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Open forum on play therapy in hospitals, May  2009

It is often a great challenge to take play to children in institutional settings like hospitals. This forum looked at interventions for chronically ill children who spend long periods away from home, under medical care. Though play therapy is relatively new in India, there are now organizations that are trying to make a difference to affected children and families by exploring ways to help them cope with the stress brought on by the hospital environment, and focusing on their emotional health and well being.

The speakers at this forum were Dr Meera Oke, Director Centre for Human Growth and Development (CHUGRAD), Pune, and Nazu Tonse of Docteur Clown India.

Meera Oke has a background in human development and has taught at Nirmala Niketan for several years. She is also associated with SOHAM and Bharatiya Samaj Seva Kendra in Pune. Dr Oke founded CHUGRAD in 1989. CHUGRAD’s mandate is to look at human development in children in difficult circumstances. Dr Oke is a strong advocate of spontaneous play and it was from her interest in understanding play that the idea for play therapy took root. She has helped develop and implement play therapy services at the Deenanath Mangeshkar Hospital in Pune and Manipal Hospital in Bangalore. CHUGRAD has also initiated similar programmes at Apollo and Malar hospitals in Chennai, and KEM in Pune.

What is play therapy?

‘The child’s play is his talk and the toys are his words.’
These words by Haim Ginott, eminent teacher and psychologist, are fundamental to the very idea of play therapy.

Meera Oke’s presentation was titled ‘Play and Educational Therapy’. She began by questioning the methods adopted by practitioners of the play way method. ‘Play is voluntary. Play is pleasurable. Play is about what the child can do actively rather than what activity can do for the child. Material facilitates play, but does the child want to play?’

Elaborating on the idea of play she talked about how it is a natural medium for a child’s self-expression. It not only reduces psychological stress but also allows children to deal with conflict and fear. Play is also the natural scaffolding for development because it helps build neural structures and synaptic connections. The absence of play can also be detrimental.

Play therapy needs specially trained therapists because it involves the systematic use of a theoretical model to establish an interpersonal process wherein therapeutic powers of play are used to prevent or resolve psychosocial difficulties and achieve optimal growth and development. This is done by allowing the child to choose, and therefore, be in control of the play process. Since the child holds the reins, she is free to explore her feelings of self worth and acceptance. The act of engaging in play, and not the material used, is important. All of this becomes particularly relevant in a hospital environment where a child experiences a frightening loss of control coupled with an upset routine. Unfamiliar people, equipment, atmosphere and intimidating doctors increase a child’s sense of insecurity. Unlike adults, children are not able to understand that they have to go through pain to get better.

How play therapy works

CHUGRAD’s play therapy programme in hospitals focuses on chronically ill children because they are hospitalized for extended periods of time. The programme has been constructed to suit the Indian context and follows a bedside model where there is one on one interaction between the child and the therapist, though there is considerable emphasis on filial play where parents and siblings are encouraged to get involved too.

The first programme

CHUGRAD began working in May 2006 in the Deenanath Mangeshkar Hospital in Pune. They observed the OPD for a month, had conversations with children, doctors and parents. They identified chronically ill children who needed intensive treatment and repeated hospitalization. They worked with 100 children and their families, with 10-14 sessions per child of 40-50 minutes duration. Each session was planned keeping the child’s age and interests in mind. The sessions were also documented and discussed in detail with the concerned doctors and support staff.

Play material used

Play material falls broadly into four categories:
  • material for expressive play since children do not always express their feelings in words (drawing, clay moulding, paper cutting etc)
  • material for domestic play since children miss their home surroundings (kitchen sets etc)
  • medical playset (replicas of instruments used by doctors as well as a rag doll in a patient’s garb, with no facial features marked out)
  • educational material like worksheets (for older children who miss school and like to keep in touch with academic activities)
Needless to say, complicated hospital procedures can be scary even for adults. In order to make it easier for Pokies children to confront them, pre-procedure play consists of allowing them to play with small working models of CAT scanners, IV sets and other equipment used in the treatment of cancer. The play session works best when conducted just 15 minutes prior to the procedure.

The play therapist does not offer any particular toy to the child and instead allows her to decide what she wants to play with or whether she wants to play at all or not. Play with the medical set is particularly popular because of the role-reversal it allows. During the course of play it becomes obvious that the children know much more about their medical condition than they let out.

CHUGRAD has also developed some teaching material. They have a booklet on nutrition and another one for helping parents cope with their children’s serious illness. They also have educational material for older children, for example, on the good and bad cells in their body.

Meera Oke emphasized the need for hospitals to take ownership of play therapy programmes so that continuity and stability do not become an issue.


Benefits of play therapy

  • Doctors and nurses report that children cooperate and adhere better to treatment processes
  • Children tend to be cheerful
  • Parents of chronically ill children find it less stressful to bring their children to hospital for repeat visits and are able to freely speak with them about their illness
  • Children eat more happily/take their medicines when engaged in play
  • Even when the children are in pain they smile when they see their favourite toy and therapist, and make efforts to be normal
  • Parents are more at ease when they see their children relax
  • Children often vent their frustration by poking and cutting up rag dolls
  • Doctors request therapists to be present during procedures

 

CHUGRAD has also taken play therapy to other settings. At the BSSK adoption agency, there is a specially cushioned room that is safe and secure for children. This dedicated play therapy room also caters to children who have behavioural problems and are referred to them by schools. Play therapy has also been successfully used with autistic children.

Therapeutic clowning, the Docteur Clown way

The second presentation was by Nazu Tonse and Mili Jalan of Docteur Clown India. Nazu came as her alter ego ‘Gladys’ in order to demonstrate the power of the clown. She had the audience in splits within minutes as she went about ‘cheering up people and spreading sunshine.’ The presentation was aided by a film that explained the work of the group in Bangalore. Mili Jalan facilitated the presentation by gently quizzing ‘Gladys’ on what it means to be a clown.

Docteur Clown India was started by Severine Blanchet in 2006. The small group of clowns has been working with hospitals in Bangalore for three years. Therapeutic clowning has been practiced in the West for over 20 years and has proved itself beneficial to the process of healing. ‘Gladys’ pointed out that the clowns need to be extremely sensitive to their environment since their job is not just about barging in and raising a few laughs. Theirs are not rehearsed acts but improvisations based on the situations they find themselves in. They cannot carry much equipment into a sick ward where hygiene is of the utmost importance and use music, bubbles and mime to communicate with the children. Conventional clown make-up can be scary and overwhelming for some children, therefore the emphasis is on minimal application of colour on the face. A clown’s red nose and a colourful costume do the rest.

For therapeutic clowning it is important to have a love for children in particular and people in general; a background in the performing arts is a must. Kindness is the chief attribute of a good clown. The clowns themselves are not therapists, but rather, the ‘toys’ the children play with. They use laughter, relaxation and imagination to enter a child’s world. Language is no barrier, though skill matters when it comes to making children, and families, feel comfortable and less scared of procedure.

While there has been a positive response to the group’s efforts in Bangalore, it has not been easy to take the programme outside the city because of the lack of trained clowns. Docteur Clown holds 5 to 6 training workshops every year. This includes an orientation to hygiene, theatre games to help a potential clown identify the hidden clown that can inspire her or him to perform and team building. These workshops are open to only to those interested in being a therapeutic clown.

Docteur Clown has worked with Philomena’s, St John’s, Ramaiah, Colombia Asia and Kidwai hospitals in Bangalore. They can be contacted through the Alliance Francaise, Vasanthnagar, Bangalore.


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