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The language of child’s play: thematic representations of healing through the process of play therapy 1998

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THE LANGUAGE OF CHILD'S PLAY: THEMATIC REPRESENTATIONS OF HEALING THROUGH THE PROCESS OF PLAY THERAPY By JANICE EBENSTINER Bachelor of Arts, Simon Fraser University, 1994 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology We accept this thesis as conforming to the require^ standard THE UNIVERSITY OF BRITISH COLUMBIA August 1998 © Janice Ebenstiner, 1998 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT Play therapy has been used for treating maladjusted children for decades and although it is recognized as a treatment of choice, a scarcity of verified, systematic knowledge on the process children typically move through within therapy exists in the literature. This qualitative single case study documents the process of play therapy over twenty sessions with an eight year old child who experienced maternal loss and separation, parental neglect, parental drug abuse and chronic instability in her home environment. A detailed account of the child's perceptions of her experience as well as the progression of the therapeutic relationship as it emerges and transforms over time is described. Significant issues of concern, areas of struggle, and patterns of improvement are documented through the evolution of the play therapy process, House-Tree-Person drawings and parent reports on the Child Behavior Checklist. The therapeutic process evolved across five phases, each illustrating specific behavioural and thematic developments and changes. This phasic process is consistent with the general findings of several play therapy clinicians and researchers. Although each of the five phases is not corroborated entirely by a single existing theory, several of the characteristic themes, play behaviours and transitions within each phase are documented in previous research. The findings of this study highlight the importance of the therapeutic relationship in the psychological healing process. The effects of parental neglect and separation are also discussed in terms of these findings. The results of this study enhance the understanding of the therapeutic process of play therapy, demonstrate the psychological effects of parental neglect and separation and indicate the importance of a consistent and nurturing parent to a child's development. iii TABLE OF CONTENTS Abstract i i List of Figures vii Acknowledgements viii Dedication ; ix CHAPTER I: INTRODUCTION 1 Research Questions 5 Definitions 5 CHAPTER II: L ITERATURE REVIEW 7 Importance of Play 7 Therapeutic Use of Play 10 Play Therapy Theories and Approaches 11 Play Therapy Research 17 Difficulties in Child Psychotherapy Research 20 Play of Abused and Neglected Children 21 Play of Adjusted and Maladjusted Children 27 Psychotherapy Process Research 29 Play Therapy Process Research 31 CHAPTER ni: M E T H O D O L O G Y 35 Exploratory Research 35 Participant Observation 35 Case Study , 36 Participant 38 Ethical Considerations 39 Play Therapy Environment and Materials 39 Research Process 41 Qualitative Data Analysis 45 CHAPTER IV: RESULTS 48 Overview 48 Family History and Concerns 7. 48 Intake Observations 51 Child Behavior Checklist r 51 iv Tracking the Process of Change During Therapy 55 Session One 55 Play Themes and Use of Play Materials 55 Emotional Expression 57 Therapeutic Relationship 59 Summary of Session One 59 Session Two 60 Play Themes and Use of Play Materials 60 Emotional Expression 65 Therapeutic Relationship 66 Information from Home 66 Summary of Session Two 67 Session Three 68 Play Themes and Use of Play Materials 68 Emotional Expression 70 Therapeutic Relationship 71 Summary of Session Three 72 Session Four 73 Play Themes and Use of Play Materials 73 Emotional Expression 74 Therapeutic Relationship 75 Information from Home 75 Summary of Session Four 76 Session Five 77 Play Themes and Use of Play Materials 77 Emotional Expression 77 Therapeutic Relationship 78 Information from Home • 79 Summary of Session Five 79 Session Six 80 Play Themes and Use of Play Materials . 80 Emotional Expression 81 Therapeutic Relationship 84 Summary of Session Six 84 Session Seven • 85 Information from Home 85 Play Themes and Use of Play Materials 85 Emotional Expression 85 Therapeutic Relationship 88 Summary of Session Seven, 89 Session Eight 90 Play Themes and Use of Play Materials 90 Emotional Expression 91 Therapeutic Relationship 92 Parent Meeting 92 V Summary of Session Eight 93 Session Nine 94 Play Themes and Use of Play Materials 94 Emotional Expression . 94 Therapeutic Relationship 95 Summary of Session Nine 96 Session Ten 96 Information from Home 96 Play Themes and Use of Play Materials . 97 Emotional Expression 98 Therapeutic Relationship 100 Summary of Session Ten 101 Session Eleven 102 Information from Home 102 Play Themes and Use of Play Materials 102 Emotional Expression . 105 Therapeutic Relationship 107 Summary of Session Eleven 107 Session Twelve 108 Information from School 108 Play Themes and Use of Play Materials 108 Emotional Expression 110 Therapeutic Relationship I l l Summary of Session Twelve I l l Session Thirteen 112 Play Themes and Use of Play Materials 112 Emotional Expression 114 Therapeutic Relationship 115 Summary of Session Thirteen 116 Session Fourteen 117 Play Themes and Use of Play Materials.... 117 Emotional Expression 118 Therapeutic Relationship 119 Summary of Session Fourteen 120 Session Fifteen 120 Play Themes and Use of Play Materials 120 Emotional Expression 121 Therapeutic Relationship ....122 Summary of Session Fifteen 123 Session Sixteen 123 Play Themes and Use of Play Materials 123 Emotional Expression 124 Therapeutic Relationship 125 Summary of Session Sixteen ...126 Session Seventeen 126 vi Information from Home . 126 Play Themes and Use of Play Materials 127 Emotional Expression 128 Therapeutic Relationship 130 Summary of Session Seventeen 131 Session Eighteen 132 Play Themes and Use of Play Materials 132 Emotional Expression 133 Therapeutic Relationship 134 Information from Home , 134 Summary of Session Eighteen 134 Parent Meeting 135 Session Nineteen 137 Play Themes and Use of Play Materials 137 Emotional Expression 139 Therapeutic Relationship 139 Summary of Session Nineteen 140 Session Twenty 141 Play Themes and Use of Play Materials 141 Emotional Expression ; 142 Therapeutic Relationship 144 Summary of Session Twenty 145 Child Behavior Checklist 145 Foliow-Up Session One Year Later 146 Final Summary 148 CHAPTER V : DISCUSSION A N D CONCLUSIONS 150 Original Research Questions 150 Overview of Findings Related to Original Research Questions 151 Play Themes, Use of Play Materials and Play Areas 154 Changes in Language, Speech Patterns and Dialogue 156 Changes in Therapeutic Relationship 157 Changes in Behaviour at Home 158 Additional Findings Unrelated to Research Questions 158 The Impact of Parental Unavailability and Loss 159 The Issue of Directive vs. Non-Directive Therapy 161 Limitations of this Study 162 Implications of this Study ; 162 Personal Reflections and Final Summary 163 References 165 Appendix A : Letter to Parents and Parental Consent Form 171 vu LIST OF FIGURES Figure 4.1 House 61 Figure 4.2 Tree 62 Figure 4.3 Person '. 62 Figure 4.4 Wolves 68 Figure 4.5 Rainbow 80 Figure 4.6 House 103 Figure 4.7 Tree 103 Figure 4.8 Person 104 Figure 4.9 House 137 Figure 4.10 Tree 138 Figure 4.11 Person 138 ACKNOWLEDGEMENTS I would like to express my thanks and appreciation for the support of the therapists at the clinic where this research was conducted and for the acceptance of this research project by the administrative staff. I would especially like to thank Roger Gale, who not only offered his excellent guidance, support and clinical wisdom as my supervisor, but whose unconditional respect and encouragement greatly enhanced my ability to grow as a therapist. I would like to thank my research committee for their support, careful reading and excellent advice. Dr. Bil l Borgen and Dr. Kathryn McCannell provided their wisdom, clinical expertise, insight and inspiration. Monika Grunberg's critical eye in reviewing some of my videos and her clinical observations, insights, and suggestions were greatly appreciated. Thanks also to Maria McLellan and Norma Lorimer for their careful editing skills and their astute feedback. Dr. Barbara Mills deserves thanks and appreciation for offering her clinical wisdom, support and research advice during the writing of my thesis. I would also like to express my gratitude to Dr. John Allan for his inspiration and involvement in the initial research proposal and for his influence in strengthening my passion for play therapy. A special thanks goes out to my family and friends for their encouragement, support and patience throughout the process and completion of my thesis. DEDICATION I would like to dedicate this thesis to "Christina" whose courage and strength have been inspiration to me and have renewed my faith in the resilience of the human spirit. CHAPTER I INTRODUCTION Play is children's natural mode of communication. Because they do not often possess the needed degree of language skills or the cognitive capacity to communicate abstractly through words, toys become their words and play, their symbolic language of self-expression. According to Moustakas (1953), play is a unique psychological tool for viewing the world through the eyes of the child. What play can tell about children and what children can tell through play are potentially significant sources of information not yet fully understood. Children's play is an expression of their experiential world and as such discloses both inner feelings and defensive attitudes to the external world. Through play, the child attempts to understand his or her perceptions of the world and to express the complexities of the adult world. It is the child's natural mode of learning, communicating and interacting with others and as such is recognized as an integral component of a child's life (White & Allers, 1994). Disruption of play may be one of the most sensitive indicators of disturbance in a child's life. The child's perception of his or her experience and the resulting emotional expression of fear, loss, anxiety, or anger may be manifested through play and may indicate the level of trauma or maladjustment he or she has experienced. Therefore, play, the child's inherent means of expression, may be the most apparent measure of symptomatology and method of treatment (Landreth, 1991). According to Mann & McDermott (1984), and Marvasti (1994), play therapy is the preferred treatment for children who have experienced maltreatment. "It is the centrality of the 2 experience of play as the child's mode of creative expression that makes it a dynamic form of therapy for those children who have been abused " (Cattanach, 1992, p. 29). In reviewing the literature, Schaefer (1998) has found 25 therapeutic powers of play which cut across the major theoretical orientations of play therapy. Schaefer recommends that the more play therapists begin to identify the process of play therapy, to understand, and to more effectively employ play to change human behaviour, the more effective play interventions will be. He urges that we seek greater understanding of the play therapy process so as not to fall into the trap of merely "playing around with children" (p. 1). Schaefer (1985) indicates the following curative powers of play: • releases tensions and pent-up emotions • allows compensation in fantasy for loss, hurt and failure • facilitates self discovery of more adaptive behaviours • promotes awareness of conflicts revealed only symbolically or through displacement • offers the opportunity to reeducate children to alternate behaviour through roleplaying or story-telling. Numerous theories and approaches to play therapy have emerged including existential child therapy (Moustakas, 1953), gestalt therapy (Oaklander, 1988) and non-directive play therapy (Axline 1947/69). Non-directive play therapy or child-centred play therapy used in this study stems from Carl Rogers' person-centred approach to therapy and was adapted to play by Virginia Axline. Within this theoretical stance the play therapist shows unconditional positive regard and acceptance towards the child, emotional warmth, self-congruence, and a professional helping attitude. Given these conditions children are able to explore the play therapy environment, the therapeutic relationship and communicate their needs, unresolved personal conflicts and deeper emotions in more symbolic form using play materials. 3 Although play therapy is the favoured therapeutic medium for children who are maladjusted or who have experienced maltreatment, according to the literature reviews of White and Alters (1994), Phillips (1985) and Schaefer (1998), there is an absence of systematic guidelines describing and evaluating the use of play therapy as a method of intervention and in particular, there is a lack of verified research describing what actually happens in play therapy. Child psychotherapy has been a frequent subject of research in the past two decades; however, most research has focused on outcome, neglecting the impact of the psychotherapeutic process on behaviour change. In order to more accurately evaluate its effectiveness, it is essential to learn more about what happens during the course of play therapy. As is evidenced in other learning experiences, the dynamic process of play therapy is not linear. In addition, the process characteristics vary between clients and across therapy, making it difficult to describe. As the clinical use of play therapy continues to increase, the process by which this therapeutic modality transforms and heals the wounded child is still not clear. In response to Phillips' (1985) and Schaefer's (1998) discovery of a scarcity of play therapy process information and Hannah's (1986) indication that because psychotherapy is not standardized the best generalizable knowledge is found by studying many individual cases and searching for commonalities, this single case study describes the evolution of the play therapy process. The three components that are examined are the emergent play themes, emotional expression and the transformation of the therapeutic relationship over time which together illustrate the evolution of the therapeutic process. The purpose of this project was to document the process of six months of play therapy with an eight year old child using an inductive, experiential case study design. Through a qualitative method of inquiry, the child's emotional experience of numerous changes, disruptions 4 and neglectful experiences are outlined as they are intrapsychically transmitted through play. A narrative of the therapeutic process of play captures the issues, themes and patterns of the internalized meanings of the child's experience as it emerges and transforms over time. This study attempts to control some of the methodological weaknesses of previous studies by including a more thorough definition of play therapy, a detailed description of the therapeutic procedure, process and outcome as well as the role and nature of change in the therapeutic relationship. In addition to the videotaped play therapy sessions, data was obtained from several sources in order to give a broader view of change over time. As a participant-observer, the researcher was able to capture subtle nuances of behaviour and gain a more holistic account of the play therapy experience that may not otherwise be available to an outside researcher. Furthermore, as this design was exploratory in nature, a more detailed view of the therapeutic process was obtained than would be possible from a more structured, experimental design using deductive methods of inquiry that may limit the depth and breadth of the information obtained. Single-subject research designs increase the internal validity of outcome/process research but delimit the generalizability of the results. As this is a single case study, generalizability to the larger population is restricted. In addition, the difficulties experienced by the participant, "Christina" may not manifest themselves within the therapeutic process in the same way as would problems of a more or less severe nature experienced by different children. However, I believe the results obtained through this inductive, exploratory study may illuminate more meaning within the current understanding of play therapy process and theory. 5 Research Questions 1. What is the process by which a child moves from psychological impairment to a more healthy psychological state during play therapy? 2. What play themes are displayed and repeated throughout therapy? 3. How are play themes and play areas integrated throughout each session and over time? 4. What materials are used most frequently in symbolic play? What might these stand for? How are they used? 5. How do the child's language, speech patterns and dialogue change over time? 6. How does the therapeutic relationship change over time? 7. How does the child's behaviour change from the beginning to the end of treatment in the home environment? Definitions Play therapy. Play therapy is "a dynamic interpersonal relationship between a child and a therapist trained in play therapy procedures who provides selected play materials and facilitates the development of a safe relationship for the child to fully express and explore self (feelings, thoughts, experiences, and behaviour) through the child's natural medium of communication, play." (Landreth, 1991; p. 14). Non-directive play therapy. Axline (1947) is credited with the creation of this specific type of play therapy based on the principles of Carl Rogers' (1942) client-centred approach to therapy. The responsibility for guidance and interpretation lies with the child who is encouraged to choose the toys and activities with which to play and is given the freedom to develop or to terminate any particular theme. The client-centered approach or non-directive play therapy promotes the process of growth and normalization which is done at the child's own unique rate. "The non-directive therapist cultivates hypotheses that are tested over time; interpretations are 6 used sparingly and then only after a great deal of observation. Non-directive therapists give the child concentrated attention and refrain from answering questions or giving directives" (Gil, 1991; p. 35-36). Repression, "a term describing the mental maneuver of doubly denying an uncomfortable feeling and/or thought; sometimes this will include associated ideas or memories. The specific issues are buried, so to speak, and the mind goes on conveniently to "forget" they exist. Repression requires a form of self-deception in which the mind tells itself to compartmentalize unwanted emotions, files them away, and forgets where they are. This process is an immature way of handling unhappy experiences and occurs as part of growing up" (Blatner & Blatner, 1997; p. 94). Theme. "An identifiable process made up of a series of actions and events having direction which are connected through a common purpose, sequence and consequence. The loading and unloading of a dump truck, building a fort, playing house and having a tea party contain within them countless themes. While these themes are underway, the participants add to and share the universe they create" (Bishop, 1982; p. 39). 7 CHAPTER II LITERATURE REVIEW Importance of Play "Play is older than culture, for culture, however inadequately defined, always presupposes human society, and animals have not waited for man to teach them their playing. We can safely assert, even, that human civilization has added no essential feature to the general idea of play" (Ludens, 1950; cited in Kenny, 1994, p. 8). The significance of play in the lives of children has been recognized as early as the 18th century by Rousseau (1762/1930) who wrote about the importance of observing play as a means of understanding children. And in 1903 Froebel wrote about the importance of the symbolic content of play and that regardless of the nature of play, it comprises both conscious and unconscious meaning as evidenced in the following quote: "Play is the highest development in childhood, for it alone is the free expression of what is in the child's soul... Children's play is not mere sport. It is full of meaning and import" (Froebel, 1903, p. 22). The engagement in play requires no formal teaching, is intrinsically pleasurable, and while it may appear to some to be biologically purposeless, its ability to evoke pleasure and enjoyment seems to foster its benefits to survival. According to Dissanayake (1992), the survival value of a behaviour is based on whether or not it makes us feel positive and good. Play is considered one of the adaptive behaviours that has persisted throughout time because of its intrinsically pleasurable qualities. The intrinsic rewards of play seem to outweigh the costs of energy expenditure and risk that it poses for many species. From her ethnological perspective, Dissanayake (1992) suggests that although play may not serve immediate survival purposes, the skills acquired during this activity contribute to the participant's ability to engage in future survival tasks such as finding food, defending herself, and 8 mating. Play is not only intrinsically pleasurable, but according to Dissanayake, it allows individuals who play to develop the practical and social skills necessary to survive, whereas those who are not inclined to play or are prevented from playing will lack the experience required to engage in these essential life tasks. Huzinga (1949) examined play as a cultural and historical phenomenon that stands outside normal life. Although it absorbs the player intensely, it is considered 'not serious'. It possesses its own boundaries of time and space as well as fixed rules. No profit is to be gained by it therefore, it has no material interest. Huzinga suggests that play is older than culture itself and that several activities were born from play. Music and dance are play, poetry is derived and nourished on play and ritual grew from sacred play. From the earliest phases of civilization, people have formed the conventions of life and rules of warfare based on patterns of play. More recently, the importance of play is indicated by the United Nations proclamation of play as a universal and inalienable right of childhood. According to Landreth (1991), as the primary activity of childhood, play is voluntary, spontaneous, is not goal-dependent, needs no instruction and as such, is intrinsically complete. Play is the way children learn what can not be taught; by exploring our symbolic world of meanings and values and through enhanced understanding they can reorient themselves to the real world. Although play is an art of the highest order (Schaefer & Reid, 1986), it is usually unappreciated, underutilized and misunderstood because of its non-serious nature. However, the processes of learning and socializing in humans and other higher order species are facilitated through play as it enables one to explore alternative actions motivated by an innate sense of fun. It offers a special and unique reality with endless creative possibilities and for this reason, 9 according to Blatner and Blatner (1997), play should be redeemed as an activity needed beyond childhood and throughout life. Indeed, play is vitally important in its role as a vehicle for learning to imagine alternate ways of being which develop our creative capacities. Cattanach (1992) quotes Jung who writes: "The creative activity of imagination frees man from his bondage to the 'nothing but' and raises him to the status of one who plays. Man is completely human only when he is at play." (p. 30) Play involves active participation, both physically and mentally on the part of the participant. It is unique and comprised of a variety of activities linked by a common bond of playfulness. According to Liebmann (cited in Gladding, 1992), play involves the following characteristics: 1. Play is pleasurable and enjoyable. 2. Play has no extrinsic goals; it is inherently unproductive. 3. Play is spontaneous, voluntary, and freely chosen. 4. Play involves active engagement on the part of the player. 5. Play is related to what is not play (p. 102). The everyday play of childhood is free and easy, bubbly and light-spirited. The normal constraints of everyday life do not apply in play. Games evolve in play when a child needs to master an upcoming step in life, to gratify an inner wish, to deal with an uncomfortable fear, or to cope with the aftereffects of an unpleasant event. What may be unmanageable in reality can be changed to manageable situations through symbolic representation of one's emotions. Alternate roles can be tried on, experimented with and discarded when no longer pleasurable. The farther the child moves away from herself, the more successful her play will be in achieving mastery. According to Nickerson and O'Laughlin (1983), play and playing games is not only cathartic, educational and self-revealing, but it is also pleasurable and fun. The unrestricting nature of play is motivating. A child's desire to try out new activities and social roles and to make 10 sense out of objects or people in his or her environment is fulfilled through the serious business of childhood, play. Play establishes a context in which typically socially unacceptable behaviours can be tolerated and even enjoyed. Experimentation with various behaviours such as being silly, babyish, bossy, seductive, or mocking of authorities are all common within the realm of sociodramatic or pretend play whereby the child explores physical, psychological and social realities. Through the natural vehicle of play, the child is able to explore the world within a safe context for self- expression (Blatner and Blatner, 1997). Play is a unique experience in our lives; it has a reality of its own as an activity in which human beings explore their identity in relation to others. Play is a creative act. It is the root of artistic expression; as through role rehearsal and make-believe, it initiates the origin of drama. Because play is important across the life span, its characteristics and its appeal differ across ages (Gladding, 1992). Therapeutic Use of Play According to Ellis (1977), individuals who do not play enough become "overly serious and mentally distraught" (cited in Gladding; p. 103). As a result they may exhibit such dysfunctional behaviour as depression, displacement or outbursts of anger or abuse. According to Gladding, one of the primary tasks of therapy is to help people to develop a more playful way of being. The use of play in therapy is based on the premise that play is non literal and can be performed safely and without fear of real consequences. The often repeated symbolic expression of real life events enables a client to re-experience the event within a safe and accepting environment whereby mastery can be achieved through repeated expression. 11 Play may be used therapeutically as a means of: 1. establishing rapport 2. understanding family and peer interactions 3. tapping unexpressed feelings 4. expressing feelings safely 5. teaching socialization skills (Gladding, 1992; p. 103). Play enables the expansion of one's imagination and creativity. Through pretending, problems can be reworked and perceived in a more positive light. By providing activities and materials that foster play and the ability to pretend, the therapeutic experience can provide opportunities for clients to become less resistant and more comfortably engaged in play (Gladding, 1992). Play enables those who are not able to express themselves verbally to communicate through the use of toys, sand or art and creative materials such as play dough, paints or clay. The use of these materials in a creative way enables the therapist to observe the choice of materials and the process in which the client engages to play out and resolve developmental and situational aspects of his or her life. Through the process of playing in therapy, the child, according to Cattanach (1992), is able to create experiences that were lost, were never provided or were too painful to be assimilated. The use of spontaneous play in a structured situation provides a therapeutic means of assessing how children perceive themselves and their world. Play Therapy Theories and Approaches There are many theories of play as well as many therapeutic approaches to its use in the treatment of children. In his classic case of "little Hans", a 5 year old phobic boy, Freud (1909) was the first to describe a psychological approach to working with a child. This case marked the beginning of therapeutic work with children. For the first time, this child's difficulty was 12 attributed to emotional causes rather than the previous view that psychological disturbance in children was caused by deficiencies in their education and training. Freud suggested that the repetition of children's symbolic games is the ego's attempt to gain mastery over a previously traumatic event. By repeating the events of their lives, children are able to become masters of the real life situations which were originally experienced passively. With every new repetition of the experience, the child develops a progressively greater degree of mastery. Hermine Hug-Hellmuth (1921) was the first to introduce play into the therapeutic process with children and to provide play materials to enable self-expression. Hug-Hellmuth did not construct a specific therapeutic approach; however, she did highlight the difficulty of applying adult therapeutic methods to children since they were unable to verbally describe their anxieties, explore their past, discuss their developmental stages and use free association. In 1919 Melanie Klein (1955) utilized play as a therapeutic means of accessing the unconscious of children under the age of six. She believed the child's use of the play materials and the accompanying verbalizations were equivalent to the adult's free associations and provided direct access to the child's unconscious. Klein used play as a vehicle for encouraging children to express their fantasies, anxieties and defenses which she then interpreted. During the same period of time, Anna Freud (1946) utilized the psychoanalytic system of child analysis to interpret the child's unconscious motivation similar to the way in which dreams were used in adult psychoanalysis. She used children's drawings, paintings and play scenarios to detect their unconscious wishes. Unlike Klein, Freud emphasized the importance of developing the therapeutic relationship before interpreting the unconscious motivation behind the child's play and drawings. The child's play behaviour was not interpreted directly until the relationship with the therapist was well established. 13 Both Klein and Anna Freud viewed play as a means to analyze problems rather than as a therapeutic tool to ameliorate the child's struggles. Although both therapists stressed the importance of uncovering the past and strengthening the ego, they differed in their views of the importance of the therapeutic relationship and the use of interpretation of unconscious material. Klein focused on interpretation and believed the exploration of the unconscious was the main task of therapy and Could be achieved through analysis of the child's transference relationship with the therapist. She believed that the anxieties expressed through the child-therapist relationship were indicative of the child's early relationships during infancy. By re-experiencing these early emotions, Klein believed the child could learn to understand them and gain insight through the therapist's interpretations thereby diminishing the child's anxieties. Anna Freud (1946/1955) used play as a primary means of encouraging a positive emotional attachment between child and therapist and as a vehicle to gain access to the child's inner world. Her main goal was to influence the child to like her. She refrained from making direct interpretation of play until she had gained extensive knowledge from both play observations and parent interviews. She did not believe in the transference relationship between the child and therapist and cautioned against emphasizing the symbolic nature of play. Instead, she viewed play as a series of conscious repetitions of recent experiences rather than emphasizing its emotionally symbolic nature. She modified the structure of her father's method of free association by de- emphasizing the cognitive component and emphasizing the emotional experience. Through encouragement to verbalize daydreams and fantasies by seeing visual images in his or her mind, the child learned to express his or her internal thoughts and to discover the meaning behind them through the analyst's interpretations. As the therapeutic relationship evolved, greater emphasis was placed on verbal interactions and the therapy became increasingly less play-based. 14 The work of these early theorists marked the first major development in play therapy theory and according to Landreth (1991), the work of David Levy (1938) denotes the second major progression. Levy's release therapy approach is based on the belief in the abreactive effect of play in working with children who have experienced a specific stressful situation. This structured approach highlights the therapist's primary role as that of recreating the child's stressful experience through the use of selected toys. The abreactive ability of play is highlighted through the reenactment of the traumatic event whereby the child is able to release the pain and tension associated with the experience. The therapist permits the child to also select his or her own play materials and scenario which enables the child to be in control of the play and to take on more of an active role. The work of Levy was extended by Gove Hambidge (1955) and has become a more directive form of play therapy entitled Structured Play Therapy. The third significant impact on the development of play therapy was through the work of Jesse Taft (1933) and Frederick Allen (1934). The philosophical grounding for their relationship play therapy theory stems from the writings of Otto Rank (1936) who stressed the importance of the development of the client-therapist relationship in the present rather than the focus of therapy being the unconscious material from one's past history. Where the psychoanalytical forms of play therapy were based on the desire to discover and release mechanisms, complexes, conflicts and unconscious drives, the curative power of the emotional relationship between the therapist and child is emphasized in relationship play therapy. The primary therapeutic focus is on present feelings and reactions; therefore, no attempt is made to draw out or interpret past experiences. Allen and Taft believed in the inner strength of children and their capacity to constructively alter their own behaviour. From this theoretical perspective stems the practice of allowing children the freedom to play and to direct their own activity or to 15 choose to abstain from playing. The basic premise of relationship therapy is that children will become aware of their separateness and their individual desires and abilities through their relationship with the therapist and his or her efforts to help children assume responsibility for their growth process. Carl Rogers (1942) expanded relationship therapy into his non-directive approach or client-centred therapy which influenced the fourth major development in play therapy through the work of Virginia Axline (1947/69). She established play therapy as the treatment of choice for children with emotional and behavioural difficulties by modifying Roger's client-centered therapy with adults into non-directive play therapy with children. The premise of non-directive play therapy is that play in itself is a healing process. Through the therapeutic relationship, the child learns about herself in relation to another and is given the opportunity to symbolically express her feelings and struggles. The child is provided with a secure environment in which to freely explore the materials as well as her self in relation to the therapist. She is free to control the choice of play materials and to direct the play process. Rules are set by the therapist only with regard to the provision of adequate safety and time. The child is accepted unconditionally and her feelings of frustration, insecurity, aggression, fear and confusion are not judged, tempered or expected to change. The principles of Axline's non-directive approach which are adhered to in this study, are the belief in an individual's innate ability to be self-directed and to strive toward growth. Through play therapy, children work toward maintaining a balance between their inner and outer worlds so as to facilitate the natural self-determining growth process. Through the active and integrative process of play, mind and body reestablish a healthy link. 16 The principles of Axline's approach are as follows: 1. The therapist must develop a warm, friendly relationship with the child. Good rapport should be established as soon as possible. 2. The therapist accepts the child exactly as he or she is. 3. The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his or her feelings completely. 4. The therapist is alert to recognize the feelings the child is expressing and reflects those feelings back in such a manner that the child gains insight into his or her behaviour. 