Puppets in therapy assessment and diagnosis

Åsa Viklund¹

1. Child and Adolescent Mental Health Services, Capio Ramsay Santé, Gothenburg, Sweden.
   E-mail: [email protected]

OPEN ACCESS

PUBLISHED: 28 February 2025

CITATION: Viklund, Å., 2025. Puppets in therapy assessment and diagnosis. Medical Research Archives, [online] 13(2). https://doi.org/10.18103/mra.v13i2.6200

COPYRIGHT: © 2025 European Society of Medicine. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i2.6200

ISSN 2375-1924

ABSTRACT

is often a modality that therapists use to enhance understanding and communication in treatment. Among many possible assessment tools suggested in work with children are puppets which appeal to a wide age range and are familiar toys to many. This article describes and compares nine different puppet therapy assessment techniques. The assessment techniques are: Spontaneous Group Puppetry; The Puppet Therapy Assessment Technique; The Family Puppet Interview; The Ross Family Puppet Technique; Puppets in Psychotherapy Scales; The Dynamics of Three; The Puppet Sentence Completion Task; The Berkeley Puppet Interview; and The Affect in Play Scale. The current study is a qualitative interview study in which thematic analysis has been applied. Five themes emerged in the analysis: methods and techniques in puppet assessment; assessment in therapy: assessment in diagnosis; different levels of structure; and what works for whom. The level of structure is emphasized in the discussion, as are age considerations. Conclusions suggest aspects in favor of, and against, using these assessments. Aspects in favor of using the techniques are, for example, the need for therapist flexibility; the necessity to create rapport; the importance of an appropriate assessment tool; and the requirement to adapt the level of structure to the client. Possible contraindications may symbolic play, and severely disturbed children may lack the necessary emotional and/or cognitive skills for puppet play.

Keywords

• puppet therapy
• assessment techniques
• child therapy
• diagnosis
• play therapy

Introduction

Since children are generally not good candidates, play is often a modality that therapists use to enhance understanding and communication in treatment. Child therapists look for play activities that might help children feel comfortable enough to play, expressing their concerns in a somewhat disguised way, aiding understanding. Among the many possible assessment tools they could use are puppets, which appeal to a wide age range and are familiar toys to many. While most puppet approaches are semi-structured (i.e., guided), some therapists have used puppets in a more formal way in puppet shows while others have used puppets in family treatment.

This paper is an attempt to sort out the similarities and differences in the most widely used puppet techniques, describing their rationale and determining what works best, and for whom. From among the many play tools one could use, puppets were selected because, to many children and even adults, puppets are magic that, over the ages, have symbolically offered strength, and even protection against death. For example, Persian soldiers took their favorite puppets to war with them, believing that they would offer magical protection against death in battle against the ancient Greeks. It is this kind of readiness to project the magic of symbolism into the puppet that makes them so valuable in artistic and therapeutic work with those of all ages.

The nine different assessment tools studied are Spontaneous Group Puppetry; The Puppet Therapy Assessment Technique; The Family Puppet Interview; Puppets in Psychotherapy Scale; The Ross Family Puppet Technique; The Dynamics of three; The Puppet Sentence Completion Task, The Berkeley Puppet Interview, and The Affect in Play Scales. The purpose of this examination is to describe and compare the many different ways that puppets are used in understanding (i.e., assessment) and helping (i.e., treatment) clients and their families.

Puppets in assessment

Puppets have been used in psychotherapeutic assessment since the 1930s when they were used as a projective technique in puppet shows shown to groups of children. Further exploration of formal assessment with puppets in diagnosis was made by.

Assessment serves as a compass for further intervention, to document change as well as to aid diagnostic understanding. Bruscia defines assessment as follows:

Assessment is that part of the therapy process concerned with understanding a client, his or her condition and therapeutic needs. Although it is most essential during the early stages of therapy when informational needs are greatest, assessment is often extended throughout the process and made an integral part of treatment and evaluation.

Assessment is described as a tool for understanding clients and is an integral part of treatment. It is interesting to note what Irwin states about puppets:

Among the most valuable, yet paradoxically, the least understood and utilized of these materials are puppets. A random assortment of puppets is generally included in most play-room-supplies, but the clinician is usually left to learn about their use (and misuse) in vivo, and thus often fails to explore their rich potential.

This article attempts to examine the usefulness of puppets and also raise awareness on how they can be used in a more systematic manner by describing and comparing different ways puppets are used in assessment. The research questions are: How are puppets used in assessment? What methods are most useful, for whom, and when? What are the contraindications for using puppets in assessment?

