Children in play therapy: what significance does this have for their parent´s perceived health?

AKADEMIN FÖR HÄLSA OCH ARBETSLIV

Avdelningen för arbets- och folkhälsovetenskap

Children in play therapy:

what significance does this have for their parent´s perceived health?

Scientific writing C

Sandra Eriksson

2014

Examensarbete, Grundnivå (kandidatexamen), 15 hp Folkhälsovetenskap

Hälsopedagogiska programmet

Folkhälsovetenskap: Teori och metod med tillämpning och examensarbete C Handledare: Leah Emegwa Okenwa

Examinator: Ola Westin, Maria Lennernäs Wiklund

Eriksson, S. (2014) Children in play therapy: what significance does this have for their parent´s perceived health? Bachelor thesis in Public Health science. The Faculty of Health and Occupational Studies. The University of Gävle, Sweden.

Children in play therapy: what significance does this have for their parent´s perceived health?

Abstract

Background: World Health Organization highlights an increasing world-wide problem

regarding mental ill health, disorders and difficulties among children and adolescent.

Research has found that health-related impairments do not only affect the children suffering from it, but their parents as well who report negative influences on their own health and burdens of different kinds. Play therapy is suitable when treating children with mental ill health, disorders and difficulties. To improve the parents´ health as well, there is a need for research looking into which kinds of interventions that is beneficial for both children and their parents. Purpose: The aim with this study was to investigate whether children´s participation in play therapy also could be beneficial for their parent´s perceived health. It was also of interest to investigate if these parents experienced the intervention as stress-reducing and social support increasing. Method: Four parents whose children had been treated or were currently treated in play therapy participated in an individual, semi-structured interview. The collected material was processed through a thematic analysis and interpreted based on the Theory of social support. Result: Four out of four participants considered themselves at better perceived health since the child´s participation in play therapy. All participants also

experienced a stress-reducing effect and three out of four considered the intervention as considerably social support increasing.

Keywords

: play therapy, mental ill health, children, parenting stress, social support,

perceived health.

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Eriksson, S. (2014) Children in play therapy: what significance does this have for their parent´s perceived health? Bachelor thesis in Public Health science. The Faculty of Health and Occupational Studies. The University of Gävle, Sweden.

Sammanfattning

Syftet med denna uppsats var att undersöka om barns deltagande i lekarbetspedagogik även kan vara fördelaktigt och främjande för deras föräldrars upplevda hälsa. Målet med uppsatsen var även att undersöka om föräldrarna upplevde interventionen som stressreducerande och socialt stöttande. I uppsatsen valdes en kvalitativ metodansats med utgångspunkt i teorin om socialt stöd och fyra stycken enskilda, halvstrukturerade intervjuer genomfördes. Deltagarna bestod av föräldrar vars barn deltagit/deltar i lekarbetspedagogik på den verksamhet som författaren var i samarbete med. Det insamlade materialet bearbetades i en tematisk analys och tolkades även utifrån teorin om socialt stöd. Detta resulterade i tre stycken huvudteman;

socialt stöd, empowerment (hanterbarhet) och relationen förälder-barn. Resultatet visade att samtliga deltagare upplevde barnens deltagande i lekarbetspedagogik som hälsofrämjande på deras egna upplevda hälsa och alla beskrev även hur de upplevde interventionen som

stressreducerande. Tre utav fyra deltagare beskrev tydligt hur deras tillgång på socialt stöd ökade signifikant, då de erhöll tröst, bekräftelse, rådgivning och hjälp att hantera

familjesituationen. Slutsatsen drogs således att lekarbetspedagogik för barn även kan vara främjande för deras föräldrar upplevda hälsa. Ytterligare forskning behövs dock för att se om detta gäller specifikt för lekarbetspedagogik, eller om interventioner av liknande slag har samma effekt på föräldrarnas upplevda hälsa. Studier som inkluderar fler deltagare, både mödrar och fäder samt barn med olika upplevelser av lekarbetspedagogiken efterfrågas även, för att resultatet inom detta forskningsområde ska kunna bli representativt och generaliserbart.

Nyckelord: lekarbetspedagogik, mental ohälsa, barn, föräldrastress, socialt stöd, upplevd

hälsa.

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Summary

The purpose of this study was to investigate if children´s participation in play therapy also can be considered beneficial for their parent´s perceived health. The aim was furthermore to explore whether the parents experienced the intervention as stress-reducing and social support increasing. The study design consisted of a qualitative method with a theoretical approach based on the Theory of social support and four personal, semi-structured interviews were conducted. Participants consisted of parents whose children had participated or was currently participating in play therapy at the corporation that the researcher was in cooperation with.

The collected data was processed with a thematic analysis and interpreted on basis on the Theory of social support. Three prominent themes where found which consisted of social support, empowerment and parent-child relationship. Four out of four participants

experienced their children´s participation in play therapy as significant beneficial for their own perceived health. They all also considered the intervention as stress-reducing. Three out of four participants experienced their children´s participation in play therapy as considerably social support increasing since receiving comfort, confirmation, advice and increased

manageability within the family situation. The conclusion was thus that play therapy for children also can be beneficial for their parent´s perceived health. Further research is needed to investigate whether this only applies on play therapy, or if similar interventions has the same health promotion effect on the parents´ perceived health. Studies which include a larger number of participants, both mothers and fathers and also children with different experiences and effects from the play therapy, is considered necessary to regard the results from this research area as representative and generalizable.

Keywords

: play therapy, mental ill health, children, parenting stress, social support,

perceived health.

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Acknowledgement

The author wishes to express her most sincere gratitude and humility towards the parents who participated in this study. Without your stories and honest sharing of your experiences, this research could not be conducted. The author wishes you all the best of luck in the future.

Finally, the author would also like to phrase gratitude and admiration towards the corporation which helped these parents and their children through play therapy. It has come to the

author´s understanding that you are of great importance to these families and have been helpful in their various family situations. You have enabled the children to heal through play and their parents have expressed tremendous gratitude for this.

“Just because an animal is large, does not mean he doesn't want kindness; however big Tigger seems to be, remember that he wants as much kindness as Roo.”

