Most people who have contact with a psychologist will have contact with a psychologist who practices psychotherapy. These psychologists are scientists who use the science of psychology to assist people who are either in distress or who wish to develop in some or other way.

There are numerous different approaches to psychotherapy. It can be confusing and it is worth spending a bit of time discussing the main differences and commonalities between these different approaches.

Let’s start with the one you have probably heard a lot from in the last while if you follow developments in the field at all. Cognitive Behavioural Therapy or CBT. CBT is often known as an evidence-based intervention (EBI) which has led to its popularity. In other words, there is a lot of research that supports the claims of CBT to make a difference in people’s lives and to assist with problems for which people typically consult psychologists. We’ll discuss research some other time; for now we’ll stay with CBT and what it does.

Cognitive Behavioural Therapy has its modern roots in behaviourism. Behaviour Therapy had arisen partially in reaction to psychoanalysis (developed by people such as Freud). Instead of trying to uncover unconscious needs, behaviourism looked at present behaviour and what led to behaviour and behaviour change. We’ll discuss behaviourism and its modern variations in a later article. Around the 1950s and 1960s Albert Ellis and Aaron T. Beck started their work on cognitive therapy. Although they had many arguments about whose approach was the best, they both focussed on the role of thoughts causing symptoms such as depression and anxiety.

Today CBT examines the role of both behaviour and thoughts in influencing how we feel and how we can change bothersome symptoms.

CBT has come far and there are now many permutations that can be used to treat a large variety of illnesses. The generic approach is known as cognitive behavioural therapy or CBT with the same name used for the work that has developed from Aaron T. Beck’s work. Work flowing from Albert Ellis’s approach is known as Rational Emotive Behaviour Therapy (REBT). Both approaches target thoughts and behaviour, but they have somewhat different theoretical approaches. I’ll discuss that in a later article. The third wave CBT approaches, often combine an element of mindfulness meditation with the impact of thoughts and behaviour. These include approaches such as Dialectical Behaviour Therapy (DBT) and Acceptance and Commitment Therapy (ACT).

 © Dr Elaine Bing | 3 Dec '17




Cognitive Behavioural Therapy - Beck approach

This is probably the most commonly used approach to CBT and has loads and loads of research support. Beck started developing it in the 1960s. In essence the approach links automatic thoughts and beliefs to symptoms. If your thoughts are irrational you will have problems in mood, anxiety and so on. A typical example would be the irrational belief that you are never good enough. A thought like that may lead to a fear of being judged and found to be inadequate. It is not hard to think that can easily result in performance anxiety. Depression is also possible. In CBT irrational thoughts such as this are challenged and bit by bit replaced with more rational thoughts.

CBT is very structured; an agenda is set for each session, homework is given and followed up on. If you see a CBT therapist everything is explained. You will never be expected to do something without having agreed to it and understanding what you are doing. It is a psychoeducative approach, in that you are taught skills which you can apply in your life.

You will be taught to recognise automatic thoughts (the ones that arise immediately) and to challenge them. Later you learn to recognise beliefs that underlie the automatic thoughts. Let’s give an example:

Activating event Automatic thoughts   Consequences
Struggle to do an assignment I’m so stupid
What’s wrong with me
I’ll never get this right
Feel despondent
Feel stupid

Automatic thoughts just come up – automatically. These can be challenged and we can think about the thoughts we have had and realise that not managing an assignment does not necessarily mean we are stupid. Not understanding something may just mean that we need to spend a bit more time on it and we will manage it. Not getting it right immediately does not mean that we will never manage it.

There are all sorts of terms that are used to describe these sorts of thinking errors, such as black and white reasoning, catastrophizing and so on.

We can take it further and look at underlying beliefs that sort of capture the essence of the automatic thoughts. Let’s assume we pick up similar thoughts in various situations. We can then think what the underlying beliefs may be and may eventually realise that an underlying belief is that intelligent people never struggle with work and that if you are to be successful you should manage things immediately and easily. Clearly, that is not based on reality and is not a rational belief.

 © Dr Elaine Bing | 4 Dec '17




Behaviour in Cognitive Behavioural Therapy

There is a lot of emphasis in CBT on thinking and it’s possible to wonder whether behaviour comes into it at all. Behaviour plays an important role in CBT and the area we see it most closely is that of anxiety. Let’s take some typical examples. Specific phobias is an area where we can easily see the role of behaviour and how CBT utilises behaviour change to achieve a change in symptoms.

