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Puppets in Psychotherapy

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 Article based on the essay:

Puppets in Psychotherapy - an international web-based

study among clinicians

Author: Åsa Viklund, University of Gothenburg, Sweden.

Photo: Love Lannér, "Embla - a girl in the middle of Universe" from Puppet Theater Peekaboo,, Sweden. With permission.

Abstract

This article is based on an essay within psychotherapy studies at Umeå University, Sweden, and is written in
2017. The aim of the study was to understand more about how puppets are used among therapists nowadays,
and to examine if as well as how they can be a useful tool in psychotherapy in the future. It was based on a
questionnaire in English, including both quantitative data and qualitative information. Thematic analysis was
used.
33 participants (n = 33) from 11 countries responded to the questionnaire. Responses show that puppet
selection as well as inclusion is wide among participants. Hand puppets are most commonly used, and
approaches are most often child-centered. Six main themes were found in the analysis; the projective, the
symbolic, the relational, the empowering, the evocative and the transformative dimension.
According to responses most clients can be suitable for the method, however especially children. Responses
also show, that precaution should be taken with those scared of the puppets and the severe mentally ill. For
shy clients, there is contradictory information. Furthermore, successful use is related to individual
characteristics in the client. Examples of beneficial characteristics are curiosity, playfulness, creativity,
acceptance and an ability to engage in the method. Less beneficial characteristics can be an inability to play,
inhibition, rigidness, having a strong cognitive orientation or negative preconceptions of puppets.
The conclusion is that puppetry can be a useful tool in psychotherapy.

Keywords: psychotherapy, puppet, therapeutic puppetry, therapy

Play is a vital part of therapy as well as therapeutic puppetry. Winnicott, an English pediatrician
and psychoanalyst wrote in his book “Playing and Reality” on psychotherapy:

Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of
the therapist. Psychotherapy has to do with two people playing together. The corollary of this
is that where playing is not possible then the work done by the therapist is directed towards
bringing the patient from a state of not being able to play into a state of being able to play.
(Winnicott, 1971, p.44)

These words serve as a backdrop to the essay “Puppets in Psychotherapy - an international web-
based study among clinicians” written at Umeå University, Sweden in 2017. The essay and the
results will be described in this article. The aim of the study was to understand more about how
puppets are used among therapists nowadays, and examine if as well as how they can be a useful
tool in psychotherapy in the future. It is a study based on a questionnaire in English, including
both quantitative data and qualitative information. Comparisons are made to art therapy, play
therapy and drama therapy including expressive art therapy and psychodrama. A quote that
supports this aim follows:

Among the most valuable yet, paradoxically, the least understood and utilized of these (play)
materials are puppets. A random assortment of puppets is generally included in most playroom
supplies, but the clinician is usually left to learn about their use (and misuse) in vivo, and thus
often fail to explore their rich potential. (Irwing, 2002, p.101)

In the essay 33 participants from 11 countries responded to the questionnaire. The countries
were Germany, US, UK, Russia, Sweden, Switzerland, Austria, France, Greece, Ireland and
Luxembourg. The largest group were women and participants from German speaking countries.
The participants were experienced and well educated on group level.

Client group and work setting

Result showed that participants predominantly worked with children, most often individually.
Ten sessions or more were most commonly offered. Clients´ difficulties were crisis or trauma,
social or communicational, psychological, somatic or psychosomatic and psychiatric. Settings
where participants worked ranged from private practice, educational system and social services
to Mental Health care / psychiatry and hospital.