SPONTANEOUS GROUP PUPPETRY

Puppetry as a therapeutic and diagnostic method was developed by Adolf G. Woltmann together with Lauretta Bender in the 1930s. Referred to as Spontaneous Group Puppetry this group activity was performed before an audience of hospitalized children with behavioral problems. Using hand puppets, adult puppeteers featured “Casper Shows”, for children from 2 to 16 years of age, with themes focused mainly on aggression, such as fighting and sibling rivalry. Before each show, children in the audience were encouraged to react freely to the shows and interact with the puppets; this was followed by a group discussion. Sometimes half shows were played, and the play was stopped at a point of conflict; the children then were asked how the problem should be solved, after which the play continued and ended as planned. The assessment is based on psychoanalytical theory. Children were asked which puppets might he/she be afraid of, and with which puppet the child identified. They were also asked to tell what Casper thinks, feels and does, thus revealing information about themselves. Scenes chosen were believed to be the ones that made the greatest impression on the child. Besides the cathartic value of puppet shows, Bender and Woltmann believed that the powerful therapeutic nature of puppetry could be seen in the follow-up group discussion after the play. Apart from the puppet shows, Bender and Woltmann also organized puppet classes in which children were taught to make puppets, and also write and produce their own plays. Woltmann writes about the protective part of puppetry that “the symbolic characters can give a free expression of aggression without causing anxiety or fear in the child, and also can give a free expression of love.” That means all feelings, including both love and hate, are accessible through puppetry.

THE PUPPET THERAPY ASSESSMENT TECHNIQUE

The semi-structured Puppet Therapy Assessment Technique was developed by Irwin and colleagues in the 1970s and can be used in diagnosis as well as in ongoing therapy. This procedure is mainly used for 5-12-year-olds, but can also be adapted for adolescents. Young children (under the age of 5) may not do well with the request to make-up a puppet story, because they may be immature, may not yet be capable of symbolism, or able to distinguish reality from non-reality. This assessment can be analyzed through content and form dimensions, defenses and coping styles, preoccupations, and conflicts. It includes a warm-up, a made-up puppet show, and a post-puppet interview, including the child’s feelings about the story. Approximately 15-20 puppets are presented to the child, representing a range of characters. The puppets should be carefully chosen, aesthetically appealing, and inviting play. When the child chooses puppets, the therapist observes carefully, noting verbal as well as nonverbal cues and what puppets are selected or rejected. The therapist then introduces the child to an imaginary television audience, and the child presents the chosen puppets and the pretend scene. If the child is inhibited, the therapist can offer more structure by asking questions the puppet (not the child), questions about “who, what, where, and when”. After the introduction, the therapist can become the audience and take notes on what happens. There is also a post-play interview when the therapist can ask about the main idea of the story, what character the child would prefer to be, and a moral to the play. And finally, the child can be asked about his/her “lived” reality and experiences, which may give clues about the child´s worries/wishes, and suggest some ways the child is dealing with current conflicts. A plot full of chaos, for example, may indicate that the child is unable to disguise unconscious impulses, while play disruption, emotional flooding, or acting out may be indicative of the child´s extreme anxiety. Conflicts that emerge in the puppet stories can then be the (indirect) focus of ongoing therapy.

THE FAMILY PUPPET INTERVIEW

In 1975, the Family Puppet Interview (FPI) was introduced by Elaine Malloy and Eleanor Irwin. This technique has a lot of similarities to The Puppet Therapy Assessment Technique but has a family format, developed for the same age group. The family is asked to create an original puppet story together. Afterwards, they are asked for a title or a moral of the story. The family members are invited to reflect on the puppets´ actions and emotions, and whether the story reminds them of anything they are experiencing in real life. In the FPI, approximately 20-30 puppets are used. Too many puppets can overwhelm the family, but at the same time, there also needs to be a variety. The family is instructed to make up a story that has a beginning, middle, and an end. There are two rules: 1) the story needs to be original, not one they already know, and 2) the story is acted by speaking through the puppets, not by narrating the story. The family has about 30 minutes to make up the story. Throughout the FPI, both the process and the content are observed, from the selection of puppets to the making of a story. The therapist (silently) notes the interaction between family members: i.e., the level of engagement and whether the family members work together or alone. How is the story line decided? Who follows and who leads? Whose ideas are accepted versus rejected? What is the emotional climate? Is the dialogue chaotic or coherent? What individual and family strengths can be observed? Thus the FPI is helpful in noting family dynamics.

