Therapeutic Presence in Play Therapy

David A. Crenshaw
Childrens Home of Poughkeepsie, Poughkeepsie, New York

Sueann Kenney-Noziska
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Play Therapy Corner, Inc., La Mesa, New Mexico

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Therapeutic presence occupies a prominent place in the study of depth psychotherapy

with adults but has received minimal attention in play therapy. The exceptions are the
humanistic psychologists Virginia Axline, Clark Moustakas, and Garry Landreth, all
of whom were influenced by the person-centered theory of Carl Rogers. In his
writings, Rogers not only emphasized the importance of the therapeutic relationship
but also did groundbreaking research that made the therapists warmth, empathy, and
genuineness cornerstones of the therapeutic relationship. In an interview later in his
career, Rogers suggested that therapeutic presence may capture all three of these
essential components of the therapeutic relationship. In this article, the concept of
therapeutic presence is reviewed along with case studies illustrating its importance.
Keywords: therapeutic presence, relationship, alliance, common factors

The presence of the therapist in a psychotherapy session is far more discussed

in adult therapy than child therapy. Geller and Greenberg (2002) defined thera-
peutic presence as bringing ones whole self into the encounter with clients by being
completely in the moment on multiple levels: physically, emotionally, cognitively,
and spiritually. The components of therapeutic presence, as elucidated by Geller
and Greenberg (2010), are (a) attunement with ones self; (b) being unguarded,
open, and receptive to what is emotionally relevant or poignant at this moment in
time; (c) an expanded sense of awareness, spaciousness, and perception; and (d)
clear intention of fully being with clients to facilitate a healing process. Geller,
Greenberg, and Watson (2010) emphasized that the therapists attunement is to a
multidimensional internal world that includes not only the verbalizations of the
client but also the clients bodily expressions, as well as the therapists own
physiological responses in the moment. An attuned responsiveness on multiple
levels thus becomes possible, involving emotional and kinesthetic sensing of the
others affect and also involving the intuition of the therapist and the relationship
between (Geller et al., 2010).

David A. Crenshaw, Childrens Home of Poughkeepsie, Clinical Department, Poughkeepsie, New

York; Sueann Kenney-Noziska, Play Therapy Corner, Inc., La Mesa, New Mexico.
Correspondence concerning this article should be addressed to David A. Crenshaw, Childrens
Home of Poughkeepsie, 10 Childrens Way, Poughkeepsie, NY 12601. E-mail: dcrenshaw@
childrenshome.us

31
International Journal of Play Therapy 2014 Association for Play Therapy
2014, Vol. 23, No. 1, 31 43 1555-6824/14/$12.00 DOI: 10.1037/a0035480
 32 Crenshaw and Kenney-Noziska

REVIEW OF THEORY AND RESEARCH

Therapeutic presence in adult psychotherapy has been viewed as a key com-

ponent of the healing process (Bugental, 1987; Geller, 2001; Geller & Greenberg,
2002, 2010; Geller et al., 2010; Hycner, 1993; Hycner & Jacobs, 1995; Koser, 2010;
May, 1958; Mearns, 1997; Mearns & Cooper, 2005; Rogers, 1957, 1980; Roemer &
Orsillo, 2009; Schneider & May, 1995; Shepherd, Brown, & Greaves, 1972; Webster,
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1998). Presence has been regarded as an essential factor in building the therapeutic
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relationship, and, in turn, the therapeutic relationship has been shown to be an