In specific phobias, people typically fear something; common fears include a fear of animals such as spiders, rodents, birds, fear of conditions such as heights, darkness, flying, and a fear of objects such as needles and so on. These are not fears of social interactions (e.g. public speaking) which will be diagnosed as social anxiety or social phobia. The fear of the object or situation is disproportional. If someone fears a hungry lion that is able to attack them it would be reasonable and not a phobia. If they fear spiders to the point of not wanting to watch television for fear that there may be a programme that features spiders, it is clearly unreasonable anxiety.

When the phobic person successfully avoids the feared object they experience some relief which rewards their avoidant behaviour. It also confirms they are safe because they avoided the situation. Add to the rewards for avoidance, they are not exposed and never have the opportunity to discover that the feared object is safe.

In these situations, CBT encourages exposure. We don’t just dive in and expose, but we start with less feared situations and work up to the more feared objects. For example, if someone fears spiders, we are not going to ask them to immediately allow a large baboon spider to walk on them! We will possibly start with a photo of a small spider which they can look at until their anxiety starts to subside. We will then take the next feared situation on the hierarchy and so on.

This illustrates the basic principle of exposure in CBT. It works extremely well and people are often surprised at how easily these fears can be brought under control. Exposure is used in other disorders, such as panic disorder and obsessive compulsive disorder. I’ll get to them in later articles.

 © Dr Elaine Bing | 13 Dec '17



Panic Disorder and

Cognitive Behavioural Therapy

Panic Disorder is common and one of the disorders that do very well with exposure.

You may wonder what the difference is between panic attacks and panic disorder. In panic attacks people have a period of intense fear with a number of possible symptoms, such as trembling, a feeling of choking or smothering, feeling hot or cold, tingling or pins and needles in hands and feet, chest pain, racing or pounding heart, feeling weak or dizzy, nausea or abdominal discomfort, a feeling of unreality or of being detached from yourself, fear of dying or loss of control or of going mad. Panic attacks can occur together with any other mental illness. In Panic Disorder we have the same symptoms but people fear the possibility of it happening again and will often avoid situations which they have associated with panic attacks. This attempt to cope with the panic inevitably leads to worsening symptoms.

At times, Agoraphobia is diagnosed as well, which is literally the fear of open spaces. The real danger, is not the symptoms of panic, but the huge impact of avoiding more and more places. For example, someone has a panic attack in a shopping mall and then starts to fearing and avoiding malls. This generalises to any situation in which there are crowds of people. Eventually it leads to situations in which the person feels trapped, like cinemas, theatres, the gym, congested traffic, and so on. It becomes a debilitating condition.

Cognitive Behavioural Therapy is very effective in treating Panic Disorder. We generally implement three elements in our approach – one where we address the sufferer’s thoughts which includes facts about panic, we develop some skills such as breathing and thirdly use exposure.

Thoughts in panic disorder, tend to be catastrophic – the worst is going to happen. For example, a slight twinge in their chest which most people would hardly notice, for the sufferer of panic disorder means that a heart attack is imminent. Anxiety at the sensation will often then lead to a panic attack. People with Panic Disorder are much more aware of body sensations than people without panic. We address the fear of panic attacks and help people realise that these are not unusual sensations in the right context – a pounding heart that is beating quickly is normal in a tough squash match.

We also teach people breathing skills. There are various approaches to this, the one I generally use is breathing in normally and breathing out slowly. Many of the symptoms are the result of hyperventilation – breathing too quickly and getting too much oxygen. Symptoms such a difficulty with breathing and the feeling of pins and needles dissipate when breathing is normalised and we get less oxygen.

The other element of treatment is exposure to both the symptoms of panic and to situations in which they have been experienced. We teach people to elicit and cause the symptoms, for example spinning around to become dizzy, hyperventilating to feel the unreality, light-headedness, pins and needles, breathing through a straw to feel the sensation of smothering, running up stairs to increase heart rate and so on. These are practised (obviously when calm!).

In all these exercises we effectively separate body sensations from panic. The eventual result is that if the individual feels the symptom, he or she is used to the feeling and it does not inevitably mean a panic attack. This is even seen in the abatement of panic attacks in sleep.

We also start exposure to situations in which panic has been experienced, for example malls, driving and so on. We also start getting agreements to remove safety behaviours in these situations, e.g. carrying water, pills, and so on if panic should be experienced.

Cognitive Behavioural Therapy is very effective in dealing with Panic Disorder and definitely worth considering.