5. The therapist maintains a deep respect for the child's ability to solve bis or her own problems if given an opportunity to do so. The responsibility to make choices and to institute change is the child's. 6. The therapist does not attempt to direct the child's actions or conversation in any manner. The child leads the way, the therapist follows. 7. The therapist does not attempt to hurry the therapy along. It is a gradual process and must be recognized as such by the therapist. 8. The therapist only establishes those limitations necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship (1969, p.73-74). The two main approaches to play therapy are directive and non-directive. The basic difference between them lies in the role of the therapist. In contrast to the directive approach to play therapy which involves the therapist taking control over the design of the activities, the selection of play medium and the creation of rules, non-directive play therapy emphasizes the innate healing process of play whereby the therapist observes the child in a non-intrusive manner and allows the therapeutic process to progress at a gradual, unhurried pace. The child is accepted without judgment or pressure to change. (DelPo & Frick, 1988). By contrast, directive therapists "structure and create the play situation, attempting to elicit, stimulate, and intrude upon the child's unconscious, hidden processes or overt behaviour by challenging the child's defensive mechanisms and encouraging or leading the child in directions that are seen as beneficial" (Gil, 1991; p. 36). Typically, directive therapies are less dependent on 17 the therapeutic transference and are more symptom-oriented and short-term than are non-directive therapies. Play Therapy Research The healing power of play has been documented by several authors (Allan, 1988; Chan & Leff, 1988; Gil , 1991; In & McDermott, 1976; and Marvasti, 1994) and has been demonstrated as an effective therapeutic approach for a variety of children's problems including decreasing aggressive, acting-out behaviours, improving emotional adjustment in children of divorced parents and those who have been abused and neglected, improving self-concept and reducing separation anxiety. In fact, according to Landreth (1991), play therapy has been found effective for treating children of all diagnostic categories except the profoundly autistic and the out-of-contact schizophrenic. Because of its potential to discover the child's inner world, the use of play as a therapeutic tool has been gaining more recognition. However, the increased popularity in the use of play as a method of treatment has not been reflected in the research. Although the literature reveals an abundance of case studies, anecdotal narratives and theoretical reflections, a search of the literature found few articles reviewing the specific use of play therapy as a treatment modality. White and Aller's (1994) review of twenty-two published articles on the use of play therapy for the treatment of child abuse and neglect found that this literature suffers from a lack of consistent definitions of play therapy, variability in the training of professionals using the technique, insufficient definitions of the role of the play therapist, the use of nonstandardized measures and modes of treatment and a lack of comparative control groups. In general, although the interest in and utilization of play therapy has increased, there is a lack of systematic guidelines describing and evaluating its use as a valid and effective method of intervention. 18 Phillips' (1985) review of the empirical research on process and outcome in play therapy found the literature replete with methodological inadequacies. He suggests that although case study research includes a wealth of supportive clinical results, it is unsubstantiated by well- designed, controlled studies. Phillips suggests that there are five obstacles explaining the lack of research on such a widely used therapeutic medium. The first obstacle to conducting play therapy research is the lack of a conceptual model of how children are helped by or are changed in play therapy. Phillips acknowledges the multitude of theoretical writing by such authors as Virginia Axline, Melanie Klein and others; however, scientific investigations have not been conducted to test hypotheses that would support these theories. Another impediment to the research is the face validity of play therapy. Due to the intrinsic value of play to children, and because it makes intuitive sense to play with children, Phillips believes that play therapy may have entered our "naive psychology" as the appropriate treatment for facilitating constructive change in children without it ever having been properly examined and substantiated. The third obstacle involves past play therapy research. Due to its statistical and technological inadequacies, it appears simplistic and archaic with largely unconvincing findings, and therefore creates minimal enthusiasm for pursuing further research. The fourth obstacle relates to the clinical origins of play therapy. Because the vast majority of researchers have been clinicians whose main objective has been to treat clients and whose ultimate concern has been their well-being, this priority has taken precedence over research. 19 A final obstacle, which Phillips considers to be the most intractable, is the lack of credibility of play. Because play is children's work and is not often taken seriously by society, engagement in play with children for therapeutic intentions engenders cynicism. Play therapists and play therapy researchers must constantly confront the skeptics who dismiss play as something considered trivial and insubstantial in academic circles where research is serious business conducted for the purpose of obtaining a scientific truth. Phillips suggests that what play therapy needs is more systematic research that clearly states its hypotheses within a well-controlled study involving carefully selected subjects, using informative statistics and measuring meaningful outcomes. However, play therapy involves both art and science and does not lend itself to the use of scientific scrutiny using quantitative psychometric tools. In addition, the use of controlled studies involving children who have had a traumatic experience would not be ethical, as the researcher would be denying one group their entitlement to treatment. In Schaefer's (1998) recent review of the play therapy literature, he indicated that Phillips' (1985) recommendations have not been heeded by play therapy researchers and, in fact, seem to have had little impact on the field. He suggests that there continues to be a lack of meaningful research to justify the use of play therapy as the preferred treatment for a wide range of disorders. Schaefer suggests that the survival of play therapy requires ongoing contributions to its scientific base. As well-established play therapy treatments for post traumatic stress disorder, adjustment disorders and non-compliance do exist, they need to be developed into practice guidelines in order that play therapy meets the developing standards and requirements of the health care industry. 20 Difficulties in Child Psychotherapy Research Development arid identification of effective treatment for children experiencing emotional and behavioural difficulties is of critical importance to mental health professionals. According to Kazdin (1991), 12-17% of American youth suffer from emotional and behavioural disorders. Due to the range of dysfunctions, the relatively high prevalence rates and societal costs for management and treatment, the need for effective interventions is imperative. His extensive literature review found over 230 psychotherapy techniques used with children and adolescents; however, without a standard of treatment or evaluation it is difficult to predict or to measure the efficacy of a treatment for a particular problem. Unlike adult psychotherapy treatment research, studies on treatment for children and adolescents have not identified a variety of client, therapist and treatment process variables that affect outcome. Variables such as age, sex, influence of peers, and frequency of treatment have been examined; however, only in isolated studies across diverse clinical problems and treatment riiethods. Factors affecting outcome vary according to clinical problem, client age, method of treatment delivery and technique. Challenges of research on child psychotherapy are compounded by special obstacles such as developmental considerations, contextual factors such as influences of social and physical environment, parent and family factors, parent dysfunction and family adversity in which child dysfunction is embedded. There is a tendency in treatment studies to evaluate therapeutic change in relation to dysfunction and to measure outcome as a result of treatment without considering contextual factors that may impact both the course and outcome of treatment. Kazdin (1991) concludes that although research on psychotherapy for children has advanced considerably over 21 the past few years, outcome research requires greater scrutiny of the effectiveness of specific techniques for each problem area. Play of Abused and Neglected Children One area of research on play and its therapeutic use that has been extensively investigated is the characteristics of abused and neglected children's play behaviours. Researchers from various theoretical orientations including behavioural, psychodynamic, neurological, cognitive, developmental and family systems have investigated this domain and several authors have begun to identify specific behavioural and thematic manifestations in the play of abused and neglected children (Fagot, Hagen, Youngblade & Potter, 1989; Harper, 1991; In & McDermott, 1976; and Terr, 1981/1990). According to White & Allers (1994), seven characteristic play behaviours of maltreated children have been identified. They include developmental immaturity, opposition and aggression, withdrawal and passivity, self-deprecation and self-destruction, hypervigilance, sexuality and dissociation. With respect to developmental immaturity, children have demonstrated developmental delays in play, cognition and language which may impair play development and normal maturation. The experience of child abuse may result in either a loss of recently acquired skills or a failure to learn developmentally appropriate behaviours. In and McDermott's (1976) study of a severely abused child found that due to the child's limited cognition, she was unable to integrate and make sense of the abusive experience which resulted in disturbed and arrested behaviour. Through play therapy the child had the opportunity to recreate her life experiences, to gain mastery and control over them and to demonstrate more age-appropriate play. 22 Oppositional and aggressive behaviour results from the child's action-oriented method of coping with stress including a low tolerance for frustration, using physical aggression, exhibiting hostility and abusing others during play. In comparison to the neglected child who may demonstrate minimal or emotionally impoverished interpersonal interactions, the physically or sexually abused child may act out her identification with the aggressor. For example, Fagot et al (1989) observed 36 preschoolers engaged in free play and found that the peer interactions in both the physically and sexually abused groups of children were significantly more aggressive than those in the control group. Withdrawal behaviours of abused and neglected children have also been evidenced in novel or stressful situations. Fagot et al (1989) found that physically abused children played more passively and were generally noninteractive. Although sexually abused children were passive, they were more interactive when approached by an adult. They were highly compliant to the adult's requests and directions. Harper (1991) also found sexually abused children to be generally compliant and to settle easily to their task. These children were responsive to the researcher, engaged him or her in verbal exchanges, asked for approval and involvement in their play and offered narratives about their worlds. With respect to self-deprecating and self-destructive behaviour, researchers have reported low self-esteem and documented comments from abused and neglected children describing themselves as bad and incapable (White & Allers, 1994). Maltreated children often blame themselves for the abuse and internalize parental messages that they are defective or not good. Sexually abused girls may refer to themselves as being ugly and boys may refer to themselves as being weak. The parent's own self-destructive feelings may be enacted through the child's 23 behaviours. In extreme cases, these self-deprecating beliefs and role models may lead to internalized anger and result in self-destructive behaviour. Hypervigilance and heightened alertness were manifested in the wariness of external danger evidenced in the play of physically abused children according to White and Alters' review. These behaviours result from a fear of being punished and may hinder their ability to freely play and explore their environment. In contrast, hypervigilant behaviour from sexually abused children may result from their anticipation of subtle, coercive sexual interactions with others. This behaviour may also result from the overly heightened level of fear and anxiety typical of sexually abused children. Unlike their abused counterparts, neglected children do not exhibit hypervigilant behaviour to the same degree as do physically and sexually abused children (White & Allers, 1994). Sexually inappropriate behaviour of sexually abused children clearly distinguishes their play from that of physically abused or neglected children. They may have a highly sexualized image of themselves or others and may assume that any contact with adults will be sexual in nature. These children may exhibit sexualized behaviour through their communication with others or during solitary play while assuming either the role of the aggressor or the victim. They may masturbate, expose their genitals, demonstrate excessive sexual curiosity, and stimulate themselves with toys or other play materials. Although sexualized behaviours are not typical of physically abused or neglected children, sexual exploration by adolescents who demonstrate developmental^ immature or aggressive behaviour may appear sexually inappropriate. Dissociation has been noted in sexually abused children as an attempt to deny or avoid their painful experience. According to Harper (1991), the dissociative child may appear to be in a world of her own, oblivious to the presence of others, self-absorbed and hypnotic. During novel or stressful play the child may appear to be in a dream-like state, shut off from her immediate surroundings and oblivious to external stimuli. Although not as well-documented, White and Allers (1994) have observed physically abused and neglected children engaged in dissociative behaviour. General play themes have also been noted in physically and sexually abused children which may help in the identification and comprehension of their trauma. Unlike the play behaviours described above, these recurrent patterns of interaction surface over time. The two themes identified are: (a) unimaginative and literal play and (b) repetition and compulsion (White & Allers, 1994). The play of abused and neglected children in Harper's (1991) study was found to be far less imaginative, elaborate or creative than that of non-abused children. Abused children appear to lack the ability to play freely, laugh and enjoy themselves. They may move from one toy to another in a haphazard and impulsive manner, unable to explore their environment in a spontaneous and uninhibited fashion. Harper found that physically abused children had great difficulty organizing their play and settling down to complete an activity and that sexually abused children's play was secure, ordered, contained and absent of fantasy. In addition to the two themes found in White & Allers (1994) review of the literature, Harper (1991) found that the Lowenfeld world play of 40 physically and sexually abused children between the ages of 3 and 9 demonstrated (a) conflict and chaos and (b) a need for protection. Most of the sand tray worlds of the physically abused children depicted wars, destructive scenes and sudden disasters. The children who were both sexually and physically abused created worlds which began as an adventure and ended in disaster. Although these disastrous scenes often involved losses, they were played out without affect. The worlds created by sexually abused 25 children depicted themes of the need for protection. Their worlds were often closed with fences, and the narratives focused on how parents should keep their children from harm. According to Harper (1991), the different thematic play behaviours represented in her study may result from conditions specific to the different forms of abuse. For instance, the physically abused child's world is usually chaotic, disorganized, threatening and dangerous. Such violence and disorganization give rise to confusion, which leads to minimal frustration tolerance and a need for instant gratification. According to this author, cause and effect need to be immediately associated because anything beyond the present has little reality. People are viewed as dangerous or threatening and are in no way related to pleasure or satisfaction. These children have difficulty experiencing enjoyment or expressing gratitude. As a result they tend to demonstrate acting out behaviour, restlessness, disorganized play, an inability to engage socially, verbal provocativeness and behaviours which are likely to provoke negative responses. According to observers in Harper's study, the physically abused children were unable to project themselves into play. The experiences of sexually abused children appear to be more diverse with respect to environmental circumstances; and therefore, there is more variance in their interpretation of the abuse. Sexually abused children seem to have the ability to seek gratification from their interpersonal environments and their play is more integrated, organized, and interactive than that of physically abused children. Sexually abused children were found to be more passive in the Harper (1991) study, and were not more negative or antisocial than the controls as was expected. According to Fagot et al (1989), because abused-neglected children show clearer signs of disturbance as evidenced by their disruptive, aggressive and antisocial behaviour, they are more likely to be identified as problems and receive treatment than are the more quiet and passive sexually abused children. In addition, despite their generally compliant and well-organized 26 behaviour, sexually abused children generated uneasiness in Harper (1991). She suggests that while on the surface they appear well-adjusted, that on some level there is an underlying pervasive emotional disturbance which may not become apparent until triggered by a developmental crisis such as puberty, marriage, or childbirth. The abused child's limited use of imaginative or creative play may result from his or her need to operate in an adult-like fashion in order to survive in a chaotic and threatening environment. It may also result from a generally greater degree of depressed affect found in abused children (Hazzard, Celano, Gould, Lawry & Webb, 1995; Stern, Lynch, Oates, O'Toole & Cooney, 1995). Harper (1991) suggests that the absence of fantasy in the play of sexually abused children demonstrates their need to operate in the present. Projection into fantasy may be too threatening due to the imminent dangers in the present. The child must direct all of his or her effort toward repetition of the present until it is satisfactorily mastered. Terr (1981/1990) also found the play of abused children to be repetitive and compulsive. Children who had been physically or sexually traumatized engaged in rigid, repetitive play, unconsciously acting out the trauma they had experienced. Terr has found this play to be accompanied by high anxiety levels which may be transmitted to others involved in the play. Post-traumatic play usually appears odd or out of place in the child's immediate environment. Compared to ordinary child's play, it is obsessively repeated, does not stop easily and may not change much over time. According to Terr, it can go on for years as the child re-enacts parts of the trauma. This type of play does very little to relieve anxiety and in fact can be dangerous and may create more terror than was consciously present when the game started. Terr (1990), in her book Too Scared to Cry describes many incidents of traumatic play evidenced by the children involved in the Cowchilla, California bus kidnapping of 1976. Much of 27 her research has been based on the traumatic effects of the kidnapping experience on these 26 children, most of whom engaged in some form of traumatic play. Terr found that this play was often a literal account of the experience, recreating the child's trauma as well as his or her compensatory wishes. An example of the post-traumatic play of one of the survivors of the bus kidnapping was evidenced in the play of "Mary", a five year old. Her traumatic experience of being buried alive in a man-made cavern dug beneath a rock quarry by the kidnappers was recreated using her Barbie as she repeatedly buried her in a hole in her grandmother's backyard. Mary's traumatic play continued for four years. Even when she moved to a different town, the play continued as Barbie was repeatedly strangled and suffocated by Mary, who, because of her parent's reluctance to seek treatment for her, had not resolved the traumatic impact of her own experience of being buried, abandoned and suffocated in a dark hole. Play of Adjusted and Maladjusted Children Most of the published play therapy research has grouped children into one of two broad categories of functioning: maladjusted or adjusted. The play of adjusted and maladjusted children as described by Moustakas (1955) differs in several areas. Whereas adjusted children were conversational and prone to discuss their world as it exists for them, maladjusted children would either remain completely silent or ask continuous questions during the first few sessions. Adjusted children were free and spontaneous in their play whereas maladjusted children were cautious and deliberate. Maladjusted children examined few toys, played in a confined area and preferred to be told what to do in the playroom whereas adjusted children explored the room more freely and independently. 28 In addition, adjusted children were more able to express their problems openly, whereas maladjusted children were more likely to use symbolical means of expression such as paints, clay, sand and water. Aggression also differed between these two groups of children; maladjusted children were more likely to be destructive both toward the toys and the therapist. Adjusted children tended to express aggression in non-destructive ways and to accept responsibility for their actions. In addition, maladjusted children were more serious and intense in their feelings about themselves, the therapist or their play than were adjusted children. Moustakas concluded that all children, regardless of the quality of their adjustment, express similar types of negative attitudes. The difference between these two groups of children lies primarily in the quantity and intensity of negative attitudes rather than in the type. Adjusted children expressed negative attitudes less often and with more focus and direction whereas the negative attitudes of maladjusted children were expressed frequently and intensely with less focus and direction. In Howe and Silvern's (1981) study, they identified differences in the play therapy behaviours of aggressive, withdrawn and well-adjusted children based on the Play Therapy Observation Instrument (PTOI) categories of (a) emotional discomfort, (b) competence in relationship to people and things, (c) use of maladaptive coping strategies and (d) use of fantasy play to express personal issues. Aggressive children presented frequent play disruptions, conflicted play, self-disclosing statements, high levels of fantasy play and aggressive behaviour toward the therapist and the toys. Withdrawn boys were identified by their regression in response to anxiety, bizarre play, rejection of the therapist's intervention, and dysphoric content in play. Well-adjusted children exhibited less emotional discomfort, less social inadequacy, and less fantasy play. 29 Perry (1988), using the PTOI, studied the play of 15 adjusted and 15 maladjusted five to ten year olds during the initial 36 minutes of a play therapy session. This researcher used three scales of the PTOI: emotional discomfort, social inadequacy and use of fantasy. The play behaviours on the emotional discomfort scale were found to discriminate maladjusted and adjusted children. Maladjusted children's play expressed significantly more dysphoric feelings, conflictual themes, play disruptions and negative self-disclosing statements than did the adjusted children's play. The maladjusted children also spent more time feeling angry, sad, fearful, unhappy, and anxious than did their cohorts. Maladjusted children talked and played out their problems and conflicts during more of the play session than did the adjusted children. There were no significant differences between the two groups' play behaviours as measured on the social inadequacy and use of fantasy play scales of the PTOI. Psychotherapy Process Research Research suggests that psychotherapy produces positive effects of respectable magnitude; however, the empirical study of the process by which this occurs is a young discipline spanning only the last few decades. In the early years of process research, the practitioner relied on theoretical assumptions, clinical wisdom, and impressions to guide and evaluate treatment; however, these practices became the object of skepticism from the academic world. Beutler's (1990) review of psychotherapy research found that the split between clinical process researchers and empirical outcome researchers may be one of the reasons that psychotherapy research continues to be slow to find acceptance in clinical practice. It appears that, in the past, empirical researchers became disinterested in the issues and methods that could be of benefit to clinicians. As instruments for measuring the constructs of client-centered therapy, and later, as the key processes of psychotherapeutic "experiencing" were developed, the demystification of 30 psychotherapy ensued as academics began to investigate these processes empirically. With the movement of process researchers into the academic arena, it has become increasingly more difficult to distinguish between process and outcome research activities. A breadth of opinions about the processes to study which range from theory-based principles to descriptive definitions of behaviour characterize this field (Beutler, 1990). According to Marmar (1990), there is currently a growing international effort in psychotherapy research to identify change processes that have an impact on outcome. Recent reviews underscore the importance of the therapist/client relationship, client experience and related variables between client and therapist in predicting the course of psychotherapy. Furthermore, Marmar suggests that patterns rather than frequency counts should be the target of study as they take into consideration individual client differences, phase of therapy, emotional state, related external difficulties and client capacity for acceptance and absorption of the process. If simple frequency counts of behaviours are conducted independent of client characteristics, meaningful relationships are obscured and subtle change nuances are excluded or overlooked. According to Mannar, identification of critical events as recurring patterns will increase the likelihood of a comprehensive reconstruction of the treatment process. In Hill's (1990) review of exploratory in-session process research, she suggests that with the lack of proven outcome differences among approaches in psychotherapy, using exploratory research, which is not aligned with any particular clinical theory and instead invites the explanation of findings from many different theories and perspectives, makes sense. She concludes that exploratory methods of research would be useful for detennining such therapeutic processes as the links between client personality characteristics, therapy process, and outcome; 31 the timing and quality of therapist interventions; and client readiness for the therapist interventions. Play Therapy Process Research Several researchers and clinicians have proposed a number of theories regarding the process of emotional expression, progression of characteristic patterns of play and changes in the therapeutic relationship within play therapy sessions. The child's experiences and experimentations within the play therapy environment are often manifested in identifiable stages of process and change. Stages in the play therapy process are the result of shared interactions between the therapist and the child, experienced in an unconditionally accepting, non-evaluative play environment, facilitated by the genuineness and caring nature of the therapist. The child experiences permission to try out different ways of being and his unique nature and individuality is both accepted and appreciated. Moustakas' (1955) analysis of case studies of disturbed children in play therapy found that children progress through the following five identifiable stages: (1) intense diffuse negative feelings, expressed everywhere in the child's play; as accepted, become less intense and more focused (2) ambivalent feelings, generally anxious or hostile; severe in intensity at first, and as expressed become less strong (3) direct negative feelings of fear or hostility expressed toward parents, siblings, and others, or in specific forms of regression (4) positive and negative feelings expressed, may still be ambivalent (5) clear, distinct, separate, usually realistic positive and negative attitudes, with positive attitudes predominating in the child's play, (p.84) According to Moustakas, consistent patterns were more clearly observable with disturbed than with normal children. The premise on which his findings are based is that in play therapy, a child goes through a sequence of emotional growth that corresponds to the normal emotional development of early 32 childhood. As the therapy progressed, Moustakas found that diffuse feelings were replaced by more specific feelings of confidence and courage which continued to vacillate with feelings and attitudes of doubt and inadequacy as the children neared termination of therapy. According to this researcher, whether the disturbed children experienced anger, anxiety or other negative attitudes, they all followed this process. Through the interpersonal relationship with the therapist the child is able to explore and express his or her emotional reactions, and through this process achieves a greater level of emotional maturity. Hendricks (1971) conducted a very comprehensive study of the process of play therapy of ten, eight to ten year old boys of average intelligence who had emotional or social adjustment problems. As the therapy progressed across 24 sessions, she discovered the following four major patterns of play: (1) expressed curiosity, engaged in exploratory, noncommittal, and creative play; made simple descriptive and informative comments, volunteered information about self and family, expressed happiness, if regression and anxiety were to appear it occurred during the beginning sessions (2) exploratory and noncommittal play decreased, creative play became the major activity, generalized aggressive play increased, verbal comments made about play and play room, information about self and family increased, expressions of happiness and anxiety continued, spontaneous reactions were evident (3) feelings of anger, frustration and anxiety began to be focused on specific concerns as evidenced in play activities and verbal comments, creative play yielded to dramatic and role play (4) increased interest in establishing an interpersonal relationship with the therapist, verbal comments and incidental play increased. From Phillips (1985) review of play therapy research, he concluded that the process of play therapy is manifested in the following four stages: (1) tentative verbal expression, cautious exploration of the playroom and therapist, verbalizations are informational or descriptive and if feelings are revealed they reflect ambivalence and anxiety (2) increase in energy and activity, negative in nature; more feelings are revealed but not necessarily verbally 33 (3) more engagement with the therapist, often concerning the child's negative feelings about other (4) more noncommittal activities as if the child were signaling a need to move away from the therapeutic relationship, increase in anxiety as termination approaches From case reviews of his clinical work with children, Landreth (1991) outlined three patterns of behaviour revealed in play therapy: (1) exploratory, noncommittal and creative play (2) aggressive play with verbalizations about self and family (3) dramatic play, relationship movement towards the therapist, and expressions of anxiety, anger, and frustration Finally, Goetze (1994) describes the play therapy relationship as moving from alienation to closeness in a four-stage process: (1) non-personal - personal distance, coolness, unpleasant feelings, use of stereotypes and labels; little emotional warmth, empathy and congruence communicated by the therapist as child and therapist are not well acquainted. There is a strong wish to leave this impersonal stage. (2) non-directive - characterized by Axline's (1969) eight basic principles of play therapy. The main goals in this stage are to get to know each other by direct experiences, to learn to accept the child unconditionally, and to develop a sense of how to interact within the space of freedom to express personal needs. (3) client-centred - more firmly established relationship, more knowledge about the unfulfilled needs and unresolved problems of the client, and a growing importance for information about external functioning ensues. (4) person-centred - signifies the therapist's role as more of a partner in play, reflection of feelings becomes less essential, and the therapeutic tasks become the integration of the therapy experiences into real life and the termination of therapy. Goetze (1994) indicates that although this model may seem consistent, logical and socially valid, empirical data to support its concepts are still missing. To conclude, several researchers suggest a variety of different stages in the play therapy process (Moustakas, 1955; Hendricks, 1971; Phillips, 1985; Landreth, 1991) and as indicated, all are different from one another making it difficult to discern a consistent therapeutic process of play. In addition, the results of several studies (Howe & Silvern, 1981; Perry, 1988; Terr, 1990; 34 Harper, 1991; White & Allers, 1994) indicate that children's quality of experience has a differential psychological effect on their degree of emotional adjustment which is manifested in their play and the ways in which they interact with their environment. In response to the gaps in the research on the process of play therapy, this study will identify the effects of an eight-year-old girl's experience of separation, loss and neglect, the ways in which they were presented thematically, and the process by which they transformed across 20 play therapy sessions. 