Applying Play Therapy in Mental Health Services at Primary School

With Chinese economy developing rapidly, the pressure put on individuals and the number of special family type has been increasing dramatically, mental health problems therefor plaguing an increasing number of children. Because the school plays an important role on children’s psychological development, the social issue above can be solved most effectively in the school environment. Play therapy, a psychological therapy which is most suitable for children, can tackle students' cognitive, social and behavioral problems when applied at school. We also provide an idea of how to apply play therapy in the school environment.


Introduction
With the rapid growth of economy and the continuous advancement of the times, social and study pressures have increased year by year. Intergenerational rearing children and left-behind children have emerged in large numbers, and with the two-child policy carried out, the special family structure of the "two-child family" is also emerged in large numbers, which makes our primary school students face more severe challenges than in the past, and is more prone to mental health problems [1][2][3][4][5][6] . In fact, a survey of more than 10,000 primary and secondary school students across the country found that primary school students with moderate psychological and behavioral problems accounted for 16.4% of the total number of primary school students, and 4.2% had serious psychological problems; moderate and serious among junior high school students. The proportion of people with psychological behavior problems was 14.2% and 2.9%, respectively [7] . It should be noted that childhood is a crucial period for the development of the individual's body and mind. The individual's body and mind will develop rapidly at this stage. Therefore, if the mental health problems of primary school students are not timely interfered, their physical and mental health will have a large adverse effect and can even lead to personality disorder [8].
The school plays an important role in solving the above-mentioned mental health problems of primary school students. With the progress of school reform, the development of students' cognitive, emotional, social and other abilities is deeply influenced by their schools. Schools are also important activities and places of life for primary and secondary school students. The mental health problems generated by students are mostly presented in in the school environment. [9][10][11] . Therefore, the school bears a very important responsibility in the development of students' mental health. In addition, when children face mental health problems and need to be intervened by professional child psychologists, it often takes a lot of money to complete in a profitable individual studio or company, which makes many families discouraged if the school is equipped with a professional child counselor. Providing psychological counseling services to students can greatly reduce the family burden of children with mental health problems [12] . In fact, the American Institute of Counseling, the American Association of School Counselors, the National Association of School Psychologists, and the American School Social Work Association have jointly requested in 2006 to use an empirically based psychological intervention to process mental health needs of school age children in schools [13] . Some research shows that if children with mental health problems receive psychological counseling services, they are most likely to be helped in the school environment [14,15] .
Interventions in primary and secondary schools at school require specific treatments. Obviously, the psychological intervention services for primary school students fall within the scope of children's psychological counseling. "It is not possible to simply treat children as 'small adults, and cannot treat their treatment as a proportionally reduced adult treatment." This has become the consensus of most clinical psychologists today [16] . The stage of development of the child, the school environment, the reasons for receiving treatment interventions and other relevant factors make unique demands on the treatment methods used in the psychological intervention services in primary schools.
In summary, professional psychological intervention counseling in primary schools is of great significance for children's mental health development, and what kind of treatment is used in resident psychological counseling is also a problem that needs careful consideration. We can consider Play Therapy to solve this problem.