 © Dr Elaine Bing | 12 Jan '18



Generalised Anxiety Disorder

For many people, the first time they probably heard the term, was with the trail of Oscar Pistorius who was said to suffer from Generalised Anxiety Disorder (GAD). GAD is however common and the chances are you will know someone who has the problem. People with GAD feel keyed up or on edge. They tend to worry and often complain that they can’t switch off their thoughts. This may lead to difficulties in sleep, and concentration may be affected, People with GAD will often complain that their muscles are sore. They may be irritable and may complain of tiredness.

As with all psychiatric diagnoses, there is only a diagnosis if it affects your life badly.

Can something be done for someone with GAD? There is a lot we can do. They can learn techniques to relax their bodies, such as progressive muscle relaxation. Meditation may also be useful.  On occasion, medication may be useful.

One of the main symptoms of GAD is worrying. How do you know that you are worrying? When you are thinking as a part of problem solving, you will progress in your thinking and feel better for the effort you put in. When you worry, you tend to circulate between the same thoughts and feel anxious and even a bit depressed. Worrying is not productive thinking.

One of the irrational thoughts people with GAD have is that the worrying is dangerous. It isn’t dangerous, just tiring and it causes the discomfort of anxiety. Equally irrational, some people think worrying is finding solutions. But when thinking about it we realise worrying never results in solutions. Often these are some of the initial irrational thoughts we challenge when working with someone with GAD.

We also teach people to rate their anxiety with regard to intensity on a 0 to 100 point scale. We are not just anxious or calm. If you struggle with anxiety, try and evaluate how anxious on a scale of 0 to 100. There are lots of different levels of anxiety. This begins to make the anxiety more manageable.

We can then start to target the content of the thoughts someone has. Visualising your child being killed in a car accident has to be recognised as a thought you have had many times before and every time your child has got home safely. Visualising his death is not helpful and is not rational. Of course the roads are dangerous, but out of the thousands on the road most get home safely. So you can tell yourself that he is probably fine, that your worrying is only making you anxious and keeping you out of sleep. Your worrying is not going to keep him safe.

The disastrous scenarios you conjure up if you don’t get a particular payment is not helpful and will probably not end the way you have fantasied it. The chances are you will be able to manage the situation. You don’t have proof the payment is not going to be made. It will probably be made. And if the payment does not come through, you will probably be able to get a loan to tide you over until it does come through. It may not always be the solution you want, but there are generally solutions that can be found when you stop worrying. People are taught to question the rationality of their thoughts and replace them with more realistic ways of thinking.

A useful technique goes beyond the challenging of the content of thoughts and simply asks if there is any value to the worrying. As we have already decided, there is no value to worrying. We then ask people to stop worrying – to postpone the worry if it is the best they can do. No one thinks they can stop worrying – that is one of the symptoms of a GAD; the sense that you struggle to control your worry. Worry is actually controllable. Let’s get an example: You are sitting and worrying. Really worrying. And if you are then told there is a fire, you are going to set the worry aside and run. No one will say: “I can’t think of fires now, I’m busy worrying!” So, we know how to set worry aside. And that is what we ask people to do as soon as they notice they are worrying. We also teach people how to control the focus of their thoughts.

All of these techniques need practise. Changing behaviour takes around three months to become something we do without thinking. This is no different. But, with practice we can gain control over GAD.

 © Dr Elaine Bing | 29 Jan '18

Social Anxiety Disorder

(Social Phobia)

Have you ever been nervous about speaking to a large group of people? Many people relate to the feeling and indeed, public speaking is the most common problem people with social anxiety report. But we are not just talking a bit of nervousness at having to speak in front of others. Someone with Social Anxiety Disorder really fears it. They fear that they are being judged by everyone in the audience or that people will see how anxious they are and they will be embarrassed or humiliated. As a result, people with Social Anxiety Disorder will either avoid public speaking or endure it with great suffering.

Social Anxiety can be a problem in numerous situations, such as having a conversation, walking past a group of people, buying something in a shop, making a telephone call, urinating in public toilets, and so on. As with all psychiatric disorders, it has to affect someone’s social, work or school life to be diagnosed. In all cases, the dominant symptoms are intense anxiety when exposed to the situation and the fear of the outcome, e.g. embarrassment, humiliation, being seen to show nervousness, incompetence and so on.

Social Anxiety Disorder is common. People with social anxiety often have other psychiatric disorders, in particular anxiety or mood disorders. Substance abuse is also quite common. Social Anxiety Disorder tends to remain a problem over years, more than some of the anxiety disorders which sometimes improve over time.