― A.A. Milne, Winnie-the-Pooh

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Table of contents

Introduction ... 1

Background ... 2

Global perspective – children´s mental health ... 2

The impact on their parents ... 2

Children and parents in Sweden ... 2

Parental access to social support – a stress reducing factor? ... 3

Theoretical framework ... 4

Parental health on a public health level ... 4

What is play therapy? ... 5

Purpose ... 6

Research questions ... 6

Method ... 7

Study design ... 7

Participants ... 7

Study setting ... 8

Data analysis ... 8

Ethical considerations ... 9

Results... 10

Introduction ... 10

Four different families ... 11

Social support - I am taken seriously! ... 12

Empowerment – Managing the family situation ... 12

Parent-child relationship – A happy child makes a happy parent ... 13

The research questions ... 14

Discussion ... 15

The key findings in relation to the background ... 15

The result in relation to previous research ... 15

The study´s methodology – appropriate or not ... 16

Strengths and weaknesses ... 16

Conclusion and future research ... 17

References ... 19 Appendix 1 ...

Appendix 2 ...

Appendix 3 ...

Appendix 4 ……….

1

Introduction

The prevalence of mental ill health, disorders and difficulties among children and adolescents is a global increasing problem. Research presented by the World Health Organization shows that as many as 20 percent of children and adolescents world-wide are suffering from ill health of this kind (1). Most probably is this percentage not accurate but should be even higher, since for example ADHD and learning difficulties are not included. World Health Organization points to the importance of interventions aiming to prevent and counteract mental ill health, disorders and difficulties among the younger population. Partly to reduce suffering among children and adolescents caused by mental ill health, disorders and difficulties, but also to prevent the negative impacts that this kind of ill health brings into adulthood (1,2,3). Studies have been conducted looking into how parents are affected by their child´s ill health or disabling difficulties. The World Health Organization contributes within this research area as well, with research showing that a significant proportion of these parents are suffering from worry, anxiety, burdens of various kinds as well as stress-related

conditions, among others (4,5). Parents whose child is suffering from mental ill health also reports more embarrassment and alienation, compared to parents with a child suffering from, for example, cancer or heart decease (4). To enable the parent´s coping of the child´s ill health, they are requesting support, information and confirmation. Several studies have come to the conclusion that access to social support has a stress-reducing effect when going through difficult situations in life (6,7). The theory of social support is well-known and commonly used within interventions, and also composes a suitable base when trying to help these parents and prevent parental ill health caused by their children´s mental ill health, disorders and difficulties. The prevalence of mental ill health among children and adolescents below the age of 17 has increased in Sweden since to 90´s (8). In 2011 turned 4 percent of girls and 3

percent of boys to health care seeking help and treatment for this kind of ill health. Due to this increasing public health problem among children and adolescents in Sweden, another risk group for ill health arises: their parents. There is thus a need for interventions targeted

towards both these children and their parents. Play therapy is a therapeutic method used since

several years back to help and treat children with mental ill health, disorders and difficulties

(9). The health promotion effect from play therapy on children is thus already known. But

there is no research on how parents to these children are experiencing the intervention, and if

the children´s participation in play therapy has a beneficial effect on the parent´s perceived

health as well. If play therapy for children has a significant positive effect on the parent´s

perceived health as well, an opportunity opens up for a possible and appropriate intervention

to help both children affected by the increasing incidence of mental ill health, and their

parents, who also represents a growing group at risk of ill health.

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Background

Global perspective – children´s mental health

World Health Organization highlights the expanding world-wide problem with disabling mental ill health, disorders and difficulties among children and adolescents (1). Up to 20 percent of all children today suffer from psychological difficulties such as trauma, depression, anxiety, communicating and social barriers, among others. The real percentage of children and adolescents suffering is probably even higher since for instance ADHD, mood disorders and learning difficulties are not included (1). These difficulties are however also important to highlight since they create obstacles and problems regarding children and adolescent’s

schooling, family life, maturity and social conditions. The prevalence of behavioral disorders has increased significantly among children and research shows that these individuals has a greater risk of drug abuse, lower occupational status and disabled social relationships in adult life if not helped and treated efficient (2). Bipolar disorder, which consists of recurring depression and mania, is becoming more common among the younger population and research post to the fact that this disorder has its roots in early life and can be prevented (3).

Interventions specially targeted at children are seen as increasingly significant and studies attest to its importance improving mental health among young individuals, as well as prevent further psychological suffering in adulthood (1, 3).

The impact on their parents

The family as a unit has a central position in all cultures and its form of cohabitation offers an opportunity for both children and adults to get their primary needs satisfied (10). These needs consist of affirmation, social protection and affection, among others. A family is thus a form of coexistence in which the individuals are closely related to each other and has great

significance for one another. In this social context have all family members influence on each other and that which significant influence one of these individuals, also affects the rest of the family. A child´s suffering from illness has thus an influence on the rest of the family

members, such as their parents, as well. Research from 2013, based on World Health Organization´s World mental health survey, shows that caregivers to a mental or physical disabled child, who most commonly consist of their parents, are dealing with burdens such as depression, reduced quality of life and stress-related conditions because of the child´s illness (4,5). The inability to help the child causes frustration and worries, and along with concerns regarding its future wellbeing and life, causes high levels of parenting stress. Families with children suffering from ill health and disorders of this kind also reports devoting time, financial burden, embarrassment and psychological distress (5).Parents dealing with a child with mental ill health, disorders or difficulties report higher levels of embarrassment and alienation than those having a child with, for example, cancer or heart disease (4). The stigma surrounding mental ill health remains widespread and often puts the whole family in

perceived exclusion. The expanding problem regarding mental ill health, difficulties and disorders among children and adolescent thus means a problem of importance among parents health as well. These parents constitute a risk group and interventions which can ease their burdens and therefore prevent ill health are of significance.