essential ingredient of therapeutic change (Bordin, 1979; Horvath & Greenberg,
1986; Kazdin, 2005; Lambert & Barley, 2001; Lambert & Simon, 2008). Stephen
Shirk has done relevant research in the dimensions of therapeutic alliance for
children and adolescents, including the three elements of therapeutic relationship,
goals, and the process of therapy (Shirk, Karver, & Brown, 2011; Shirk & Peterson,
2013). Through their studies, Shirk and colleagues established that treatment
alliance, which includes the therapeutic relationship, is an important predictor of
therapeutic outcomes with youth and may well be the essential ingredient that
makes diverse child and adolescent therapies work (Shirk et al., 2011). These
studies also confirmed that alliances not only with youth but also with parents are
predictive of treatment outcomes, so working to develop an effective therapeutic
relationship with parents increased efficacy.
Psychotherapy outcome research (Duncan & Moynihan, 1994) has shown that
it is the clients experience of the therapist that is strongly associated with session
outcome and the quality of the therapeutic relationship. In contrast, the therapists
experience of themselves is less predictive of the quality of the therapeutic rela-
tionship, process, and outcome. In the early pioneering psychotherapy outcome
research of Carl Rogers, he observed that it was the degree to which the client
perceives the therapist as being genuine, empathic, and unconditionally accepting
that is the main factor for good therapeutic outcome (Rogers & Truax, 1976).
Geller et al. (2010) found that clients reported change and a positive therapeutic
relationship after sessions in which their therapist was present and engaged with
them.
Studies of the treatment of traumatized youths reveal the importance of a
strong therapeutic relationship for successful treatment (Eltz, Shirk, & Sarlin, 1995;
Kearney, Wechsler, Kaur, & Lemos-Miller, 2010; Ormhaug, Jensen, Wentzel-
Larsen, & Shirk, 2013). The therapeutic relationship has been key to outcome in
individual child, adolescent, and adult therapy (Hovarth, Del Re, Flucikger, &
Symonds, 2011).
In play therapy, less attention has been paid to the role of therapeutic presence,
with the exception of child-centered play therapy and the writings of Virginia
Axline and Garry Landreth, and the humanistic psychology of Clark Moustakas.
The theoretical basis of child-centered play therapy is Rogerss person-centered
theory. Rogers, late in his career, came to see therapeutic presence as an integrative
and overarching concept. Rogers is quoted by Baldwin (2000):
I am inclined to think that in my writing I have stressed too much the three basic conditions
(congruence, unconditional positive regard, and empathic understanding). Perhaps it is something
around the edges of those conditions that is really the most important element of therapy when
myself is very clearly, obviously present. (p. 30)
 Therapeutic Presence in Play Therapy 33

Clark Moustakas was one of the leading experts on humanistic psychology and
clinical psychology and, along with Carl Rogers, helped to establish the Association
for Humanistic Psychology and the Journal of Humanistic Psychology. He was a
pioneer in heuristic research. Moustakas, who studied with Virginia Axline at
Columbia, placed great emphasis on presence of the therapist as a human being in
the play therapy process. Moustakas (1997) was intent on describing the essence of
the therapeutic process of play therapy. The attitudes of the play therapist, in
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Moustakass view, were as important as the accurate understanding of a childs

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behavior and play experience. In Children in Play Therapy (Moustakas, 1953),

Moustakas emphasized the values of faith, acceptance, and respect in play with
children and in play therapy. The ability of the therapist to be with the child fully,
to listen deeply, and to hear the childs thoughts, feelings, and perceptions were
critical to what Moustakas called relationship play therapy. Moustakas (1997)
described his personal journey in play therapy, leaving behind nondirective play
therapy as a model, because he valued, from the very first moment of meeting a
child, that active sharing between child and therapist was an essential dimension of
the relationship.
The relationship play therapy model emphasized the incorporation of the
therapists theories, ideas, thoughts, feelings, and preferences into interactions with
children. In Psychotherapy with Children (Moustakas, 1959), Moustakas further
expanded on his humanistic framework that shares many of the tenets of his fellow
humanistic psychologist, Carl Rogers, and child-centered play therapy as developed
by Axline and Landreth: The therapist begins where the child actually is and deals
directly and immediately with the childs feelings rather than with his [or her]
symptoms or problems. The therapist conveys his [or her] unqualified acceptance,
respect, and faith in the child and the childs potentialities (Moustakis, 1959, p. 5).
In relationship play therapy, the presence of the therapist was viewed as the
key. Moustakas (1997) explained,
Perhaps the most important attribute of the play therapist is his or her presence (italics in the
original) as a human being, a person committed to being with a child, listening and hearing the
childs perceptions, thoughts, feelings, and meanings. Through empathy, compassion, and intuitive
sensing, the therapist discerns the rhythms of the child, recognizes, accepts, and values the childs
own ways, and reinforces the childs potentials of authentic expressions of self. (pp. 9 10)

Carl Rogers (1980) delineated a similar concept of deep hearing, which he

believed to be such a powerful experience that every time he was able to listen in
such an in-depth way, it enriched the life not only of the speaker but also the
listener. Deep listening required such engaged presence that what was heard was
not only what was said but also what was unsaid, and the meanings not only
accessible to the conscious of the person sharing the story but also implied, but not
consciously available, to the teller of the story. Moustakas further developed the
concept of presence and fully engaged hearing in the book Who Will Listen?
(Moustakas, 1975).