THE ROSS FAMILY PUPPET TECHNIQUE

Another family assessment tool was developed by Patricia Ross in the 1970s, The Ross Family Puppet Technique. This assessment technique was made to assess parent-child and family interaction patterns for those with children in the early grades. Ross believes that this technique can elicit the traditional diagnostic interview. In the interview, the therapist puts a box with puppets in the child’s lap. He/she chooses two appropriate puppets, representing the mother or father, and a child. The therapist stimulates engagement, helping by instructing the family, two at a time to take a puppet and reenact a troublesome situation. Family members are encouraged to use the same words and tone of voice as the situation they are reenacting. Even before the reenactment begins, the therapist gets a lot of important diagnostic patterns. During the assessment, the therapist observes as much as possible, so that the family can talk to each other (not through the therapist). If there are two parents, the observing second parent will have an audience role. In part two, the puppeteer roles are reversed, as the parent and child play each other. In part three, the child and parent play how he/she wishes they would have acted in the situation.

PUPPETS IN PSYCHOTHERAPY SCALE

Elaine Portner developed the Puppets in Psychotherapy Scales (PIPS) in her doctoral dissertation in which she analyzed the spontaneous puppet stories of school-aged children. The session begins with structured play to help the child feel comfortable with the setting and the examiner. Children are told the beginnings of stories and are asked to make up endings for them using toy people, animals, or puppets. The children are then asked to select puppets that interest them from a lot of 28, using a small stage set on a table. Once they introduce the puppets, they usually begin to create a spontaneous drama. As happens in the Puppet Therapy Assessment Technique, the examiner engages the puppets and puppeteer in a conversation following the story, gathering the mutual story technique, children are asked about the possible moral or lesson of the story as well as their preferences for certain puppet characters.

THE DYNAMICS OF THREE (DIE DREIERDYNAMIK)

The Dynamics of Three, or “die Dreierdynamik” in German, was developed by Swiss Kathy Wüthrich (1931-2007) in cooperation with Klaus Harter and Gudrun Gauda. The title of the method refers to the use of three puppets and three props. There are also three main steps in the instructions: choosing props, choosing puppets and decorating of the stage. This technique is based on Jungian psychology and was developed for children. The method is frequently used today in Germany and Switzerland with children as well as adults. Often the client makes his/her own hand puppet using styrofoam and papier mâché clay for the head. The body is usually made in textile with one hole each for the puppeteers two fingers (the puppets arms). In this way, the puppet can feel things, handshake with others and pick things up. The first instruction to the client is that he/she should pick three props. It is important to pick props before choosing puppets to avoid stereotypical choices. The props are important in triggering change and bringing in action to the story. Then three puppets are chosen: three human characters, three animals or a combination of both. The client decides who should play which puppet/puppets. The therapist can play with one or two puppets. Different puppets symbolize different things. For example, a witch can represent a mean mother, a police officer can represent a helpful father, a doctor can represent healing, a robber can symbolize greediness, and a devil can symbolize temptation. Finally, the stage is decorated with cloth of different colors and textures and can include natural materials such as stones and wood. An ironing board is used as a stage since it can be set at different heights depending on the player´s wishes and body length. With this structure, a story usually develops. Throughout the play, the client leads, and the therapist follows.

THE PUPPET SENTENCE COMPLETION TASK

The traditional Sentence Completion Task is a projective technique frequently used with adults and adolescents. The use of this technique dates back to the late 1800s and is composed of incomplete sentences that the client is asked to complete. According to Susan Knell, Sentence Completion Tasks may be problematic with children, and therefore it is helpful to integrate puppets with this task. While the PSCT can be used with children 3-7 years old, often the older the child, the less interest in the puppets, while she has found that the younger the child, the less verbal he/she is. In the PSCT, puppets are placed at the child’s eye level and the child is instructed to choose a puppet. The therapist observes how the child makes a puppet choice. In this way, the therapist gathers clues about the child’s level of functioning, needs, and emotional conflicts. After establishing rapport, sentence stems that are unique for the child’s situation or specific populations are given. After the child has chosen a puppet, the therapist chooses two puppets, or the child can also choose puppets for the therapist. In the first part of the assessment, the therapist´s first puppet states a sentence stem, the therapist’s second puppet responds. The therapist then turns to the child’s puppet to get a reply. When the child has understood the task, the therapist moves to part two of the puppet states a sentence stem to the child’s puppet, and the child responds through his/her puppet. Examples of sentence stems are: “I love to…. I am afraid of… My biggest problem is…” It is not necessary to use all sentence stems.