35 CHAPTER IH METHODOLOGY Exploratory Research This study was conducted using a discovery-oriented approach which Hill (1990) considers to follow the true spirit of the scientific method. Exploratory or discovery-oriented research describes what occurs within psychotherapy from a nontheoretical stance. Typically, scales or categories used to code behaviour or to describe experience of participants are developed. A n attitude of openness is maintained by the researcher in order to learn about the process. The ultimate goal is the development of theory based on findings. The typical procedure is the observation of a clinical phenomenon, hypothesis formulation and testing, refinement of the hypotheses, replication of the results and finally, development of theory. Participant Observation Because of the complexity of each case and the desire to capture the subtleties of human behaviour, the role of researcher as participant-observer in this study was imperative to gaining a deeper, albeit subjective perspective and understanding of the individual. Participant observation is a means of collecting data based on a two-fold function of the researcher. He or she becomes a participant in the actual context or process under study and an observer of those processes. Through participation as therapist, the researcher can focus on the process and not simply the means or the ends to behaviour (Bogdan & Biklen, 1982). As both the play therapist and participant-observer in this study, I participated directly in the play therapy and observed the child throughout the sessions. As participant-observer, my role fluctuated along a continuum of involvement. At one end of the continuum is the detached and distanced observer. At the other end is the complete 36 participant whose position is analogous to the participant in the study (Bogdan & Biklen, 1982). Throughout this study, I endeavoured to find an ideal position along this continuum whereby the communication between researcher and participant was enhanced, and the complete subjectivity of the research was reduced. My role and function of the researcher/play therapist in this study shifted from participation in the data collection phase as the nondirective play therapist, to observer of the data recordings of videotapes, to recorder of reflections, questions or perceptions in the field notebook. Case Study The case study is a process of research which describes and analyzes an event, an individual, or a setting in qualitative, complex and comprehensive terms as it unfolds over time. The descriptions of real life events and explanatory or analytic commentaries based on these descriptions enable the researcher to obtain deeper meaning of the object of inquiry (Wilson, 1979). According to Stake (1994), contemporary psychology's reliance on comparative, quantitative research has resulted in a negative bias toward the study of the individual. However, according to this author, what is found in one may be true in many. "The purpose of case study is not to represent the world, but to represent the case" (p. 245). "The qualitative case study is characterized by the main researcher spending substantial time on site, personally in contact with activities and operations of the case, observing, recording, interpreting, reflecting, verifying and reinterpreting meaning" (Stake, 1994, p. 242). The capability of the case study to examine events across time is an important advantage of this research method and was, therefore, chosen for this study due to its emphasis on the study of a process over a period of time (Stake, 1995). Through the case study method, the researcher 37 may emphasize episodes of nuance followed sequentially toward a holistic account of the therapeutic process of play therapy. Another strength of this method of inquiry is its ability to deal with the intertwined complexity of details in human life. Case studies, with their intensive focus on the individual, are ideally suited as a means of analyzing a particular event in pursuit of a small aspect of the case which may modify or illumine the existing understanding of cases in general. Case studies offer an understanding of a particular case but enable extension of this experience to increase the conviction in that which is known (Stake, 1995). The case study is an appropriate method when the research question asks "how" or "why", and when the researcher has little control over the behavioural events, as in the present study (Yin, 1984). This method contrasts with both the experimental design which requires direct control over the events, and the survey approach which is concerned with the frequency or the incidence of events. The impetus for choosing a case study design was based on the desire to capture two elements which may not have been accessible by any other method: the intricate qualities of human nature and the study of a condition over time. The following quotation by Stake (1995) captures the essence of this method: The real business of case study is particularization, not generalization. We take a particular case and come to know it well, not primarily as to how it is different from others but what it is, what it does. There is emphasis on uniqueness, and that implies knowledge of others that the case is different from, but the first emphasis is on understanding the case itself, (p. 8) The emphasis in this study is on the understanding of the case for its uniqueness and particularities in its entirety as well as the patterns of change observed over time. Evidence of general patterns and changes in the presentation of this case may lead to enhanced knowledge or 38 the generation of hypotheses regarding subsequent cases. Although it is not appropriate to draw general conclusions, it is possible to highlight findings and compare them to the play therapy literature. Participant Three children referred for treatment to the community mental health agency where the study was conducted met the criteria which included an age requirement of between four and nine years and no previous experience of play therapy. Parents were informed that the researcher wished to study the play behaviour of children who had been referred to the agency for play therapy and that the study would proceed for the duration of time the researcher needed to complete her practicum at the agency. The child, "Christina", who participated in this study was referred by her father for play therapy and was the only child given permission to participate. Written permission was obtained from her father for her full participation in the study including play therapy, obtaining historical information, videotaping the play therapy sessions and completing the Child Behavior Checklist (Achenbach, 1991a). Christina's father was informed that the videotapes would be viewed by myself, my supervisor at the agency, and by my research committee. Christina was informed that we would be playing together weekly and that she was free to play with any toys or materials as she wished. I explained to her that in order to help me learn and remember what she said or did during the play therapy, I wanted to record our time together on video tape. I also told her I needed to complete a project that I would write up and hand in to my teachers at the university that would describe some of the ways in which she played in the room and the items with which she chose to play. Christina consented verbally to be included in my study. I told her that her 39 name would be changed in order that what happened in this room would remain private. A more complete description of the participant is included in the results section of this study. Ethical Considerations In accordance with university ethics regulations for research with human participants, a synopsis of the research and methods was submitted to the U B C Behavioural Sciences Screening Committee for Research and other Studies Involving Human Subjects. Prior to the commencement of the play therapy sessions, approval was received from both U B C and from the Director of Planning and Evaluation at the agency where the therapy took place. Informed consent for participation in the study was secured in writing from the child's parent. A copy of the letter to parents describing the research objectives and the form for parental consent can be found in Appendix A . Play Therapy Environment and Materials According to Cattanach (1992), an optimum play therapy environment must include the following: • A safe place for the child, which the child recognizes as a play space. • Play materials which facilitate embodiment, projective and symbolic play. • A therapist capable of providing an empathic relationship with the child, which means that she is able to be the adult who listens, acknowledges and stays with the feelings of the child. The therapist can offer these skills to the child without intruding on the child's own creativity, (p. 53) The selection of the play space, toys and other play materials is integral to the development of the therapeutic process of play. The room itself must convey the message of being a warm, friendly and safe place for children. The selection of toys requires some thought and effort to ensure that they will provide a variety in choice and a medium through which the child can express feelings, explore relationships and understand self. The toys should be durable 40 enough to withstand aggressive play and appropriate to the developmental level of the child. As play is the child's language, the toys become the words through which they express themselves. Therefore, the selection of toys needs to be based on the desire to facilitate expression and communication (Landreth, 1991). The play therapy room used in this study was located in an urban community mental health agency that provided assessment and counselling services to adults, families and children of all ages experiencing mental health illnesses or other developmental, relationship or intrapsychic difficulties. This 8 by 10 foot room was the only child-oriented space in the large office. The room was designed specifically for play therapy and contained built in cupboards for storage of art materials, games, and seasonal items as well as a double sink. The walls were a neutral colour and two thirds of the floor had blue indoor/outdoor carpet and the other third was covered with linoleum. The room contained six activity centers: (a) an art center with a variety of art materials and a small table and two chairs, (b) a sand tray with a low shelving unit containing a variety of symbolic miniature animals, people and vehicles (c) a wooden doll house containing a variety of furniture and people (d) dress up clothes, shoes, hats and jewellry (e) a shelf with a variety of puppets, books, medical equipment, and doll clothes, and (f) a home centre containing dolls, a doll-sized play pen and a child-sized stove and microwave unit containing pots, dishes, utensils and play food. Appropriate toys for play therapy can be grouped into three broad categories: real-life toys, aggressive toys and expressive and creative toys (Landreth, 1991; Muro & Kottman, 1995). The play materials used in this study comprised toys from each of these categories. Some of the real-life toys included were a doll family and doll house; dishes, pots, pans and utensils; puppets 41 and toy figures which could represent family members; a telephone and transportation toys such as cars, trucks and boats. The aggressive toys provide the child with a socially appropriate means of expressing aggression symbolically through inanimate objects. Some of these items included toy soldiers, a plastic knife, plastic swords and puppets representing aggressive animals. Other items in this category which facilitated the enactment of fearful situations included toys such as monsters, spiders, and snakes. Clay also fit within this category as it can be used for pounding, smashing, tearing or cutting as a means of venting aggressive feelings. The final category of creative and expressive materials includes toys that encourage the expression of creativity, imagination and emotion. Some creative items used in this study included sand and water, play dough, paints, crayons, and markers. In addition, pretend toys such as dress-up clothes and shoes, purses, masks, and jewellry provided disguises and a means of taking on another role. Research Process Play Therapy Christina received weekly child-centred play therapy from the researcher/play therapist. The play therapy sessions were between 45 and 55 minutes in length and were conducted over a six month period, resulting in twenty sessions. Each session was video-taped to facilitate the collection of subtle behavioural and language displays by the child. Case notes Observational notes regarding the themes demonstrated during the sessions as well as any unusual or unique thoughts or feelings which arose in me during the session were recorded. A narrative description of each session was also included in my case notes following each session. 42 Discussions with Father and School Counsellor Christina's father was consulted on an ongoing basis regarding any progressive or regressive changes in her behaviour at home and her school counsellor was consulted on three occasions for information regarding her level of social and emotional adjustment at school. Both of these sets of anecdotal reports by Christina's father and school counsellor were recorded in my case notes. These pieces of external information provided a more holistic understanding of Christina's progress as change was tracked both in therapy and in her home and school environments across the six month period. Field Journal A field journal (Krefting, 1991) containing questions, problems and frustrations regarding the overall research process as well as reflections of my thoughts, feelings, ideas, and hypotheses generated through review of the videotapes was also part of the process and has become part of the written narrative. Child Behavior Checklist Christina's father completed the parent report form of the Child Behavior Checklist (CBCL - P/4-18); (Achenbach, 1991a) for children aged 4 to 18 at the beginning of the study and again upon completion of the play therapy. The C B C L was chosen for this study due to its popularity as one of the most frequently used descriptive tools by child psychopathology researchers. It has good reliability and validity and has been proven a competent standardized measure of the behavioural problems and abilities of children by their parents or others who know them well (Christenson, 1992). This tool measures both internalizing and externalizing behaviours as well as the child's level of social competence. 43 House-Tree-Person Drawings Christina was requested to draw House-Tree-Person (H-T-P)(Buck, 1948) drawings on three occasions during therapy. The drawing sessions took place at the mental health clinic during the second and eleventh play therapy sessions, and again during termination. The drawings were completed in the play therapy room where the environment was free from distraction. Christina was requested to first draw a house, then a tree, then a person. I assured her that artistic ability was not important and that there were no rules and therefore, no right or wrong way of drawing. I informed her that pictures children draw sometimes tell a story, and that I was interested in hearing about her drawing through a series of questions she would answer upon completion of her pictures. Christina was provided with blank paper and a pencil with which to draw so as not to distract from the projective process. During the question period, she coloured her pictures while answering the questions. According to Buck, the house, tree and person drawings are a particularly informative way of providing information about the child's inner world both pictorially and verbally. This projective technique has been used extensively as an application to personality and intellectual assessment. Buck developed the technique that was later revised by Buck and Hammer (1969). As houses, trees and persons are significant influences in a child's life, Buck (1948) and D i Leo (1983) suggest these drawings are representative of the child's perceptions of the foundation of his or her world. According to D i Leo (1983), Thompson and Allan (1987), and Wohl and Kaufman (1985), a house represents the child's environment, his or her family relationships, where he or she seeks affection and security, and the degree to which the child receives protection. The tree is representative of growth and, according to Thompson and Allan symbolizes the emotional realm of the child. The person is considered an expression of the self and of the integration of the 44 personality. Buck proposes that drawings of people disclose how the child feels physically and emotionally at the moment, what he or she would like to be, and the general attitude toward interpersonal relationships. Due to the projective nature of these drawings, they can reveal more intimate details about the child's inner world than she or he would be able to express verbally. Although the reliability and validity of projective drawing instruments have been questioned, they have been used widely by clinical psychologists, educational psychologists, social workers, art therapists and other professionals as a preliminary assessment tool (Hagood, 1992). The drawings in themselves are not sufficient to make a diagnostic decision; however, Hagood suggests they are of diagnostic value in understanding children's fears and anxieties, their view of family and home, and their self-image. The H-T-P drawings were used as a means of developing rapport with Christina and as a tool for providing information about her view of herself and her world at the beginning of play therapy, and for indicating changes to this perception at the midpoint and upon completion of therapy. Triangulation The use of multiple methods and sources of measurement enhanced and clarified the meaning and validity of this study. The process of triangulation "refers to the application of more than one method to the same research issue to broaden the perspective and strengthen the findings of a study" (Krahn, Hohn & Kime 1995, p. 208). The process of gaining information from Christina's father, her school counsellor, and from both the standardized C B C L and the projective drawings helped to verify my perceptions and to clarify the meaning of these perceptions by taking into account information from other sources and the perspectives of others. This process helped to minimize misperceptions and enhance the validity of the findings. 45 Qualitative Data Analysis The analysis of the videotaped data involved a series of stages. First, the videotaped therapy sessions were transcribed verbatim within 3 or 4 days following the therapy in order that the experience was fresh and I was able to record as much of the dialogue, subtle change points, and critical moments as I remembered. Following this initial viewing and transcription, the tapes were viewed again and compared to the transcripts to ensure accuracy of the dialogue and activity of both the participant and myself. A third review of the videos was conducted in order to record the themes, change points and my personal reflections of the meaning of the play content. These theme summaries were recorded on a word processing program along with case notes describing the content of each session. Three video tapes that captured the significant changes in the therapeutic process were chosen and reviewed by my primary research advisor and a colleague studying the same thesis topic and working as a play therapist. Their reflections, observations and views on the themes and change process were incorporated into the analysis. Most of the themes I had tentatively documented were verified by my colleague and advisor. This process served as a means of corroborating my own perceptions and made possible convergent validity of the study. Following meetings with my research assistants, the resulting corroborated themes were grouped into broader categories that depicted the areas of change I wished to track. The transcripts and theme summaries were then colour-coded according to the following categories: play themes and materials, emotional expression, therapeutic relationship, information about self and family, and entering and leaving the playroom. I then began the daunting process of combining the colour-coded groupings into meaningful written form. Critical moments and periods of change were documented within each 46 category in conjunction with verbatim portions of dialogue representing this process. When all of the colour-coded groupings from each of the twenty sessions were documented, I began the process of editing redundant material, resulting in the collapse of five broad categories of change into the final three categories: play themes and materials, emotional expression and therapeutic relationship. The data from information about self and family and entering and leaving the playroom were incorporated into the three final categories as well as the session summaries. Once the final draft was complete, the tapes were again viewed in their entirety to ensure accuracy of the delineation of the phases and categories of the therapy. The results were then re- edited to reflect any changes or omissions that were indicated based on this additional analysis of the tapes. The drawings completed during therapy were viewed and analyzed during the writing phase of the play therapy process, and these results were incorporated in chronological order into the final written draft. The Child Behavior Checklists were hand scored once the results of the play therapy process were complete in order that these quantitative measures did not influence my qualitative analysis of the therapeutic change process. Descriptive statistics based on the results of these measures were then added to both the beginning and the end of the qualitative analysis of the play therapy, to coincide with the points in therapy during which the measures were completed. My reflections regarding the research project and insights related to my data analysis and readings were recorded in my journal throughout my analysis in order to aid in the documentation of this process. Session notes, parent reports and conversations with the school counsellor were also incorporated into my written analysis in order to provide a holistic and chronological account of Christina's change over time. 47 Because the critical issues, areas of study and the theory regarding this exploration were unclear at its inception, this case study evolved as the data was analyzed. As researcher, I set the criteria upon presentation of the information collected, of what needed to be reported in order to most fully represent this particular case. Both corroborating incidents and disconfirming instances were considered as means to better understand the case. Through this process, relationships between incidents were analyzed and interpreted, main issues of concern were probed, and data was structured and assessed categorically in order to better understand the case in its entirety (Stake, 1995). This intrinsic case study does not generalize to other cases but describes the unique qualities of the therapeutic process of play with one child. It captures the unique complexities of the child's therapeutic progression across time using divergent sources of information. The descriptive analysis of data is based on the transcriptions of the video tape recordings of the play therapy sessions, the results of the CBCL-P/4-18, and my interpretations of three sets of H-T-P drawings as well as other drawings, each of which provided unique sources of information. Themes and subtle nuances of meaning were captured through the variety of measurement tools used to describe the child's progression through play therapy. In summary, the completion of this exploratory, inductive study involved reflecting on the data collected, making tentative interpretations and revising meanings of the process as it unfolded. This case is described in descriptive finite narrative in sufficient detail so that readers can gain vicarious experience of the events and arrive at their own interpretations and conclusions. 48 CHAPTER IV RESULTS Overview "Christina" was an eight year old, female white girl from a low income family of British descent. She lived with her father, Bill and seventeen year old half-sister, Susan in the basement suite of a rental house. Christina, who had attended the same school since Kindergarten, was in grade three and also went to daycare after school. Christina had been seen by her school counsellor on a few occasions during family crisis situations and during the course of play therapy was involved in weekly group counselling at school with other children her age whose parents had separated or divorced. Christina was referred by her father due to his concerns that she was suffering the loss of her mother who was currently unavailable to her due to her drug addiction and subsequent unstable lifestyle. Her father reported that Christina was often tearful when her mother did not show up for visits or left unexpectedly and projected her anger regarding her mother's unavailability toward her father through physical and verbal aggression, tantrumming and tearful and angry outbursts. Her father was concerned about the impact of the disruptions in her family and wished for Christina to have play therapy to help her express her feelings of hurt, anger, loss and rejection. Family History and Concerns Christina's father, Bil l and mother, Lisa were married until she was two years old. When her parents separated Christina lived with her mother and step-sister, Susan until she was five at which time her father took her to live with him due to her mother's use of cocaine and heroin and lack of consistent caregiving. Christina's contact with her mother then became increasingly 49 inconsistent due to Lisa's continued drug use. Christina apparently had no pre-natal exposure to drugs, however had observed her mother using drugs, was exposed to her unstable and erratic behaviour, and on two occasions, had witnessed her mother's arrest. Bill also had a history of drug and alcohol abuse but had been "clean" from cocaine for three years other than a short relapse the year prior to Christina's referral. Bil l had been involved with A A for thirteen years and reported that he was no longer drinking. Christina's father was employed full-time as a hair-dresser at two different salons. Lisa's employment history was sporadic due to her drug habit; however, when not using drugs, she would occasionally work on an on-call basis helping to set up equipment for concerts. Because her addiction resulted in the creation of a destructive and chaotic lifestyle, Christina's mother was often dependent on her ex-husband for support and protection. According to Bil l , Lisa occasionally stayed with him and Christina. However, she often disappeared unexpectedly during the night and then would not contact Christina for weeks at a time. Bi l l had difficulty setting boundaries around the nature of her visits and often assumed the role of Lisa's caregiver, causing additional stress to himself and confusion to Christina. Understandably, Christina had difficulty dealing with the unpredictability of her mother's presence in her life, as well as the nature of her mother and father's relationship. Several times throughout therapy I stressed the importance of structuring consistent visitation between Christina and her mom in order to reduce the emotional turmoil it caused her. Christina tended to protect her mother and was unable to accept the lack of her mother's presence in her life. Bill attempted to explain her mother's absence to her but struggled with the degree to which he should inform her about the nature of Lisa's lifestyle. In general, he was honest with Christina and attempted to remain hopeful that someday she and her mother would 50 have a more consistent relationship; however, was realistic about the degree to which Lisa would ever be available to Christina. Lisa's seventeen year old daughter, Susan, who moved in with Bil l and Christina just prior to commencing therapy, also had a history of heavy drug use. During the course of Christina's therapy, Susan was struggling to stay off drugs and was also in and out of their home. Susan's lifestyle and inconsistency in Christina's life also confounded the impact of her mother's absence. Bill reported frequent discord between himself, Susan and Lisa which caused Christina a great deal of distress. Bil l and Christina had a good relationship with his sixteen year old daughter, Brianne, from his first marriage. Brianne lived with her mother, Mary and her half-brother Ken. Mary occasionally cared for Christina when her father was at work and daycare was not available. In some respects, Mary acted as a surrogate mother to Christina and on occasion, looked after her, took her to appointments and attended school events when Christina's own mother was not available. Christina occasionally spent weekends with her maternal uncle and aunt and her three year old cousin when her father had to work. It appeared that this extended family was a stabilizing influence on Christina. Christina had minimal contact with her paternal grandparents who moved to Vancouver from the East six to eight months prior to the commencement of therapy. Bil l reported that he grew up with a high level of dysfunction in his own family and wished for Christina to have a more functional family experience than himself. His contact with his parents continued to be somewhat strained and as a result, he and Christina did not see them as often as his parents would have liked. Christina's maternal grandparents lived out of the province and she had limited 51 contact with them; however, a family reunion took place following termination of Christina's therapy. Intake Observations Christina was seen with her dad in a regular office at the clinic during the intake meeting. She was quite friendly and outgoing but at times became shy and withdrawn when questions were directed at her. She resisted giving a direct answer with regards to questions about her mother but instead would usually offer "I don't know" as a response. Christina remained alert and inquisitive during the adult conversation and the questions her dad was responding to. Towards the end of this initial interview, I took Christina into the playroom to help get her acquainted with the space and the materials. We spent about 20 minutes together during which time Christina drew pictures as she talked about her friends and her experiences at school. She seemed more comfortable with me in the play environment, was enthusiastic about the variety of play materials she found and was eager to play. Christina did not present with a specific psychiatric diagnosis, however, her father reported that on occasion she would say "I wish I was dead". Christina received learning assistance for reading during grade one and two; however, with the extra attention Bil l had given to teaching Christina how to read at home, he reported that she was improving and no longer required extra assistance at school. Child Behavior Checklist The CBCL/4-18 (Achenbach, 1991a) was filled out by Christina's father between the first and second sessions and again at termination between the nineteenth and twentieth sessions. Bil l was simply asked to fill out the form and describe Christina's behaviour as he saw it at that point in time. The C B C L was not part of the regular intake procedure at the clinic where Christina was 52 referred and was only used for the purpose of this study. It was not scored during treatment or used to develop therapeutic goals or interventions. Christina's profiles were scored following my analysis of her therapy in order that this information not bias my own perceptions of her. The first C B C L profile will be described here and the second one at the end of session twenty. The Competence Scales consisting of activities, social and school competencies, assess children's overall social competence. Prior to the C B C L there had been little research to determine which competencies reportable by parents actually discriminate between children who are adapting successfully and those deemed to need help for behaviour/emotional problems. According to Achenbach (1991b) standardized competence items on the C B C L discriminate significantly between children referred for mental health services and nonreferred children. Christina's score on the Activities scale was 3.5 where she was in the 8-9th percentile for her sex and age. These scores put Christina in the low normal range for activities as her dad indicated that she engaged in three sports and three activities at home and her abilities were mostly below average to average. In addition, Christina did not engage in any specific chores at home. Christina's score on the Social scale was 7.0, placing her in the 55th percentile. Christina's score for social competency was above average as her dad indicated that she had many friends at daycare and got along with her siblings and behaved with her parents about average. In addition, Bil l reported that Christina got along with other children and played and worked alone better than the average child her age. Christina's school competency score of 3.5 was only in the 5th percentile putting her in the borderline clinical range. When completing the form Bil l made reference to Christina's need for learning assistance and that her performance in all of her subjects at school was either average or 53 below average. Christina's overall Competence score of 14.0 also put her in the borderline clinical range with a total T score of 38. There are eight syndrome scales on the 1991 C B C L profile: withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behaviour and aggressive behaviour. An additional syndrome is designated as sex problems. Withdrawn, somatic complaints and anxious/depressed are grouped under the heading Internalizing. Delinquent behaviour and aggressive behaviour are grouped under the heading Externalizing. These groupings of syndromes reflect a distinction that has been detected in numerous multivariate analyses of children's behavioural/emotional problems. These two groups of problems have been variously called Personality Problem versus Conduct Problem, Inhibition versus Aggression and Overcontrolled versus Undercontrolled (Achenbach, 1991b). Christina's scores on all problem scales were within the normal range except somatic complaints where her score was 5 which put her in the 95th percentile and the borderline clinical range. Her father indicated that Christina was sometimes overtired, and often complained of aches and pains, stomache aches and growing pains in her legs. Although not in the clinical range, Christina's score in the anxious/depressed category was in the 88th percentile as her father indicated that she sometimes complained of loneliness, felt worthless or inferior, complained that no one loved her, felt too guilty, felt sad, depressed or unhappy and that she often was self- conscious or easily embarrassed. The first three scales: withdrawn, somatic complaints and anxious/depressed comprise the Internalizing group of problems. Christina's score of 14 and her T score of 63 indicated that she was in the borderline clinical range for Internalizing behaviour. The remaining five scales comprise the Externalizing group of problems: social problems, thought problems, attentional 54 problems, delinquent behaviour and aggressive behaviour. Christina's score of 12 and her T score of 57, put her in the high normal range of externalizing behaviours. Overall, Christina's total problem score was 38 which indicated a T score of 60, and put her in the borderline clinical range. Achenbach (1991b) suggests children not be classified as Internalizing or Externalizing unless (a) their total problem score exceeds the clinical cutoff on at least one of the three instruments, and (b) the difference between their Internalizing and Externalizing T score is at least 10 points on one instrument or at least 5 points on two instruments. Therefore, although Christina scored within the borderline clinical range on the Internalizing group of problems, she did not exceed the borderline range and her T scores on the two groupings were only 6 points apart which would not warrant a distinct classification in the Internalizing group. Achenbach indicates that the relationship between Internalizing and Externalzing scores is analogous to the association between verbal and performance IQ scores on intelligence tests. Although Internalizing and Externalizing scores represent contrasting kinds of problems, they are not mutually exclusive. Across groups of children, Internalizing scores typically correlate positively with Externalizing scores because children who have very high scores in one area tend to have at least above-average scores in the other area as well. In summary, Christina's C B C L profile at the beginning of therapy indicated a total competence score in the borderline clinical range and high scores on both the Internalizing and Externalizing groups of problems with the Internalizing group also reaching the borderline clinical range. 