Issues and Controversies

In the technological age that characterizes our modern world, some observers
(Crenshaw, 2008a, 2008b; James, 1994) have expressed concern that the pressures
 34 Crenshaw and Kenney-Noziska

for quick therapeutic results will result in greater emphasis on tools of the trade.
The net result of such technological emphasis will move us further and further away
from the appreciation of the rich, but complex, emotional underpinnings of the
children we see. Fascination with the technology of the field also moves us further
away from the solid theoretical foundations emphasizing the therapeutic relation-
ship and the therapeutic process elucidated by Sigmund and Anna Freud, Melanie
Klein, Donald Winnicott, John Bowlby, Carl Rogers, Virginia Axline, Clark Mous-
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takas, Garry Landreth, Beverly James, Helen Benedict, and Eliana Gil, to mention
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some, but not all, of our historic and contemporary leaders in the field. The authors
call for a renewed appreciation of the depth and richness of the therapy process,
with its emphasis on the therapeutic relationship and client resources, the two most
potent factors in determining psychotherapy outcome (Duncan, Miller, Wampold,
& Hubble, 2010; Kazdin, 2005; Norcross, 2010). Although technology has radically
contributed to our personal well-being and to advancements in our field, the risk is
that our fascination with the tools of the trade will lead to a disproportionate
emphasis on techniques compared with the common factors in psychotherapy such
as therapeutic presence and the quality of the therapeutic relationship. As one
indication of this trend, on October 16, 2013, a search for articles in the PsycINFO
data base of the Johns Hopkins University Library turned up a total of two articles
on common factors in play therapy; the search terms therapeutic presence in
play therapy resulted in no articles; the search terms therapeutic relationship in
play therapy yielded 29 articles; the search terms therapeutic alliance in play
therapy turned up a total of six articles; the search terms play therapy process
resulted in 247 articles; whereas the search terms play therapy techniques turned
up a total of 515 articles. The conclusion is data driven that the common factors,
particularly the quality of the therapeutic relationship, contribute far more to
outcome than any specific approach, method, or technique (Duncan et al., 2010;
Kazdin, 2005; Lambert, 2013; Wampold, 2012), yet the literature search points to
the relative neglect of these factors in the play therapy literature.

The Elusive Search for Breakthrough Techniques

Beverly James warned that the process of therapy, especially laying the foun-
dation for trust, and gradual disclosure in the context of a safe and solid therapeutic
relationship, requires an appreciation of the fundamentals of the therapy process,
including the common factors. She stated, The process leading to children being
able to trust their therapists, allowing them to be vulnerable and revealing tender
feelings can be likened to the slow, complex development of a critical mass of
emotional safety, not a sudden breakthrough (James, 1994, p. 62). Dangers are
associated with what she called breakthrough ideology. James elaborated,
The clinical focus becomes the search for the perfect, clever intervention; the relationship with the
child becomes less valued and in some cases ignored; the clinicians professional self-esteem
becomes eroded by lack of success; and such beliefs reinforce and support the procrustean policy
of ruthless conformity to brief therapy for children. (1994, p. 62)

Another astute, recognized authority on clinical process, LAbate (2012) ex-

pressed concern about mindless creativity, which he suggested as another name
 Therapeutic Presence in Play Therapy 35

for Tower of Babel when clinical techniques are not anchored clearly in theory
and lack conceptual clarity, not to mention empirical support.