Cognitive Behavioural Therapy works well for people with Social Anxiety Disorder. Again, we create a hierarchy of less feared to most feared situations and use exposure. We also look at the thoughts of sufferers and challenge irrational thoughts (e.g. “If I mess up the presentation I will have no future in the company; everyone will know I’m a fraud.”). Another element that appears to maintain social anxiety is the tendency of sufferers to focus on themselves and their discomfort. In treatment they are taught to focus more outwardly – for example to watch people’s reaction to them (e.g. other people in the queue don’t roll their eyes and get irritated when they fumble slightly looking for money in their purse). People can also be taught to relax on cue when in anxiety provoking situations.

When necessary, sufferers are referred for medication. It is definitely worth treating Social Anxiety Disorder, as we encounter people daily. Typically, trying to avoid anxiety provoking situations can worsen the condition.

 © Dr Elaine Bing | 29 Jan '18


Separation Anxiety Disorder

When we hear the term Separation Anxiety Disorder we probably think of the four year old clutching her mother’s skirts and refusing to go to pre-school. We often think it is something that will pass. However, we now know that Separation Anxiety Disorder is common and can continue into adulthood. Around four per cent of children under the age of 12 are diagnosed with Separation Anxiety Disorder in a 12-month period. It is the most common anxiety disorder among children. As for adults, we are looking at between one and two per cent.

Separation Anxiety Disorder is interesting as it often acts as a sort of initiator into anxiety disorders; a child with Separation Anxiety Disorder often develops into an adult with panic disorder or generalised anxiety disorder.

Let’s look at the symptoms of Separation Anxiety Disorder: A person with it, shows fear or anxiety that is not appropriate for their age when separated from people to whom they are close. When separated from them they show excessive distress and may worry about something bad happening to them. They not only worry about something bad happening to attachment figures, they may worry about something bad happening to themselves that causes them to not have contact with the person they are close to. For example they may worry that they will be kidnapped, when this is a totally unrealistic fear. Because of the fear of separation they may fear going to school, work, sleeping out and so on. The anxiety can also manifest in nightmares of being separated or in physical complaints such as tummy aches. These symptoms are generally a problem in children for about four weeks before we make a diagnosis. In adults we would be looking at about six months.

The question is whether this is treatable? We have previously spoken about exposure and exposure plays a role in the treatment. Through exposure people learn separation is not dangerous, and that they can learn to cope with the feelings. They also discover the feelings do get better with time. As with all exposure, it is a joint decision where we start. We use a hierarchy of least scary to most scary and we repeat exposure for the same incident. It is also important to do it over multiple areas – e.g. at school, sleeping over and so on, to prevent relapse. Parents are involved in the treatment of children as they need to know what helps and what prolongs anxiety and to adjust their behaviour to assist their child. With adults we involve other important attachment figures for the same reason.

The basic message is that Separation Anxiety Disorder should not be left and it can be treated.

 © Dr Elaine Bing | 20 Mar '18



Specific Phobias

Heard of claustrophobia, emetophobia, arachnophobia or anatidaephobia? And what about lepidopterophobia and paraskevidekatriaphobia or friggatriskaidekaphobia? There are many long lists with even longer names describing all sorts of things people fear irrationally. These include fear of natural events such as storms or lightening or the dark. It includes fears of many animals and reptiles and insects. It can also be a fear of medical procedures and so on. It is an irrational fear as the sufferer knows he or she is afraid beyond what is reasonable. They either avoid the feared object or situation or if they have to endure it, it is with extreme discomfort.

Sometimes there is a known history where the fear developed, but there is not always. It is exacerbated every time the sufferer avoids the feared object or situation. This is because the sufferer experiences a sense of relief when avoiding the situation which rewards the escape and confirms the danger of the feared situation. The sufferer also never gets the opportunity to discover that the feared situation or object is not dangerous and to confirm that their thoughts are irrational.

Now to treatment: When we treat Specific Phobias we call on the work of Joseph Wolpe, a South African psychiatrist who developed an intervention known as systematic desensitisation in the late 1950s and 1960s. We still use the principles he described at the time. He referred to SUDS (Subjective Unit of Disturbance Scale) which is a subjective scale which indicates how frightening the individual finds the situation or object. For example, a person might score standing outside an elevator as 20 on a SUD Scale. Getting into an elevator and going up a floor may be scored 60 and getting in and going up twenty floors may be 100. We use these scores to establish a hierarchy of the feared object or situation. We then start exposing the person to the object or situation, starting from about a SUD of 30. We maintain the exposure until the fear decreases. In Wolpe’s work the exposure was paired with muscle relation, which is still sometimes used. We’ve found that it is better if the individual is exposed to the actual feared object or situation than imaginally. Depending on the object or situation, sessions may be spread over a few days or a long session over a few hours may be used.