THE BERKELEY PUPPET INTERVIEW

The Berkeley Puppet Interview (BPI) is an evidence-based puppet assessment tool, developed in 1998 by Jennifer C Ablow and Jeffrey Measelle. The authors designed this interview for 4-8-year-olds, since there was an absence of standardized self-reports for young children adapted to their shorter attention span and less mature expressive skills. The BPI blends the structured and semi-structured interviewing methods. The BPI has 41 items and all items, scales, and domains are well-validated. Research indicates that the BPI is a reliable and validated measure for children’s perceptions of themselves and of relationships. The scales are linked to Diagnostical and Statistical Manual (DSM), but do not yield a diagnosis. The BPI uses two identical hand puppet dogs, “Iggy” and “Ziggy”. The puppets are non-gendered and have movable mouths. They are presented to the child as a mate that wants to get to know him/her, and they make opposing statements about themselves. The child does not have a puppet, the therapist has both puppets. The child gets practice questions before the interview questions. Examples from the interview are: Iggy: “I don´t worry a lot” and Ziggy: “I worry a lot”, and then Iggy asks the child: “How about you?” The child can answer verbally by saying the puppet’s name, or non-verbally, for example, by pointing at or touching a puppet. Open-ended follow-up questions can follow this 10-25 minute interview.

THE AFFECT IN PLAY SCALES

The Affect in Play Scales (APS) was developed in the 1980s to meet the needs for a standardized measure of affective expression in fantasy play. It includes a criterion-based rating scale. The play task consists of two puppets with neutral facial expressions, one boy and one girl, plus three small brightly colored blocks in different shapes. The task is videotaped and administered individually to the child. In the free-play instructions, the therapist asks the child to do something together with the puppets, i.e. play in any way he/she likes for five minutes. The task is discontinued if there is no play within a 2-minute period. The child is told when it is one minute left. If the child has difficulties playing, the therapist can encourage the child to play, for example, by saying “You still have time, keep going.” The instructions can be given to invoke different types of affects. Aggression can, for example, be altered by asking the puppets to disagree about something. Both emotional content and expression of emotion in the play are coded, as are cognitive dimensions such as quality of imagination. Each unit is rated on a 1-5 scale. The five minute interview is easy to administer and the scoring system takes 15-20 minutes. Used with 6- to 10-year-olds, the APS is suggested to be a quick assessment of play skills.

Methods

The study is a descriptive and comparative interview study. Nine different assessment tools have been described and compared. Information about the assessment tools have been collected by studying the literature. The protocol was made by the author and reviewed by an experienced therapist. Some smaller adjustments were made after this, and one question was added. The responses were analyzed with thematic analysis.

The coding generated five themes, see Results section for more details. Six persons in the field were interviewed in a semi-structured interview. The interviews were answered in written form. The respondents have a long experience in the field and three of them have Ph.D.s. Five of them are female; one is male. They come from different parts of the world: the US, Greece, Germany, and Russia. Most are psychologists; however, one is a social worker, and one is a psychiatrist. The respondents use or had earlier used the FPI, the PSCT, The Dynamics of Three, the Puppet Therapy Assessment Technique and one respondent used a technique of her own. It was not possible to find respondents representing each assessment technique. One respondent was contacted after the interview to get more in-depth information.

Results

The themes collected through the thematic analysis were: Methods and techniques in puppet assessment, Assessment in therapy, Assessment in diagnosis, Different levels of structure, and What works and for whom. They are described below.

METHODS AND TECHNIQUES IN PUPPET ASSESSMENT

A respondent wrote about the Family Puppet Interview (FPI): I use the FPI when I work with children in play therapy and I want more info on how the family interacts with the child. The FPI gives all family members an opportunity to participate and express themselves. The FPI provides rich, qualitative information about the family.

Another respondent uses complimentary methods: “When I do an assessment of a preschooler, it is easier to begin by using the sand box or the miniature toy interview. These diagnostic procedures are relatively unstructured.” That same respondent also says about the use of creative art modalities and emotional distance: At other times, however, patients, perhaps feeling frightened, begin to intellectualize, ruminate and/or obsess, using many words to try to regain control and move away from feelings. At such times, one of the creative modalities may be helpful in accessing the warded-off feeling states. At other times, the therapist might consider engaging in a nonverbal art dialogue with the patient, or even, at times, using a puppet to talk to the puppet. This might provide just enough emotional and aesthetic distance to enable the patient to feel more in control.

One respondent uses her own way of assessing. She uses both puppets and dolls in semi-structured and unstructured ways. She especially observes the modeling of the dolls and puppets; the relation to the material, where the client starts and ends, comments during the modeling and changes from the original idea. She also notes the features of the doll/puppet such as size, color, how the puppet parts are connected, the degree of detail, stability of the figure and the puppets sex in relation to the clients sex. The therapist then has a discussion with the client based on these aspects.