55 Tracking the Process of Change During Therapy The process of play therapy across each of twenty sessions is documented with a focus on the following three components of the therapeutic process: (a) play themes and use of play materials, (b) emotional expression, and (c) therapeutic relationship. A final summary outlines the stages and characteristic changes that evolved across the course of the therapy. In the tradition of ethnographic research and qualitative studies and to facilitate the immersion of the reader into the therapeutic process, each play therapy session is described in the present tense from the perspective of the participant-researcher's observations. In addition, relevant discussion of environmental factors and parent comments will also be examined. Such external information is placed in the past tense to coincide with the later temporal context in which this information was obtained. Session One Play Themes and Use of Play Materials Exploration/Connection In this initial session, Christina brings over a variety of miniature animals one by one to the table where I am seated. She uses the toys as relationship building tools as they prompt her initiation of a topic of discussion about their characteristics and she uses them to demonstrate her knowledge and intellectual competency. The toys are used in an effort to connect with me. Sand tray Christina inspects the sand in the sand tray by running her hands through it while asking me some personal questions in an attempt to check me out. The sand seems to serve as a distraction from the intimacy of the conversation as she is able to focus on the sand while avoiding eye contact with me. 56 Burying Christina buries horses in the sand while she talks about her wishes to be with her mom and to have a new baby brother. She tells me with delight that she likes to hide things from her teacher in the sand at school. Christina creates a type of hide and seek game with herself as she closes her eyes and searches in the sand for the horses. She says "I'm going to make sure they're all covered well." I wondered at the time if she was referring to her buried feelings. Separation/Loss Christina stands six horses together in the sand and asks if they are all there. I comment "They're all standing together now in a circle. They've been reunited". Christina then replies "No. They've been this thing" (gestures pulling them apart). She then laughs and finds the missing horse, puts it with the others then pulls them apart and repeats this several times. Interestingly, she ends with seven horses which may represent herself and her family members. This scenario seems to demonstrate what Christina's experience of unpredictable separation and loss is like. Danger/Protection During her sand tray scene a white horse reunites some smaller horses then kicks them all, down. As I comment "The white one stands alone", Christina says "Not for long" and brings in a tiger. The horse overcomes the tiger and then a leopard and stands alone again. Christina then brings in a ship and has the white horse rescue all of the animals. Baby/mother relationship/lack of protection Following the above scene, Christina brings a baby and mommy leopard into the sand tray and a tiger appears and bites both of them. The baby pushes the tiger away and is buried and Christina reports "He's going to fake being dead". The adult tiger and leopard continue the battle 57 and do not notice the missing baby. The baby leopard eventually returns and flings him out of the sand. Christina laughs and picks up the animals and puts them on the shelf. In this scenario, the mommy is not able to protect its young from danger. This may represent Christina's own experience as her father reports that she often takes on the role of caretaker and assumes the responsibility of nurturing and trying to protect her mother. Emotional Expression On several occasions throughout this first session, Christina's affect is often not synchronous with her activity as indicated by laughing or giggling during the aggressive sandtray scenes. Christina denies difficult feelings when she mentions a time she used to live with her mom, and when I note that it must be kind of hard for her not to be living with her mom she expresses her wish to live together with her mom in a big fancy house. As the therapy progresses, I realize that Christina uses wishful thinking as a protection from her difficult feelings regarding family issues. Later in this conversation, Christina expresses her prime life difficulty in the following dialogue: C: And then I can move back with her (her mother). J: You can move back with her. C: Ya, two years ago I used to live with her for three years with my dad. Three years ago we went on vacation...and now I live with my dad. J: And then you went to live with your dad. C: Uh, hmm. And then I'm changing again and again and again for three years. J: Lots of changing. 58 C: So in 1997 I'm going to move in with my mom...probably. J: Is that something you and your mommy talk about? C: Ya, and Susan. J: Lots of changes for you. C: (Nods). But it's fine. J: It takes a while to get used to changes, doesn't it. C: Y a (looks away)...Have you ever seen a gold eagle? (changes subject) When discussing her mom, Christina raises the inflection of her voice while providing wishful statements about their reunion. She seems to be expressing her experience of numerous changes in her life and a lack of consistency in her relationship with her mom, however, is not able to admit the difficulty of this experience as evident by the abrupt change in topic at the end of this exchange. Christina expresses some ambivalence about having her sister back home again when she states that its "cool" but that she "bugs her a lot" and that they fight. She also expresses her wish for a baby brother that she can tease. When I openly wonder if sometimes, as the youngest in her family she gets teased, she shakes her head in denial and says "no", then later admits "well once they tortured me", referring to her sister Susan and her boyfriend. Christina changes the subject and begins discussing the miniature horses with which she is playing. During the sandtray scene the intensity and aggressive nature of the separation/loss theme suggests the degree of unexpressed anger Christina experiences possibly due to the lack of control she has over the separations in her own family situation. When the horses are together they are hurtful and aggressive toward each other and then quickly they are pulled apart. Christina's baby 59 voice following the scene seems to indicate the difficulty she has resolving her feelings about her hurtful experiences in her own family. Therapeutic Relationship During the beginning of the first session Christina makes contact with me by sitting beside me at the table sharing information about her friends and family members. She uses the items in the room as a prompt to the topics she discusses and demonstrates her knowledge about their various characteristics in order to gain acknowledgment and acceptance from me. This phase of rapport building is done in a safe and predictable way. As the session progresses, Christina moves to the sandtray and begins asking where I am from, why I am at the clinic and how often I come. She asks me various personal questions and checks my responses in relation to her own experience in an effort to ensure I am a good and trusting person. Anxiety is evident throughout this session as several times before the session is over Christina asks if it is time to leave. A slight shift in C's "safe" interchanges with me occurs toward the end of the session when she is playing in the sand tray and "accidentally" flicks sand over the edge and on to the floor and then looks at me. A few moments later, she states that the horses are killing each other, laughs and looks toward me. This seems to be the beginning of her attempt to test the rules to determine the degree to which I will be permissive and accept her "inappropriate" behaviour and ultimately her, no matter how "bad" she can be. v Summary of Session One In the beginning of this first session, Christina uses the miniature animals as a means of developing rapport, connecting with me and letting me know about her interests and competencies. She speaks fondly of school and daycare and some of the activities she engages in 60 there and also discusses her various family members and reveals her wish to live together with her mother and father in a big fancy house. Her use of a high-pitched voice and her tendency to look away when discussing her mom indicates that this is a very difficult topic for her which continues throughout therapy. Christina's sand tray enactment with horses reveals her sense of unpredictability around the separations and reunions in her family. This play seems to be an outlet for her own hurt and anger that may result from feeling powerless to control or enforce some stability and predictability in her own life. In addition, her symbolic play seems to be representative of a child's basic need for attachment and protection from a mother figure. Yet clearly, her play suggests an absence of these basic needs. Session Two Play Themes and Use of Play Materials House-Tree-Person Drawings I request Christina to complete the house tree person drawings and questions about her drawings at the beginning of this session. According to Buck (1948) due to the projective nature of these drawings, they can reveal more intimate details about the child's inner world than she or he would be able to express verbally. House. According to Thompson and Allan (1987), Wohl and Kaufman (1985) and D i Leo (1983), a house represents the child's environment; his or her family relationships, where he or she seeks affection and security, and the degree of protection the child receives. Christina drew the house (Fig 4.1) quickly, using pencil at first and then pastels. The drawing is less detailed and refined than you would expect from a child Christina's age. It is also not symmetrical as neither the walls nor the 61 door and windows have straight lines. There are no other images in her picture such as flowers, a sun or any other elements of nature beyond home. This lack of detail may indicate a tendency to be self-absorbed or depressed and therefore pay little attention to the rest of the world. In addition, the house is not touching the bottom of the page which may indicate House a lack of groundedness. The slanting nature or asymmetry of Christina's house may indicate a lack of balance, instability and insecurity. In addition, according to Thompson and Allan (1987), a lack of chimney on a house drawing may indicate an inability to express emotions. In general, due to the very limited detail, and the lack of symmetry, these authors would suggest that Christina lacks a sense of security, stability and self-direction which seems to coincide with her life. Christina's responses to the questions about her house indicate that it is a type of senior's home which is a happy place. Christina wishes for her grandma and great, great grandma to live there. To me this indicates a desire for a stable, nurturing and protected home and mother figure. Christina also indicates that she would like to live in the top of the house, perhaps where she can observe what is going on. She indicates that the house needs food and sun which is our life force, indicating a need for nurturing, brightness and emotional warmth. Tree. The tree is representative of growth and according to Thompson and Allan (1987) symbolizes the emotional realm of the child. Christina's tree (Fig 4.2) drawing also seems to be from a younger child but has a more positive presentation than the house. Christina's tree has a strong base and an abundance of green foliage which may indicate a potential for emotional growth. Christina indicates that her tree is a meeting place for herself and friends when at school. It is a place where 62 they meet to plan play activities during recess and lunch and the nine yellow images under the tree are the rocks they hold onto when talking and planning. The tree is well watered by the janitor. This tree's connection to Christina's school and friends seems to indicate that these are very important entities in her life. Perhaps school is the only place in which she feels emotionally secure. Person. The person is considered to be an expression of the self and of the integration of the personality. According to Buck (1948), drawings of people disclose how the child feels physically and emotionally at the moment, what he or she would like to be and the general attitude toward interpersonal relationships. Christina requests to draw a dead person (Fig 4.3). The figure has a very large head and only a stick figure body. According to Klepsch and Logie (1982), a stick drawing may indicate a low IQ, a resistance or defensiveness, a reluctance to reveal self, and a disconnection from feelings. The person has no feet or hands, which often indicates a lack of control or power in children's drawings. In addition, the person has no ears, perhaps so that she can't hear things she isn't supposed to hear. Also, hair is only present on half the head. When she completes the drawing and hands it to me she says, "Here's the messy girl" as she has smudged the red pastel down the figure's face. Overall, this drawing is very stark, empty and incomplete. One can hypothesize that this may give a general sense of how Christina feels in her internal world. Figure 4.3 Person 63 Christina's answers to the questions contradict the visual image when she reports that this person is happy, that she has never been hurt and that she has positive thoughts and wishes for the future. Following both responses she laughs and her voice changes to a high-pitched tone, probably indicating that she is concealing her true feelings. When asked what wishes the person has, Christina first says she wants to be a mommy then switches her response and says "mummy" and uses her arms to demonstrate a dead figure. I'm not sure whether the mention of "mommy" was too emotional from her and she said "mummy" to distract from this topic or whether it was an indication of her internal feeling of emotional "deadness". Exploration/Aggressive play Following the drawings, Christina begins to explore the playroom and discovers the puppets. She makes several animals attack her Elmo doll she has brought to the session. Christina has the wolf puppet bite me and then attack Elmo in various ways. Video Camera Several times during this session, Christina shows the toys to the camera, uses the binoculars to "spy" on the camera and then at the end of the session uses Elmo to blow raspberries at the camera. Although Christina denies feeling self-conscious, it seems that she was feeling intruded upon by the video camera. Danger/Protection/Mother/Baby The little cheetah is buried in the sand and has to protect itself from the spider as the large cheetah stands helpless. A large tiger then attacks the large cheetah and the little cheetah again has to protect the large cheetah. In another scenario, an extra guard is needed to protect the babies from the danger that comes during the night while the parents are sleeping. 64 These scenarios may be a depiction of the fear Christina has for her safety. It is apparent to me that unexpected events often occur in her own family at night. Separation/Reunion/Protection Christina groups the small and large tigers and cheetahs together in the sand tray, pulls them apart, then the donkey figure puts themback together again and guards over them. Again, as in the last session, Christina may be playing out her own experience of repeated separations from her mother and other family members and her experience of a lack of protection, both physically and emotionally, from the adults charged with her care. Food/Nurturing During the last few minutes of the session, Christina removes Elmo from the pot where he is being cooked and pretends to feed and give him some tea. This scene, as it occurs at the end of the session, seems to be a way for Christina to nurture the doll she fiercely aggressed toward throughout most of the session, and to come to some resolution around her angry feelings. In addition, it may have been a way for her to receive the nurturing she needed in order to end the session in a more manageable and contained fashion. Elmo DoU This toy is brought from home as a transitional object and is the victim of a number of aggressive acts by a variety of animals and then he is nurtured by Christina. Binoculars These were used several times during the session to both spy on the video camera and to check me out without getting too close. 65 Emotional Expression Within the first few minutes of the second session, Christina tells me about her wish to have one of her friend's cats because hers have died. She proceeds to describe the deaths of several of her cats. When I reflect "That's very sad", Christina does not acknowledge this reflection, but instead continues her story. Later, I remark "That's hard to deal with all those cats dying like that". Christina comments "Ya. Now I'm going to get another one, a little kitten, black." Again as in the previous session, Christina relays her experience of loss. I am not sure whether this story was reality-based, however, it seemed to be representative of her experience of multiple losses in her life. Christina engages in a variety of aggressive play using her Elmo doll and sand play figures. Elmo is eaten, thrown on the floor and dumped upside down by a number of animal puppets, abandoned in the sand, bitten by the wolf and then cooked on the stove. As Christina enacts this scenario she expresses the feelings of both Elmo and the other animals, such as "He hates Elmo" and "He doesn't like elephants". Most of these statements are made in a baby voice and her movement about the room is also done in a toddler-like fashion using very small steps. Again her emotions and activity are not synchronous as she giggles while engaging in this aggressive play. As I reflect the feelings of Elmo, Christina either does not acknowledge my reflections or switches play. She also wears the tiger mask and crown as a disguise and then attacks Elmo herself. Through this symbolic play Christina seems able to project her own feelings of anger, rejection and abandonment onto Elmo. Christina also directs her aggression toward me during this session by having the wolf puppet bite my face. Following this interaction, Christina shows the wolf and then Elmo to the camera which may indicate that she wants her feelings acknowledged. When it becomes too 66 difficult for her to contain her emotions, Christina engages in regressive play, walking and talking in toddler-like fashion or switching back to exploring the toy shelves and the sand tray miniatures. Therapeutic Relationship Christina begins the session again today by sitting with me at the table sharing news about a sleep over, and her wishes for a cat and a "Tickle Me Elmo Doll". These exchanges seem to be wishes rather than based in reality. In order to gain my acceptance, Christina seems to present herself as a girl who has more than she needs rather than the reality of a child whose needs are not met. Her testing of my acceptance of her ensues as during the house-tree-person drawings, Christina asks if she can draw any kind of person and then she says she is going to draw a dead one. Later, she points out her messy hands and says "messy girl" about her picture. During the questions about her picture, she is quite evasive in her responses and at times resists giving me genuine responses. As indicated earlier, she tests my acceptance of her anger by having the wolf puppet bite my face, then shortly after uses the binoculars to look at me and wave. I wave back in return and say "hello". Christina comments "You're right there"..."I can touch you". She seems to be both checking my acceptance of her feelings and attempting to connect with me. Information from home At the end of the session today, Christina's dad, Bil l , informed me that his eldest step- daughter, Susan, had stolen money from him last night and was no longer permitted to live with them. In addition, he informed me that Christina's mom, Lisa, is now living with them. Bil l reported that Lisa's ex-boyfriend had been stalking her for the past two weeks and that the police 67 had become involved. He noted that although Christina had not witnessed these incidents, she had overheard conversations about them. Summary of Session Two Christina continues to experience constant change, unpredictability and a lack of safety both through exposure to unsafe people such as her mother's stalker, as well as due to a lack of structure and a predictable environment. She provides stories based on wish fulfillment in order to deny the realities of her own disappointing, hurtful and fearful experiences. Christina's house-tree-person drawings seem to represent a child who has potential for emotional growth and a strong connection to school and grandma, yet who feels insecure and is strongly defended. The danger/protection and separation/protection scenarios constructed in the sand tray seem to closely represent the current events in Christina's life. She uses the animal puppets and the miniatures to represent her intense angry feelings. Christina tests my acceptance of her by directing her aggression toward me as well as the video camera. Elmo is brought from home as a transitional object and perhaps for safety and security in the playroom. He is the object of much of her aggression expressed through puppets. Towards the end of the session, Christina seems to bring resolution to her expression of difficult emotions by feeding and nurturing Elmo with a tea party. As she leaves the room she holds Elmo to the camera and blows raspberries which perhaps indicates her self-consciousness resulting from the camera witnessing her play and expression of difficult emotions. 68 Session Three Play Themes and Use of Play Materials Family/Nurturing At the beginning of the session, Christina draws a family of 8 dogs (Fig 4.4) and discusses the various siblings, each one drawn progressively smaller. She regresses into baby talk when the mommy is discussed. Later, she tells me they are wolves and prints "wolves" on her picture. She then draws a very large wolf who seems to be overseeing all the others, perhaps for protection. She reports that the wolf is scared because he has to box and he's afraid he won't win. "wolves* This theme also emerges at the end of the session when Christina places various animal families in separate lines to receive food. As each group is fed, they are placed in separate animal groupings, isolated and disconnected from each other. As Christina continues to add animals she methodically sorts them into family groupings and describes them to me using a baby voice. This grouping behaviour may be a way to create order out of her sense of chaos. In addition it was also a way to demonstrate mastery, and to remain somewhat distracted from the family theme that seems to be a difficult topic for her. Captured/trapped Christina creates a complex sandtray scene whereby horses are barricaded into stables by a "mean" horse owner. She tells me "he collects kids". Christina adds some guards and tells me "If they (horses) don't listen, they (guards) kill." Christina engages intensely in this play and narrates 69 the activity as the scenario progresses. One horse breaks free, lets the other horses out and they retaliate against the horse owner but are eventually captured again. Danger The danger theme surfaces when the horse family is reunited and the mean horse owner returns and hovers around the family. This scene seems to indicate a world where the threat of danger is pervasive. Mother/Babv/Separation/Loss Christina tells me the mother and baby horses are separated by one of the mean guys. The baby horse then sneaks back over to its mother. At the end of the scenario, the mother animals are killed and only the babies survive. Eventually the mother tiger and lion are resurrected to be surrogate mothers and care for all of the babies. Safety/Protection/Freedom A tiger appears and locks up the mean horse owner. Christina removes the barricades and she puts away the guards. The horses are then free to run but this is only temporary. Separation/Loss/Reunion Later, Christina tells me one of the small horses isn't free because its dad and mom died. She then contradicts her story and says they are not really dead. She then brings in the horses' parents and brothers and sisters and they cuddle as they are reunited. She comments "But they still have stables" and later she tells me the barricades "rot away and disappear" and she says "The animals will be free". This may be a symbolic representation of Christina's wish that all of the forces keeping her family apart will break down and will no longer exist. 70 Danger/Resilient babies At the end of the sandtray scene, unexpected danger occurs when sharks attack the animal families from underneath the sand. One baby from each family survives while the others are killed by sharks. Christina tells me the baby cheetah is the toughest as he proceeds to kill the sharks. The mommy tiger and cheetah eventually come to life. When I reflect that the babies can be cared for after all, Christina switches her play and pretends to use the elephant as a puppet. Animals Again in this session, Christina uses animals as a symbolic representation of her feelings about self and her family relationships. She draws pictures of a funny horse, a sad puppy who has lost his mommy, a family of dogs and a scared wolf. She also uses a number of animals in the sandtray scene she creates. Emotional Expression Several times during this session, Christina shifts activities, turns away, changes the subject or regresses when she and I begin discussing difficult feelings on a conscious level. For instance, when discussing a poster of an anger mountain in the playroom, Christina asks "Where's the happy?" As I explain the premise of the anger mountain in that it results when people hold in their anger, she switches topics and begins talking about some felt pens she got. Later, when talking about her sister's absence in their home, Christina denies missing her, turns her body away from me and asks to draw a funny horse. These shifts seem to be a strong message that she is not able to discuss difficult topics, only happy or funny ones. When Christina draws a puppy and tells me it is sad because it's mommy died and I reflect its sad and lonely feelings, Christina scribbles on her picture and begins to draw another one. Also, when I reflect the wolfs scared feelings, 71 Christina's behaviour regresses as she says "me done" and tells me a "story" about being tired of drawing because she got up early in the morning and was drawing when her dad was asleep. During a sand tray scene using horses, Christina symbolically makes the following disclosure about herself: C: He's wild in his own life. J: He's wild in his own life? He's kicking away at the walls. That's a very small space for him. He's very agitated. A : It's a she. J: Oh, she... So what does it mean when you said that the horse was wild in its own life. C: She doesn't like being wild around other horses. J: Oh, I see. Only when she's alone she shows who she really is. C: Yup. J: Oh, I see. And around other horses she acts differently. She doesn't act like herself. C: Yup. This exchange seems to reflect Christina's need to shield her true, vulnerable self from others. Therapeutic Relationship Throughout this session, Christina comes within a closer proximity to me and makes more eye contact than in previous sessions, however, has a strong need for control as demonstrated by her contradictions of my reflections. During her sand play scene, she appears to be engrossed in play for a time, ignoring my reflections, or tolerating them. As I continue to reflect, she shifts her play, changing the story as she goes along, seemingly in an attempt to keep me at a distance. The following is an example of such behaviour: J: They don't need the guards anymore. Those horses must feel much freer now. 72 C: He don't (holds onto small horse in the sand). J: That one doesn't. C: His dad and his mommy died. J: Ahh. C: But they didn't. They're right here and there. J: But he thinks they're dead? C: But they're not. J: They're not really dead ... he just assumes that they are. C: So does she. They're brothers and sisters (puts white horse with black one.) J: Hmm. So they both are missing their parents, I can imagine. C: No they're not (brings parents over to young horses). Summary of Session Three Christina begins this session as in the previous ones by sitting at the table with me and telling me "stories" about her friends and family. These fantasy tales were more evident in this session than in past sessions. Her abrupt change in topic and her fidgety body language during each of these exchanges seems to indicate that these stories are a projection of Christina's wishes to create a reality she would like, a life full of fun, fulfillment and a close and supportive family. As in previous sessions, Christina uses animals to express feelings about her family relationships. The sandtray scene seems to depict Christina's experience of repeated separations and reunions with family members and a pervasive sense of being blocked from togetherness as a permanent family. Although the families are eventually fed and appear safe and nurtured, imminent danger recurs, breaking up families and killing many except for the babies, who are left to take care of themselves, until the surrogate mothers finally appear. The themes of danger, being 73 trapped and captured are similar to the themes portrayed in the first session. The mother/baby/family theme was also pervasive throughout this session both in drawings as well as in the sand tray. Christina's need for control is evidenced by distracting from my reflections, changing her play, contradicting what I say or turning her body away from me. Her overriding need to self- protect through denial and avoidance of feelings precludes her ability to connect with me and allow me into her world. At the end of the session, Christina chooses to put away the animal miniatures and she methodically groups them into families. This safe, ritualistic play seems to be a way for her to regain emotional containment prior to leaving the play room. Session Four Play Themes and Use of Play Materials Aggression AV olf Puppet The wolf puppet is the key animal used throughout the session to express anger, often directed at me. Christina also uses other puppets including a wizard who puts a spell on me. Christina enacts a brief scenario with miniature dinosaurs who attack each other in the sand tray and blow raspberries at the camera. Guessing Game Christina finds some jewelry and has me guess which item she is concealing. This theme seems to fulfill Christina's needs to regulate her emotions, maintain control and engage with me in a safe and predictable manner. 74 Video Camera Again as in session two, Christina is very conscious of the camera and directs her anger through the puppet's actions of repeatedly blowing raspberries at it. Large Stuffed Bear Christina directs some of her aggression toward the bear and then engages in some nurturing play with it. Emotional Expression At the beginning of the session, while decorating a Valentine cookie I brought for her, Christina tells me happily that her sister returned home in the night. She then discusses some wishes regarding Valentine gifts she hopes to both receive and to purchase for her family. Following this activity, Christina expresses a lot of anger and negative emotions through the puppets, much of which is directed at me. She uses the wolf as the main aggressor and also has several other animal puppets bite me and blow "raspberries" at me and laugh. The wizard puppet casts a spell and turns me into a cow. When I reflect "He just wants me to go away and be something else. He doesn't want me to see his angry feelings", this seems to be an accurate reflection of her desire for me not to talk about her feelings as Christina puts the wizard back on the shelf and takes the baby monkey puppet and regresses to making monkey sounds. Following this exchange, Christina has several puppets blow raspberries at the camera and then a fight ensues in the sand tray between two dinosaurs. The aggression is directed away from me until she asks if it is time to go and I tell her there is twenty more minutes. She shows her anger by having the dragon growl at me. The aggression theme continues to the end of the session and she directs her aggression directly at the large bear. When I reflect the anger Christina makes animal sounds, giggles and runs and hides from the camera. For the first time she 75 raises her voice at me and shouts "No!" when I question whether the camera makes her feel self- conscious today. Again, Christina switches her play in order to regulate her emotions and begins to look for clothes to dress the miniature doll. Therapeutic Relationship As indicated in the emotional expression section, Christina's testing behaviour increases during this session as she checks the degree to which I will accept her anger through the puppets and eventually by directly expressing verbal aggression at me. In addition, for the first time Christina admits frustration and then accepts help from me. To me this indicates a slight opening and a trust in allowing me to see her vulnerability. Christina conceals herself behind masks and toys in an attempt to get closer to me and to disguise her true self-expression. Following a display of aggression with puppets, she uses the elephant mask and comes close to me, puts the bear on her knee, and says "You sit on Santa's knee." Following her request to finish the session and my indication that we still have time left, she hides behind the binoculars and blows raspberries at me. This behaviour seems to indicate Christina's ambivalence about our relationship. Christina's need for control is frequently evidenced during this session. She contradicts my reflections several times and also creates a guessing game whereby she structures the rules so that they can be changed to ensure that I lose or win, whatever suits her needs. Christina seems to be using the relationship to work through her feelings of powerlessness. Information from Home At the end of the session today, Christina's dad informed me again of changes at home. Susan returned last night to live with them and told her stepfather that she had taken herself off drugs. Bil l said that he let her move back in with some strict guidelines. In addition, Christina is 76 aware that her mom's boyfriend has been put in jail for stalking her. Bi l l reported that it has been a very difficult couple of weeks. Summary of Session Four This session marks the beginning of the second phase of therapy as Christina's emotional expression becomes more direct, her testing behaviour and need for control increase and ambivalence in our relationship begins to develop. The majority of her play involves expressing anger, often projected at me. When these feelings are reflected, she switches her play rapidly, regresses her behaviour or hides from me. Christina is very aware of the video camera during this session possibly evidencing increased anxiety resulting from exposing her vulnerabilities. Christina asks repeatedly whether her time is up. A new theme of guessing emerges during this session. Christina seems to use this game as a means of gaining control, to demonstrate mastery and perhaps as a way to work through her own experience of unpredictability and "trickery" in her own life. Christina accepts help from me for the first time during this session, however, does not yet trust me enough to allow her vulnerabilities to be reflected. Her ambivalence in the relationship is evidenced by her attempts to connect with me through the animals, gain acceptance by allowing me to "win" during the guessing game yet needing to control, hide her feelings and distance from me. 77 Session Five Play Themes and Use of Play Materials Play dough Christina manipulates the play dough throughout the first half of the session which seems to soothe her and reduce her anxiety while she talks about her family and friends, similar to how she used the sand tray in the first session. Hiding/guessing Christina uses the puppets as well as the miniature animals and has me guess which item she is hiding. At first, Christina plays fairly however, as the game progresses she becomes unhelpful and changes the rules so that I will guess incorrectly. Emotional Expression At the beginning of the session, while Christina sits at the table with me manipulating the play dough, she expresses her wish to have regular access to her sister, to live with her mom and / then tells me that she is moving. When I comment how hard it is when people are moving in and out Christina laughs and claims that it is funny. This topic is emotionally triggering for her and she is unable to maintain the topic of discussion. She turns her body away from me and anxiously manipulates the play dough. During this session, I am witness to a greater lability and variety of emotions than I have seen so far. Through the guessing game she seems to be able to contain her emotions and retain control. When not in control of the game, her voice raises, her tone becomes more directive and she begins to change the rules, making it more difficult for me to guess correctly. The scattered and confusing progression of this game may indicate how little sense Christina can make out of the constant changes in her own life. 78 For the first time in therapy, she laughs several times during the guessing game she sets up as she seems to gain pleasure in the control she can attain and expresses joy both through her body language and voice tone. Her sense of humour also emerges as she uses her body to try and hide all of the puppets and then the large bear. She seems to take great pleasure and laughs heartily at her humorous attempt to hide these items that are impossible to completely conceal. Therapeutic Relationship Christina's ambivalence about our relationship continues as she increases her attempts to connect with me by comparing our experiences while also testing my limits of acceptance of her. While playing with the play dough she tells me that she has eaten play dough and worms before and that her friend also ate a slug. She then asks me what I ate when I was little. Later, she asks me what my favourite colour is. When I respond with "purple", she says, "mine's not, mine is..." and then becomes distracted as she notices my pants and tells me her sister has the same ones. Christina's feelings of confusion, chaos, and unpredictability are transferred to me during the guessing game. She uses the game to test my loyalty to her when on two occasions she accuses me of peeking. She also raises her voice and becomes very stern and directive on a number of occasions. Perhaps due to past experience, Christina struggles with trusting my acceptance and loyalty to her for fear that I will deceive her and let her down. The guessing game seems to demonstrate Christina's ambivalence with regard to keeping things from me versus trusting me and letting me into her secret world. Christina also uses the game to work through her anxiety over loss and separation when she pretends to leave the room and hides while my eyes are closed. When I find her hiding behind the large pillow she laughs with delight. This reminds me of a typical toddler game whereby a child works through the anxiety of being separated, then reunited with a caregiver. 