The results from exposure therapy for specific phobias is very good and people can be assisted to get over their fear.

For an amusing example click here

 © Dr Elaine Bing | 12 Apr '18




We all feel depressed, despondent, hopeless on occasion. This feeling can come and go and generally although we don’t feel very good it doesn’t really affect our lives very much. This is not what we are talking about when we refer to clinical depression. In clinical depression we are talking about an illness that affects the sufferer’s whole body and their interaction with their world. It takes over lives, quite literally at times as depression is one of the major reasons for suicide.

A metaphor about depression that Alex Korb (The upward spiral: Using neuroscience to reverse the course of depression, one small change at a time) uses, speaks to me about depression. Airports represent the different brain structures. Different airlines (brain circuits or systems) flow from the airports in different directions. But, if something goes wrong in one system the effect can spread throughout air traffic all over the world. And business meetings are cancelled, holidays disrupted, important appointments missed and so on. Just so with depression. Something goes wrong in one system, but the interrelated nature of everything in our bodies affects our entire being.

Typically when people are depressed, they feel hopeless, worthless and struggle to think anything can be better. It’s hard to enjoy anything. Depression also affects you physically leaving you tired and yet often struggling with sleep and appetite. Depression can lead to you sleeping too much and not wanting to get out of bed. It can also lead to insomnia, typically sufferers fall asleep easily and wake in the early morning hours, not being able to fall asleep again. And as regards appetite, you may find yourself losing weight, or eating every carbohydrate in sight. Concentration becomes a problem with it feeling as though you are thinking through grey cotton wool. It becomes a major task to decide what box of cereal to buy at the store, as your ability to make decisions is badly affected. Your self-worth tumbles and you feel horrible about yourself. You often end up feeling guilty and can lose your perspective on what was really your responsibility. It can become hard to think and move, or you may be very restless and struggle to sit still. And let’s not forget death. When severely depressed we can feel that only death will bring relief. We can actively start planning our suicide.

As you can hear, this is much more that an off day. All sorts of interrelated systems are affected, from our emotions to our thinking to our sleeping to our appetite.

I have described here is a major depressive episode. If you have been experiencing a number of these symptoms most of the time the last two weeks, it’s time to speak to a psychologist.

This is one of the forms in which depression appears. There are others. I’ll go through them one by one in the next few weeks. I’ll also start discussing what works to manage depression.

 © Dr Elaine Bing | 8 Jul '18




Persistent Depressive Disorder

Ever thought you were born depressed?

You may have Persistent Depressive Disorder. A diagnosis of Persistent Depressive Disorder is made when someone has symptoms of depression that are always there. We only make a diagnosis if the symptoms have been there for two years.

The symptoms for Persistent Depressive Disorder include a depressed mood and symptoms such as poor appetite or over-eating, struggling to sleep or sleeping too much. Energy can be low and the individual may complain that they are tired. It may be hard to have hope and the individual may feel bad about themselves. Their concentration may be poor or they may find they struggle to make decisions.

These symptoms often tend to creep on you – it’s easy to think they are normal as you may have felt like this for years. One of the factors that tends to heighten risk for Persistent Depressive Disorder is a history of having been treated badly as a child.

The symptoms can sometimes deepen and you may experience a major depressive episode on top of the Persistent Depressive Disorder.

As with all psychiatric illnesses the diagnosis is only made if it affects your ability to function.

Can people with Persistent Depressive Disorder be helped? They can, but it can take time as feeling bad has become normal. They often don’t go to a psychologist because of the depression, but because of some other crisis in their lives. There is also less research on the treatment of Persistent Depressive Disorder than in the treatment of Major Depressive Disorder. Generally, a combination of medication and psychotherapy gives the best results.