Being and Doing Are Both Important

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Carl Rogers (1980) recognized the importance of our way of being not only in
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therapy but also in life. Moustakas (1997) suggested, Perhaps what is most
essential is the being of the play therapist (p.18; italics in the original). Included in
being are the openness and receptiveness to the child. Also included are love for
children, enjoyment of playing with children, and the ability to enter the childs
world fully. In humanistic psychotherapy, being is primary and what guides the
therapy. The doing is secondary and derives from your being. Being involves
attunement with the child and the childs internal world, as well as attunement with
the self of the therapist and attunement with the relationship with the child. Being,
which is an inclusive concept similar to presence, assimilates the cornerstones of
therapeutic healing delineated by Rogers, in other words, empathy, genuineness,
and warmth. Being is not possible without presence, so the two are inevitably
interwoven. The advantage of honoring presence as an essential ingredient is that
it encompasses attunement with child, with the self of the therapist, and with the
relationship.
Doing also has its place if it emerges from presence and is grounded in clear
theoretical and research foundations, in contrast to simply a tool box of assorted
techniques that threatens to reduce us to simple technicians. A recent experience
validated both the value of doing and being in play therapy. The therapist
planned a group play therapy series with toddlers and preschool children in an
emergency foster care program. The doing consisted of therapeutic rituals; an
opening ritual consisting of a set of calming, focusing, sensory-motor activities and
a group song. A closing ritual was developed to help children focus on, and cope
with, separation and loss, given their recent experience of forced removal from
their homes by child protective services. The authors wish to honor the value of
both the doing and being rather than either/or, and to call for a balance
between the two that reflects the research on common factors in psychotherapy that
place greater emphasis on the quality of the therapeutic relationship than any
specific approach or technique (Lambert, 2013; Lambert & Barley, 2001; Lambert
& Simon, 2008; Norcross, 2010; Seymour, 2011; Wampold, 2010, 2012).
Therapeutic rituals have a time-honored place in psychotherapy, and in psy-
chotherapy research are regarded as one of the common factors in many forms of
psychotherapy (Arkowitz & Lilienfield, 2006; Wampold, 2010). The beneficial
power of the group rituals was quickly revealed with both children and staff
observed singing the group song in between sessions, and in the eagerness of the
children to do the rituals at the beginning and ending of the session. Experienced
participants were also eager to teach the group rituals to new participants in the
group. In the beginning, with such a young group, the therapist and his graduate
students who were assisting thought the whole session would need to be structured
to prevent chaos. When the therapist moved the group from the opening ritual to
free play, he quickly realized that the sessions were more productive when the
 36 Crenshaw and Kenney-Noziska

therapists simply were fully present and not doing. The children led us to their
places of internal pain as they created pictures in the sand tray of looking for their
mother or their home, or played out scenes of domestic violence with the family
play house or with puppets. Frequent portrayals of violent scenes they had wit-
nessed prior to being removed from their homes were represented in the sand tray,
play house, and puppet theater. It was striking that even children as young as 2
engaged in free play that had compelling value for them in attempts to master the
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fears and, in some cases, trauma associated with the removal from their unsafe
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homes.
Thus, the being and the doing can both contribute to the therapeutic
process. Being and presence are essential to a healing context, and doing can
help create the safety and the therapeutic context essential to creating the trauma
narratives that are the cornerstone of empirically supported, trauma-informed
therapy with children. Specific and structured interventions can assist with thera-
peutic goals, as will be illustrated in the case illustration of Eddy and Tim. Rather
than the dichotomy of being versus doing, both are of value, especially when
the doing emerges from the being (Kenney-Noziska, Schaefer, & Homeyer,
2012).

CASE ILLUSTRATION: EDDY AND TIM

The case studies use fictitious names and identifying details of these cases have
been changed to protect the privacy of the children without sacrificing the essential
features of the treatment process.
The therapist (David Crenshaw) was called on to intervene in an unthinkable
tragedy when two boys, ages 4 and 10, from Puerto Rico woke up on Christmas
morning to find their mothers body laying between their beds with multiple, fatal
gunshot wounds. What ensued was one of the most intense and challenging ther-
apeutic journeys that I have ever undertaken. When I reflected on the 76 sessions
conducted with the two boys together (each had weekly individual therapy and art
therapy sessions in addition to their joint sessions with me), it was clear that both
being and doing had been critical to the therapeutic work. Specific interven-
tions (doing) were useful in accomplishing specific goals, such as giving each boy
their own drawing pad to externalize, through art, the trauma images that haunted
their minds during the acute posttraumatic period when they could not sleep. I will
never forget Eddy in a session about a month after the tragedy, sharing with relief,
joy, and excitement that he was able to draw a picture of his mother not covered in
blood for the first time since that horrifying night.
On another occasion, I set up a puppet scenario when I was worried about
Eddys increasing depression and I felt he needed encouragement to externalize
some of his rage. On that occasion, I told both boys to pretend the alligator puppet
on my hand represented a person or a situation that they were angry toward and to
show the alligator puppet just how angry they were. Neither child stayed in the
metaphor and, immediately, Eddy grabbed the plastic baseball bat in the room and,
after I placed the alligator puppet on the floor so I could move safely out of the way,
he pounded the alligator puppet with the bat while screaming, You killed my
 Therapeutic Presence in Play Therapy 37