Children and parents in Sweden

The mental ill health among children in Sweden at the age of 17 or younger has increased since the 1990`s (8). It is primarily the occurrence of stress, anxiety and depression which has enhanced and the use of psychotropic drugs has also increased. Concentration and

hyperactivity disorders are also becoming more common and the use of ADHD-medication

increases rapidly. In 2011 were 4 percent of girls and 3 percent of boys below 17 years of age

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in contact with medical care seeking help and treatment for mental ill health (8). Mental and emotional difficulties are however at a greater percentage than that, since many don´t turn to medical care when experiencing psychological problems (5). An increasing share of Sweden´s children and adolescents suffer thus from mental ill health, difficulties and disorders. This also means that there are a growing proportion of parents within the country affected by their child´s mental ill health. Parenthood can be stressful itself due to the demands and

responsibilities of being a parent, even though not having to deal with a child suffering from mental ill health or difficulties. A study which aimed to look into parental stress among Swedish mothers and fathers in early parenthood concluded that there were several factors which could eventuate in stress (11). The experience and worry of being a dissatisfaction parent and lack of support were two of the prominent issues which could cause stress. The conclusion from this study pointed to the importance for healthcare professionals to be aware of which factors that can cause parental stress, and there for give better support to the parents within their parenthood. Another Swedish study report how parents with children born with a lifelong disability report unanswered needs for information and support (12). The information requested is wished to be helpful for these parents and their understanding of the child's illness. Counseling is also desired by these parents and described as important for their perceived ability to deal with the family situation which has arisen. Support, such as comfort, encouragement and understanding, are also important for these parents when dealing with the fact of having a lifelong disabled child (12). Research shows the same parental need when a previously healthy child is being admitted to hospital. A Swedish study found that if parents´

needs were fulfilled, they were better able to cope with the child´s illness (13). The

perception of being trusted, confidence towards health care providers, access to information, supportive surroundings and guidance, are all examples of needs reported by these parents.

This study also highlighted the significance that healthcare professionals acknowledge the children and parents´ importance towards each other. Support is thus not only needed by the children being ill but by their parents as well. The research within Sweden is quite limited regarding experiences and health among parents with children suffering from mental ill health, difficulties and disorders. Research has to some extent been done aimed to get a better understanding regarding parents´ perspective and health when having children with

concentration and hyperactivity disorders. This research shows that these parents suffer from perceived powerlessness and loss of control (14). With the increasing prevalence of mental ill health and disorders among Swedish children and adolescents, a need occurs to also

understand how this affects their parents´ health. It is also important to learn more about which interventions that can be health promoting and helpful for these parents.

Parental access to social support – a stress reducing factor?

When experiencing difficult times in life, studies show that access to social support and supportive social networks has a reducing effect on the vulnerability to develop stress-related conditions (6,7). Such a situation in life could consist of a parent having to deal with their child´s mental ill health, disorders or difficulties. Many parents who is going through this, experience high levels of stress caused by worries for the child, embarrassment, psychological distress and lack of information (4, 5, 12, 13). Among these mothers and fathers, there is also common with a need for support (11, 12, 13). Studies have shown that the best way to satisfy parental need and support families is by providing services and interventions based on social support (15, 16). To help the increasing amount of parents in Sweden having to cope with their children´s mental ill health, difficulties and disorders, and prevent parental ill health such as stress-related conditions, an intervention which could increase the social support and

reduce the parental stress seems appropriate. If this intervention also could be beneficial for

the children’s mental disorders or problems, you could kill two birds with one stone.

4 Theoretical framework

The theory about social support is a concept which involves an individual´s ability to get help and support in social relationships and networks (6). The social support received from one-to- one interactions is divided into four different categories: emotional, informational,

instrumental and appraisal. Affection, empathy, intimacy, love, trust, concern and caring are some of the components representing the emotional support. The relationships providing this kind of support are sources of emotional warmth and are important for the individual´s sense of self-worth. Informational support consists of relationships providing advice, knowledge and guidance. This information is important for the individual´s ability to understand and cope within different situations in life. Instrumental support encompasses acts which directly assist a person in need, for example financial assistance and material contribution. When self- evaluating and for example dealing with a process of change, relationships providing

constructive feedback and confirmation are important and represent the appraisal support.

Social networks consist of several relationships surrounding the individual which together compose a close and supportive social environment (6). Family and relatives, friend circles, work colleagues and classmates could compose such a social network. Access to some kind of social support or a social supportive network can become a suitable base when composing interventions aimed to help children suffering from mental ill health and their parents. An interest arises whether interventions already available and which have a health promotion effect on these individuals, offers social support of some kind and that it is this fact which has a positive effect on their health. The theoretical framework in this study will thus be the Theory of social support, which has influenced the study´s purpose, research questions, interview guide and interpretation of collected data.

Parental health on a public health level

The public health agency of Sweden has a national responsibility for the population´s health and the issues which influence the public health. Eleven target areas have been identified to promote the health among the population. Target area number two concern economic and social conditions and how this is essential for good health (17). The social aspect consists of the individual´s safety and equality in social contexts. Alienation, anxiety and inequality at home, at work or in the community are all examples of social conditions that can cause illness. Children and adolescents’ upbringing represents the third target area and it highlights the importance of the environment and conditions during childhood on mental and physical health throughout life (17). The parent – child relationship, school environment and physical lifestyles are some examples of such of importance within this area. The sixth target area regards a health promotion health care (17). Some of the aims within this target are

comprehensive preventive and treatment interventions, health promotion actions and active

dissemination of knowledge regarding diseases and ill health. The increasing prevalence of

mental ill health, disorders and difficulties among children and adolescents (8), and its further

health impairment consequence within their parents is a public health issue which should be

impeded according to these three target areas. The parents are at risk for decreased social

conditions when experiencing embarrassment, alienation and lack of support, which makes

this a public health issue in line with target area number two. The mental ill health or

hardships which the children suffer from increases the risk of health problems later in life,

which points to its importance to prevent in obedience with target area number three. The

parents´ need for significant information and health promotion interventions makes the

problem even important due to target area number six. Swedish population statistics from

2012 regarding different kinds of households shows following percentages: single parents

with children 0-24 years of age represent 5, 9 %, cohabiting parents with children 0-24 years

of age represent 22,2 % and other households with children 0-24 years of age represent 2,9 %

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(18). A total of 31 percent of Swedish households thus includes children and adolescents. This means that a significant part of the population in Sweden consists of households with children and caregivers, most common parents. This further means that a significant amount of parents are at risk for ill health. With an expanding problem, which should be prevented according to three of The public health agency´s target areas, regarding children and adolescent´s mental health and the health impairment affect this could have on their parents, there is a need for research investigating which kind of interventions are suitable to help both children and parents. In addition to the suffering among these children and their parents, there is another reason to investigate how to prevent and diminish this public health problem. Ill health composes a significant financial burden within the Swedish society. A report from 2010 conducted by the public health agency of Sweden reveals how ill health costs the society 120 billion a year (19). The report further state how these numbers probably only composes the top of an iceberg, which means that the ill health is an even higher financial burden for the society. This fact lays even more importance to the need for interventions aiming to prevent and reduce mental ill health among children and their parents.