Another respondent said: “cases always end up differently than we imagine, and patients rarely stay within one modality in therapy”. This emphasizes the need for flexible therapists and having a wide toolbox in one´s repertoire. One respondent wrote on being an inclusive, flexible therapist: If I am working with a child who does not like to use puppets, I will use something that the child likes better. For some kids that might be toy cars or trucks, stuffed animals. I have even used blocks to communicate with a child, where I (as therapist) and the child each have blocks communicating with each other.

ASSESSMENT IN THERAPY

One of the most effective ways that puppets work therapeutically is through their protective function. One respondent puts it this way: “it gives your participants the opportunity to externalize, without barriers”. It gives a feeling of safety to the client and a decrease in the psychological defenses. According to a respondent, this “makes it possible to obtain information about such aspects of the personality that are usually hidden from observation”. One respondent said about communication: I believe that using puppets with young children enhances the clinical experience and helps the child and the therapist communicate with each other. Although not all children enjoy working with puppets, in my experience, many children really love it. They are able to communicate through the puppets in ways that they could not with words alone.

Another respondent raises the question about the advantage for some when the story disappears after it is played: Sometimes it seems that one advantage of puppetry is that the story as soon as it is enacted. With highly anxious or guilt-ridden children, this might paradoxically be an advantage, since there is no reminder of the story while there is a picture that remains at the end of art therapy session, a reminder of what just transpired. Sadly, sometimes traumatized individuals feel (re-traumatized) by the image of a finished product. On rare occasions, patients, startled, (perhaps to an earlier abusive situation). While normally individuals are helped by seeing what has just been created.

Another respondent states: “I have noticed that many families allow the child to lead in this activity. This is often different from how things are at home.” This is another reason for choosing puppets as a modality in therapy. One respondent writes about puppet selection: A useful puppet collection might include realistic and royalty figures; wild and domestic animals; fantasy puppet (such as monster, witch, devil and so forth); and puppets, such as doctor, nurse, farmer, and others of that ilk. Obviously, if something is missing, the individual can always make (create) the character from readily available art materials. Nevertheless, cost is sometimes a factor to be taken into consideration in choosing a preferred technique. Since groups need many puppets, it is sometimes better to have the participants make their own puppet characters. So, the therapist would benefit from having a selection of many different types of puppets. In group work, where even more puppets are needed, they can be self-made. Finally, one respondent states: “the client ‘looks’ at the object, as in a mirror: interacts with himself and can see himself from the outside.”

ASSESSMENT IN DIAGNOSIS

Much of puppet assessment has both therapeutic and diagnostic value, for example, the making of a puppet, as the quote implies: “Puppets often arise at milestones in therapy. For the therapist, it offers a wide range of information about the client, both with regard to diagnostic aspects and the achievement of therapy goals”. The information conveyed by a puppet is very helpful in painting a diagnostic picture. One respondent wrote about the Dreierdynamik and its use in diagnosis: This procedure is known as a “Dreierdynamik” […] because it limits the number of puppets and the number of objects to three each. By playing with the puppets, client and therapist enter into a dialogue that serves to collect information in the diagnostic setting. The communication is not limited to the oral use of the language. In particular, the non-verbal communication about the active actions and the reactive actions of the characters is a great source of information.

Another aspect that has both therapeutic and diagnostic value is the animation of puppets: After modeling, the puppet is brought to life. The client picks up the puppet for the first time, moves it, gives it a voice. Here is the opportunity for the therapist to interview this character, to get to know her. This is an enormous source of information for the diagnostic as well as for the therapeutic process.

When conducting an assessment, there are many considerations and decisions, including offering other arts modalities in addition to puppets. Successful diagnostic sessions call for consideration of age, reason for the referral, and the stated reason for the diagnostic request. This allows the therapist to select the most appropriate arts or play modality that seems to fit those criteria. Regarding interpretation, one respondent writes: “In particular, the symbolism of the puppets, objects and places used is interpreted. A special focus in the evaluation is on the dynamics between the characters. Aspects of developmental psychology are also taken into account.”

DIFFERENT LEVELS OF STRUCTURE

There are different levels of structure in assessment – structured, unstructured or free play, plus a level in between, usually defined as semi-structured. Different levels of structure are used depending on the client’s age, maturation and assessment goals. A respondent considers the structured work to be used in diagnostics and the less structured to be used in therapy. Free play serves to help the child relax and cultivates the relationship between client and therapist. Also, the modeling of a puppet is more often useful in the diagnostic phase and for assessing the degree of achievement of the therapy goals. One respondent wrote: “If the interview is part of a diagnostic process, puppets are used in a semi-structured way, but in ongoing treatment, puppets are used by the patient as needed to fit the need of the moment (i.e., unstructured).” The same respondent also sees risks with the different levels of structure. In unstructured play chaos may arise and therapy goals may get lost when the child becomes anxious: The less structured form harbors the possibility that the play gets out of hand, the plot gets lost, chaos arises and the play itself can no longer be evaluated. This form requires more focus and discipline on the part of the therapist. […] If free play is used so frequently that the structured or less structured form is suppressed, there is a risk that the therapy will become significantly flattened and lose sight of the therapy goals.