mother Anthony. I hope you rot in hell! His little brother Tim then took the bat
and hit the alligator puppet, but not nearly with the same force or intensity as his
brother. Tim yelled, I hate you Anthony and I hope you rot in jail. Tim then
quickly added, But I forgive you. Anthony was his mothers boyfriend and Tims,
but not Eddys, father. That intervention, followed by verbal expressive exploration
of Eddys rage, led to a noticeable reduction in Eddys depression. Except for the
directed artwork in the beginning, which focused on reducing intrusive images,
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flashbacks, and terrifying nightmares, and the directed puppet play to externalize,
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particularly Eddys rage, all of the other artwork and puppet plays were child
directed during the course of therapy. These directive interventions and this
doing were successful in meeting the therapeutic goals that guided their use. The
cornerstone of this extreme trauma case, however, was the therapeutic relationship
formed, which consisted of being and therapeutic presence. The trust that was
established, in part, by making myself available daily to the boys during the first 10
days following the murder. The therapeutic relationship was further strengthened
by accompanying them, at their request, to the funeral home to see their mothers
body before it was transported to relatives in Puerto Rico.
Therapeutic presence, as defined by Geller and Greenberg (2010) and de-
scribed specifically in relation to play therapy by Moustakas (1997), played a vital
role in enhancing the therapeutic relationship. The sessions, because of the horror
and magnitude of the tragedy, and with a court trial hanging like a sword over the
heads of the two boys, as well as myself, were riveting and emotionally exhausting.
I had been told by the county district attorneys office that the two boys would be
required to testify in open court, and that I would also be called to testify as to any
anticipated discrepancies in their trauma memories due to the significant age
differences between the boys. Gradually, over time, trauma memories emerged
about what the boys had witnessed and experienced the night of the murder, and
what they saw when they awoke the following morning. At the end of some of these
sessions, I felt the weight of the shared material to be so heavy that I could barely
rise from my seat to walk the boys back to the cottage where they were living in the
emergency foster care program. Therapeutic presence in this instance not only
meant attunement to the inner emotional world of the boys, which included
profound sorrow, intense rage and unspeakable terror, but also attunement as
Geller et al. (2010) explained with their hyperaroused physiological states. Al-
though it took an emotional and physical toll on me and everyone else who was
actively involved in helping these boys, therapeutic presence in the form of attun-
ement to their inner life on multiple levels also facilitated empathy and compassion
for what these boys had survived. Given the impact on me of hearing their story, I
kept imagining what these boys, who actually lived this horrifying nightmare, must
be feeling. It helped me to appreciate the magnitude of their loss and sorrow, the
depth of their rage, and the extent of their terror.
One session in particular stands out. On that afternoon, Tim wanted to use
Play-Doh to create the murder scene. Although I had seen the pictures of the scene
drawn and colored in their sketch pads many times, I was not prepared for the
impact of the three dimensional scene created with Play-Doh. It was real, vivid, and
jolted all of us in the room to silently witness a symbolic representation of what the
boys saw when they woke up that morning. For a few moments, no one could move
or speak. The impact was striking for each of us. I finally broke the silence and
 38 Crenshaw and Kenney-Noziska