Results showed that puppet selection as well as puppet inclusion were wide among participants.
Hand puppets were most commonly used and approaches most often child-centered. Six main
themes were found analyzing the qualitative data; the projective, the symbolic, the relational,
the empowering, the evocative and the transformative dimension. The symbolic and evocative
dimension were the most frequently mentioned. The dimensions will be presented below along
with how, when and for what puppets where used.
The projective dimension

The projective aspects of therapeutic puppetry include projecting inner life on the puppet, as
well as feeling protected by the puppet, engaging in a non-threatening situation, transfer onto
the puppet instead of therapist, also, moving to a meta level, looking at the difficulties on a
distance. Quotes from the responses are: “my puppet represents the bits of me which I dare not
be in real life…; Puppets add a layer of protection when telling a story about yourself; Puppets
as a powerful projection tool allow children to speak all different aspects of themselves with
playful freedom…; A puppet can be brought alive and then it is a projection screen of all
involved emotions, problems, anxieties…; With the puppet the client has the opportunity to see
his problems from another and outstanding perspective.”

The symbolic dimension

The symbolic dimension refers to the wordless and unconscious aspects of therapeutic
puppetry. An object represents something more than the object itself. The dimension is multi-
layered and naturally holds contradictions. It also includes bridging between the non-verbal and
verbal. Examples from the responses are: “working with their inner conflicts on a symbolic
level…; Letting the unconscious talk through the puppet in a symbolic language…; it is much
more easy to "speak" without words about inner processes…; I can do things (or handle), what
is'nt (even) possible to be said!;…the child can tell about his unconscious problems directly,
you can work with non-speaking children or mentally disabled children.”

The relational dimension

Positive social interaction is included in the relational dimension as well as conflict and
problem-solving related to others. ´Relational´ can refer to the therapist relation, to other group
or family members and also the relation to the puppet. Examples of this dimension from the
questionnaire are: “Common play between the child and his parents. Functional and social-
emotional problem solving….; social adaptation, communication with others…;…parent-child
interaction…; the child can see / feel / speak with a part of himself.”

The evocative dimension

Joy, anger, shame and sadness are feelings included in the evocative dimension, interest and
engagement as well. Work in this dimension can be getting in contact with emotions, identify
feelings as well as regulate them. Examples from the questionnaire are: “the puppets appeal
naturally to most children and they express their feelings with them in a way they could never
do with words...; puppet play is a good possibility and prop for children to send their feelings
outside…; …the puppet allows the child to more open show feelings like rage which normally
are not so easy allowed to show…; It is a direct way to one's feelings! …they don't have to act
out their feelings and experiences as they would in a role play. The puppets do it 'for them'.”

The empowering dimension

The empowering aspects of therapeutic puppetry include working with self-esteem, self-
confidence, self-assurance, self-reliance, self-image and coping skills. Working with these
aspects the patient gets strengthened. Some examples: “They feel more self-reliant and become
more self-assured…; development of more self-confidence…; the correction of “self-image”,
the search for personal resources…; The key is the understanding their self-image; participant
can feel empowered and experience new ideas about themselves. “

The transformative dimension

The transformative dimension holds change. In that sense, it is always a part of therapy, no
matter psychotherapy or creative arts approach. It can be seen in a wide range of therapeutic
processes ranging from self-discovery and rehearse in role-play to healing and trauma recovery.
Some examples from the questionnaire: “Playing with the puppets children feel encouraged to
try out new alternatives of behaving and acting…; When acting or using puppets clients go to
a place where they are 'me & not me' at the same time which allows space for self-discovery…;
I support the children in the process of overcoming their relationship and attachment disorders
and psychic traumas.”

Therapeutic puppetry methods

About half of the participants describe a method sometimes referred to as Dreierdynamik used
in the German speaking countries. In this method, the client - often a child - selects three props
/ symbolic objects, then three hand puppets and after that deciding which roles are played by
the therapist or client. Stage decoration of an iron board is also included, for example by using
differently colored shawls. The iron board makes it possible to adapt scene height to the client.
The client plays his / her story and the therapist assists. The approach is Jungian and include
archetypical puppets. Other examples of methods described are work with a readymade puppet-
buddy, the use of a doctor puppet prescribing songs for bad mood, puppet making with polymer
clay, papier-maché, wool, textiles, mixed material and recycled material and the use of
storytelling. A quote from a participant: “Children write a story about a character having to deal
with a problem. Then design and make the puppets for the story to be performed. On this process
we reflect together about different coping strategies to find a solution.”
Finally, a participant state what is not beneficial in these interventions: “They benefit least from
only making a puppet and not playing with it or from only using ready-made puppets and not
making some of their own.” This suggests that the complete process from puppet making to
play is vital to offer when possible.