The risk of chaos and need for structure is also raised by another respondent regarding the FPI: In the Family Puppet Interview […] structure is even more necessary because there are more participants, and, before long, the usual family dynamics patterns emerge, with issues of dominance, control, competition, subservience, rivalry and so forth. While diagnostically this is very instructive, structure is needed to maximize all the potential information from the session. Here, is very helpful and, for some families, may even be needed to minimize chaos.

Another respondent also talks more about structure in the FPI: If it is an initial diagnostic interview, I structure the session to help the child feel comfortable enough to create an original story, thus using the puppets in a symbolic, original way. Often the patient, who may be anxious about seeing a therapist, is helped by having some sense of what to do (i.e., direction or structure), rather than just being told to pick up a puppet. I offer enough structure (in my mind) to help the child to create a good beginning, middle and end to a story.

One respondent emphasizes that less structured ways of working are more appropriate for younger children: “less structured arts or play interviews […] are more appropriate for younger children, who may not have yet acquired a degree of mentalization, self-control, and familiarity with reality necessary for puppetry.” One respondent says that most patients experience a degree of comfort (i.e., less anxiety) if given a general idea of what to expect in an initial session. Finally, one respondent also says that the structured form of puppet therapy requires a great deal of personal commitment, empathy and practice from the therapist: Learning the structured form of puppet therapy with regard to the play and the evaluation of the play requires a great deal of personal commitment. Going through a process of self-awareness is extremely important in order to play the play in the interests of the client and not be controlled by his own emotions. A high level of empathy is just as important as the ability to fill other roles in a lively manner. The evaluation requires a lot of practice.

WHAT WORKS AND FOR WHOM

One respondent believes that puppet assessment, “can be used with children or people of any age.” About younger children, one respondent writes: “preschoolers may not have developed sufficient self-control to be able to pretend and ‘stay in character.” She further states that: “Young children do well in somewhat unstructured interview sessions” and “Preschoolers sometimes use puppets as they would any other toy in the toybox.” One respondent talks likewise about preschoolers: Similarly, most preschoolers are too young to engage in puppetry, unless it is with very few puppet figures. Generally, young children have not yet developed a firm capacity to symbolize and tend to be concrete in their thinking. The exceptions would be for kids who are intelligent and have developed the capacity for symbolization and self-control. Otherwise, young children have a hard time developing a story line and may tend to use the puppets as “objects” rather than see them as carrying symbolic meaning.

The same respondent further writes: Kids need a certain amount of self-control to be able to symbolize and engage in puppetry. Therefore, an acting-out, impulsive child may not be a good subject – their stories are likely to be simplistic or more often chaotic and confusing, reflecting their confused thinking process. Similarly, a deeply disturbed, psychotic child may do better with a less active, more directive diagnostic task – like artwork.

Finally, another respondent expressed thoughts about therapist flexibility: “What is important is to follow the patient, wherever the path leads, fantasies, and ideas were being expressed”. These modalities can, for example, be visual art, stuffed animals, blocks or toys.

Discussion

In the following a results discussion is followed by a method discussion. The research questions are in focus: How are puppets used in assessment? What methods are most useful, for whom, and when? What are the contraindications for using puppets in assessment? Contraindications are emphasized as is the level of structure in the assessments. Assessment tools can, as earlier described, be considered more or less structured. The Berkeley Puppet Interview is, according to the author, considered the most structured of the different assessment tools. It includes preselected puppets, questions and suggested answers. It is evidence-based and is considered a reliable and validated measure. For this reason, it is the most suitable for using in evaluation, research, and diagnosis. The other assessments are considered to be more or less semi-structured, with The Puppet Therapy Assessment Technique and the Family Puppet Interview closest to the unstructured end of a continuum. They all include predefined aspects, such as which puppets or objects to use, how many of each, and so forth. The semi-structured methods can be individually adapted and are suitable for most therapeutic goals. The unstructured methods are seen as helping the child to be comfortable, promoting the therapeutic relationship. When needed, more structure can be given by asking questions to the child or the puppet. Semi-structured tasks along with unstructured ones are seen as suitable for younger children.