What is play therapy?

The distinct use of play within therapy first occurred in the early 1900´s when psychoanalyst

Sigmund Freud saw the act of play as a possible therapeutic method (9). This new kind of

therapeutic setting was considered suitable for young children´s need to express feelings,

experiences and thoughts. Therapists such as Anna Freud and Melanie Klein continued the

sequent development of children´s play as a stimulating and therapeutic process. In the mid

1900´s were play therapy heralded to the next development in the therapeutic field by

psychologist Virginia Axline (9, 20). Axline was a pioneer within play theory and founded

therapeutic principles based on the belief that children hold possibilities to heal themselves

within ideal therapeutic settings (20). During the following decades, play theory developed

into a well-known and widely used method when treating and helping children suffering from

mental and emotional difficulties, behavioral problems and trauma (9). Today, play therapists

are helping children expressing themselves all over the world and this kind of intervention is

commonly used (20). This therapeutic method currently exists of many different types of use

of play, but they´re all based in the beliefs that play is a possible tool when helping young

children. Most children under the age of eleven are unable to verbalizing their problems and

inner thoughts, whereby the act of play becomes an important possibility for the child to

express itself. When playing, the child explores the surroundings, processes experiences and

practice problem solving. The ability to play is also necessary for the child´s personal and

social development (21). Play therapy is today used to alleviate and treat young children with

mental ill health such as anxiety, depression and trauma, behavioral problems such as anger

and irritability and difficulties regarding coping, social interaction and emotions (9). This kind

of therapy is therefore a suitable intervention to decrease the problem of today regarding

Swedish children and adolescent´s mental ill health, disorders and difficulties. It is currently

common used within children´s ward within Swedish hospital care. However, there is no

research on how parents whose children being helped by and treated in play therapy are

experiencing this intervention, and if they consider it health promotion on their own perceived

health. By investigating the significance of children´s participation in play therapy for their

parent´s perceived health, an opportunity opens up to consider play therapy as an intervention

not only health promotion for the participating children but for their parents as well. This kind

of intervention could thus become one appropriate solution regarding the increasing mental ill

health, disorders and difficulties among children and the health impairment consequences this

could have on their parents.

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Purpose

The purpose of this study was to explore if play therapy is beneficial not only for the children taking part of it but also for their parents´ perceived health. The aim with this study was furthermore to increase the understanding regarding if children´s participation in play therapy has a stress reducing and social support increasing effect within their parents.

Research questions

1. Has the child´s participation in play therapy had any significant effect on the parent´s perceived health?

2. Has the parent perceived their child´s participation in play therapy as a stress reducing intervention?

3. Has the parent perceived their child´s participation in play therapy as a social support

increasing intervention?

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Method Study design

The purpose of this study was to investigate if children´s participation in play therapy also could be beneficial for their parents, by increasing the knowledge and understanding about which effect this kind of intervention has on the parent´s perceived health. It was also of interest if the parents perceived the children´s participation in play therapy as something stress-reducing and social support increasing. The aim was thus to comprehend the parent´s point of view and answer questions like “How?”, “In what way?” and “Why?”. To

accomplish this was a qualitative method with an inductive approach chosen and collecting of data consisted of private interviews. This study design is appropriate when aiming to describe, explain and understand (22). Qualitative methods most commonly consist of a research

process where texts are analyzed with the purpose to understand contexts and experiences within the chosen area. The texts which are used either consist of data who the researcher has collected from interviews or video recordings and thereafter transcribed, or from textual sources written by others such as books, diaries or articles (22). In this study were texts used which consisted of transcribed material collected in the interviews. The private interviews in this study were semi-structured and based on an interview-guide with three themes: before and after the child´s participation in play therapy, the parent´s perceived health and perceived stress and social support. The interview guide and it´s questions were developed based on the Theory of social support. For more details regarding the interview guide, please go to

appendix one and two. The first theme consisted of questions regarding the family situation:

what led the family to seek help and which changes the parent had noticed within the family since the intervention. Focus within this theme was on the whole family situation and this was chosen to make the participant comfortable with the situation and answering questions, before moving on to personal issues (23). The following theme was based on questions regarding if and how the parent´s perceived health had changed and if so, if this change had been

influenced by the child´s participation in play therapy. This was done, for example, by asking the participant to describe their general health status on the basis of a scale which ranged from very good to very poor. The interview guide´s last theme concerned the participant´s

perceived stress and social support. Questions asked concerned if the level of stress had changed and if so, if this had been affected by the child´s participation in play therapy. The parent was also asked to describe if their access to social support had increased and to which importance this kind of support could be for parents.

Participants

The method used to find participants in the study was purposive sampling. This sampling

method is suitably in qualitative research (24 ). Purposive sampling is characterized by the

aim to select and identify certain participants most appropriate to answer the research

questions, which in qualitative research has the intention to get a greater understanding and

knowledge within a specific population or situation. Selection of participants is thus not

randomized or representative of the larger mass of the population. Purposive sampling is

further divided into different and more specific kinds of sampling methods. The one used in

this study is criterion sampling which consist of a selection of participants based on particular

characteristics (24). The particular criterions are based on the study´s purpose and specific

research questions and are done so to accomplish the most suitable basis in the research. The

criteria decided to be fulfilled for the participants in this study were that they had to be parents

whose children had been/were currently attending in play therapy at the corporation in which

the researcher were in cooperation with. No further preferences were given such as sex, age,

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ethnicity or profession. Sex possible participants were found who fulfilled the criteria and they were all asked to participate. Of these it was four who chose to participate in the study.