Play Therapy
Play Therapy refers to a way to create a gentle, trustful and completely free environment for children through games, to enable children to detect their own problems in the game, to tap their potential, and to make changes in the inner world [17] . This therapy dates back to the early 20th century, the case of the Austrian psychologist Sigmund Freud's "Little Hans" [18] . Although Freud did not directly propose game therapy, he should have laid the foundation for the game therapy of future generations in response to this child visitor. Since then, the first child psychoanalyst, Hermine Hug-Hellmuth, has been recognized for the first time as a analytic approach to psychological intervention for children, and she has published an article pointing out the importance of the game in guiding psychoanalysis [19] . But she did not provide a structural framework for treatment. Until the 1930s, Melanie Klein and Anna Freud systematically used games as a method of psychoanalysis, making psychoanalytic game therapy the first organized game therapy orientation. And provides a description of the principles and practices of theory [20,21] . In the 1940s, Virginia Axline fully integrated the theory and game of personal-centered therapy into her psychological counseling and intervention work -with a toy room as a safe environment allows children to fully express their inner self through the game and establish a healing relationship with the therapist [22,23] . Axline's work provides a structural theory and a lot of practical research evidence for game therapy, and it has also made this therapy widely available [24] . In the 21st century, many game therapists have applied the above orientation to actual case response, and gradually formed Child-centered Play Therapy (CCPT), which has become a major part of game therapy. Mainstream [25] .
Game therapy has many unique advantages over other psychotherapies. The main form of the various psychotherapeutic methods that exist today is language, that is, most interventions need to be completed through the verbal communication between the visitor and the counselor. However, because of the limitations of language development, it is more difficult for children to communicate with counselors through words that are more abstract concepts (e.g., emotions). The game is the child's "most natural language", a way of expressing comfort and comfort, and children can express themselves better through the medium of games. In addition, a good counseling relationship during treatment has an important impact on the final treatment outcome. And the game can make children feel happy and meet their needs, so that therapists can establish a safe and full healing relationship with children. Many experts in the field of clinical psychology also said that in many psychological interventions, game therapy is the only intervention that is specific for young children and children [26][27][28][29] .
Many child-development-theories can support the core perspective of game therapy. In his Theory of Cognitive Development, Swiss psychologist Jean Piaget believes that individuals use their existing schema to perceive and think about the surrounding environment, while the schema is an individual from childhood. In the process of development, based on the things that they have touched and the events that have been experienced, the empirical network is gradually constructed and expanded through Assimilation and Accommodation [30] . Through the game treatment process, children can feel the sense of security, empathy, and rule restrictions in the game room into their own patterns, and this pattern helps children better adapt to the society in the real world. Requirements, in order to achieve the improvement of their psychological quality. At the same time, Russian development psychologist Vygotsky proposed three functions of the game from the perspective of individual social development: children can show higher-level functions in the game without being constrained by reality. Games can help children to meet reality. The tendency and thought of completion; if children complete an imaginative game, they can learn to distinguish between imagination and reality; children can also express themselves in the game through Private Speech [31,32] . Therefore, game therapy can help the counselor better understand the child through the above functions of the game, and help the child to relieve anxiety and stress, and finally get healing.
In addition, a large number of studies have shown that the effectiveness of game therapy in dealing with children's multiple mental health problems is good and positive, and is universal, irrespective of demographic factors such as gender, age, and living environment of the visitor [33]. Game therapy addresses children's love for hair extraction, improves children's selective silence, reduces child violence and impulsive behavior, improves children's divorce, abuses and abuses children, witnesses children's emotional adjustment, and reduces hospitalized children Stress and anxiety, improve children's adaptation and academic performance in school life, reduce children's depressive symptoms and separation anxiety, and promote the development of children's self-concepts are particularly effective [34][35][36][37][38][39][40][41][42] . Child-centered game therapy is compatible with the age of children aged 3-12 and is suitable for multicultural counseling interventions. Through child self-expression and processing of their own experience, positive and unconditional positive attention and In a sincere and safe therapeutic environment, children are encouraged to embark on a path of selfrealization that is well adapted to society [26,43,44] . Therefore, game therapy can be applied to psychological intervention in primary schools.