described how hard it was for me to see symbolically what they had seen for real;
something that no child should ever have to wake up to, to open their eyes and then
see.
Creating safety for the boys in their daily life and in the therapeutic relationship
was an overriding priority. The challenge was made all the harder by the frequent
dreams that the alleged killer had escaped and hunted them down to do the same
thing to them that he did to their mother. The challenge was magnified because the
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children were aware that the county jail that housed the alleged killer was a short
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distance down the road from the emergency foster care placement. The combined
efforts of everyone working with these boys, but most especially including the
therapeutic relationship with its gradual building of trust, enabled them to continue
to develop more of the trauma narrative as time went on. What enabled these boys
to share their trauma stories (i.e., the murder of their mother, the culmination of
living with repeated domestic violence, fleeing and hiding from the violence) was
not the employment of clever techniques or strategies, although at strategic times,
specific techniques proved useful to meet particular therapeutic goals, but rather it
was the healing context of the therapeutic relationship and its key components of
warmth, genuineness, empathy, and attunement on many levels that constitutes, in
our view, therapeutic presence.
The degree of safety and trust that developed, and the evolving strength of the
therapeutic relationship led Tim, just 2 weeks before the trial was to begin, to
request a private session with me. Even though he was 4 and his brother was 10, he
was protective of his older brother and felt that what he had to tell me would be too
upsetting to Eddy. Tim told me that he had actually witnessed the murder. He told
me that he only pretended to be asleep, heard the screaming, and actually got up
out of bed and tried to stop Anthony from shooting his mother. At that point, his
mother was still alive.
I encouraged Tim not to bear this secret alone any longer, even though he was
incredibly loyal and loving in his wish to protect his older brother. Eddy expressed
shock at first but then expressed sadness that his little brother had carried the
burden of this secret all alone, and was so glad that Tim finally told. In the judgment
of the authors, Tim told not because of breakthrough techniques but through the
gradual evolving strength of the therapeutic relationship, with its key component of
therapeutic presence and the safety it provided. Tim also told because of the
remarkable courage and resilience of a 4-year-old boy and the bond with his
10-year-old brother. It should never be forgotten that of all the factors in decades
of psychotherapy outcome research, that client resources trumps all others (Bohart
& Tallman, 2010; Duncan et al., 2010).

CASE ILLUSTRATION: STACEY

The therapist (Sueann Kenny-Noziska) experienced the power of therapeutic

presence in play therapy in a case involving a 5-year-old female, who will be
referred to as Stacey. In spite of her young age, Stacey had experienced a lifetime
of child maltreatment and trauma. The first suspected child abuse report was filed
before Stacey was even discharged from the hospital. Despite the fact that there
 Therapeutic Presence in Play Therapy 39

were 25 reports filed and 18 substantiated allegations, Stacey remained in the care
of her biological mother until the day of Staceys fifth birthday. At that time, she
was taken into protective custody and placed in a foster home. In addition to being
exposed to brutal domestic violence, being the victim of physical abuse, and a
victim of suspected sexual abuse, the primary form of child maltreatment Stacey
suffered was neglect. She lived in squalor, typically went without food, and clearly
did not have her emotional needs met.
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Once in the care of the state, Stacey was referred to therapy. Prior to coming
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to this therapist, Stacey had received services from four other providers, each of
which referred her to a new provider, due to the fact she was resistant and
wouldnt participate in sessions. Given her history, this was not surprising.
I recall meeting Stacey for the first time in the office waiting room. She was a
darling child with huge eyes, wearing a dress with her hair meticulously done in
braids. I knelt down and introduced myself. Much to my surprise, this tiny child
responded with a snarl and growl, much like that of a scared animal. Remembering
the importance of therapeutic presence, in conjunction with knowledge of her
history and referrals to multiple providers, I carefully backed up and thanked her
for letting me know I was too close to her. This was the first pivotal effort at
therapeutic presence being in the moment and aware of her suffering and lack of
trust.
For the first several sessions, Stacey was escorted to the play room by her foster
mother as I walked behind them, allowing enough space to create a sense of safety.
During the beginning stage of treatment, several rituals developed. One ritual was
that Stacey always entered the playroom first and I entered second. Another was
that, upon entering the playroom, Stacey would direct me to go into the life-sized
jail cell built into a corner of the room and constructed out of wood, metal conduit,
and a gold latch that served as a false lock. Stacey would then collect all the
babies from the playroom, matter-of-factly toss them into the jail cell with me, and
shut and latch the jail door. Following this, she would explore the playroom, picking
up and manipulating toys and play media without any actual play or thematic play
emerging. Anytime I attempted to therapeutically respond, Stacey would quickly
snap her head in my direction and scream, Shut up! Naturally, the first several
times this occurred, I was taken back; such harsh words shouted in such a threat-
ening voice by such an adorable child.
Recalling that children will correct you when you are wrong, I eventually
opted to listen to Stacey and shut up. This paved the way for true therapeutic
presence to occur. After many sessions like this, Stacey eventually began to depict
aggression with the play media. Some of the conflict and fighting would be con-
tained and sublimated in the play, whereas other instances would be raw and not
sublimated. During this play, I began to rock, nurture, whisper, and swaddle the
babies locked in the jail cell. Stacey always attended to this and would gaze in
wonder.
Finally, there was a breakthrough. It was the day that Stacey stopped her battle
between the dinosaurs, noted me nurturing the babies, and brought a basket of food
from the play kitchen over to the jail cell. Without a word, Stacey set the basket of
food down, turned around, walked to the other side of the playroom, sat down, and
stared at me. I simply responded, Thank you, and pretended to feed the babies.
 40 Crenshaw and Kenney-Noziska