Structured assessment	Semi-structured assessment	Unstructured assessment or Free play
Most structured assessment	Can be individually adapted. Suitable for therapeutic goals.	Promotes the relationship between client and therapist. Suitable after structured play. Comfortable.
Berkeley Puppet Interview (BPI)	Spontaneous Group Puppetry	The Family Puppet Interview
	Puppet Sentence Completion Task (PSCT)
	The Affect in Play Scale (APS)
	The Ross Family Puppet Technique
	The Dynamics of Three (Die Dreierdynamik)
	Puppets in Psychotherapy Scales
	The Puppet Assessment Interview

The structure of the assessment also depends on how you adapt the assessments. For example, the Spontaneous Group Puppetry can be seen as more unstructured, such as when working with half-shows or individual puppet making, rather than when the child is an observer of a “Casper show”. Regarding “What works when”, there are many different aspects to be considered. Age is a key consideration. Some respondents find puppets are possible for use with all ages. Age limitations in the assessments range from 2 years of age to 16 years of age, though obviously much depends on the developmental level of the child. The Spontaneous Group Puppetry is used for the oldest and youngest children, while The Dynamics of Three is for children as well as adults. One respondent states that the assessments are not always appropriate for preschoolers, because sometimes younger children are not developmentally mature enough to distinguish between fantasy and reality, and are unable to symbolize. The same respondent compares puppetry to art therapy, writing that the latter is more familiar and might be more comfortable with some populations.

APS also does not suggest using puppets for the young children, and uses stuffed and plastic animals instead of puppets. They comment that puppets may be more difficult for younger children to manipulate. On the other hand, the PSCT was made to adapt a traditional Sentence Completion Task to smaller children. Irwin suggests that the use of puppets in therapy and assessment is well documented and age appropriate for young children, offering non-threatening forms of expression. Several writers remark, however, that preschoolers may have difficulty manipulating hand puppets, and may not have developed sufficient self-control to be able to pretend and stay in character. Additionally, preschoolers may also have difficulty distinguishing between fantasy and reality, may engage in concrete thinking, and may not yet be ready for symbolization. Irwin compares different emotional states in the child, suggesting that while some engage in appropriate play, the play of others may be rigid, regressed or chaotic, and this helps clarify the assessment picture: The child who plays with appropriate control, being neither overcontrolled and rigid, nor undercontrolled and regressed, demonstrates ego-strength and a potential for insight-oriented work. A child whose play is chaotic and impulse-ridden, on the other hand, needs a structured, ego-building approach in treatment.

Regarding the BPI, children with neurodevelopmental disorders, like moderate-to-severe autism, might experience puppets as socially aversive and there are specific guidelines for this. The puppets should be introduced separately at the beginning of the interview. With children who have comprehension difficulties, one should use a truncating tactic, repeating the alternatives in the question to the child. This author writes about when puppet therapy seems least beneficial. Examples are when clients think of the puppet as just a toy and cannot engage in playful activity; when children are fearful about creating something concrete; when children are too repressed to play; or others who are over-controlled and guard against “letting go”, not daring to play, or others who see puppets as childish and restrictive. Some children are cognitively immature and are frightened by the make-believe of puppets, while others with traumatic experiences or with severe attachment problems, may shy away from puppets because they evoke (unconscious) fears of past experience. Children with autism may also be afraid of puppets, and therapists must proceed sensitively and cautiously with this population.

In general, however, it is uncommon that children are afraid of puppets. When this is the case, puppet therapy may not be appropriate for initial work. With frightened, inhibited, deeply troubled or strongly defended children, the first step is always to develop a safe environment. This may mean suggesting “psychologically safe” activities when clients´ resistance is intense, until one develops a trusting relationship that might allow more creative play. A stimulating environment is always needed, however, allowing for play with appealing toys, including art materials and puppets, enabling the therapist to suggest modalities that range from highly structured to less structured activities, according to the child´s needs.

As suggested, some children are too inhibited or disturbed to be able to play or create a story, as this author has written. Deeply troubled children are often unable to take responsibility for their puppet’s actions, because pretend play may stimulate a loss of control, or even loss of contact with reality. Under the grip of unreality, such disturbed children can become behaviorally difficult, even destroying the puppet, stimulated by powerful (unknown) aggressive emotions. It is of course very difficult to work with such deeply traumatized children, a task that requires patience, compassion and understanding, undergirded with training and super therapy. In cases in which it is difficult to establish a safe, conducive space and trust in working with children who might be resistant to most interactions or exhibit psychotic behavior due to trauma response, it is the responsibility of the therapist to evaluate and refer the client and their family to other types of therapy or psychiatry when warranted.