79 Information from Home Folio wing the session, I followed up with Bil l regarding Christina's discussion about moving. He mentioned that he wished to move out of the city because he felt that his and Christina's safety were in jeopardy as a result of Lisa's stalker. Although this person was presently in jail, he was being released in ten days and Bil l feared further aggression towards them in retaliation for having been put in jail. He noted that Christina had been expressing a lot of anger at home towards both himself and Lisa. He said he was still struggling to provide a consistent and stable lifestyle for her and felt that this would become more of a reality if he were to move out of Vancouver. Bil l also reported that Susan, his step-daughter, was again asked to leave as she was still using drugs. He indicated that she would not be returning this time. Bil l promised to keep me updated on his moving plans and noted that he hoped to keep Christina in therapy, even if they moved. Summary of Session Five As in the first session, Christina brings a transitional object from home and her bunny is the object of the only overt aggression demonstrated throughout session five. Christina seems anxious throughout this session and has difficulty regulating her emotions and staying on topic. This seems Understandable given the report from her dad regarding the constant changes and lack of a sense of safety she must be experiencing. She continues to have difficulty tolerating discussions about family and home as evidenced by her tendency to shift the topic and to engage in regressive behaviour. In addition, her tales about her life continue to be based on her fantasy of a consistent and nurturing family rather than the reality of the instability she experiences. 80 During the last half of the session Christina engages in a guessing game using puppets and sand tray miniatures. She laughs for the first time while playing this game and experiencing unlimited control. She allows me to guess correctly at times, however, often changes the rules and cheats to regain control. This game appears to serve as a means for Christina to work through the unpredictability of her life, to regain a sense of power and control and as an emotional coping mechanism. Ambivalence about our relationship is evidenced by Christina's shifts from engagement to disengagement by changing the rules and contradicting my statements. During this session, the therapeutic relationship seems to be the main vehicle through which she expresses her feelings of hurt, disappointment and need for control. Christina chooses to clean up following my two minute ending warning. Her attempt to take the large bear from the playroom during clean up seems to indicate a desire to retain some of the positive feelings she experiences in the playroom. Christina checks her appearance in the mirror before leaving the play room. Session Six Play Themes and Use of Play Materials Drawing Christina engages in drawing for the first half of the session. She first draws a sad whale and then a rainbow (Fig 4.5). As she colours, Christina reports that the reflection in the clouds are a different colour than the rainbow. I wondered if this was an indication of Christina's experience that even something that seems 81 to be constant and predictable such as a reflection may not be what it appears. Hiding/Guessing Christina hides from me in the waiting room at the beginning of the session. Also, throughout her drawings, Christina keeps me guessing what images and colours she is going to add to her pictures. Later, Christina constructs a guessing game using all of the items on the toys shelves. She is the first to hide objects but then has us switch roles part way through the game. She seems to be feeling more empowered to chance being tricked by me as well as asking for clues. At times however, she needs to peek in order to ensure she guesses correctly. Doctor kit/Aggression/Healing Christina takes out the doctor kit and first suggests she is going to hurt me with the instruments then gives the wizard puppet a needle. She also demonstrates aggressive and hurtful play with the stethoscope when she yells in my ears. She then enacts some reparative play by checking the wizard's heart and reflexes. This play seems to be a way to both heal her emotional pain as well as to demonstrate her distrust of people who are supposed to be caring but are actually hurtful. Large Bear During the guessing game Christina lays on the large bear on the floor. She seems relaxed and is able to use the bear to find comfort and security in the room. Emotional Expression Several times during this session Christina describes physical ailments which appear to be a way to demonstrate her emotional state and feelings of hurt in a safer, more concrete way. For instance, upon entering the session today, Christina tells me she is very tired because she had to go to bed very late last night and she fell out of her bed and the dog woke her up. Later, she 82 bumps her head on the furniture and hits herself in the head with the sword. At first, when I reflect her pain she laughs but at the end of the session she announces "I hurt myself again", and giggles. I believe she was looking for the acknowledgment from me of her feelings and because this behaviour occurs several times, must benefit emotionally from my nurturing of her pain. For the first time, Christina initiates telling a story about her mom. It is not based on wishful hopes for the future, instead it is a positive story about some practical jokes her mom played. Interestingly, this story reflects a theme of trickery that occurs during the night. Perhaps this story is a metaphor for the real trickery Christina experiences in the night when her mom disappears unexpectedly. As Christina is drawing, she expresses dislike for her picture, pushes it away, agrees with my reflection that she does not like it and states "I'm going to draw another one." Later she says "bad", turns her paper over and begins to draw another picture. These examples seem to indicate a slight shift in Christina's ability to accept her sense of vulnerability in acknowledging her imperfections. Later, she demonstrates pride in her drawing, holds it up for me to see and then gives it to me to display on the wall. The following is an example of Christina's developing ability to express emotion: C: He's a sad whale. J: Oh. What is he sad about? C: Nothing (giggles). J: He's just feeling sad. C: Cause he's a baby and he has to dive in the water. J: Oh, and he's a little bit scared of that. C: Nope (shakes head, giggles), he's nervous. 83 J: He's nervous. He's worried about what might happen when he dives in. In this vignette Christina is able to both hear my reflections as well as add her own feelings to the story. When Christina discusses a scary experience regarding a bee chasing her at school, she changes the story and says it was funny. Later, when she talks about her mother's stalker knocking on the window and their need to hide from him in her room, she eventually admits to some level of fear. However, she quickly distracts from the conversation by engaging in self-talk about her picture. This strategy is something I have not seen before and I wonder if she is beginning to use it to soothe herself when trying to contain difficult emotions rather than engaging in denial and regressive behaviour as has been evident in the past. Christina expresses aggression toward me at the end of the session when she takes out the doctor's kit and tells me she is going to "shoot" and "stab" me and then gives the wizard puppet a needle. She asks me to put on the stethoscope, yells into it, promises she won't do it again, then yells one more time. I reflect "sometimes it hurts when people play tricks on us". Because she then laughs and changes her play, I sense that this was a fairly accurate reflection of her attempts to show me her pain. Christina has difficulty regulating her emotions during clean up when she hits her head on the chair and giggles uncontrollably. When I reflect her hurt she becomes somewhat calmer and then resorts to some regressive behaviour. Shortly after, she begins to giggle again and continues until we leave the playroom. Again, at the end of the session, Christina looks in the mirror, perhaps to ensure that she looks composed enough to leave the room. 84 Therapeutic Relationship Christina's trust in me seems to have increased since the last session as she demonstrates less aggression toward me and during the guessing game gives me many clues, comes within close proximity and even allows me to rub her head when it gets bumped. When she hands me her picture to display at the end of the session, she demonstrates not only pride but also trust that I will display it with care. Ambivalence is still indicated when I reflect her feeling of sometimes wanting to help and sometimes wanting to trick me and she yells over top of my voice and tells me to close my eyes. The hurtful doctor play may symbolize her experience of caring adults who hurt and may indicate her fear that I may be just like them. Christina checks my reaction following this play by making eye contact and grinning. She seems to be testing whether I still accept her. Summary of Session Six This session seems to indicate a turning point in Christina's therapy as she moves into a third phase of treatment. Overall, she seems to demonstrate increased emotional expressiveness, greater trust in our relationship, less need for control, less anxiety following reflections, greater ability to self soothe, increased physical contact, and less aggressive and ambivalent feelings. Christina is still not able to express her emotional pain directly however, she seems to express some of her hurt through physical bumps to her body. For the first time she initiates conversation about her mom without becoming triggered, and also relays family stories that are not based on fantasy wishes. Perhaps the symbolic meaning of her rainbow indicates a preparation for transformation. 85 Session Seven Information from Home When Christina arrived at the clinic with her dad, Bil l noted that the person who had been stalking Lisa was convicted and will likely spend the next few years in jail. He expressed relief that there is no longer a threat to their safety. Play Themes and Use of Play Materials Hiding/guessing Christina begins the guessing game immediately upon entering the playroom and it proceeds for the duration of the session. For the first time she allows me to hide the items first while she guesses. Throughout the game, she manipulates and tries on most of the guessed items. Christina also hides from me today as in the previous two sessions. Baton The baton is used throughout this session to point to items, express aggression, carry items, pretend to be blind and pretend to be old and unable to walk. Bear and Large Pillow Both of these items are used as comfort objects. The pillow is also used for hiding behind. Sleepers The sleepers are tried on during termination. Emotional Expression j Christina's emotions during this session seem quite close to the surface as she fluctuates through a variety of feelings including frustration, joy, pride, anger and disappointment. Christina demonstrates a greater expressiveness in her tone of voice and body language which often is more synchronous with the intensity of her feeling than in previous sessions. 86 Throughout the last half of the session, Christina's voice raises, her tone is sharper and she becomes very directive in the guessing game, often demanding that I close my eyes quickly. She aggressively hits the baton on the floor and on one occasion uses it to hit the cat puppet and tells me it's "nasty" and later on raises it as if to hit me and tells me she is the teacher. At one point she raises her voice and states "Now you're tricking me." I reflect how unfair that feels but she does not respond. It felt to me that her accusation had more meaning than the present situation. She seemed to be suggesting that I was like other adults and she still could not trust me. As in the previous session, Christina finds comfort in the large stuffed bear and appears relaxed when curled up in it. She also spends part of the session lying on the floor while guessing what items I am hiding. Her body posture seems to be opening up and is less protective than in past sessions. There are two incidents during this session that appear to be emotionally triggering for Christina. Toward the end of the session, a miniature gun falls from a basket and the following dialogue ensues: C: This is her (doll's) gun. J: She has a gun. C: Yes. J: She needs to protect herself. C: Yes. She needs to shoot everybody in this whole entire world (yells while waving the baton in the air.) Now close your eyes! (Wants to get back to the game). J: Everybody has hurt her. C: Look what I got. I got... he's yellow, he's yellow, he's really, really yellow and it has long hair. 87 Christina continues to distract from this conversation and begins singing a nonsense song. I'm not sure what meaning the gun had for her but it appeared to be an emotionally laden object. It may have been a symbolic way to express her own intense anger at the world for not helping her to feel safe, or a trigger for an actual event she had experienced. Following this incident, Christina finds a miniature male doll that is naked and she begins to giggle. She directs me to dress the figure, begins to look for clothes and tries to take them off another doll. I respond with "You want him to have clothes on". Christina then rapidly switches the activity and her behaviour becomes quite erratic as she begins to grab several toys and give them to me then yells "Okay, now, start getting to work. I can't give you anything, anything at all" and then begins the guessing game. She then switches rapidly from being giggly to using an angry, demanding voice for several minutes. It appears as though this naked figure was emotionally triggering for Christina. At the time I pondered her past experience and wondered whether she had been the victim of or a witness to a sexual experience. Similar to the previous session, following my ending warning Christina's behaviour regresses and her emotions become very disregulated as she switches from giggling to bumping herself to yelling. When trying to put away a toy I reflect "Things just don't go the way you want. Does it sometimes feel like you have to guess what's going on in your life like we guess about these games we play?" she turns and looks at me and says "Yes". This is the first time that Christina acknowledges a reflection that is linked to her own life. Following this dialogue, Christina closes her eyes and uses the baton as a cane and pretends to be blind. She ignores my reflections as I continue to talk about how difficult all the changes are for her. It seems as though this shift to blindness is a way to deny her experience by suggesting she can't "see" or bear to look at what is going on in front of her. 88 Shortly after this as I reflect my assumption of her increased sense of safety now that the stalker has been arrested, she takes the baby sleepers from the dress up corner and attempts to put them on. Her speech and behaviour regress as she struggles to wear these sleepers that are clearly too small for her. This regression into infant-like play seems to be an attempt to return to a safer, more protected time of life. Therapeutic Relationship A turning point in our relationship is evident in this session as the difference between play and relationship becomes less distinct and Christina uses the therapeutic relationship to work through her emotional issues rather than using symbolic play themes. The reciprocity of our relationship is slowly evolving as we become more comfortable with each other, laugh and enjoy the game play, and engage in some physical contact. Christina continues to be directive and to make demands of me in order to feel in control, and there is still a slight element of distrust. However, she accepts consoling from me when she gets frustrated for not guessing an item correctly and when I reflect that perhaps it doesn't seem fair for me to pick an item she may have not seen before, she replies "It's okay". Her increased trust is also evidenced during the guessing game as she provides me with a lot of clues about the items she is hiding and at times seems happy when I guess correctly with her help. At one point in the game I acknowledge that Christina gave me a clue and she grins and responds," Ya, well you gave me a clue". On one occasion she screeches "Noooo" and says "You were supposed to get it right" in frustration that I am not guessing her item correctly. She seems to want recognition of her efforts to help me. At the end of the game she assures me "I won't look, I promise". Christina pretends to leave the room and hides behind the pillow again during this session. I interpret her hiding to be a way to calm herself by shifting activities as well as a way to check my 89 level of commitment and attachment to her. Christina giggles joyfully when I find her. Her demeanor following this interlude is much calmer and relaxed. Summary of Session Seven Christina immediately engages in play without either a transitional object or activity during this session. She interacts with me during the guessing game for the duration of the session and for the first time does not initiate any stories either real or imagined, about home or school. She demonstrates greater expressiveness in her tone of voice and body language which is more synchronous with her expressions. Christina's emotions become more aggressive during the last half of the session as she becomes more demanding in her voice tone and body language. Christina hides herself again during this session seemingly as a way to shift the focus away from her difficult feelings as well as to check my level of commitment and attachment to her. She uses the bear and the large pillow again as comfort objects. In this third phase of therapy, Christina appears to be using the therapeutic relationship to meet her emotional needs and there is less distinction between play and relationship. There is greater reciprocity, increased comfort and enjoyment of each other. Christina has less need for control and is becoming less demanding and oppositional and more accepting and helpful. Although her trust in me is developing there is still some ambivalence about whether I will trick her. For the first time she acknowledges a reflection that I link to her life. Following this, her behaviour regresses and once again termination is difficult for her. 90 Session 8 Play Themes and Use of Play Materials Hiding/Guessing Christina begins the session with the guessing game and asks me to hide the item first. She provides me with clues at the beginning and also requests clues for herself throughout the game. Again in this session, she inspects, manipulates or tries on most of the items both she and I choose during the game. Christina uses one of the bead necklaces and creates a series of three games: tug of war, a running race to the necklace, and eventually a game of hide and seek. She seems to use these games as a way to achieve a sense of mastery. Wolf Puppet The wolf puppet is used briefly as a symbol of aggression. Pillow and large stuffed bear These items are used again in this session to hide in a humorous way as well as for hiding objects under. Throughout the guessing game Christina lays on the bear and also hides under him. These objects continue to be a source of comfort and connection to the playroom. Video Camera Christina uses the video camera several times during this session. Once she uses it to look at me, later she shows the necklace to the camera and then makes a face into it. Also, Christina speaks directly into the camera during my meeting with her dad. Sand tray Christina uses the sand tray in which to bury the necklace and have us each search for it. 91 Emotional Expression At the beginning of the session Christina tells me she likes being tricked and claims that it is fun. When I suggest that sometimes it is fun and sometimes it is frustrating, she doesn't acknowledge my reflection and shifts into playing the guessing game. At first she gives me many clues but then begins to trick me. At one point during the game, she puts on the wolf puppet and growls at me because I guessed the puppet's name. I reflect the wolfs anger and she lunges the puppet at me twice, growls again, then flings it from her hand. She quickly switches back into the guessing game while laying on top of and then under the large bear, seemingly to soothe herself and to contain her emotions. Later in the game she repeatedly flings the bead necklace at me, tempts me to pull it from her, then quickly pulls it from my reach. She laughs deviously and uncontrollably while laying on the floor, then gets up and shows the necklace to the camera. When I reflect "This is a fun game when you can trick the adult", she continues to entice me into trying to take the beads from her. When I do not comply, she switches to a new game of racing for the necklace. Several minutes later I give her the ending warning and she talks over my words. She continues with the racing game and makes it increasingly more challenging. Prior to the end of the session we play a quick game of hide and seek with the necklace. As she hides the necklace she states "You're never going to guess it". Christina seems to enjoy the competition of the game and the ability for her to feel in control once again. During my meeting with her dad at the end of the session, Christina has a lot of difficulty waiting in the playroom until we are finished. I noticed when reviewing the video (which was left on unintentionally during my meeting with her dad), that she did not engage in play but repeatedly moved from the playroom to the hallway, peeking in the office window where her dad and I were 92 meeting. Each time she returns to the playroom she lays on either the bear or the pillow. She eventually shuts the door to the playroom, sits facing the camera and says "Let me share a little secret with you". She whispers something about her dad into the camera and tries unsuccessfully to put the lens cap on it. She then says "My dad sometimes tells secrets that I don't like". It seems that the anger Christina was expressing throughout the session may have resulted from her anxiety about my meeting with her dad and the nature of the information her dad was going to share with me. Therapeutic Relationship Christina's attempts for control intensify toward the end of the session as she engages in a lot of passive-aggressive behaviour using the bead necklace. During the bead tug of war I felt as though I was being set up to receive something then without warning it was pulled away from me. A tension grew between us as she continued to test me and strive to retain control. The racing game following relieves the tension and we both enjoy the increased energy and positive interaction. Christina's anxiety about the meeting with her dad seems to reflect a continued ambivalence about her relationship to me. It appears that her lack of trust results from the inconsistency in her family relationships and a disbelief that family is caring, supportive and protective as was evident in her reaction to the meeting. Parent Meeting Bill expressed his frustration and disappointment that regardless of his efforts to make his family's life more settled this year, it has been more disruptive than ever. Christina's mom and half-sister continue to come in and out of their lives unexpectedly. Bil l reported that he has finally set boundaries with them and is no longer going to be emotionally or financially helpful as he is 93 feeling used and realizes the impact the inconsistency is having on Christina. When Bil l informed Christina that her mom is not welcome to stay with them but may come over for scheduled visits, Christina was angry with her dad. However, she told him that it scares her when she is with her mom as she fears she is doing drugs and agreed to only have her mom visit at her dad's house. Lisa has not been able to follow through with the planned visits so Christina has not seen her for a few weeks. Bil l noted that Christina is getting more "mouthy" and that they often have power struggles, in particular, in the morning. As this is likely a result of the changes in her contact with her mom, I encouraged him to provide Christina with extra emotional support. In addition, we discussed ways that he could provide Christina with opportunities to make choices as well as increase the structure in her routine in order for her to feel more in control of her life. Bil l also informed me that Christina and a couple of her friends were skipping class and were caught in the hallway at school. She wrote a letter to her dad expressing her love for him as well as her remorse for what she had done. It appears that whenever Christina gets in trouble from her father, she shows a great deal of remorse and acts as if she is fearful of also being abandoned by him. Bil l informed me that he is still proceeding with his plans to move out of the city as soon as possible. I suggested that it would be beneficial for Christina to keep some consistency in her life including finishing the year at her school as well as continuing with therapy. He assured me that he would find a way for her therapy to continue even if they move. Summary of Session Eight Christina begins this session by allowing me clues and playing the games fairly and allowing us equal control, however, as the session progresses, she fluctuates between being 94 helpful and needing control by tricking me. She disregards or talks over my reflections and comments about her desire for control. Her emotions during the bead tug of war fluctuate between uncontrollable giggling and aggressive and demanding behaviour. The wolf puppet emerges briefly again as a vehicle for expressing anger toward me. Christina attempts to extend the session today perhaps due to the pending meeting with her dad. While in the playroom alone, she uses the video camera to make known her disapproval of her dad revealing her secrets. This seems to be a vehicle through which Christina could express her concerns directly without fear of rejection or abandonment. Session Nine Play Themes and Use of Play Materials Hiding Christina and I spend the entire session playing hide and seek with a bracelet. During the game she also hides herself under one of the dress up skirts by putting it over her head instead of covering her eyes. Throughout the game she uses a mallet to pretend to look for gold around the room. Large bear Christina uses the bear as a comforting spot to hide her eyes during the game. Emotional Expression Christina's mood is much more consistent today as she giggles with pleasure throughout the hide and seek game. She demonstrates a sense of competency as she suggests a need for more challenging hiding spots. As she finds increasingly more creative spots to hide the bracelet from me she shows pride through her smiles and facial expressions when she is successful. When she 95 accuses me of concealing a hiding spot I state "I know it makes me mad when people keep secrets from me or hide things from me. It doesn't seem fair". She then hits herself with the bracelet, says "Ow" and seeks comfort from me. She admits that people hide things from her in real life. I begin to wonder if this game is a symbolic way of working through and successfully coping with the unknowns in her life. Unlike in her reality, she can control the outcome in the safe and nurturing environment of the playroom. Therapeutic Relationship During this session I notice Christina approaching me more readily and spending longer periods of time next to me. During the "hide the bracelet" game, she is helpful with her clues and tricks me only once. I found myself becoming bored with the game but realized that Christina's needs for safety and control were being met through it and I worked hard to remain engaged. About halfway through the session Christina changes the rules and has each of us close our eyes while she throws the bracelet and we search for it together. Christina seems to delight in the mystery of where the bracelet has landed. We are both engaged in a common goal and as a result we are more connected. There seems to be less ambivalence about our relationship. Christina has less need for control and directs my play less than in past sessions. The directives she does provide are said with less intensity, are less demanding and she does not raise her voice. On one occasion she even requests that I direct her. When I am not actively helping her search, she questions whether I know where the bracelet is. She doesn't believe my response and replies "Why aren't you helping then?" She is genuinely seeking my help without the tendency to then reject or push me away in order to disengage as has been evident in many previous sessions. 96 Summary of Session Nine Christina demonstrates greater trust in me and less need for control and embarks on a new, less competitive game. She demonstrates increased positive affect and expressions of competency and pride. Rather than using control tactics, telling me tales and denying my reflections, she seems to be trusting me enough to allow a more genuine self to emerge. At one point during this session she seeks physical comfort from me however, appears to disengage quickly as she is not able to tolerate the closeness. The only information Christina shares with me about her external life is a swimming field trip with her school. The duration of the session is spent fully engaged in the hiding game with the bracelet. She appears joyful throughout and has a difficult time stopping the fun to end the session. She requests to extend the session and I allow her to take one additional turn at the hiding game. Although Christina continues to suppress her feelings and not express them directly, they are less on the surface and more contained, and she is beginning to both accept and concur with more of my feeling reflections. For the first time during this session she expresses physical pain and is able to contain her emotions when I draw attention to it. Although I do not discuss the video clip of her following last week's session, I believe I am able to let her know I understand how difficult the experience of secrecy and betrayal in her family has been for her. Session Ten Information from Home Christina missed three weeks of therapy due to Easter and Spring Break as well as her dad forgetting about an appointment. I phoned Bil l following the missed session to see how things 97 were at home. He told me he had completely forgotten and admitted to being preoccupied with getting Susan into a detox program. She has returned to live with them while she awaits a vacancy in a drug treatment program. Bil l informed me that Christina has been expressing her grief openly both at school, where she was crying to the counsellor about her sadness over not seeing her sister, and through a letter she wrote stating her belief that her mother and sister don't love her because they never come to see her. Christina has also been very distressed at home because her mother has not been returning messages she leaves on her pager. Bill continues to be angry about Lisa's ongoing tendency to let Christina down and to have difficulty acknowledging the impact his own inability to set boundaries has on his daughter. Play Themes and Use of Play Materials Hiding/Guessing Christina engages in hiding and guessing games throughout the session using a variety of items from one toy shelf. She uses a number of creative ways to conceal items which include hiding them behind her back as well as underneath fabric and scarves and between her crossed legs while sitting on the floor. Christina tests out, plays with and tries on a variety of items as the game proceeds. Her need for control is evident through her voice quality and use of the flute to direct my activity. Christina chooses a ring toward the end of the session in which to play "hide the treasure". She also uses the monkey mask and the scarves as well as hides herself on the bottom of the toy shelf to escape from difficult dialogue. 98 Flute The flute was used as a form of communication during part of the guessing game. It seems to be a way for Christina to have her own secret language and to keep me guessing about her feelings. She also toots the flute while marching around the room. Video Camera Christina holds the flute in the playing position facing the video camera at first and then waves the flute in front of the camera and turns with her back to it and plays a tune. Magic During the guessing game, Christina uses the baton and pretends to be a magician who makes toys appear from behind a scarf. Camera Christina takes the toy camera and pretends to take pictures of me and the rest of the room. Doctor's kit The doctor's kit syringe is used to hurt me and later Christina heals me with the stethoscope and blood pressure gauge following her enactment of a baby monkey whereby she verbalizes "I want a mommy". Emotional Expression For the first 15 minutes of the session, Christina's mood is quite calm and stable as we take turns hiding items. However, she demonstrates increased hostility as the session progresses. Although her unresolved feelings seem to be spilling over, she is not able to communicate this directly to me. Her mood seems quite hostile as she cuts off many of my comments and blows in 99 my ear with the flute. She seems quite frustrated at times when I can't understand her flute blowing and screeching yet continues to communicate using her secret language. The following scenario develops when I express my reactions to Christina's demanding mood: 14 J: Boy, I have to do what I'm told. It doesn't feel very fun when I get bossed around like this. Does that ever happen to you? C: Growls and flings scarf. J: Do you ever feel like people are bossing you around? C: Growls more intensely interrupting J. J: You don't want me to talk about that right now. C: Puts on monkey mask and growls at J. This scenario exemplifies Christina's difficulty owning and expressing her feelings directly. This dialogue was very difficult for her to hear as she put on the mask as a way to both shut me out and conceal herself. Following this dialogue Christina continues to hide and further covers herself with scarves then engages in regressive play: C: C sits on the floor in front of J, growls, shakes her head then whimpers. J: Oh, it sounds like a little animal now. C: Whimpers again, lays on her back and kicks her legs and arms in the air. J: Or maybe it's a little baby. C: Vocalizes like a baby. J: Some kind of baby. C: Gurgles and makes a monkey sound. 