Study setting

The study took place in the southern part of Norrland in Sweden during the first half of 2014 and was conducted by a student graduating from a college in the area. The research was done in cooperation with a corporation that operates health promotion with children and families in the middle of Sweden. This corporation has been operative during a number of years back helping families and children with various problems, and works for example with cooking groups, drug-free youth activities and therapy sessions. One of the interventions offered in the corporation is play therapy for children. The search for participants was first made by the corporation´s personnel who handed out covering letters to parents who had children being attending in their play therapy. For more details regarding the covering letters, please go to appendix three and four. Those parents being interested in further information and

participation contacted the researcher by mail or telephone. The participant´s rights and the basis of the study were ensured during this time of contact, followed by the determining of time and place for the interviews according to the participant´s preferences. Two interviews were conducted in the participants’ home, one at the corporation where the children

participate in play therapy and one took place at the participant´s workplace. All interviews were hold in personal meetings between the researcher and one participant at a time. Two of them were to some extent accompanied by the participant´s child who was in the vicinity at some of the time. The interviews lasted between 35-50 minutes and were recorded with a Dictaphone or the researcher´s cellphone. The interview guide was also available at each interview by the researcher´s laptop.

Data analysis

The data collected in the study was processed in a thematic analysis and interpreted on the basis of the Theory of social support. This process first began with a transcription of the materiel recorded in the interviews. Each recording was listen through and literally

documented as close to the interview as possible. The timeframe was important, so that the researcher who conducted the interview wouldn´t create misunderstandings or forget details when transcribing (23). While literally writing down what was said by the researcher and the participant, it was also noted how they said it. Feelings such as anger, relief and happiness were written within parenthesis so that information expressed in other ways than by words, also could be used in the following steps in the analysis. Sounds from the surrounding were also noted and described in the document to ensure that all collected material were noted, but was no data of importance during the following steps. When all recorded data had been transcribed it was read through to get a comprehensive overlook and a first sense of different categories and themes. The next step in the thematic analysis was to print out the documents with large margins on the paper, which enabled the researcher to make notes while reading through the material a second time. Important statements and information given were

highlighted with a marker. These notes and pick outs consisted of information significant for

the study´s research questions. The selected parts of the material were thereafter read through

and cut out into small pieces of paper only consisting of significant material. On the backside

of each piece of paper was the meaning unit condensed into a short summary, in terms of

codes. This was done to facilitate the following step, when the cutouts with codes were used

to compile a number of categories and recurring themes representing the manifest content

from the interviews (23). These different categories were thereafter summarized into a smaller

number of main categories, from which the prominent themes were identified. The last part of

the thematic analysis consisted of a comparison and analysis of the study´s purpose, the

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research questions, the Theory of social support and the found themes. The outcome of this data analysis engendered the study´s result.

Ethical considerations

To make sure that the study was implemented in an ethic proper way, it was put through according to the guidelines from the Science council. These guidelines are categorized in to fours requirements regarding information, consent, confidentiality and use of collected data (25). Possible participants were first contacted by the therapist helping their children and if interested they received a covering letter. This was made to make sure that no one unwilling to participate would be contacted direct by the researcher and thus experience possible feelings of inconvenience. Due to the study´s delicacy it was seen as a possible ethical problem to cause eventual participants the feeling of violated integrity. Only those comfortable and interested in participation in the study were thus in contact with the

researcher. The covering letter contained information about the researcher, the purpose of the study and to which public health use the collected data could be. It also declared the

participation as voluntary, anonymous and the participant´s right to interrupt the partaking at any time. Those interested of taking part in the study thereafter contacted the researcher and time and place for the interview were decided according to the participant´s wishes and comfort. Further details regarding the interview were also given at this time and participants had the opportunity to ask questions. At the time of the interview ensured the researcher the participant´s consent about participating and the right to discontinue at any time. The

researcher also explained how collected data would not be dealt with by anyone else and that it would be discharged after completion the study. When transcribing, analyzing and

presenting the collected material were personal information, such as names and locations

which could reveal the participant´s identity, removed or replaced with fictitious figment. To

further unable the identification of the participants and their children, were the children´s age

and sex removed when presenting the result from the thematic analysis. The data were not

used during any other circumstances than implementing the study. By doing as described

above was the study planned and fulfilled in consent with ethical guidelines.

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Results Introduction

The thematic analysis resulted in three prominent themes which were social support, empowerment and parent-child relationship. The theme social support consisted of the participants´ parental need for acknowledgement, someone to listen to and give comfort regarding the problematic family situation. Advice and information which enabled the

participants´ to understand and manage the situation within the families composed the second theme, which was empowerment. The parent-child relationship constituted the third theme and consisted of how the parents´ wellbeing was depending on their children´s health, which furthermore made them feel as good or bad parents. For more details, please go to Table 1.

Table 1 Prominent themes from the thematic analysis of data collected in four private interviews.

Codes Categories Main categories Themes

“I was so lonely.”

“.. they didn’t listen.”

“ .. made me feel important.”

“Acknowledged our problem!”

“Comforted me..”

“..support.. help.”

Need to be seen Someone to listen Acknowledgement Given importance Willing to help

Comfort and reassurance

Being heard and seen Taken seriously Confirmation

Social Support

“Didn’t know what to do..”

“Felt so useless!”

“.. the feeling of powerlessness.”

“I didn’t understand why.”

“.. gave me guidance.”

“I couldn´t explain..”

“Helped me with the situation.”

Given information Useful tools Comprehending the situation

Parental confidence Understanding the child´s situation

Explanations

Advise and answers

Manageability

Understanding

Empowerment

“I just wanted to help.”

“It’s a horrible feeling..”

“.. made me feel such a bad parent.”

“It makes you so sad.”

“.. when they´re not happy..”

“.. couldn´t express.”

“ They had problems verbalizing..”