When and for what

Regarding age many suggest children as the most beneficial group to work with, some specify
age 3 and upward as well as before reaching teen or young adult years: “I find that people of
all ages can benefit greatly from puppet-therapy. For children between 3 and 8 years, however,
it is a very helpful method for them to express themselves…”.
Another participant state that with: …“children (4-6 years), it is often necessary to involve the
physical experience...” However, some explicitly say it suits adults too, others recognize it as a
method for all ages: “Every age - from child to a person in front of death.”

Considering what diagnoses or difficulties it suits best for one participant says: “Children with
low confidence and low self-esteem, aggressive children, children needing to make sense of a
challenge in their lives.” Other examples: “Children who are inhibited, those who refuse to be
received individually, hyperactive children, psycho-social problems, psychic trauma; Clients
with a strong "inner child", without serious childhood trauma; All children who suffer from
emotional instability and children who have problems in social behaving (aggression against
other children or themselves for example); Children who have not yet words for their problems;
adult persons without speak (e.g. after a stroke) or mentally disabled persons; Even autistic
children” and at same time it is seen as not beneficial for “autistic children who are very deep
in the spectrum.” Other examples where clients benefit least from the method are: “Children
with narcissistic disorders or profound identity disorders, children with perverse or asocial
structures (seeking to destroy the group); Adults with difficulties to be engaged in therapy; Not
advisable for psychotic or delusional children.; Overwhelming for people with tendencies for
psychosis.” Finally, hope is spread even for some of these clients by a participant saying: “Over
time, though (…), after watching the process, (they) almost always decided to participate.”

Preconceptions and engagement reoccur in the questionnaire as factors of value for being a
suitable client: “people who think positive about the medium…; Any person who can engage
with the method and relate to it” and similar:“creative children with all sorts of problems;
children and parents interested in emotional work; children or adults who love to play stories;
Adults who easily play; Curiosity & social abilities in group work, permission and acceptance
of symbolic work individually” and more communicational skills: “Children who are to some
extend capable of using language and who are to some extend able to communicate with me as
a therapist.”

Therapeutic use of puppets seem least beneficial when: “clients think of the puppet as just a
'toy'; children prefer not to create something concrete; for “…persons with strong suppression;
persons (mostly adults) with a very cognitive orientation have problems to release; very shy
kids do not dare to play; (clients) own preconceptions of puppetry work as they see it as childish;
restrictive and inhibiting assumptions about puppetry; They could make children scared when
introducing them too early (less of symbolic understanding); some children with traumatic
experiences or with severe attachment problems are afraid of the puppets, they can't do enough
as if...; children who don't like puppets and have a poor sense of imagination; Children who
continue to live in instable circumstances; customers with a strong ´controlling parent´, with
rigid psychological defenses; …not all children are able to play – for them it is sometimes not
possible to find a story.”

Other factors mentioned on the down side of using puppets are that it is time consuming, when
clients´ resistance becomes a problem and when an angered puppet is destroyed. The need for
both artistic and therapeutic competence is as well mentioned as problematic, also the fact that
the method requires equipment, that trained staff in sufficient number can be hard to find, that
it is not a mainstream therapy tool and that people may not consider the methods own
therapeutic dynamic.

Summary

According to results most clients can be suitable for the method, however especially children.
Results also show, that precaution should be taken with those scared of the puppets and the
severe mentally ill. For shy clients, there is contradictory information. Furthermore, successful
use is related to individual characteristics in the client. Examples of beneficial characteristics
are curiosity, playfulness, creativity, acceptance and an ability to engage in the method. Less
beneficial characteristics can be an inability to play, inhibition, rigidness, having a strong
cognitive orientation or negative preconceptions of puppets. The conclusion is that puppetry
can be a useful tool in psychotherapy.

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