100 J: A baby monkey? C: No, I want a mommy (said in a high-pitched voice) J: Sounds like you're calling for your mommy, monkey. Christina then fluctuates in and out of her role pretending to be a baby and denying that she is one. Following this she uses the flute to direct me back into the game. Later, she takes out the doctor's kit and gives me a needle in my arm. She then heals me with the stethoscope and blood pressure gauge. Christina seems to be expressing her hurt and anger over the loss of contact with her mom. Perhaps this is also a literal reenactment of some of her mother's drug using behaviour. At the end Christina seems to engage in some symbolic healing play. Therapeutic Relationship As indicated earlier, Christina's need for control is evidenced by her use of a flute instead of her voice. Diking the session, she is quite demanding of me as indicated by the inflection of her voice, her gestures and by sharply playing the flute. She seemsto enjoy the fact that I can't understand her secret musical language. I become increasingly more frustrated with this means of communication and express my difficulty in understanding her. However, she continues to blow the flute and seems to find pleasure in my lack of understanding. Towards the end of the session I ensue a monologue, as Christina listens, about how difficult I believe all the changes in her life are for her and that this is a safe place to talk about her feelings. Because we had such a long break from therapy and in light of the information I had received from her dad, I felt I needed to give her permission to talk about difficult things in the playroom and to reassure her I wouldn't have to share the information with her dad. Although she 101 doesn't really respond, she becomes more settled in her play and begins engaging with me through a hiding game and abandons the flute. Summary of Session Ten Christina brings her Elmo doll from home today and wears her sister's clothes to the session perhaps as a way to maintain a connection to family and help with her sense of loss. She continues the hiding/guessing game throughout this session. A new theme of "magic" also appears for the first time. Both of these themes seem to meet her needs for control and predictability. In addition, the theme of magic may help her to cope with the appearances and disappearances in her own life. Christina's mood is generally hostile as she engages with me in a directive and demanding way throughout much of the session and uses a wooden flute with which to sabotage our ability to communicate. She listens as I acknowledge how hard it is for her to tell me when she has hurt or angry feelings and remind her that this is a place where we can talk about them. It seems that this statement captures her feelings as she then abandons her flute. Toward the end of the session, she frequently lays on the floor and across the chairs perhaps in an attempt to feel grounded as she is having difficulty containing her emotions. Christina has difficulty ending the session again today as she tries to extend our play and then bumps her head. When leaving the playroom she attempts to take some sport medals with her. 102 Session Eleven Information from home Prior to our session today, Bil l informed me that Susan has gone through detox and is now living with them again. He is relieved to have her home and his effort to look for a drug rehabilitative program for her is taking up a good deal of his time. Bill noted that there has been increased disruption at home due to the discord between himself and Susan and also because Lisa showed up unexpectedly and then left again. Bil l is unable to locate Lisa now and continues to be angry with her due to her influence on Christina's and Susan's struggles. At the end of the session, Bil l informed me with great relief that the stalker had been sentenced to one year in jail and his motivation to move quickly has subsided somewhat. However, he is still looking for a new home for himself and Christina and now plans to move once therapy has ended. Play Themes and Use of Play Materials Hiding/Guessing Once again, Christina begins the session in a safe and controlled way playing hide the ring. House-tree-person drawings Christina was very resistant to completing the questions and therefore they had to be conducted across two sessions. However, for the purpose of continuity, they will all be discussed here. House. Christina draws her house very quickly and again as in session two uses pencil at first and then colours the entire house with a blue felt pen (Fig 4.6). As in the first series of H-T-P drawings, her house is less detailed than you would expect of a child her age. It has only one window 103 and a very small door that she has coloured over in blue making it look quite inaccessible, barren and bleak. It contains little colour, no natural elements, and lacks life, a sense of warmth or welcome. This picture may reflect the tentativeness of Christina's present home and the lack of security, warmth, or permanency she finds there. Again, this house, like the first one, is not House touching the bottom of the page which can illustrate a lack of groundedness in the illustrator. In addition, this house also lacks a chimney, possibly indicating an inability to express emotions which has definitely been my experience of Christina. Christina states that this is her uncle Peter's old house. By her description I believe that it was a symbol of warmth and nurturance for her as she used to spend a lot of time at their home but indicates she doesn't see them anymore. Christina describes her house as happy, but laughs and says she never saw it talk. She does not indicate wanting anyone to live in the house yet says she wants to have binoculars and to live in a room upstairs. A similar wish was also expressed in her previous house drawing. She indicates that the house needs cleaning up which may be symbolic of her confusion in an "untidy" environment. Tree. Christina's tree drawing (Fig. 4.7) seems less solid and grounded than the previous tree but was drawn quickly with little care. Christina's second tree also has an abundance of green foliage which may indicate a potential for emotional growth, however the colour is less vivid than the previous drawing. Christina reports that her tree is a lucky tree, then says it is a nothing tree and writes "nothing" in purple on the green foliage. The tree lives in heaven and F ' P ^ 4 7 Tree 104 is not alive. She indicates that it is healthy and gives out food to people. The season is winter and the weather is snowy. She says that no one has ever hurt the tree. Christina suggests that what her tree needs most is to be mad and that it likes to be grumpy. Christina's responses seem to reflect the anger that she has indicated in previous sessions as well as insecurity and a lack of emotional expression. Person. While beginning the person drawing (Fig. 4.8), Christina indicates that she is not good at drawing people. She proceeds to draw a quick stick figure that is very immature in form and although it is more evenly proportioned than the previous one, lacks detail including a second eye and legs. She scribbles over the mouth and later writes the word "He" across the face of the figure. The scribbling in purple pastel and the word "felt" is printed later when she begins to sabotage the activity in an attempt to regain control. If this drawing is presumed to disclose how a child is feeling physically and emotionally at the moment, Christina's stick person seems to reflect a lack of groundedness and power due to the absence of legs, feet and hands. In addition, her drawing lacks ears and an eye. As has been indicated in previous sessions, Christina often denies hearing or seeing events in her life that are painful. Again as in the previous person drawing Christina disfigures the face, which may indicate a self-image that feels messy and incomplete. Christina indicates that the person is her uncle Peter who is dancing and that he needs felts, then writes "felt" at the top of the page which seems like an attempt to distract from the process. As Peter is her mom's brother, it may trigger memories and thoughts of her mom. Christina suggests that the person has never been hurt. She says he feels happy because his wife is going to have another baby. These drawings and in particular the questions appear to be too emotionally triggering for Christina perhaps as a result of all the uncertainty she is currently experiencing. 105 Therefore, I reiterate the tentative nature of my interpretations and I caution the reader regarding further interpretation of either the drawings or the questions. Baton Christina refers to the baton as her "magic stick" and takes it with her to the table when it is time to complete her drawings. It seems to be both a source of security for her as well as a means of distraction. Christina uses the baton in a number of ways during the drawing process and throughout the session including balancing it on her nose, swinging it over her head, using it to dance with and pretending it is a musical instrument. Chair Christina uses a small chair to comfort herself and to distract from a difficult topic of conversation following her request to leave the playroom early. She holds it over her head, climbs on it and eventually lays under it while we talk about moving. Emotional Expression Christina giggles happily throughout the hiding game at the beginning of the session, however, her demeanor makes a drastic shift when I ask her to complete the house-tree-person drawings. Although she quickly and easily completes the drawings, the questions appear to be too emotionally triggering and she engages in several different distraction tactics including balancing the baton on her nose, switching topics and evading the questions. At one point she begins to yell her responses at me and when I reflect her anger she replies "No!" and continues to answer "No" and "Nothing" to the remaining questions, scribbles on her person picture and her behaviour begins to regress. I eventually give her the option to finish the questions the following week and comment "I think you're not feeling like you want to do this right now" and she replies " I want to go to school." When I let her know it is not yet time she lets out a scream. Her behaviour then 106 fluctuates rapidly from singing to dancing to laughing and yelling and she is unable to regulate her emotions. Moments later, when she observes me putting her name and date on her pictures, she states "I'm a month" and a conversation ensues about birthdays. When I suggest it will be her birthday in six months she replies "And I will be long gone. I will be in Ladner." I ask her what she thinks about moving and she replies "It's nice out there". She tells me she likes the sunshine and mentions her baby sitter who lives out there. She then tells me that she will not be able to go to her daycare either. When I wonder if she has any worries about moving she replies: C: Nope. Oh great, but the bad thing is that Spook (her dog) might not be able to come... And the cat. We have to give them away. J: The dog and cat both? C: Ya. And I've had them for a long time (sounds disappointed). Since he was a puppy, puppy, puppy. J: That would be very sad. C: Ya. J: You would miss him. C: Yaaa. I'm going to let Spook come though. I'm going to tell my daddy cause he won't listen to anyone else. So I'm going to stay here [if Spook can't come with us]. As Christina continues her story she climbs on and around the chair and then ends up laying on the floor with the chair on top of her. She tells me that, her dad is going to ask the owner of their new place if the dog can live there. She claims that if the dog is not allowed, then they will live in a bigger house and her dad will try to arrange for her dog to stay with them. Christina then asks again if she can go see her dad. Understandably this is a very difficult topic for her to 107 maintain due to the potential losses she will face if they move. It appears to have been triggered by the drawings and seems to be a great source of anxiety for her. Therapeutic Relationship When I request Christina to complete the house-tree-person drawings and ask if it is okay for me to make a decision about what we will do she replies "I don't care". It appears however, as she completes her drawings, that she would prefer to continue to have control over the session as she becomes evasive about her answers to the questions. I believe the potential losses she will face if they move are impacting on her desire for control. Summary of Session Eleven Christina's degree of emotional lability, her inability to complete the H-T-P, her desire to end the session early and her attempts to take items from the playroom may result from several recent emotional disruptions in her life including the reunion with her sister, her father's attentiveness to Susan's drug treatment, her mother's recent appearance and disappearance as well as her father's plans to move. The house, tree and person images and accompanying responses seem to represent a child whose environment lacks warmth and security, who is not well-grounded, lacks emotional expressivity and is strongly defended. As indicated earlier, the disruption during the drawing and the incompleteness of the questions make it difficult to make any definitive interpretations about Christina's images. However, their quality and tone are similar to the drawings done previously and my interpretations are reflective of the observations and hypotheses I have made throughout the therapy thus far. 108 Session Twelve Information from School Due to the recent changes in Christina's life, I called her school counsellor to see how she has been coping at school. She reported that Christina has been hiding at school and not going to class and when caught will often break down and cry. Her counsellor remarked that although Christina's home life is often unstable and unpredictable, she has been resilient in her ability to cope and is in fact learning at school, however this has not been easy for her. Christina continues in a couroelling group at school and is making progress in her ability to express her feelings in this group setting. Her counsellor noted that the one-to-one contact she has had with Christina in the past has always been too intense for her but she is opening up within the group as she sees her peers modelling self-expression. The counsellor is aware that Bil l is thinking of moving to Ladner and she reports that Christina has told her she doesn't want to move because she will miss her friends. Of note also was that Christina is very upset because her best friend has been forbidden to play with Christina as her mother is concerned about the negative impact Christina's family's lifestyle may have on her daughter. Play Themes and Use of Play Materials Hiding Game Christina chooses to take turns hiding the necklace. Burying/Uncovering/Loss Christina first lightly buries the necklace in the sand tray and indicates for me to look there. I sense that she has made it easy for me to find as it is partially revealed and very near the surface of the sand. 109 Moments later, Christina indicates that she has thrown the necklace and doesn't know where it is. She suggests we look together in the sandtray and when it is not found indicates that it is lost. She then "discovers" it in the chimney of the dollhouse. Dollhouse I draw Christina's attention to a new doll house that has been added to the playroom. She looks towards it, says "Wow" but does not approach it. Christina has paid little attention to the previous doll house except to use some of the items during the guessing game. I sense that this medium would conjure up feelings about her home and family that she wishes to avoid. Cape Christina notices a new dress up cape and puts it on. She briefly puts on the matching head piece, but removes it. The cape remains part of the play for the duration of the session. Baton Christina uses the baton and pretends to be blind while looking for the necklace. She also uses it as her "magic stick" and tries to turn me into a number of different animals. Flute Christina plays the flute periodically throughout the hiding game while I search for the necklace. It is also used to distract from my feeling reflections and to communicate the whereabouts of the necklace. Phone Christina brings out one phone for each of us and "phones" me to distract from a discussion about feelings. 110 Xylophone This instrument is initially chosen to distract from my conversation about difficult feelings. Christina then has us take turns using it to make music. Emotional Expression Christina giggles and seems relaxed during the guessing game, however then appears to become bored. I suggest that there are other things we can do if she ever tires of playing this game. She proceeds to "melt" to the ground following this statement and lay on the floor then turns me into a variety of animals using her "magic stick". I get the distinct impression that she is feeling hurt and rejected as a result of my remark. I realize what I have done and acknowledge how much she likes this game and give her permission to continue. I then state "Sometimes I think it's easier just to do the same thing isn't it" and she nods in agreement. I then begin "I think it feels..." and she interrupts my statement by playing the flute. She is able to acknowledge the comfort she gets from the sameness of the game, however is triggered immediately upon hearing about her feelings. Throughout the rest of the session Christina uses a variety of means to distract from and deny my feeling reflections. When I make a comment about Susan being home and that I imagine it has been a difficult time for her she denies it and frowns. She picks up a phone, begins talking in a high-pitched baby voice as she phones me and then hangs up. I sense this is her cue that she would like the conversation to end. As I reflect, "She doesn't feel like talking... about hurtful things or scary things or worries" she begins playing the xylophone and then responds in a high- pitched voice "No, nothing like that we are not talking on the phone." Clearly, the phone was used as a vehicle through which to reject my statements, deny her feelings and protect against her sense of vulnerability. I l l Christina requests that we take turns playing musical instruments and begins playing the xylophone in a very loud and aggressive manner. I label her "angry" music and spontaneously begin conducting her to switch between "angry" and "calm" playing. Although this activity was not following Christina's lead in true child-centred form, I believe she was able to respond angrily through the instrument thereby releasing some of her pent up emotion as evidenced by the gritting of her teeth and her tendency to get her whole body moving as she banged loudly on the keys. Therapeutic Relationship Several times during the session Christina makes overt attempts to engage with me and to seek my acknowledgment of her. When beginning the hiding game, she pretends not to know where the necklace is and elicits my help and later in the session when playing the musical instruments directs me to take turns with her. When Christina tries to get rid of me using her magic stick I definitely sense her feelings of rejection as they are transferred to me. I believe that through my attempts to overcompensate for the difficult session Christina had last week completing the house, tree and person drawings as well as my own feelings of inadequacy, I was reflecting feelings that were too intense for her to acknowledge and as a result she was distracting from them and disengaging from me. Christina's need for control continues as evidenced by her attempts to silence my reflections. She seems to enjoy her role of conductor which provides an avenue for her to feel in control in a safe and nonaggressive way. Summary of Session Twelve I was pleased to hear that Christina was beginning to express herself in the group counselling setting and wondered how her work with me has impacted on that progress and vice versa. 112 In attempting to complete the H-T-P questions, Christina tells a number of stories to shift from discussing family and self-related issues that are emotionally triggering. During the session she engages in a variety of avoidance tactics such as playing the musical instruments, talking over my words, hanging up on me on the telephone and concealing herself with clothing. Overall, Christina was trying hard to regain control of her emotions during the session as indicated by several attempts to leave the session early today. I sense a continuing ambivalence to open up and trust me with her feelings. Perhaps, due to the number of recent changes and disruptions in her life, she continues to uphold her protective defenses in an attempt to cope in a confusing and unpredictable world. Session Thirteen Play Themes and Use of Play Materials Games Christina engages me in some magic tricks as well as a game of "Go Fish". There seems to be a shift in her game playing during this session in that the games are less about competition and more about demonstrating her competency and ability to alternate between control of the outcome and coping with the unexpected. This transformation seems to bring Christina into a fourth phase of therapy. Hiding/Guessing Christina requests to play the game of taking turns guessing objects chosen from the toy shelf. She hides them behind her back as well as under the scarf and cape. Danger/Loss Baby eagle flies, becomes hurt and then dies. Later it searches for its mommy. 113 Magic/Loss This theme emerges in a more extensive way than in previous sessions as Christina demonstrates some magic tricks using cards, scarves and the baton and then teaches them to me. She also requests me to teach her a magic trick. Christina pretends to make a bunny appear from a hat. Sandtray Christina uses the sandtray to demonstrate a magic trick using the baton, scarves and playing cards. Large Bear and Pillow Christina notices that these items have been unexpectedly removed from the playroom. Baton The baton is used during the guessing game to point with and as a cane. Cape Christina first puts the cape over my head to hide my eyes. Later she puts on the cape and then a crown and tells me she is the queen of New Brunswick. Baby Eagle Christina flies the baby eagle toward me and has it "hurt" me. The baby eagle dies, comes to life, then searches for its mommy. Bunny Christina has the bunny "appear" from a hat and then has it bite my mouth. Death , Christina announces "I'm a dead person" and then looks for her "cane". She also puts the baby eagle on top of the baton and says "Dead person hangs himself'. 114 Emotional Expression Christina demonstrates a transformation into a fourth therapeutic stage as she accepts more feeling reflections, acknowledges a few difficult feelings relating to her current struggles, expresses less anger, and indicates some positive and hopeful feelings about herself. She seems more joyful in the session as she laughs with ease, makes rhymes, sings and is more able to ask for what she needs rather than becoming frustrated. In addition, she seems more accepting and confident as she indicates that the cards are "perfect" for her magic trick and then successfully demonstrates her card tricks. Also, she instructs me not to worry if I'm not successful completing her trick, accepts not being in the lead during the "Go Fish" game and makes positive self statements when she is winning by saying "I'm magic" and "I'm lucky". Christina's pride in her self-image is reflected when she shows me her new bracelets and painted nails and checks herself in the mirror when putting on a hat. Christina also demonstrates acceptance when she realizes that the large pillow and bear, which have been her comfort objects, are now missing from the room. I disclose my own sad and disappointed reaction upon discovering that my colleague had thoughtlessly removed them and thrown out the bear. I anticipate that she will also be very disappointed, however, she listens to my explanation about their whereabouts, seems content and shifts directly into the guessing game. During the guessing game Christina enacts a scenario whereby the baby eagle hurts me, dies, comes to life, then searches for its mother. When reviewing the videotape, due to the ominous and confusing quality of this scenario, I wondered if it was a symbolic reenactment of a specific experience with her mom that involved danger, confusion, hurt, lack of safety and loss. This scenario seems to be very triggering for her as following this she immediately shifts back into the game but seems agitated and both physically and emotionally disregulated. 115 After acknowledging that it feels like a mean trick when her mom disappears in the night, Christina demonstrates a magic trick whereby her theme of loss has a more positive resolution than has been expressed in past sessions as indicated in the following: C: It's going to disappear. J: It is. Wow, I like it when things disappear (not reflective of her experience!). C: And you might not ever see it again. J: I may not ever see it again. C: Say goodbye to the card. J: Goodbye card. You might be gone forever. I hope you'll come back and visit though. C: Giggles (releases emotional tension). It's going to the magic place. J: The magic place. C: The magic world. J: The magic world far away. , C: Okay (performs trick). At first the trick does not work and then Christina repeats it and eventually the card "disappears". Christina then redoes the trick and has the item eventually appear. I wonder if this magic trick is a way to feel a sense of control over her own experiences of loss. Therapeutic Relationship Christina makes several overt attempts to connect with me during this session. For instance, I choose a bracelet to hide and Christina remarks "Yeah. That was my favourite bracelet". Also, while setting up her magic trick she instructs me not to look but suggests that I can talk. For the first time, I feel that she is seeking verbal interaction from me and I wonder whether she is beginning to seek comfort in my reflections. 116 Our interactions are more cohesive during this session as I sense a greater ease and openness between us. We make full eye contact and smile reciprocally on many occasions. Christina spends less time in competition or in control of the session. As she performs her magic tricks I assist her and then later she teaches them to me. We are also within very close proximity, closer than we have been, as she assists me in preparing the materials and carrying out the trick. I respond to her demonstration with much interest and enthusiasm and remark "you're magic" when she is done. She seems to radiate a feeling of omnipotence. There seems to be a shift in trust and the development of empathic feelings toward me. Christina directs me using a gentler and less demanding tone, is helpful during the games and apologizes when she accidentally hits me with the baton. She asks me if I want some clues during the guessing game, then seeks acknowledgment when she provides them. During the game of "Fish" she reminds me not to show her my cards and is accepting when I am in the lead. This seems to indicate a greater trust in me as well as in her own ability to cope with trickery and the unexpected. In addition, she has no difficulty with termination as has been evidenced in the past several sessions. Summary of Session Thirteen Christina enters into a fourth phase of therapy during this session as indicated by a shift in her play themes, greater trust in the therapeutic relationship, less anger and increased emotional expressiveness and competency. Christina continues with the guessing and hiding game at the beginning of the session but shifts into a new theme of magic which is less focused on competition and control and instead she uses it to demonstrate her competency. The magic also appears to be a symbolic way for her to be in control of appearances and disappearances and to learn to cope with the unexpected. 117 The therapeutic relationship involves more reciprocal interactions and a greater degree of physical and emotional connection. Christina is less demanding of me, demonstrates increased empathy and also makes more overt attempts to connect with me without demonstrating vulnerability. Unresolved issues about home and family continue to be expressed on a symbolic level using animals as well as through transference to the therapeutic relationship. Session Fourteen Play Themes and Use of Play Materials Games Christina uses a wider variety of games during this session to show her competency. The guessing game is played during the first half of the session whereby Christina hides items behind her back and under scarves. She also engages me in a quick game of catch, a battaca battle and then a baseball game during the last half of the session. In the last few minutes of the session, Christina engages in a staring contest with me. Baton Christina finds her "magic stick" and uses it throughout the guessing game to point with. Later she calls it a "lucky wand". She also wraps it in scarves and uses it as a way to relieve tension as she swings it in the air during the guessing game. Scarves Christina drapes scarves over me as well as herself as a way of hiding our eyes during the guessing game. She also creates a "Royal Chair" using scarves. 118 Wolf Puppet The wolf has a prominent position on Christina's "Royal Chair" and is adorned with scarves. Crown Christina wears the crown and also places it on her royal chair. Video Camera Christina looks through the video camera to see what her royal chair looks like. Camera Christina takes a picture of me wearing the crown sitting in the royal chair. Emotional Expression Overall, Christina is in a happy and playful mood today. She giggles and laughs throughout the game playing. She hums to herself several times during the session and shows relatively no frustration or anger. She talks excitedly about an upcoming trip to visit her grandparents in Alberta. Christina demonstrates pride and dances excitedly when she shows me the "royal chair" she has decorated with scarves. During the guessing game she requests that I hide under the scarves. I indicate "it's hot under here" and she tells me to have patience. As in the previous session, she seems to be more able to regulate her own emotions and therefore tells me to do likewise. During the baseball game, Christina uses the sword as a bat and swings with great force, often gritting her teeth. This activity seems to be an emotional outlet for her as she laughs freely throughout. When I ask her what she does at home when she gets angry she tells me "I squeeze my pumpkin (a squishy ball)" and indicates that it helps with her angry feelings. Although she switches away from this topic when I question her too much, she admits to having angry feelings for the first time. 119 Therapeutic Relationship Christina continues to demonstrate greater trust and empathy toward me. She allows me to put scarves over her head during the guessing game, shows interest in how I made the scarves and then indicates that I don't have to put them over my head because they are too hot. She places me in a very special position as the queen in her "Royal chair". When she completes the decoration of the chair with scarves, I compliment her beautiful creation. She is very excited by my reaction and requests that I sit in the chair so she can take a picture. It seems to be a symbolic gift giving as I believe she made it especially for me. For the first time I sense that she is feeling more empowered, less vulnerable, and is able to give a part of herself to me. This was a very touching moment for me as I realize that she has internalized the special nature of our relationship. Following this activity she switches back to safer game playing perhaps because she is feeling too vulnerable. She quickly identifies with me again when she stands on a chair during the game of catch and indicates "I'm as tall as you". She giggles and enjoys the interaction throughout the rest of our game. During the staring contest that Christina initiates, it brings us within a very close proximity for an extended period of time and she becomes very giggly and has difficulty stopping. She suggests that we look into the mirror instead of each other's eyes but this is not successful either. She then announces that it is time to leave so we should clean up. It seems as though she is wanting to have this intimate connection to me but perhaps she is still too self-conscious. At the end of the session I give Christina the lucky penny that was found in the playroom. Because she told a fib about the penny initially, I realized how much it meant to her and I wanted to honour her wish. I think it was my way of acknowledging my unconditional acceptance of her as well as expressing my wishes for good luck. 120 Summary of Session Fourteen Christina continues in this fourth stage of therapy to demonstrate competency through game playing in addition to greater creativity. The emotional content is mostly positive and as in the previous session, Christina demonstrates increased ability to regulate her emotions. Her mood is light and playful as she frequently giggles, laughs and hums to herself. There is relatively no expression of anger or frustration and she is able to describe a positive outlet she uses when angry at home. She appears less vulnerable and more confident and as a result her tendency to present a more genuine self is more apparent. Christina is seeking greater intimacy with me through physical closeness rather than emotional expression and seems to be internalizing the special nature of our relationship. She continues to have difficulty expressing her true feelings about her mom and family issues and to shift the focus away from these discussions. However, she is better able to manage her emotions and does not regress or become disregulated at all during this session even when talking about her mom. Session Fifteen Play Themes and Use of Play Materials Games Christina continues to engage me in a variety of games throughout most of the session including hide the necklace, a battaca battle, catch and volleyball. Nurturing/Danger/Protection Christina regresses and takes on the role of a baby dog named "Moofy" who has a number of different pets who are both aggressive and friendly. 121 War/Good/Bad Christina sets up an army of soldiers and has them guarding a gate and a magic bridge from the enemy. During the soldier battle Christina discusses the "good" and "bad" guys and there is some confusion as to who is who. Death Christina pretends she goes "back to the dead" and buries herself under the large pillow. She talks of her soldiers being killed during the miniature war she creates. Large Pillow Christina hides her eyes in the pillow and also pretends to be buried under it. Dressup Christina briefly dresses up during the guessing game while waiting for her turn. Snake This is used as an aggressive object during her dog role play. Emotional Expression Christina is playful and joyful during the guessing game. Following this activity she appears fidgety and somewhat anxious as she switches frequently from one activity to the other. I make note of her difficulty staying with one activity and wonder whether she has things on her mind. She indicates that she is thinking of several events including going to a baseball game with her sister, her family coming to her sports day, and a trip to Alberta. As we discuss her upcoming family reunion in Edmonton, I comment that it is nice to have fun things to look forward to and she doesn't respond. Although Christina presents these events as fun on the surface, they all involve depending on family members and given Christina's history, I wonder whether she is feeling ambivalent as she anticipates disappointment and loss. 122 The theme of nurturing/danger/protection emerges again as in stage one of therapy however, Christina engages in the role herself during this session. Following a discussion about her hopes for her mom to come to sports day, Christina regresses into the role of a baby dog who has a number of pets. She first states that "Moofy" the dbg doesn't like me and then that Moofy does. Moofy has a number of pets who are both aggressive and friendly. This role play changes rapidly making the themes difficult to discern. To me this scenario reflects strong ambivalence between what is safe, what is dangerous and who can be trusted. Nurturing play also evolves as she cares for the pets, bathes and feeds the snake and tells me to "Be very careful" with the horse. She seems to be stating symbolically her needs to be treated carefully, protected and nurtured. Towards the end of the session, following a discussion about her mom, Christina uses miniature soldiers to guard a magic bridge and only she is allowed to cross it. As the good guys cross the bridge the bad guys are shot off. She continues to shoot and stab the enemy until they are dead. She has two figures hug and rejoice as they say "Ya, for ever you killed him, no more". I began to wonder if the bridge was the access to her good feelings and the battle that ensues was a way to work through her ambivalence. Therapeutic Relationship At the beginning of the session as in the past two sessions, our relationship involves reciprocity and sharing and my role is no longer as a competitor, but rather as a playmate. She demonstrates competence through her game playing and allows me to take some pictures of her as she poses with the baseball bat and with her bear, "Doodles" from home. She is helpful and respectful during the hiding game which seems less about hiding and more about engagement. During the battaca battle she states "We can't stop this time. Until I say stop". She is less inhibited 123 than last session during the battle and is able to continue for an extended period of time until she tires of it. About halfway through the session, Christina begins to express anger and disappointment and no matter how hard I try I can't seem to perform according to her needs. Several times she directs comments at me such as "You're not supposed to throw it so high" or "Not like that!" and eventually abandons the games. During the "Moofy" role play her anger, confusion, and ambivalent feelings of good/bad are expressed symbolically and transferred to me. Summary of Session Fifteen Christina brings her "Doodles" dog to the session today possibly indicating a need for extra comfort and security. She engages in a number of games and at first seems happy and joyful but as the session progresses she becomes more demanding in her directions and switches frequently from one game to another. Upcoming family events and a holiday seem to be on her mind and possibly triggering many ambivalent and difficult feelings. Christina's first role play and miniature war scene both reflect themes of danger, protection, and ambivalence. When engaged in her miniature play Christina seems to struggle with leaving the session. I believe her statement "I don't have to clean up" is an indication that she experiences rejection upon ending prior to her play being complete. Session Sixteen Play Themes and Use of Play Materials Drawing Christina begins the session requesting to draw but sits talking to me and does not produce a picture. 