Review of school game treatment effects
In fact, the application of game therapy to the primary school environment has a long history. In the 1950s, researchers conducted a more detailed and systematic study of how to use game therapy and school game therapy in schools [45] . Since then, there have been many studies on game therapy in schools that reflect the effectiveness of school game therapy from an empirical perspective. The application of game therapy in primary schools can promote the healthy development of primary school children from the four levels of mental health, behavior, social and cognition.
Game therapy in primary school can significantly improve the psychological aspects of many students. Kostina, through a study of first grade students, found that school game therapy can significantly reduce student anxiety and improve their adaptability to the newly entered primary school environment [46] . Risk students in grades 4-6 (e.g., facing parental divorce problems) do not occur after their Child-Centered Game Therapy (CCPT) in school, their self-esteem and their own control of fate (intermediate control point; Locus of Control) do not change, but students without receiving intervention, have a decline in performance on these two variables, that is, school game therapy can be more effective in preventing mental health problems for children at risk [47] . For primary school children who have experienced traumatic events, short-term school game therapy can significantly reduce their anxiety and suicide risk [48] . It can be seen that the application of game therapy in primary schools can more effectively solve the common mental health problems exhibited by students and play a preventive role for students in the risk environment of mental health problems.
Using game therapy to intervene in primary school students can also significantly improve their behavioral problems in school and at home. A study of students in grades 6-9 found that after six weeks of game therapy at school, self-efficacy improved significantly, and teachers reported significantly fewer behavioral problems than untreated students [49] . The use of game therapy in the school environment is also significantly better for children's problem behaviors (e.g., aggressive behavior) than some forms of school intervention (e.g., groupguided courses, traditional behavioral interventions) and applies to cross-cultural children [50][51][52] . However, compared to some school interventions (e.g., cognitiveverbal groups), game therapy does not show a clear advantage over the problem behavior [53] . In addition, school game therapy has a significant positive effect on children with special educational needs. Fall and his colleagues found CCPT in schools by comparing children who received CCPT at school and did not receive any intervention at school. These children's behavioral and social problems can be significantly improved [54] .
The use of game therapy to provide mental health services to schools also helps improve the social relationships of the students being served. When children receive CCPT intervention in kindergarten, their parents report a significant reduction in parent-child relationship pressure [55]. A study of children of a greater age span (pre-school to grade 5) showed that school CCPT interventions can significantly ease tensions between teachers and students [56] . In terms of the social aspects of students and peers, the abused victim students who received 15 weeks of Directed Play Therapy at the school had more co-games with their peers than those who did not intervene, and received group game therapy. Students in grades 3-6 are more likely to acquire more social skills than those who receive "placebo" intervention and no intervention [57,58] .
Game therapy interventions at school can also improve students' cognitive-related problems. Kindergarten students with sluggish speech development, after receiving CCPT for 25 weeks and 30 minutes per week, have significantly improved their language skills and abilities [59] . Blanco studied the effects of game therapy after the first-grade students with poor academic performance and concluded that after 16 CCPT treatments, students who received the game treatment were in the course of the course compared to the first-year students who did not receive the game treatment. Significant progress in performance [60] . In addition, school game therapy can significantly improve students' concentration issues. Ray and his colleagues randomly assigned children who met the diagnostic criteria for attention deficit hyperactivity disorder (ADHD) to the control group or the reading control group to receive one-on-one CCPT and reading-guided interventions. The results showed that the two interventions Both methods can improve the symptoms of ADHD in students, and CCPT has a significant advantage in improving the emotional instability, anxiety and withdrawal of students [61] . A case study also found that after primary school students received a mixed intervention with CCPT and other therapies, ADHD behavior improved and task concentration time was extended [62] .

Methods of applying game therapy in primary school
It can be seen from the review of predecessors' research on the effect of school games. The application of game therapy to the primary school environment can significantly improve the current mental health status of primary school students in China. It is also necessary to discuss how to apply game therapy to primary schools. surroundings. Game therapy has many forms such as case counseling and group counseling, and contains a large number of professional skills to intervene in children. The complete intervention process in case-to-case cases mainly includes assessment, intervention, and settlement [13] . Therefore, we consider game-based assessment. The four links of case intervention, group counseling, and universal prevention are used to apply game therapy in the school environment.