Care for the child Sad child – sad parent Being a good parent Responsibility

Knowing what´s wrong Understanding

Sympathy

Parental satisfaction The child´s wellbeing Communication

Parent-child relationship

11 Four different families

The first participant was a mother whose two youngest children are partaking in play therapy since fifteen months back and she will henceforth be referred to as Abby. These children´s biological parents had problems of such degree that their children could no longer live with them, so the children were placed within Abby´s family. When arriving into their new home were the children distressed and unable to settle down. Abby noticed how they had difficulties playing like other children at their age and they didn´t know how to use the toys which were given to them. The family situation was affected by the children´s constant running around and screaming and a frustration arose within the parents since not being able to help the children to calm down and play naturally. The children also seemed to have a need to process and express what they had experienced in their previous home. Abby´s wellbeing was

negatively affected and she experienced feelings of stress and lack of energy. All her focus and attention were prioritized towards the children´s needs. To help the children with their difficulties playing and settling down she turned to a corporation which offered play therapy.

Becky is the fictional name for participant number two, who was a mother of a child

participating in play therapy since just over a year back. The family situation which led them to this therapeutic method was caused by the separation between Becky and the child´s father.

The situation, which was sudden and unexpected, caused a lot of sadness within Becky and her child. The child had a hard time understanding the situation and blamed the parent´s separation on itself. Becky noticed how her child was experiencing severe stress, for example by having nightmares and loosing hair. The child also had concentration difficulties at school.

Becky experienced stress and moods of grief. Unhappiness caused by the separation together with the distress of the child´s mental ill health made Becky search for help, both for herself and for her child. This led them in contact with the corporation in cooperation with the researcher in this study.

The third participant was a mother whose child is being helped by play therapy since over two years back and she is given the fictional name Carolyn. The child is adopted and Carolyn has experienced the child as withdrawn and struggling with connection towards the family ever since the arrival. When growing up had the child communication difficulties which caused frustration within the parent – child relationship. Problems also occurred in school where Carolyn´s child experienced alienation and conflicts of various types with other schoolmates.

Carolyn noticed how her child´s wellbeing was negatively influenced and when she tried to solve the problem by contacting the school´s personnel she received no response. The family situation was by this time characterized by unhappiness and the parents´ frustration over the inability to solve their child´s difficulties. Upset and worried for her child´s wellbeing did Carolyn search for help elsewhere and came thus in contact with play therapy in a nearby corporation.

Participant number four will henceforth be referred to as Diana and she was a mother whose two children had been participating in play therapy in three rounds over the past years. Diana and the children´s father separated which made the siblings sad and unhappy. The children had difficulties dealing with the situation and struggled with talking about what was

happening. Their mother were at the time suffering from burnout and were thus decrepit and

felt unwell. This furthermore led to Diana´s difficulty helping her children processing their

parent´s separation. Diana became frustrated and felt even worse unhappiness. She noticed

their inability to express their feelings and thoughts, and this together with her own limitations

made her decide to look for help. The search led them to a corporation, the same as mentioned

above, where the children got to participate in play therapy.

12 Social support - I am taken seriously!

Carolyn described her frustration and feelings of being disregard when trying to contact the child´s school for help solving the problem with the child´s classmates. She received no response which made her feel that their situation was of no importance. It made her sad not being heard and seen, when trying to help her child. This changed when the child started the participation in play therapy. Carolyn was listened to and the child´s therapy made her feel that their situation and problem were acknowledged.

“I was taken seriously! ..fantastic feeling that they wanted to help..”

Carolyn, participant number three Another participant who described similar experiences of confirmation when receiving help was Becky. She described the perception of relief and acknowledged related to her child´s participation in play therapy. Her previous feelings of loneliness reduced and she felt listened to. Unlike before, she now had someone to turn to for support when dealing with the situation where both she and her child had problems. Becky further talked about the significance of being helped and given importance when going through parental struggling. She explained how she felt that the play therapy not only was helpful for her child, but for herself as well.

“They lift a burden.” “I don´t have to do everything by myself.. they support both myself and my child.”

Becky, participant number two All four participants described how their children´s participation in play therapy has made them feel supported, which resulted in reduced stress and worries regarding if the children´s situation could be solved. These experiences of social support are described by the

participants using words like comfort, encouragement and confirmation. They described how they used to talk to the personnel when leaving and picking up their children from the play therapy, and how these conversations offered an opportunity for the parents to ease their thoughts and feelings. The play therapy by itself, with other words the fact that their children received help, also made them feel supported as parents. It was furthermore agreed by all participants that social support is needed when being a parent, and especially when handling a situation where their children suffering from mental ill health, disorders or difficulties.

“All forms of support are of course important, you know, but as a parent you need the support, especially when it's hard with the kids.”

Diana, participant number four Empowerment – Managing the family situation

The inability and not knowing how to the help her children is described by Abby as a situation having a very negative effect at her perceived health. She saw them struggling and having problems settling down peaceful in their new home and she wanted to help and make them come to a harmonic state of mind. The worries and concern for her children and their problems, together with the feeling of being unable to manage or influence the situation caused her high levels of parental stress. She eventually noticed how the situation made her anxious and that the high level of stress made her tired and lacking energy. When the children started their attendance in play therapy an opportunity opened up for Abby to get her

questions answered how to help and support her children. She described how the personnel

gave her advice and increased her understanding regarding the children´s behaviors and

problems. This made her feel more confident and capable managing the situation.

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“Now, I have it explained to me. You know what to, how to handle it when they´re doing like that.. and I know why, what causes them to..”

Abby, participant number one Becky and Diana also talked about how their feelings of powerlessness in the situation caused them stress. Diana, who was going through a burn out, experienced not having enough energy to help her children. This made her feel anxious and useless as parent, when not being able to handle the situation as she wished to. Becky described how her child´s sadness and blaming of itself as the cause for the parent´s separation, made her feel terrible. While she herself was feeling unhappy and tried to cope with the separation, she also wanted to help her child and get this to understand the situation. When not being able to do this, both due to her own lowered mood and the fact of not knowing what to do, she felt stressed. The personnel at the corporation where her child later on began in play therapy helped her coping with the

situation and how to answer the child´s questions regarding the parent´s separation. This guidance and source of advice made her feel less stressed.