124 Games Christina's predominant activity during this session is games, however less time is spent playing than talking with me. She begins the guessing game by having me guess the items she has chosen. She changes to hiding some jewelry and giving each other "warm", "cold" and "hot" clues. Following the ending warning she chooses to play catch. Baton Again the baton is used as Christina's "magic stick" during the guessing game. Large Pillow As in previous sessions the pillow is used for comfort and for hiding her eyes during the games. Happy/Sad Clown Christina hides the clown puppet during the guessing game and we discuss the expressions on its face. Emotional Expression Christina expresses pride and competence during the guessing game as she asks not to have any clues and then she quickly finds the item and bounces on the spot grinning broadly. Also, when she notices that the sinks in the playroom are full of water she states "I can get it" and successfully unplugs one, then states "I did that one. Maybe I can do this one." I believe she felt very empowered accomplishing something I was unable to do myself. Christina continues to have difficulty expressing feelings of hurt, sadness or anger directly. As was indicated in earlier sessions, she demonstrates these feelings by drawing attention to her physical state when she tells me she has had a cold, sore throat and flu for the past two weeks. Also Christina hides the happy/sad clown and when she exposes the sad face I comment "Oh, 125 clown, what made you so sad. Why are you crying clown?", Christina replies in a high-pitched voice, "No, he's happy." She waves the scarf at me and then demands "Okay, get on the point here". Later when the puppet is used again, I make reference to the happy and sad face and Christina picks up the puppet, throws him in the air and lets him drop to the floor and then switches games. At the end of the session I ask how sports day was and she distracts from this topic by telling me I can't make a sound. Later, I find out that nobody came and I tell her I am sorry. She distracts from this topic and begins talking about her sister and her friends. She eventually tells me her mom had to work and is not triggered by this conversation. When I reflect how disappointed she must be she looks directly at me and states "No... She had to work". She tells me her god- mother came instead. Christina continues to protect her mom, however perhaps her sense of disappointment is reduced as she has learned to cope by having fewer expectations of her. Therapeutic Relationship Several times during this session Christina makes overt attempts to connect with me. She tells me about her weekend sailing trip with her aunt and uncle to an island I have also been to and she compares my experience to her own. She seeks my acknowledgment by asking me to watch her catch a piece of jewelry and later takes my picture. Christina also attempts to impress me with her knowledge about Mt. Everest and K2 at the end of the session. Although there were these attempts to connect I sense some pulling and pushing away in our interactions today. During the games she accuses me of peeking, demands that I go to the corner and hide my eyes on two occasions and makes several oppositional comments following my content reflections of her play. She also tests my reaction when she shines the flashlight in my eyes after I have told her it can be hurtful. 126 Summary of Session Sixteen More of this session is spent either discussing events in Christina's life or rules of the games rather than in actual game playing. Christina makes several attempts to connect with me through questions about a place we have both visited, seeks my acknowledgment of her physical and intellectual abilities and accepts my praise with pride, however continues to disengage demonstrating her ambivalence. Christina continues to have difficulty addressing difficult feelings, to offer wishful stories about herself and her family, to seek my acceptance and to deny the distressing realities of her life. I realize when reviewing the video tape that I ask a lot of questions of her during this session. Perhaps this results from my awareness, as we near the end of therapy, that her therapeutic work is not done and I am attempting to push for resolution of some of her remaining issues. Session Seventeen Information from Home I spoke briefly with Christina's Dad before the session to discuss the possibility of meeting with her mom prior to the end of therapy. He gave me Lisa's pager number but cautioned me that she probably wouldn't show up. I phoned Lisa and left messages on two occasions within the next few days and never received a reply. Bil l advised me that their trip to Alberta is planned for four weeks time. I informed him that because I will be finished at the clinic before they return, I will begin termination with Christina today so that we will have four sessions to process the ending of therapy. 127 Play Themes and Use of Play Materials Games Christina sets up volleyball, golf and baseball. Sink/Rescue During the golf game, Christina places fabric on the floor to represent water and indicates that if one of us gets the ball in the water the other person retrieves the ball and frees the other player. Aggression/Devil/Wolf Christina dresses up in a cape and announces that she is the "mean devil" who lives in a cave which she creates with fabric under the table. She shifts rapidly between the characters of devil and wolf while expressing a lot of anger at me. This role play ensues following discussion about her mom as well as termination of therapy. Cat Puppet Christina uses the cat puppet as her "mean pet kitty" during the wolf/devil role play. Fabric/Scarves The scarves are used to make a volleyball net and a variety of fabric is used for water during the golf game, to make capes and to create her cave. Danger Christina sets up a miniature army of "trolls" who are attacked repeatedly by a lion who continues to come to life. In this scenario there is a pervasive sense of danger. War/Enem ies/Loy alty/Am bivalen ce This theme transpires twice during this session using two different play mediums. Christina has us don capes and at first says that we are going to play baseball and that we're enemies. She 128 then suggests that she is the black devil and I am the red devil. Later in the session Christina uses coloured miniatures to set up armies and discusses being on two teams. Everyone dies in the end of the scene. Emotional Expression Although Christina expresses a positive sense of satisfaction in the volleyball net she constructs by remarking "There, perfecto", the majority of her expression today is anger. As we are fixing her cape during the devil roleplay the following dialogue develops: C: (Growls) J: Are you growling as the devil? C: Ya. J: Are you an angry devil? C: Yes. J: What makes the devil angry? C: Ahhhhhh. (Doesn't respond, twirls around and hides under cape.) Moments later stands up. C: My mom is coming over this weekend. My dad's going to pick her up. J: Is she? She's going to come over to visit. C: Uh, hmm. J: You sure look forward to seeing her don't you? C: No response... I think I'm going to fix my house. I'm still the devil you know (puts another scarf over her head). Christina continues to distract from talking about her mom on a concrete level and to have no conscious access to the anger she feels toward her. 129 Following my discussion about termination, Christina does not verbally express any anger but continues in her role play as a "mean devil" who lives in a "very nasty cave". She chooses the cat as her pet and indicates that he is a mean kitty. She asks me to babysit her kitty and when I ask how to take care of it she informs me that the kitty will let me know. Christina then lunges the kitty toward me, growling. She gives the kitty to me and then continues growling, rolling on the floor and lunging at me. As I reflect the activity of the devil she tells me she is now a wolf and continues growling and lunging at me. She then switches from a devil to a wolf so that I make incorrect reflections about her character. As she continues in this intense and disjointed play I ask: J: Is the devil always mean and angry? C: Grunts and nods. J: Yes. The devil never feels like being nice and kind. I wonder what made the devil feel mean and angry? He feels so angry all the time. Maybe the devil hasn't been taken very good care of. Maybe people have hurt the devil before. C: Growls more intensely and knocks over the chair. J: The devil is really angry now. The devil is angry about something...Are you angry with me devil? C: Growls and lunges toward J. Christina continues to express her anger at me in her role of the wolf/devil. I wonder out loud if I did something to make the devil angry. Christina lays on the floor silently, face down as if to shut down her feelings then abruptly gets up, growls some more, then states "Let's play ball" and giggles self-consciously. I ask her if she is back or if she is still the devil. She tells me she is back and that all the anger is gone to the devil. She then asks me how much time we have and appears anxious to leave the room when I tell her there is still 15 minutes left. 130 Although not addressed directly, I believe that this intense display of anger was a reaction to the termination of therapy. My reflections at first indicate that I thought the display of anger was a projection of her feelings toward her mom and did not reflect the anger she may be feeling toward me due to the therapy ending. I do not believe that Christina would have been able to address these feelings directly due to her need to protect herself from hurt and vulnerability. Therapeutic Relationship The discussion of termination seems to intensify Christina's ambivalence toward our relationship. When I inform her that we have four more sessions together she flings a toy she is holding. I indicate that I am feeling sad and I am going to miss her and in an attempt to ease her pain I comment "We've had lots of fun together in here" and she responds "You have?" I missed addressing her ambivalence but I believe her response indicates disbelief that I have enjoyed being with her because her ambivalent and difficult feelings have often been manifested through her attempts to disengage from me. In an attempt to process Christina's feelings about termination, I ask how she is feeling about ending soon and she tells me she doesn't know. I tell her that sometimes it's sad to say goodbye to people. She disregards my statement and continues enacting the play with miniatures and has the horse kick down and kill one of the soldiers. I attempt to continue this conversation again and tell Christina that I am leaving and will be replaced by someone that she will meet before she goes on holidays. She finally engages in conversation and asks me where I am going and why I have to leave. I explain to her again as I had in the beginning of therapy that I was at the clinic as part of my training for university and my work is fmishing shortly after she leaves for holidays. I again express my sadness about leaving and she continues her play and states "The black guys are against the white guys." 131 Christina then engages in some safer play sorting the miniatures and talking about her favourite colours. To my surprise she asks "How many girls do you see here?" I tell her that I see one other girl and Christina is surprised that they are the same age. It seems that she was questioning who else I see as a way to deal with the separation and to assess my loyalty to her. She continues talking about the teams she is sorting and states "You can be on the same one as me if you want." This is a touching moment for me as I believe this statement indicates a sense of resolution around her feelings of anger and rejection due to the pending termination. Christina seems to indicate the sense of support she feels from me as she requests that I be "part of her team". Summary of Session Seventeen Christina's reaction to my news about our pending completion of play therapy brings us into the fifth and final phase of treatment, termination. Although she doesn't discuss her feelings about ending on a conscious level, the increase in Christina's testing behaviour through aggressive play toward me indicates that she does not take this news well. As I experience her anger I feel torn due to my recognition that she is not ready to finish therapy. However, due to the timing of her holidays in conjunction with the ending of my clinical practicum, our relationship must terminate. I plan with Christina when she will meet my replacement and inform her that she will have a new therapist here in the event that her family doesn't move. Christina's ambivalent feelings about relationships continue to emerge in her play. During her miniature battle she struggles to decide what team she is on as the war between the teams ensues. Perhaps these wars are an indication of the internal struggle she experiences due to her efforts to make sense of her family loyalties. 132 Session Eighteen Play Themes and Use of Play Materials Sandtray At the beginning of the session the sand is manipulated while talking about her family, her dad's new girl friend and her pending holiday. Games During this session, Christina engages me in "I Spy" and "Hide the treasure" using a ring. Hiding Christina hides herself under the table and behind the large pillow while I hide the ring. War/Rescue/Loss Christina plays war using a variety of miniature figures. The Captain is killed off and the most powerful character is rescued by the pterodactyl who later also helps a cowboy retrieve his stolen ring. The cowboy is then lost on a deserted island and is able to get himself across the water using a bicycle. Unlike the war in the previous session where everyone dies, this scenario ends in a positive way and the main character gets help from a bird to retrieve his lost ring and is then able to rescue himself from his aloneness. Chair Christina positions herself on, under and around the chair during the "I Spy" game perhaps for security and as a way to remain emotionally grounded. Large Pillow Christina carries the pillow during the hiding game and also lays on it in the middle of the floor. Later, she remains on the pillow guessing where the ring is hidden by pointing to various 133 items in the room. Christina also buries her face in the pillow to distract from my feeling reflections. Emotional Expression Christina's energy level is lower today as indicated by the amount of time she spends laying down on the pillow during the session. She seems to have difficulty regulating her body as she is agitated, paces around the room and bounces under the pillow to hide her eyes and hits her head. It would appear that the number of pending losses she expresses today may be impacting on her energy level. When she enters the playroom she informs me that her dad has a new girlfriend and then to avoid talking about it tells me she is going to Alberta soon and that her cat is going to be given to her grandparents. She then resorts to game playing before I get a chance to discuss her feelings. On two other occasions during the session she avoids conversation about her dad's girlfriend by changing topics and hiding her head in the pillow. In discussing their possible move Christina reports that she feels "okay" about it but uses a high-pitched voice. She acknowledges that it will be hard to leave her friends but adds hopefully that her sister is going to get a car and drive her to visit them. Christina later admits that her mom didn't visit her and claims that she is not disappointed because she had to work. Her anxiety about this topic is evidenced when shortly afterward she asks if her dad is here yet. During the war with the miniatures Christina tells me the captain is killed. She tosses him aside and replaces him with another character who loses his magic ring and the pterodactyl is brought in to help retrieve it. As this scenario ends in a positive way and the character is able to help himself escape from the desert island, I wonder if Christina is beginning to make sense out of her own losses and to use her inner resources to cope with them. 134 Therapeutic Relationship Again my role in this session is one of playmate and helper however, she remains in control, her testing behaviour increases slightly and she seems to be distancing from me by remaining on the pillow in the middle of the room for the majority of the session. Her need for control is evidenced during the games when she wants me to give up guessing, gets angry when I don't and is deceitful about where she has hidden the ring. She grins broadly when I have to work hard to find it- Christina involves me in her miniature play by looking at me as she narrates the story. When she uses a different character in replace of one that doesn't fit on the bicycle she states "Just pretend it is him right now okay". I realize that in the past few sessions she has shared her miniature play by either involving me in it or making sure I follow the story. This has changed from the initial sessions where my role was more of an observer or witness to her miniature scenarios. Information from Home At the end of the session today, Bil l informed me that they are leaving for Alberta earlier than planned so Christina will only be able to come for two more sessions. He told me his new relationship has progressed and they have plans to move in together in the near future. He seemed to be aware that an immediate move would be too premature as both families need some time to adjust to each other. Summary of Session Eighteen In general, Christina seems to have less energy today and to require comforting and grounding as evidenced by laying on the pillow in the middle of the room. Her anxiety seems to 135 mount at the end of the session as she requests to leave the playroom before I indicate the session is over. The theme of loss is pervasive throughout this session both on a conscious level as Christina discusses the loss of her cat, moving to a new home and her dad's new girlfriend as well as through her symbolic play. She appears to be more resolved about the separation from her mom as she seems to express genuinely that she is not disappointed about a missed visit. Perhaps Christina is finding a way of resolving her sadness and disappointment regarding her relationship with her mom. I hope through therapy she has found some inner strength to deal with this difficult and chronic issue. Parent Meeting Bill provided me with an update on Christina's recent experiences at home. He indicated that Christina has been expressing some jealousy with regards to sharing his attention with his new partner, Laura and her five-year-old son. He provides Christina emotional support through reassurance that she is still his number one priority. I highlighted Christina's need to have time to adjust to his new relationship and cautioned that Christina's feelings toward her mom may be projected onto his new partner. He noted that he has made Laura aware of Christina's emotional needs and feels that she is able to support her. He expressed some ambivalence about the rapid pace of his relationship but feels confident that Laura will be a good role model for Christina. Bil l also reported that Christina's mother's drug habit has intensified and he worries that i f she continues at this level she may not live much longer. He fears the impact this will have on Christina. Bill tries to protect Christina from her mother and continues to encourage consistency of visits however, Lisa's contact remains extremely inconsistent and she continues to break 136 promises to her daughter. Christina tells her dad she hates him and wants to live with her mom but questions her mom's love for her. He explains to Christina that she will be able to stay with her mother when she quits using drugs and alcohol and he feels comfortable about where she is living. Bil l has noticed several changes in Christina over the last few months including increased maturity and independence, a greater sense of competence and increased assertiveness. He reported that she often checks his parenting style and is developing a sense of what is right and wrong. She informs her dad when he is treating her unfairly and lectures him when he has lost his temper. Bil l indicated his own efforts to improve his parenting skills. Bil l expressed his desire for Christina to continue with counselling and indicated that therapeutic support will be critical if she is forced to accept the complete loss of her mother. I informed him that Christina will meet my replacement before we terminate and should they move and not return to this clinic, one of the therapists can assist with a referral. I suggested that due to Christina's exposure to her family's drug use, she may be susceptible to drug abuse in later years, and recommended that her father continue to educate her about the dangers of drug use and to consider enrolling her in a support group for children of parents who abuse drugs. I highlighted the importance of stable and supportive relationships to Christina and suggested that he continue to facilitate her connections to her aunt and uncle as well as friends from school should they move. Bill acknowledged the importance for Christina of continuity in relationships, however, he indicated that Christina makes friends easily and although it will be an adjustment for her to change schools, he feels that the benefits of living away from Vancouver outweigh the drawbacks of staying. 137 Session Nineteen Play Themes and Use of Play Materials Sandtray Christina briefly spends time manipulating the sand while talking about her upcoming holiday and school field trip. House-tree-person drawings House. Christina's house (Fig 4.9) which again was drawn very quickly, has more detail than in previous drawings yet is very tiny and appears insignificant in proportion to the garden and fence. She tells me it is her grandparents' farm and adds her •Li L LJ.,1.. <ft-E L.L \...1JX grandma in the carrot garden which surrounds the " fw ' 9 house. Again, as in previous drawings, this house seems to lack warmth and welcome. It has more life than in previous drawings and is heavily protected by a large fence. As was evident in her previous houses, this one also lacks a chimney. Christina has difficulty answering the questions completely as again she seems to become emotionally uncontained. She tells me that this is a Disneyland house, that it needs gardening, has never been hurt and she would like to be in the living room and have only grandma and grandpa live there. It seems that she is looking forward to her visit with her grandparents and may be wishing for a house full of fun, amusement and fantasy, like Disneyland. Tree. The tree drawing (Fig 4.10) is also very tiny, like the house, possibly indicating feelings of inadequacy, withdrawal and an attempt to remain distant. The large roots may indicate emotional growth and placement toward the top of the page may indicate striving for unattainable goals. Christina emphasizes that the tree is growing roots, that it is a normal healthy tree, has never been 138 hurt, and is located near her house. She tells me it is summer and is raining and that the tree needs her to climb it. These responses indicate a tree that is alive, growing and healthy however, the rain may indicate sadness. Person . Christina draws a very tiny figure Tree (Fig 4.11) at the top of the page and as I ask her the questions she scribbles over it. She tells me the scribbled image is her grandma and calls her "Octopus Woman" who has many soft arms and is happy. Christina tells me the tiny figure is her grandpa, who is two years old, combing his hair, thinking of nothing and feeling happy. He has never been hurt and has no wishes. Although the person drawing is presumed to disclose how a child is feeling physically and emotionally at the moment, I believe this picture represents the strong defenses against revealing herself that Christina has created in particular now that therapy is nearing completion. This drawing is very confusing and not representative of a human form. The tiny stick figure at the top may represent a child who is feeling very insignificant in the world. Again, as in previous drawings, Christina attempts to distract from the process by providing nonsense responses. Therefore, it is Figure 4.11 difficult to make any definitive conclusions about the P e r e o n relationship of her drawings to her external world. Games Following completion of the pictures, Christina chooses to use a bracelet to play "Hide the Treasure". Following this game she engages with me in "I Spy". 139 Cape Christina first wears the cape then spreads it on the floor and lays on it for most of the session. As the pillow was used last session, the cape seems to be a way to give her a sense of grounding and comfort in the room. Baton Christina again uses the baton as her magic stick to point to the hiding spots in the room. Emotional Expression When Christina enters the room she blurts out that she is going to Alberta, nods when I reflect her excitement and also excitedly tells me she is going swimming tomorrow with the whole school. As the session progresses, Christina's energy level and emotional expressivity decrease and she spends a lot of time laying on the floor. As is indicated during her house, tree and person drawings, she remains strongly guarded against revealing her emotions. On two occasions she hits herself with the baton, seemingly on purpose, and replies "Ow". I begin to wonder if Christina is again indicating her emotional pain through physical means. When we complete the house, tree and person drawings, I ask Christina what her wishes are for the coming year and she indicates that she has none, turns away from me and avoids further questions. Although I had not thought of it at the time, as I review the video tape I wonder if this behaviour, coupled with the house, tree, person drawings, may indicate a depressed affect. Therapeutic Relationship Christina's interactions with me indicate a strong need for control throughout the session. On several occasions during both games she is deceptive, resists giving accurate hints and tries to conceal the true hiding spot from me. She also becomes aggressive and screeches at me indicating that she is ready for me to take my turn. When Christina asks my permission to play "I Spy", I 140 reply "We can play whatever you want to play. You are the boss in this room, right?" She replies "No!". When I attempt to process these feelings she begins playing the game. Toward the end of the session, in an attempt to make a connection, and express my sadness about termination, I comment "I'm going to miss you coming here, do you know that?" She nods and I continue, "I'm going to miss seeing you". Christina doesn't respond to my comments and resumes the game. I persist with "Are you going to miss coming?" and she nods, says "Ya" and immediately resumes playing the game. It seemed important to try and let her know that although she worked hard at preventing me from getting too close at times, I was still going to miss her. As we end the session I ask her if it has been helpful coming to play and she replies " Ya" but is not able to reflect on what has been helpful. I tell her that her dad is going to make arrangements for her to come back when school resumes in the fall if they don't move and she replies "Oh, cool". It was important for me to hear from her how she felt about leaving and in hindsight I realize it was only meeting my need to process the ending. However, due to the increase in her testing behaviour, ambivalence toward me, and given my experience of Christina, she was not going to tell me openly how she was feeling. Summary of Session Nineteen Christina's strong emotional defenses are evident during the house, tree and person drawings and as was evident previously, this activity seems to trigger home and family issues that are difficult for her to address. The size of Christina's drawings seem to indicate a strong feeling of inadequacy and I wonder whether her dad's new relationship has produced feelings of insignificance. Her pending reunion with her grandparents seems to be taking on a significant role in Christina's life. As they are her maternal grandparents perhaps she feels comforted by the 141 opportunity to connect with her mom through them. Her impressions of their home in Alberta seem to represent the fun-filled fantasy life Christina desires to have. Although her strong need for control continues during the "I Spy" game through deception and verbal aggression, Christina denies feeling like the boss in the room. Perhaps this results from the lack of control she has had over the ending of therapy. She continues to struggle with termination as evidenced by anxiety, avoidance, and requesting to leave before the end of the session, however, my attempts to process her feelings are met with resistance. Session Twenty Play Themes and Use of Play Materials Games Christina chooses to play "I Spy" at the beginning of the session Cape The cape is again used for laying on in the middle of the floor. Dollhouse During the "I Spy" game, Christina asks whether my colour refers to any of the furniture in the dollhouse. I indicate "no" and she giggles and asks "Want to see a chair coming down the stairs?" and proceeds to drop it down the stairway. This rather destructive vignette is the only occasion that Christina has paid any attention to the dollhouse. Termination At the end of the session, Christina and I decorate cupcakes together and I present her with v. a book of photographs and a letter I have written. She happily decorates her cupcake and as we discuss our memories of our time together and our feelings about ending therapy, Christina 142 continues to place icing and as many smarties as she can on it which seems to help reduce her anxiety. Hiding Christina places a scarf over her head and hides behind the door when I bring in Diane, the new therapist, to meet her. She seems joyful when she is found and becomes regressive in her behaviour as Diane introduces herself. Christina's hiding behaviour with this new person, as was also evident in earlier sessions with me, seems to be a way for her to investigate one's level of interest and attachment to her. Emotional Expression As in the previous two sessions, Christina spends a lot of time laying on the robe on the floor, and often seems anxious and in need of the robe for security. However, she expresses confidence as she asks me to choose a hard item for her to guess. Later she looks frustrated when I haven't challenged her enough. She also chants during the game "I think I know, I think I know. I didn't give up, I didn't give up." Two times during this session Christina refers to her physical ailments and seems to be looking for sympathy from me. On one occasion, she pokes herself in the eye and on another she indicates that she has many more mosquito bites than me. While decorating our cupcakes I ask Christina what she will remember about coming to the playroom and she responds: C: Trick or treat (giggles) J: Playing the trick game. C: I spy. I'll remember the camera (points to it), grins, and you. And the icing and that and that and that (begins pointing to everything in front of her). 143 This seems too intense for Christina as she loses focus. Later, however when she completes her cupcake and I ask her to make three wishes she replies: C: I wish to stay here (then distracts by showing her cupcake). J: You would wish to stay here. C: Ya. J: To keep corning. C: Ya. And I wish that, that, that, you wouldn't leave (looks directly at me). Oh, ya and I wish you have a fun time at school. J: Oh, thank you. And what about wishes for you? What do you wish for in the next year? C: I wish I could live in Alberta. J: Hmm. You're really looking forward to going there on your trip aren't you. C: Yes. J: And what else would you wish for? C: I wish that (friend's name) wouldn't move. J: Oh, is she moving too? C: Ya. J: That's sad. You guys are really good friends. C: And I wish I wasn't going to leave my school. It has been rare during the course of therapy that Christina has been able to express her feelings so honestly. She seems to have let down some of her guard as our last session comes to an end. She is later able to express her wish that she could go to her mom's house on the weekends. In my attempts to help her see all of the people in her life that show they care I begin to name her dad, aunt and uncle and she adds "and my teacher does too", then relays a story where 144 her teacher showed concern about her loose teeth and had her call her dad. This is one of the few times that Christina has relayed a completely coherent story that contained a beginning, a middle and an end. It seems that Christina has internalized this caring gesture and as she tells it her degree of animation demonstrates the positive impact it has had on her. Therapeutic Relationship Christina's need for control intensifies during this last session. This is indicated through repeated requests for me to give up, thereby defeating me, as well as by providing deceiving clues, and laughing and taunting me when I have been tricked. When I challenge her attempts to trick me by saying "You just don't want me to guess them today, do you. You're not giving me any clues", she lays down on the robe, begins rolling on the floor, and vacillates between screeching and moaning in between taking her turns. As the session nears completion, Christina becomes anxious and as a way to distract from talking about ending and some of her unresolved issues, she asks to meet the new therapist. As indicated earlier, she hides behind the door and grins when found. The ambivalence about loyalties is expressed when Diane comments on her scarf and Christina indicates that I have made it. She uses a baby voice and connects with Diane by showing her the "messy cupcake" she has made and by showing her how she uses the scarf to hide herself. When Diane says goodbye, Christina also seems anxious for closure and asks "Um, Janice, is it time to go?" We leave the playroom together and spend a few minutes in the waiting room where she is much more relaxed. During this time she chooses the pseudonym "Christina" to be used in my study. Our final goodbyes are an emotional moment for me, however, Christina is well-guarded even as she gives me a hug. 145 Summary of Session Twenty Christina uses the robe as a security object again during this session and spends a lot of time laying on the floor. Her need for control remains high as she continues to trick and deceive me throughout the game. In addition, Christina demonstrates high levels of anxiety, increases her testing of me and at times throughout the session seems unable to contain her emotions. During our final session, Christina is able to openly express several wishes without regressing or distracting from the discussion. As she expresses her wishes, I realize that they all relate to losses she is having to face in the near future including her desire that therapy was not ending, her friend was not moving, and her wish to live with her grandparents, possibly indicating a desire to avoid facing all these changes. I am relieved that she feels able to express her wishes to me however, have to overcome my feelings of powerlessness to lessen her pain. I realize that my time with her was limited and can only hope that by providing her with a safe environment, where she could be in control and receive unconditional acceptance, she has internalized a more positive sense of self that feels worthy of being respected and cared for and that our experience together will help her get through the rough road ahead. Child Behavior Checklist Christina's second profile indicated very similar results to the first profile in terms of the Competence scale. Her score of 13.0 and T score of 35 put her slightly below her initial score of 14 as Bil l did not report as many hours spent with her friends at daycare. This may have been an oversight on his part or perhaps she was not spending as many hours at daycare towards the end of therapy. Bill indicated that Christina had more close friends than he had recorded on the first profile and that her performance in school was generally average. Both of these areas seem to have improved over the course of therapy. 