Game-based assessment
Regardless of the type of psychotherapy, a detailed assessment of the case is a critical step in the overall treatment process. It helps the therapist to objectively and comprehensively understand the individual's actual situation, determine the direction of intervention, develop adjustment interventions, manage potential risks, provide valuable feedback to visitors [63,64] . In game therapy, the evaluation of a case is mainly based on the form of the game, and the performance of the case is observed to achieve his or her assessment. Through evaluation, you can understand the social relationship, family relationship, personal personality, cognition, social development and other aspects of the case. Due to the limitations of the school environment, the assessment techniques used in schools need to be characterized by easy availability of materials, limited site constraints, and short duration. Therefore, we recommend evaluation techniques in the three game treatments of mental development assessment, intrinsic motivation, and family animal maps to evaluate school cases. A brief introduction to these three technologies will be given here.
Mental Development Assessment: The mental development assessment technique in game therapy is rooted in the painting projection test. It uses a bucket of 12-color watercolor pen, several fruit and vegetable shaped toys of different colors, and an A4 white paper. Simple materials, through the evaluation of children according to the color of the toy, follow the painting, creative painting, the child's language, understanding, application, concentration and other basic cognitive development level. Because this evaluation method is simple and the process is standardized, non-professionals (such as teachers and parents) can also learn to assess the child's cognitive development level.
Inner Motivation: The intrinsic motivation assessment in game therapy also uses 12-color watercolor pen and A4 white paper as materials. Children can choose the pen of their favorite color. The therapist asks and writes 3 children's favorite. Things and things that the three children least like. Through this assessment, you can understand the inner cravings and sources of fear, the people or things that are most concerned, and the sources of trauma, the sources of positive and negative emotions, and other elements related to intrinsic motivation.
Family Play Genogram: The family animal map (or family game animal map) method is completed by three kinds of animal toys, white paper and pen. Let the child select from the animal the animal that is considered to be the most representative of his family member in the corresponding position in the family map. This technology allows you to assess your child's current family situation and the family's impact on children's psychology.

Case intervention
Unlike other psychotherapies, interventions in game therapy need to be done in a unique environment in the game room. Therefore, before the game therapy intervention in the school, a specific room must be set up as a game room, and the game room in the school needs to meet the following requirements in terms of site selection, scale, and layout.
To set up a game room in a school, the location should be chosen in the area that will not disturb the visiting children and school staff. This is mainly because the faculty and staff of the school often need a quiet environment to complete the desk work such as correcting assignments and preparing lessons. The children who are intervened in the game room may be loud and noisy, affecting the work of the faculty and staff. In addition, if the child can hear the noise outside the game and think that his voice will be heard, he or she may feel that his privacy has been violated, which will make it difficult for the therapist to establish a healing relationship with the child. . However, due to the particularity of the school environment, it is also an unrealistic goal to build the game room in a completely isolated place. The size of the game room is also very important. A room about 15 inches long and 12 inches wide is the room that best meets the needs of gaming treatment. The area is too small for children to move; and the area is too large for the therapist to keep close to the child. However, it is often difficult to provide the most suitable room in the school as a game room, so the therapist should also creatively determine the way the toy is placed according to the specific situation to meet the requirements as much as possible. In addition, the layout of the game room should make the children feel friendly, open and safe, and should convey to the visiting children the message "This is your own world". Building materials such as blinds, plastic flooring, enamel paint are all materials suitable for use in the layout of the game room.
After the game room is completed, you can start selecting children to start formal case intervention. Since there are often hundreds or even thousands of children in the school who can benefit from game therapy, the number of game therapists who can be stationed in the school is often only one or two, and the time spent in school is limited, so how to choose children to intervene and how to rationally arrange interventions has become a problem that needs to be seriously considered by resident school game therapists. The Association for Play Therapy (APT) certified game therapy supervisor Ray has proposed a viable approach: first determine the number of sessions that can be used for game therapy interventions based on the therapist's school schedule; then list all previous preassessments referral or a list of children directly referred by the teacher; then based on the child's background information to determine whether it is possible to refer to an off-campus professional psychologist, determine the severity of the child's psychological status and thereby arrange the order in which each child receives the intervention; After the determination, the child will be intervened. After every six treatments, the case will be settled. If the case is closed, the next child will be arranged according to the order, otherwise the case will be intervened six times [13] .
In addition, game therapists in schools need to pay attention to the work of school administrators, teachers, and parents, compared to game therapy on individual cases in independent counseling organizations or research institutes. For school administrators, it is necessary to strengthen their openness and understanding of game therapy, to demonstrate as much as possible the empirical research of the game treatment effect and the background of the resident game therapist, so that the game treatment carried out in the school can be obtained maximum support by the school administrators. For the school's teachers, the resident game therapist needs to understand that the teacher is the second most important child in the development process of the students. It is necessary to pay attention to the teacher's role in the connection between the therapist, the student and the parent, and to talk with the teacher about the progress in treatment and information on student and to get the students performance, parental feedback from the teacher in time. Even in school, the parents of the students are the final decision makers for the psychological intervention in the school. Therefore, it is also crucial to maintain communication with parents, get parent support and agree to work for resident game therapists.