All the different assessment tools include some degree of interpretation, for assessment, evaluation or to guide ongoing treatment. The Puppet Therapy Assessment Technique, for example, comprises content and form dimensions such as defenses and coping styles, preoccupations, and conflicts. Aspects observed in the puppet play are, for example, to note the play organization or disorganization; clarity or confusion; completion or incompletion; the degree to which the story is original or stereotypic; age-appropriate or immature; expansive or constricted; simple or complex. These are all form dimensions that give information about the child.

Despite all that has been said about assessments and their benefits, using assessment tools and interpretation can be problematic. It can be seen as a way to measure and label people. It may for example be contradictory to the creative arts therapies such as the Expressive Arts Therapy (EXT). This because, as is well known, unless the therapist is skilled and well-trained, his or her use of interpretation may flatten the play, rather than expand it. In any event, one only gets to know the client over time and then can only convey grasp the meaning of troubling behavior, and then Meeting clients should be flexible and multifaceted. In EXT, the focus is on dialoguing, not interpreting. It is important to listen to what the artwork has to say, rather than forcing an interpretation or questions about it. Every person as well as his/her artwork is unique and cannot be reduced to categories. As van der Bossche and Welten eloquently write about drama therapy: We are not looking for generalities but for the unique person behind the client. We look to comprehend the person in his or her full complexity. […] Our field requires awareness of the uniqueness that cannot be measured with standardized tools and cannot be treated with standardized treatment.

Other theoretical orientations that point out challenges with assessments and diagnosis are humanistic and existential psychology. These traditions were developed as a reaction to psychoanalysis and behaviorism, and have their roots in phenomenology and philosophy. In these traditions the focus is person-centred, focused on personal growth, the here and now, intentionality, free will, unconditional positive regard, self-awareness, self-actualization, and how to live a meaningful, authentic life. The genuine encounter between client and therapist is emphasized, as is empathy and congruence. These perspectives suggest the limitation of rigid use of assessment and diagnosis. However, it is always important to use assessment data carefully and sensitively, listening with empathy and openness. When multiple symbolic meanings of the play are used to supplement other can be deepened and enriched. Understanding is further helped by carefully choosing assessment techniques appropriate for the age, abilities and assessment questions being asked. The more unstructured and projective the tool, the more one writes on the limitations of assessing: It is important to remember that all clinical assessments are limited in the information they can provide and the insights they can bring. Notwithstanding the power of the method or the skill of the therapist, it is impossible to understand every facet of a client or to explain every aspect of a pathological condition. Human beings are too complex to be contained within any method of assessment or to be grasped in their entirety by another person.

Finally, the method of the study, contributed to rich information about assessments in general and some assessments in particular. It would have been interesting to have respondents representing all the nine different assessments. However, this was not possible. It was difficult to find interested participants and sometimes difficult to get contact information. Some methods are not used today and therefore it is not possible to find participants for those. More information could also be received if the interviews were verbal instead of written. Then follow-up questions could be asked. Hopefully the study in its current shape can in some way contribute to the research. It can spread clinically relevant information to therapists and alike. The quality of the study could have been raised by having several sources of information. For example, it could have been combined with interviews of clients to get another perspective. In the future, to know if the assessments work effectively, one can have a control group where one group does not get an assessment and the other group does. In the best-case scenario the study can be scaled up to more complex, higher evidence research on the topic.

Conclusions

In conclusion, there are at least nine assessment tools to use in the field of puppet therapy. This article has shown aspects both in favor of and against using these assessments. Important aspects to be considered in favor of some of these approaches are: the need for therapist flexibility; the necessity to create rapport; the importance of an appropriate assessment tool; and the requirement to adapt the level of structure to the client. Some contraindications are: limitations of some of these techniques for preschoolers; and the difficulty of working with deeply disturbed youngsters with poor self-boundaries, as well as with those who are unable to play because of developmental problems of emotional difficulties. There are contradictions using assessments in EXT as well as in humanistic and existential approaches. These traditions value people as whole, inseparable beings. This is proposed as being in contrast to measuring and interpreting people in assessment. At the same time, as stated initially, assessments can help in understanding a client condition, concerns, therapeutic needs and also assist in developing an appropriate treatment plan. Assessing and looking upon the person as a whole is theorized as to be the cardinal rule of most therapies. In this way the practitioner´s observation skills can be more organized, and treatment can be optimized, as drama therapist Read Johnson and colleagues state: In fact, we believe that experience in assessment primarily improves […] Following an organized way of observing phenomena, in this case client behavior, results in more accurate observation, and this leads to better treatment. Empathy and the ability to be present with clients must be based on accurate listening and accurate observation. These skills are directly enhanced by experience with assessment.

Conflict of Interest:

None.

Funding Statement:

None.

Acknowledgements:

None.

 

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