Stacey silently watched every nurturing movement and behavior I displayed toward
the babies. This became the new ritual.
Eventually, this progressed into Stacey responding, Youre welcome each
time I thanked her for bringing the food. Slowly, Stacey placed fewer babies in the
jail cell and ultimately only had me in the jail. I strived to remain fully present in
sessions and communicated empathy, warmth, and positive regard throughout. As
more progress occurred, Stacey began leaving the jail door open. And, finally, the
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day came when Stacey did not place me inside the jail cell but allowed me to remain
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out in the playroom itself. Safety and trust had been achieved.
This was such a challenging case for me. Aware of the pressure for results, some
of which was imposed by me and some of which was imposed by others, it was
difficult to remain present and in the moment. With the guidance of supervi-
sion and consultation and self-awareness, the process became easier. However, the
challenge then became my need for self-care as I realized the harm and suffering
this child had experienced.
As treatment entered the working phase, themes of abandonment, loss, rejec-
tion, trauma, and abuse were woven throughout Staceys play. When in doubt,
when impasses became evident, or when therapeutic responding was rejected, I
would be reminded of the importance and power of therapeutic presence. Again,
being fully present in a genuine, empathetic, accepting manner was essential in
understanding the suffering Stacey had experienced and her struggle to make
meaning out of the senselessness.
It was not a specific intervention, therapeutic response, or interpretation that
led to healing for Stacey. Rather, it was the therapeutic presence communicated via
positive regard, genuineness, and warmth that fostered her growth. Early stages of
therapeutic work, albeit stressful and experienced at times as unproductive, were
critical, as this time allowed Stacey to experience my presence and a relationship
with an adult who had the ability to remain with her in a manner that fostered a safe
distance yet conveyed to her worth and value. Therapeutic presence was what she
needednot a magic bullet, panacea, or evidence-based protocol. Had I allowed a
hidden agenda or other pressures to guide treatment, another injustice would have
been done to this young child. She needed someone to be fully present and bear
witness to her suffering.

CONCLUSION

Every well-known approach to psychotherapy appears to emphasize the ther-

apeutic relationship as a crucial element. Recently, there has been increasingly
more interest in what elements of the therapeutic relationship appear to affect
change. The quality of the therapeutic relationship and therapeutic presence clearly
appear to be avenues for change, and serve a meaningful purpose in psychotherapy
and play therapy. This is true even with the push for practitioners to use evidence-
based protocols. Indeed, when implementing evidence-based or best practices, the
therapeutic relationship is an important part of this process. Although certainly not
the only component related to outcomes in psychotherapy, therapeutic presence
may establish the foundation from which other positive change and growth may
occur.
 Therapeutic Presence in Play Therapy 41

Gaps in the research regarding the specific elements and mechanisms by which
the therapeutic relationship contributes to change is evident. Rigorous research in
this area may provide information for play therapists to utilize to improve their
ability to be with unique children in ways that are healing and meet their individual
needs.
Play therapists need to recognize the importance of therapeutic presence and
its pivotal role in the play therapy process. Common factors in play therapy,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

including the therapeutic relationship encompassing presence, empathy, warmth,

This document is copyrighted by the American Psychological Association or one of its allied publishers.

and genuineness, is relatively neglected in the play therapy literature, despite the
data pertaining to child and adolescent psychotherapy pointing to their overriding
importance. Regardless of theoretical orientation, clinical interventions, and ther-
apeutic tools, being mindful and purposeful by being fully present in the therapy
relationship is essential. Communicating acceptance, empathy, and genuineness,
and being fully present, aids the healing process and may even establish the context
from which healing occurs.

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Received August 7, 2013

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Revision received October 31, 2013

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Accepted November 6, 2013

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