 © Christa Visagie | 15 June '19 |




Play therapy: five frequently asked questions

1. What is play therapy?
Play Therapy refers to many treatment methods that apply the therapeutic benefits of play. Play Therapy differs from regular play in that the therapist systematically utilizes the curative powers of play to address and resolve problems. In Play Therapy toys are the child’s words and play is the child’s language. Through play children can express what is troubling them. Play provides a safe psychological distance from problems and allows expression of thoughts and feelings in a way that is appropriate to the child’s level of development. This is especially true if these thoughts and feelings are filled with conflicts and worries. Within the Play Therapy setting problems are confronted, thoughts and feelings communicated, and problem-solving skills and solutions are developed.
It involves the systematic application of a theoretical model of Play Therapy. The theoretical models in Play Therapy range from structured to unstructured. These models have varied levels of efficacy with different populations. Unstructured models assure the least intrusion and suggestion by the therapist and are widely used by Play Therapists.
Play Therapy generally involves the use of a playroom suitably equipped with specifically selected toys. The range of toys represents specific categories [e.g. real life (e.g. doll family); aggressive release (e.g. soldiers, rubber swords) and creative expression (e.g. art material, sand)]. Some Play Therapists use a “Tote Bag Playroom” when travelling to hospital or school settings.
The content of the child’s play behaviour and specifically the play themes that develop across sessions provide the Play Therapist with information regarding the child’s experiences, feelings, needs and beliefs regarding him/herself and others. In practice Play Therapy typically involves the parents/caregivers of the child. Regular communications with the parents/caregivers provide the parents and the Play Therapist with the opportunity to plan for resolving problems and to monitor the progress. Parents might be involved directly in what is called Filial Play Therapy or the whole family may be involved in Family Play Therapy. Communication with the parent/caregivers also provides parents with a better understanding of the child and or parenting skills to improve the parent-child relationship.

2. Is any psychologist a specialist play therapist?
A registered psychologist is not automatically a specialist Play Therapist. The practice of Play Therapy requires extensive specialized education, training and experience. A Play Therapist is a mental health practitioner, for example, a psychologist, who has gained advanced specific training and supervised experience in Play Therapy.

3. What ages are suitable for play therapy and how long does it take?
Typically Play Therapy would be indicated for children from the age of approximately 3 years to approximately twelve years. After the age of twelve years most children can use abstract reasoning and play-based forms of therapy are not necessary. The emotional maturity of the child can also be considered in deciding whether Play Therapy is an appropriate intervention.
The period of Play Therapy would be dependent on the presenting problems; continued presence of symptomatic behaviours and/or continued stressful circumstances. Research suggests that it takes an average of 20 Play Therapy sessions to resolve problems of the typical child referred for treatment (Landreth 2002; Carmichael, 2006). Typically, symptomatic behaviours start to change within the first phase of therapy (after about 4 sessions). If a child is in a climate of chronic psychological stress the therapeutic plan often, includes some measures to address this. This is to avoid treating a distressed child in isolation for a continued period while the child is still exposed to stressful circumstances.
Each child and her/his family situation are unique and the period of therapy is planned with this in mind. The planned period of therapy would usually be revaluated during consultations with parents.

4. In what way and how often are parents/caregivers given feedback?
Parents are generally given verbal feedback. In the beginning of therapy, it is decided how often feedback will be given. Children and families heal faster when they work together. The therapist respects the need of parents for feedback and to be involved in their child’s treatment. The involvement of parents/caregivers can significantly influence the success of the child’s therapy. A review of treatment outcomes in Play Therapy shows that training parents and involving them in their child’s play therapy is highly effective (Bratton, Ray & Rhine, 2005).

5. Is the child entitled to confidentiality?
It is deemed professional, and a critical part of informed consent for parents to be involved, regarding the Play Therapy of their child. This feedback gives information regarding the model and play techniques used. The rationale that informs Play Therapy is also discussed. Reporting on the findings is done with the child’s knowledge and age appropriate consent. Reporting on the findings is brief and factual and will give the child’s play themes and what they mean. This typically excludes any verbatim accounts or detailed descriptions of conversations or play behaviours, to respect the child’s right to confidentiality. It is the rule that all information disclosed by a minor in the course of therapy is treated as confidential. The goal with reporting to parents, (with the age appropriate knowledge and consent of the child) is to further the interest of the child in a discrete manner while maintaining the child’s right to confidentiality.

Allan, A (2001). The Law for Psychotherapist and Counsellors. Somerset West: Inter-ed Publishers.)
Bratton, S, Ray, D, and Rhine, T (2005). The efficacy of Play Therapy with children: A Meta-analytic review of treatment outcomes. Journal of Professional Psychology Research and Practice, 36(4), 376-390.
Carmichael, K.D. (2006) Play Therapy: An Introduction. Glen Veilo, IC, Prentice Hall.
Landreth, G.L. (2002). Play Therapy: The Art of the Relationship. New York, NY: Brummer-Rutledge