Group counseling
Game therapy can also be applied to student group coaching in class. Due to the large gap between the number of t game therapists in school and the number of students, case-based interventions can often only be targeted at children with a risk of mental health problems or children who have expressed psychological behavior problems. Group game therapy based on class can better solve this problem. In addition, group game therapy has many unique advantages: because of the presence of peers, each student participating in group counseling is significantly less anxious about the new environment, new ways, new social objects (therapists) [65] . When children can observe each other's interactions, this environment will allow them to develop, so that they can be more quickly involved in the process [66] ; group game therapy also provides the therapist with an observation of children's interaction with others. The opportunity to see the child's performance in various environments more completely.
Group game therapy at school requires a distinction between class and team building activities. Class group building activities tend to focus on the improvement of group cohesion, emphasizing that all students work together to accomplish a goal that is difficult to accomplish on their own, but class group games should reduce the guidance for cohesiveness and reduce the attention to results, but should pay attention to responding to children in a timely manner. Responsiveness and performance, using the sincere warmth of the child and the timely response of the therapist to the needs of the child to achieve healing for children participating in group games.

Universal prevention
Teaching school treatment skills and children's development concepts to school teachers and parents can help to achieve universal prevention of mental health problems among students. As we all know, the importance of parents to the development of children's mental health is self-evident, and the teacher is also the primary caregiver of the students after the parents. Through the training of teachers and parents, it is conducive to creating a positive, friendly and open school atmosphere, providing timely and adequate support for students' emotional development, cultivating and establishing students' sense of belonging to the school, improving the academic performance of all students and reducing the risk behavior of students [67] .
Training for parents and teachers can be done through lectures, group counseling, etc., or through a one-on-one discussion to the teacher or parent to propose interventions for specific students. Specifically, lectures and group supplements can be offered to teachers and parents in the form of courses, one to two lessons per week, for one semester or several semesters. The resident psychotherapist can also arrange a specific time to meet with the parents or teachers on the day of the school counseling, and give advice based on the student's situation. Through the above two methods, the strength of teachers and parents is used to prevent students' mental health problems.

Conclusion
This paper summarizes the previous research on the application of game therapy in primary schools and found that applying game therapy to boarding school student mental health services is conducive to improving the current severe mental health status of children in China, and at the same time puts forward the precautions and operational procedures for specific applications. Future research can explore the feasibility and effectiveness of the application method proposed in this paper through the form of empirical research. In addition, we can also try to combine game therapy and other psychotherapy and counseling genres into the school environment, so that various genres can be organically integrated and complemented, and more effectively solve the mental health problems faced by children in China.