“I felt powerless. I felt, I was not enough.” ”.. when giving me information about how to do, how I should answer the difficult issues and questions which I don´t know how to. They have

given me suggestions and advice how to answer.”

Becky, participant number two Three out of four participants explicit expressed how they received information, advice, guidance and answers through their children´s participation in play therapy, which helped them managing the family situation. This was furthermore described as helpful in the understanding regarding the children´s problems, coping with the situation, knowing how to support and help the children and lastly as stress reducing. The feeling of being more secure in the role as a parent and able to help the child decreased stress-related perceptions such as worries, anxiety and inability to wind down. The participant who did not receive the support of this kind, however, explained how this was due to her since she did not ask for answers or suggestions. She further said that if she had felt the need for advice, she did not hesitate on that the staff had helped her.

Parent-child relationship – A happy child makes a happy parent

Four out of four participants described the negative and harmful influence on their parental health due the situation which made them seek help. Even though going through and dealing with different kinds of family situations, they all expressed how their children´s mental ill health, disorders and difficulties made them feel as poor parents. The parents´ sympathy regarding their children´s state of mind, results in a happy parent if a happy child and thus a sad parent if a sad child. Words used to describe their feelings and perceived health as parents in this situation was horrible, sad, troubled and unhappy. It was described how the child´s wellbeing and health is of big importance for the parental health and also acts like evidence of whether one is a good or bad parent.

“It is very hard being a parent, when you get in something like this.” “I was so sad, seeing my child so unhappy..”

Carolyn, participant number three

“As a parent, if your kids are not feeling well you also feel very bad yourself, you know.”

Diana, participant number four

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Two of the participants expressed how their perception of being poor parents also increased by the feeling of being unable to understand and communicate adequately to their children.

The perception of not understanding the situation from the child´s point of view made them fell stressed and frustrated. It was described how it is the parent´s responsibility to listen to the child´s feelings, thoughts and desires, and furthermore to make sure that these are fulfilled and taking under consideration within the family. When thus having communication problems within the parent-child relationship and difficulties as a parent understanding your child´s perspective, it leads to the feeling of a failure as a parent. So when the children´s ill health, disorders and difficulties eased thanks to their participation in play therapy, the parent-child relationship improved and the participants perceived themselves as successful and good parents.

The research questions

Four out of four participants experienced their child´s participation in play therapy as significant beneficial for their perceived health. They ranged their general health before the intervention as poor or very poor, on the scale used within the interview. For more details regarding the interview guide, please go to appendix one and two. Words used to describe their perceived health at this time were powerlessness, lack of energy, unhappiness and stress- conditions of different kinds. After their children’s therapy, they all experienced their general health as improved and ranged it from good to very good, since experiencing relief, harmony, joyfulness and an enhanced family situation. Two of the participants described how this health enhancement not only was a result from their children´s participation in play therapy, but on their own therapeutic treatment as well. When asked if they still thought that their children´s attendance in play therapy had had a substantial importance for their improved general health, they both ensured it without hesitation. Four out of four participants felt that their children´s participation in play therapy had had a stress-reducing effect on themselves. A factor of big importance which made them less stressed was their increased manageability, understanding and empowerment within the family situation. Four out of four participants described how the intervention had increased their access to social support which consisted of comfort, acknowledgement and the feeling of being taken seriously. Three out of four

participants also felt that they had access to further social support when receiving guidance,

advice and information useful for understanding the family situation. In summary experienced

three of the participants their children´s participation in play therapy as a significant social

support increasing intervention.

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Discussion

The key findings in relation to the background

The theory of social support, which was used to create the purpose, research questions, interview guide and within the analyze and interpretation of the collected data, complies with two of key findings. Four out of four participants described how they felt supported by the personnel at the corporation when receiving comfort, confirmation and being heard and taken seriously. This furthermore had a beneficial effect on their perceived health. The perceived support experienced by the participants matches one of the subcategories within this theory, namely emotional support (6). According to the Theory of social support has access to supportive relationships a health-promoting effect and may prevent ill health, when going through a troubling and difficult situation. The fact that the participants felt a positive

influence on their perceived health by this described support, thus consistent with the theory.

The second key finding was the three out of four participants´ increased feeling of

empowerment within the family situation, thanks to the guidance, advice and explanations given when their children participated in play therapy. This helped them understand and cope with their children´s mental ill health, disorders and difficulties, which additionally made them feel less stressed. Once again were they experiencing a kind of social support which can be understand and explained according to the Theory of social support. That, which they described improved their empowerment, is named informational support within this theory (6). The participant´s experienced beneficial effect on their perceived health caused by their children´s participation in play therapy, can thus be explained since they got emotional and informational support. The third theme found in the thematic analysis was parent-child relationship. This consisted of how the parent´s wellbeing and general health were under great influence of their children´s health status. The feeling of sympathy towards their

children and the importance of they being happy and healthy, complies with the social context that constitutes a family, and how all therein affect each other (10).

The result in relation to previous research

The health impairment described by the participants caused by the family situation which made them turn to play therapy, consistent with previous research showing the family as a cohabitation where all family members influence one another (10). Studies, such as World Health Organization’s world mental health survey from 2013, has come to the conclusion that a child´s ill health has a significant importance for their parents health status as well (4,5).

The participant´s feelings of distress, unhappiness, worry and failure as a parent within the situation where their children were suffering from mental ill health, disorders or difficulties, thus correspond with previous research. An unhappy child makes an unhappy parent. The children´s participation in play therapy had furthermore a stress-reducing effect within their parents. This was shown by the participant´s when describing their health status as currently more peaceful, harmonious, happier and manageable. They all also explicitly told how they experienced their present family situation as less stressful. Previous research has pointed out how parents having to cope with a child at ill health is experiencing high levels of parenting stress, and when being helped and the child´s being under treatment is the levels of stress decreased (4,5,6,7,12,13). This is for example due to the child´s improved health, the support given to the families and less parental concern regarding the child´s future health and

wellbeing. The collected and analyzed data within this study came to the result that the parents received emotional and informational support through their children´s participation in play therapy, which had a beneficial effect on their perceived health. Prior studies has shown the parental need for support, especially when having an ill or disabled child (11,12,13).

When fulfilling the parents need for supportive interventions, they are better able to deal with

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parental stress and avoid health impairments when coping with a child at mental ill health, disorders or difficulties (6,15,16). Studies have shown how parental empowerment represents a significant factor to prevent and diminish negative influences on their health, when having a child suffering from ill health or disabling difficulties. Mothers who feel supported and receives information and advice from health professionals which enables them to cope and understand their child´s critical illness, report higher levels of empowerment which

furthermore decreases their perceived stress (26). Also when having a child with a chronic illness or disability, such as sickle cell disorder, thalassemia, and behavioral problems, have parental empowerment been pointed out as a health promotion factor (27, 28, 29). The result from this study regarding the participants´ experiences of improved empowerment and how this had a beneficial influence on their perceived health, thus corresponds to previous research.

The study´s methodology – appropriate or not

The decision to use a qualitative study method was based on the study´s purpose and research questions. The aim was to increase the knowledge and understanding concerning if play therapy for children also could be beneficial for their parent´s perceived health. It was also of interest to look into if they perceived their children´s participation in play therapy as a stress- reducing and social support increasing intervention. To achieve this, was a research method needed which created opportunities for the participant to openly describe and talk about their personal perspective, perceptions and experiences. To create this opportunity for the

participants was private semi-structured interviews chosen. The choice of a qualitative study method is still considered a suitable decision by the researcher, since the collected data was useful to achieve the purpose of the study and answer its research questions. The honest sharing from each participant of inner thoughts, experiences and perspectives, enabled the researcher to get a greater understanding and knowledge regarding the importance of children´s attendance in play therapy for their parent´s perceived health. All three research questions composed in this study could be answered with the collected material. If the chosen study method had been of a quantitative character, for example by using a survey, difficulties had arisen when aiming to answer the research questions in this study. A qualitative method is appropriate when aiming to answer questions like “Why?”, “In what way..?” and “How?”, and thus get an increased comprehension of individuals beliefs, inner thoughts and

perceptions (22). The researcher also has a possibility to ask following questions and guide the participant during the interview, which enables the researcher to get all the personal perspectives needed to answer the research questions. Compared to surveys, where the researcher has no chance of encourage the participant and affect the collecting of data to the personal and openly level needed to get the increased understanding regarding the study´s theme.

Strengths and weaknesses

There is a gap within Swedish research regarding which kind of interventions that is health

promotion for both children who is suffering from mental ill health, disorders and difficulties,

and for their parent´s perceived health as well. Since the mental ill health among children and

adolescents in Sweden has increased ever since the 90´s (8), there is a significant need for

improved understanding and knowledge regarding how to help and treat the younger

population. Another group of the population who is also in need for this research, is the

children and adolescents´ parents, which research has shown suffers from distress, anxiety,

worries and burdens of different kinds when having an ill child (4,5). International studies has

pointed out that these parents have a need for social support such as comfort, confirmation,

information and advice (15,16). The same conclusion has been drawn within Swedish studies

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(11,12,13). This study is thus a contribution to the area where there is a lack of research. It also offers another way to use social support to act health promotion. Play therapy has been known for a long time to be a suitable therapeutic method when helping and treating children with mental ill health, disorders and difficulties, but this study add the possibility to consider play therapy for children also beneficial for their parent´s perceived health. The three

strengths of this study is thus the new perspective towards the beneficial effects of play therapy, the contribution to a research area that lack sufficient studies and a possible solution to the problem regarding the increasing ill health among children, adolescents and parent´s in Sweden. The weaknesses of this study consist of the following problems. The first is the fact that the participants consisted only of mothers. Since no fathers participated, there is no data on how these experienced their children´s participation in play therapy and no conclusions can thus be drawn regarding an eventual beneficial effect on their perceived health as well. This means that the result from this study only is representative for women in parenthood. Another important question within this study is if the participant´s improved perceived health is a result of the children´s increased wellbeing thanks to the play therapy, or a result of the intervention by itself. Would the participants experienced such a beneficial effect on their perceived health, less stress and increased social support, even though the children’s´ mental ill health, disorders and difficulties hadn´t been improved? Is it also enough to improve the parents´ perceived health by acknowledging and fulfilling their needs, regardless which kind of intervention they´re being helped by? Since all the participant´s children had been helped by the play therapy, problems arise when trying to profoundly understand the different mechanisms within the intervention which improved the participants' health. These issues have a negative influence on the study´s validity. Has the research really increased the knowledge and understanding regarding the importance of children´s attendance to a specific therapeutic method for their parent´s perceived health, or has the study found out that parental health is positive influenced when receiving social support and seeing their children at better health? Another weakness which occurs regards the study´s generalizability. Partly because of the low validity, but also since using a qualitative study method with few participants, chosen with purposive sampling. Problems arise when trying to draw conclusions about the

population as a whole on the basis of the study´s result. To consider the study's result as representative and generalizable, it would have consisted of a greater number of participants, children with different outcomes from the intervention and include both mothers and fathers.

Conclusion and future research

The conclusion of this study is that children´s participation in play therapy has a significant beneficial effect on their parent´s perceived health. The participating parents also experienced the intervention as stress-reducing and social support increasing. The prominent themes from the thematic analysis and interpretation based on the Theory of social support, was social support consisting of comfort, acknowledgement and the feeling of being heard and seen, empowerment which consisted of the participant´s increased feelings of understanding and manageability within the family situation and lastly the parent-child relationship, which was based on how the parent´s wellbeing and happiness was under great influence of the

children´s health status. Further research is needed to investigate if the improved perceived health only applies on mothers whose children is participating in play therapy, or if the same health promotion effect also is experienced by the children´s fathers. Studies which include a greater number of participants or a great number of studies completed, is necessary to

conclude an association between children´s participation in play therapy and a beneficial

effect on their parent´s perceived health. These studies should also include children with a

larger number of different kinds of mental ill health, disorders and difficulties, and also

differences within their outcome of the intervention. The reason to do this is to furthermore