146 A considerable change was also indicated in Christina's scores on the problem scales. Whereas at the beginning of therapy, she was in the borderline clinical range for somatic complaints, Internalizing problems and total problem score, in this profile, all of her scores were within the normal range. Christina's highest score was still somatic complaints where she scored 2 and was in the 78th percentile. Her dad indicated that her complaints occurred less frequently than at the beginning of therapy. Of the 8 problem scales, 7 yielded scores around the 50th percentile and there was more consistency between scores than in the previous profile. Christina's Internalizing score was only 5 with a T score of 51 and her Externalizing score was 4 with a T score of 44, both well below her scores on the initial profile. The results of this second profile also indicated the following specific improvements over the initial profile: Christina was no longer arguing a lot or deliberately harming herself, was eating better, not as easily jealous, no longer felt "too guilty", was not overtired, no longer screamed a lot, was not secretive, self-conscious, or shy, and did not talk about killing herself, have temper tantrums and was not unhappy or depressed. Her father indicated that she "sometimes" felt worthless or inferior, complained that no one loved her, couldn't concentrate, demanded a lot of attention, and was disobedient at home. However, as indicated by her scores, in general Bill's responses suggested a positive trend in the changes in Christina's behavioural and emotional functioning since the beginning of therapy. Follow-up Session One Year Later While I was writing up this study a year following the termination of therapy, I contacted Christina's father and asked if I could meet with her. He willingly obliged and we met at her home the following Saturday. When I approached her house, Christina had been watching for me and 147 came out into the front yard and introduced me to her dog, Spook and her sister, Susan. She commented, "I haven't seen you for a very long time", which I understood to mean that she was glad to see me. We spent the afternoon together eating ice cream, playing at the park and browsing through the shops on the busy street where her father's hair salon is located. Christina seems to spend a lot of time in this area while her father is working as she knew it well and felt comfortable among all the busyness. Christina engaged freely in conversation about the recent events in her life with friends and at school as well as told me about her upcoming holiday to Alberta again this year to visit her grandparents and to a camp where she will learn to ride horses. She talked about her sister, her father and grandparents and about halfway through our meeting mentioned a dog her mom used to have. I asked her if she sees her mom and she said "No. She sometimes visits and brings me a present". Christina was not triggered by my question and did not change the subject as had previously occurred. She was honest in her response and seemed accepting of the minimal contact with her mom. Christina's father mentioned that he had stopped all visits with Lisa unless she informed him beforehand. He noted that Christina now accepts this arrangement and no longer feels sad or angry when not in contact with her mom nor does she long for her to visit. We discussed Christina's increased maturity, greater sense of independence, her greater emotional expressiveness as well as her ability to accept the things she can not change about her life. Her dad says she focuses on other, more positive events in her life and no longer dwells on her mom's absence. Her dad also noted that her sister, Susan's consistent presence in their lives over the last three months has greatly pleased Christina. 148 Christina did not move as was planned last year, as Bill's relationship with his partner ended. He also realized that taking Christina out of the stability of her school environment would have had a profound impact on her as she has been there since kindergarten. She therefore remains in the same school, daycare and home in which she lived last year. Christina did not continue in therapy as had been planned. I was pleased to see the positive changes in Christina, in particular her ability to be more emotionally expressive and use more productive coping methods. She was familiar with me and seemed very comfortable. She talked with pleasure of her memories of game playing in the play room. She remained close to me during our walk, talked openly and made full eye contact. Although at times I suspected that she was trying to please me by embellishing on stories, unlike in the past, many of these events were not part of her fantasy life, they were now part of her reality. Final Summary Christina demonstrated significant change across the twenty weeks of play therapy which was indicated by the following five phases of the therapeutic process: Initial phase (1 - 3) - exploration of the play materials and environment; rapport- building by connecting through toys; cleanliness and orderliness anxiety; reveals safe, positive information about friends and family; no internal state language; strong conscious denial of difficult issues; symbolic enactment of critical issues using miniature animals; aggressive play emerges followed by safe play; therapist's role is as observer; begins to test the therapeutic relationship. Second phase (4 - 5) - more positive affect; testing behaviour and need for control increase; avoidance and distraction from difficult issues continues; ambivalence in therapeutic relationship develops; increased expression of anger projected at the therapist; regressive behaviour ensues; increased self-consciousness; demonstration of mastery; attempts to take items from the playroom. Third phase (6 -12) - greater emotional expressiveness in voice tone and body language; aggression during last half of sessions; greater acceptance of feeling reflections; 149 acknowledgement of difficult feelings; information revealed about family based more on reality; game playing is the major activity; comfort objects found and used in the playroom; less need for control; ambivalence about relationship continues, but increased trust is evident; therapeutic relationship used to work through critical issues; less distinction between play and relationship; increased comfort and enjoyment; termination difficulties begin; attempts to take items from the playroom continue. Fourth phase (13 - 16) - less anger, increased positive emotions; increased ability to regulate emotions; increased competency; more of genuine self revealed; less need for competition and control; greater trust in the therapeutic relationship; therapist's role is one of playmate; control needs played out symbolically; greater degree of physical and emotional connection; increased empathy; increased creativity; role play begins; more time spent in discussion. Termination phase (17 - 20) - increased testing behaviour, need for control and aggressive play projected toward therapist; symbolic miniature play representative of termination difficulties and unresolved issues; conscious acknowledgment and expression of feelings; reduced energy; increased anxiety; increased inner strength and coping abilities; difficulty terminating. Christina used the safe and protected space of the play therapy room to externalize and to play out the conflicts in her internal emotional world. The therapeutic relationship evolved as a result of her opportunity to be in control, to have freedom of choice and responsibility and to experience unconditional positive acceptance. Across the 20 sessions of play therapy, Christina's emotional defenses were reduced, she demonstrated an increased sense of competency and confidence and a more genuine expression of self evolved. 150 C H A P T E R V : DISCUSSION A N D C O N C L U S I O N S This chapter summarizes the major findings of the study. Conclusions related to the original research questions will be explored first, followed by additional findings, limitations of the study, implications for theory, practice and future research, and finally, my own reflections regarding the process and outcome of the research will conclude this chapter. Original Research Questions 1. What is the process by which a child moves from psychological impairment to a more healthy psychological state during play therapy? 2. What play themes are displayed and repeated throughout therapy? 3. How are play themes and play areas integrated throughout the session and over time. 4. What materials are used most frequently in symbolic play? What might these stand for? How are they used? 5. How do the child's language, speech patterns and dialogue change over time? 6. How does the therapeutic relationship change over time? 7. How does the child's behaviour change from the beginning to the end of treatment in the home environment? It was anticipated that the play themes that emerged across the play therapy sessions would provide routes of access into the process of change from the perspective of the child. It was further anticipated that the researcher's immersion into the details of the participant's thematic material would lead to an elucidation of the process of play therapy as it pertains to the child's evolving world of experience and meaning. 151 Overview of Findings Related to Original Research Questions The process by which Christina moved from psychological impairment to a more healthy psychological state was delineated by five phases across the course of 20 sessions of play therapy. As these were discussed in the previous chapter, they will now be compared to existing research on play therapy process. No single theory coincides with the results found in this study, yet several theories support the findings of a phasic process of play therapy. According to the findings in this study, the initial phase consisted of the following characteristics: exploring the play materials and environment; developing rapport by connecting through toys; cleanliness and orderliness anxiety; revealing safe, positive information about friends and family; no internal state language; strong conscious denial of difficult issues; symbolic enactment of critical issues using miniature animals; aggressive play emerges followed by safe play; therapist's role is as observer; testing of the therapeutic relationship begins. This initial phase is similar to the first stage described by several theorists and researchers. For instance, Guerney (cited in Landreth, 1991) and Hendricks (1971) found that within the initial stage of therapy the child acclimatizes herself to the play room, materials and play therapy procedure similar to the way in which Christina explored the environment during the initial phase of therapy. As was evident in this study, Phillips' (1985) initial stage also demonstrated exploration of the playroom and therapist, and verbalizations that were informational or descriptive in nature. Similar to Schaefer's (1985) findings, diffuse and undifferentiated emotions that were negative in nature emerged in the first phase of Christina's therapy. In addition, Mills (1995) and Mills and Allan (1991) found that cleaning and tidying behaviour was evident in this stage. Also similar to Christina's process, these researchers found that children engaged in symbolic enactment of the source of their pain in this initial stage. The findings regarding Christina's emotional 152 expression during this initial stage also coincided with some of Mills' (1995) findings that topics about family were avoided, no internal state language was evident, children avoided revealing their conscious self and the role of the therapist was one of observer rather than playmate. During the second phase of therapy the following characteristics of the therapeutic process were evident: more positive affect; testing behaviour and need for control increase; avoidance and distraction from difficult issues continues; ambivalence in therapeutic relationship develops; increased expression of anger projected at the therapist; regressive behaviour ensues; increased self-consciousness; demonstration of mastery; and attempts to take items from the playroom. Mills and Allan's and Mills' second stage also found increased negative expressions, testing behaviour and ambivalence. Guerney noted increased testing behaviour, expression of anger and experience of freedom. Mbustakas (1955) also found an increase of ambivalence at this stage in therapy. As was apparent in Christina's second phase of therapy, Phillips found an increase in feelings, but they were not necessarily verbalized and Schaefer (1985) indicated an increase in anger expressed specifically. In Christina's third phase of therapy she demonstrated the following: greater emotional expressiveness in voice tone and body language; aggression during last half of sessions; greater acceptance of feeling reflections; acknowledgement of difficult feelings; information revealed about family based more on reality; game playing is the major activity; comfort objects found and used in the playroom; less need for control; ambivalence about relationship continues, but increased trust is evident; therapeutic relationship used to work through critical issues; less distinction between play and relationship; increased comfort and enjoyment; termination difficulties begin; attempts to take items from the playroom continue. 153 In accordance with the findings in the present study, Mills and Allan (1988) and Phillips (1985) also indicated that more time is spent in the third phase of therapy using the therapeutic relationship to act out psychological pain. In addition, Mills and Allan also found that the sessions in the third stage of therapy began with positive interaction and enthusiasm then anger and negative attention-seeking, manipulation and unresolved feelings are directed at the therapist in the second half of the sessions as was apparent in the third phase of Christina's therapy. Mills also noted that leaving anxiety begins in the middle stages of therapy as was evident in Christina's third phase. The fourth phase of Christina's therapy was indicated by: less anger, increased positive emotions; increased ability to regulate emotions; increased competency; more of genuine self revealed; less need for competition and control; greater trust in the therapeutic relationship; therapist's role is one of playmate; control needs played out symbolically; greater degree of physical and emotional connection; increased empathy; increased creativity; role play begins; more time spent in discussion. Moustakas (1955) and Schaefer (1985) also indicated that the fourth stage of therapy gives witness to both positive and negative feelings as was evidenced by Christina. Mills and Allan (1991) and Goetze (1994) noted that the therapist's role is more of a partner in play and more time is spent talking or engaging in creative or reciprocal play during the fourth stage of play therapy as was indicative in Christina's therapy. Unlike several of the theorists, I separated Christina's termination phase from her final therapeutic stage as it was marked by the following changes in behaviour: increased testing behaviour; need for control and aggressive play projected toward therapist; symbolic miniature play representative of termination difficulties and unresolved issues; conscious acknowledgment 154 and expression of feelings; reduced energy; increased anxiety; increased inner strength and coping abilities; difficulty terminating. Moustakas (1955) indicated that during the fifth stage in therapy realistic positive and negative attitudes are expressed which became apparent in Christina's final stage of therapy. Increased anxiety and termination difficulties are also common during the termination phase according to Phillips. Play Themes, Use of Play Materials and Play Areas With respect to the research questions addressing play themes, use of materials and play areas, there were repetitive themes and subsequent use of specific play areas and materials particular to the themes that were evident throughout therapy. In the initial phase, play themes included (a) separation/loss, (b) danger/protection (c) mother/baby relationship/lack of protection, and (d) captured/trapped. A l l of these themes were enacted using primarily miniature animals in the sandtray except in session two where Christina used Elmo as a central figure of symbolic enactment and in session three where she also engaged in representational drawings of animals. These themes seemed to represent Christina's unconscious feelings and experiences that were too painful to portray in human form. These non-human figures provided enough distance from reality to allow enactment without conscious retraumatization or becoming triggered. As indicated previously, Christina showed no interest in the dollhouse or the family figures except in the last session when she enacted a brief and destructive vignette whereby she sent a chair tumbling down the dollhouse stairway. Avoidance of this play medium seemed to indicate that even the metaphorical home and family environment was too triggering an area for Christina to explore. In the second to final stage of therapy Christina's primary play activity involved game playing in which hiding, guessing, trickery and magic were the predominant themes. These games 155 evolved due to Christina's needs for control, predictability, and a safe attachment to me. According to Allan and Pare (1997), hiding games are helpful for children who have suffered a loss or broken attachment and do not experience feeling wanted or desired. These games evolve organically when there has been a weak attachment bond or breaks in attachment and when children have been unable to accomplish the developmental tasks of mastering interpersonal anxiety, separation anxiety and the experience of a separate identity leading to the development of emotional (or object) constancy. The progression that the games of peek-a-boo, chase and hide- and-seek follow is based on a natural sequence in the emotional development of children. These games help children cope with the transformation from needing an adult's physical presence to tolerating their absence while still mamtaining an inner psychological bond to the caregiver. Christina's game playing began with toddler-like hide and seek, evolved to hiding of objects, and on to more complex games involving skill, competency, and mastery. In the hide and seek games, Christina seemed to be reworking through a hiding and rediscovering of the self by confiraiing her existence and importance. Through the kinesthetic games Christina found comfort in her own body, was able to connect with me and the environment and ground herself in reality. M y role in her play began as an observer and commentator and evolved as Christina actively solicited my involvement which at first was fully proscribed, however, toward the end of therapy, was a playmate whereby the rules of competition became increasingly less important. Christina's tendency toward game playing seemed to provide the opportunity to develop emotional constancy, externalize the pain of broken attachment bonds, overcome anxiety, gain mastery over loss and build a stronger sense of self. Themes of rescue and loss were revisited in the termination phase, however, the principal player, which was representative of a male human form, was helped and rescued from his 156 aloneness, demonstrating a more protected and empowered self figure. As the ending of therapy approached, a new theme of war emerged. I interpreted this theme as an indication of Christina's inner struggle to make sense of the "good" and "bad" factions of her life and to resolve the ambiguity in her prominent relationships including perhaps her relationship to me. Toward the end of therapy, symbolic enactment was in part replaced by verbal discussion of current life and family issues that were a more conscious metaphor of the same themes. Changes in Language, Speech Patterns and Dialogue The subtle changes, characteristics and patterns in Christina's language over the course of therapy seemed to indicate the degree to which the topics of discussion and symbolic material were emotionally tolerable. In the beginning phases of therapy, when engaged in discussion about family, Christina's voice tone was often high-pitched and inflated indicating an inauthenticity between presentation and internal feeling states. Most of her spontaneous dialogue involved statements, questions or descriptions of concrete materials in the play room, or future events or activities in her personal life. Christina made no reference to current needs, feelings or physiological states until session six whereby she began to indicate her emotional state through descriptions of physical ailments. As therapy progressed and family topics became less painful, Christina's stories about her life events were embellished less frequently and instead were based more on reality and revealed real life metaphors for unresolved hurts and issues. She resisted verbally expressing her needs, feelings, or wishes throughout the course of therapy, however, until the last session when she was able to consciously express her genuine wishes for both herself and for me. 157 Changes in Therapeutic Relationship As therapy progressed, Christina's defenses lowered and her attachment to me increased. Anger, testing behaviour and ambivalence then emerged and continued throughout most of the therapy. Ambivalence was evident by the second phase, continued through to the third and with less force in the fourth phase, only to increase again during termination. In addition, as the therapeutic relationship evolved, Christina demonstrated increased aggressive behaviour toward me beginning in the second phase of therapy, reducing significantly in the fourth and then peaking again during the termination phase. According to Mills (1995) and Rosen, Faust and Burns' (1994), negative transference in the form of aggression accompanies increased trust and attachment and indicates a more solid therapeutic alliance. Although there isn't any available data base about the processes that bring about effective resolve of children's problems, there is consensus in the adult literature that a positive relationship between the client and therapist is a critical component of the process. Furthermore, research has supported the position that the most important aspect of effective psychotherapy is the interpersonal skills of the therapist, rather than the techniques. Critical interpersonal skills are: empathy or the ability to "be with" the child, non-possessive warmth, and genuineness or coming across as a real person (Axline, 1969). The findings of this study point to the importance of the relationship between the child and the therapist as a key ingredient in the healing process. Not only is the child provided with a safe and protected space that is important to forming a healthy attachment, but also to an alternate relationship model from which the child is able to redevelop healthier ways of relating. I believe that through my ability to project unconditional acceptance, genuine caring, warmth and empathy, Christina was provided with a relationship that differed from any other she had experienced and 158 through this encounter she was able to release some of her internal relationship models, and develop enough trust to engage in a reciprocal, give and take fashion during the game playing, come within closer proximity to me, tolerate physical caring touches, and make efforts to connect and identify with me without fear of being overpowered, let down, rejected or abandoned. It was apparent during my follow-up visit with Christina one year after the termination of therapy that she had internalized the nature of our relationship and still viewed me as someone she could trust and by whom she felt genuinely accepted. Changes in Behaviour at Home The comparison of Christina's C B C L profiles at the beginning and end of therapy indicates that there were notable changes in behaviour at home across the course of therapy. Although Christina's competence score remained similar across the two sets of profiles, her dad indicated that she had more close friends and that her performance at school had progressed from below average to average at the end of therapy. Christina's problem scales progressed from borderline clinical range to within the normal range for all problem categories. Bil l reported that Christina indicated fewer somatic complaints at the end compared to the beginning of therapy. In addition, although not all of her emotional and behavioural difficulties had been resolved, several of her problematic behaviours such as arguing a lot, harming herself, tantrumming and sleeping and eating difficulties had been ameliorated by the end of treatment. Additional Findings Unrelated to the Research Questions This section will briefly address several relevant findings that merit further elucidation and discussion. 159 The Impact of Parental Unavailability and Loss The impact of parental separation and loss on Christina was evidenced by the degree to which she engaged in play themes of loss, unavailability and lack of protection. It seemed that her relationships with her primary caregivers shaped the themes demonstrated in her play and the patterns of interpersonal relating that were evident throughout therapy. According to Mills (1995), children bring to therapy a style of interpersonal relating that has been learned and practiced within relationships with significant caregivers in their lives. Children who have been exposed to unavailable, inconsistent or hurtful parents form models of relationships that are unavailable, unsatisfying and unsafe. As a result the child feels incompetent, unworthy, and ' unlovable. Attachment theorists stress the importance of a maternal attachment figure in the healthy development of a child and maternal loss as a factor in maladaptive patterns of development. The child's task during the first three years of life is to develop a close relationship with the mother and through this connection begin to develop a sense of self which is separate and distinct from mother. Without this relationship due to death, abandonment or unavailability, the child feels unsafe and unprotected (Bowlby, 1988). If a loving and available caregiver has met the child's needs for (a) regulation of the environment that provides both environmental and internal stability, (b) consistent, reliable and positive caregiving that conveys safety and a sense of self as good and worthy, (c) a secure and dependable base from which the child can explore and interact with the world, (d) a language to describe and affirm the child's emotional, physiological, interpersonal and sensory experience, and (e) affirmation of the child's needs and perceptions of reality and a requirement to consider the needs of others then the child will develop the social and communication skills, the curiosity and 160 self assurance, and the degree of trust that promotes learning and allows for the formation of healthy relationships. However, within an inconsistent, unpredictable and neglectful environment, the child is unable to develop the skills required to function and cope in the world as models of relationships that were originally adaptive in the home environment are no longer adaptive to the social and learning requirements of the external world (Mills, 1995). According to Mills, maltreated children differ from their well treated counterparts with respect to affect modulation, quality and content of internal state language, quality of relationships including ability to show empathy, drawings of self and family, relationship patterns with adults and projective images and storytelling. Many of these differences can be attributed to the defensive processes that maltreated children must employ in order to cope with a caretaking environment and/ or traumatic experiences that contradict their inherent needs. Because attachment to the primary caregiver is a survival ' requirement of a young child, in order to accommodate and accept irreconcilable parental demands, the needs of the child are often sacrificed forcing the child to remove from conscious awareness those feelings and experiences that are incompatible with continued access to the caregiver. According to Bowlby, this process of repression involves blocking from conscious awareness those experiences and emotions that may cause withdrawal or alienation from the primary caregiver. Repression is one way a child preserves hope and meaning in his or her life, as the alternative of acknowledgment may lead to utter despair and hopelessness. It would appear that due to a lack of nurturing and consistent parenting in particular in Christina's early years, her needs according to Bo wlby's theory of attachment may not have been fully met. Her early experiences, as well as the chronic instability in her life, have influenced her . pattern of communicating and relating within the therapeutic relationship. Her pervasive tendency 161 to avoid discussing her family relationships and her strong defense against revealing her feelings of hurt, anger, loss and abandonment resulted from her experiences of relationships as painful, unsafe and unreliable. Christina's resistance to reveal her true self by avoiding and denying difficult family topics seemed to provide a psychological mechanism that would protect her from the realities of the constant unpredictability, change and disruption in her life. The Issue of Directive vs. Non-Directive Therapy Through my experience in Christina's therapy and with subsequent child clients, I have come to realize that by following the child's lead and affirming their projective play through the principles of non-directive play therapy, the healing of unresolved unconscious material evolves at the child's own rate of processing. Christina's path in the therapeutic journey took her where she needed to go in order to heal her psychic wounds and cope in her world of confusion and unpredictability. Due to Christina's degree of repression, it was imperative to provide her with control and freedom of choice in order that she not become further resistant to acknowledging her difficult and troubling experiences and feelings. I do not believe that Christina's healing could have been hurried, however, perhaps having access to more play materials and resources that related to her own experience would have been beneficial. For instance, the children's book entitled An Elephant in the Living Room (Typpo & Hastings, 1984) which deals with the impact of alcohol and drug use on the family may have been a useful adjunct to Christina's therapy. In particular, perhaps now that she is more open about her life and feeling stronger, her participation in a group for children of alcoholic or drug abusing parents would be beneficial. In addition, children's books about grief and loss may also have helped Christina deal with the separation from family members. 162 Limitations of this Study As Christina's father signed consent forms and was aware of the nature of the study, his behaviour may have been indirectly influenced which in turn, may have had an effect on her behaviour thereby influencing the therapeutic process. Furthermore, changes in her home or school environment or her experience in group counselling may have confounded the process and outcome of the play therapy intervention. Because of the nature and design of this study and the time constraints due to the length of the practicum placement in the therapeutic setting, the ending of therapy was more of an arbitrary decision than would have occurred naturally. Generally, the end of therapy involves a phase of termination once the client has reached a natural conclusion and there is significant evidence of symptom reduction. Therefore, the characteristics of the termination phase of therapy may have looked differently had Christina been able to come to a natural conclusion in her healing process. Implications of this Study I believe the patterns described in this case study have led to a better understanding of the therapeutic process of play therapy and the evolution of the transformation toward healing. The significant issues, areas of struggle, and patterns of improvement detailed in this study may help play therapists track the healing process of subsequent children. Even though this case may not be typical of the experiences of other children, it may provide insight into the therapeutic process of play therapy in general and suggest complexities for further investigation and development of theory. This case study has allowed for an indepth inquiry into a very complex process that would not have been possible through the utilization of a quantitative methodology. The therapeutic process and patterns of change provide further understanding in which an emergent theory can be 163 proposed. Although this method of research does not allow for generalization of the results, I believe the depth of detail, and the patterns and processes that were elucidated may provide an opportunity for other clinicians and researchers to compare these results to the details of their own cases. Lincoln and Guba (1985) suggest that the results of individual case studies may be transferred or generalized on a case by case basis according to the corresponding features of new cases. Kazdin (1991) and others (Finkelhor and Berliner, 1995), conclude that for psychotherapy in general more research is required to determine which type of treatment is effective for each particular problem. This study may provide impetus for further research which applies the application of case study methodology and qualitative data analysis to homogeneous populations, according to problem areas. Such research may entail designing a process study of thematic changes among children who have experienced parental drug or alcohol abuse or maternal separation. By obtaining further knowledge about the impact of such experiences, clinicians may become better informed about ways in which to design therapeutic interventions for this particular population. Personal Reflections and Final Summary The tremendous breadth of knowledge I have accumulated through this research project not only encompasses child development, the inner emotional world of the child and the evolution of the therapeutic process but also self knowledge. I have become more aware as a therapist of the need to maintain a healthy, balanced inner world and to remain conscious of the impact my own way of being and engaging interpersonally has on the therapeutic process. I believe in the significance of the therapeutic relationship and the principles of genuineness, unconditional acceptance, and positive regard as being integral to unleashing the inner 164 strength and healing potential of the client. I have gained a great degree of respect for the capacity of children to work on their own problems or to achieve a healthier expression of themselves through the establishment of a therapeutic relationship. This project involved many hours of meticulous scrutiny of videotape and transcripts, the complexity of which was compounded by the difficulty in maintaining objectivity when reflecting on my own behaviour and clinical skills. Several times I became overwhelmed by the process as I began drowning in a sea of data. It was difficult to overlook my own misgivings and to remain focused on exploring the data without becoming discouraged by my own subjective critique. By viewing the tapes a year following the termination of therapy, I have had the opportunity to reflect on my clinical skills and to observe the growth that I have undergone as a play therapist over the past year. New meanings and interpretations have come to light with each viewing of the video when distanced from the relationship and from the time and space of therapy. 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The Dynamics of Therapy in a Controlled Relationship. New York: Macmillan. Terr, L . (1990). Too Scared to Cry. New York: Basic Books. Terr, L . (1981). "Forbidden games": Post-traumatic child's play. Journal of American Academy of Child Psychiatry, 20, 741 -760. Thompson, F. & Allan, J. (1987). Common symbols of children in art counselling. Guidance and Counselling, 2, 24-31. Typpo, M . H . & Hastings, J. M . (1984). An Elephant in the Living Room. Center City, Minnesota: Hazelden Educational Materials. White, J. & Allers, C. T. (1994). Play therapy with abused children: A review of the literature. Journal of Therapy & Development, 72, 390-394. Wilson, S. (1979). Explorations of the usefulness of case study evaluations. Evaluation Quarterly, 3, 446-459. 170 Wohl A . & Kaufman, B . (1985). Silent Screams and Hidden Cries. New York: Brunner/Mazel Inc. Yin, R. K . (1984). Case Study Research: Design and Methods. Beverly Hills, C A : Sage Pub. 171 Appendix A T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A Department of Counselling Psychology Faculty of Education 2125 Main Mall Vancouver, B.C. Canada V6T 1Z4 Tel: (604) 822-5259 Fax:(604) 822-2328 Dear Parent or Guardian, Under the auspices of the Greater Vancouver Mental Health Services I am looking for children who have been referred to the agency for play therapy to participate in my thesis project. I am a student at the University of B.C. as a Masters candidate in the Department of Counselling Psychology. My work with your child, pending your written consent on the attached form, would be under the professional supervision of Dr. John Allan (phone no. 822-5259) of the U.B.C. Department of Counselling Psychology, and would involve at least 20 weekly play therapy sessions of fifty minute duration. My study is entitled: "The Language of Child's Play: Thematic Representations of Healing through the Process of Play Therapy". I have long been fascinated by the potential of play for growth and healing. Under the guidance of a play therapist, children are able to work out inner conflicts, and find their own paths to growth and wholeness through the manipulation and fantasy exploration of toys, doll houses, puppets, art materials, sand, water etc. My research will look at the child's choice and use of play materials, the evolution of play themes and how these symbolic expressions change across the course of therapy. 1 am interested in discovering the process by which your child's play leads them on a path toward healing. I will be comparing the play therapy process of your child with that of other children. This study will be solely descriptive and nonintrusive for your child. In the write- up of the research, your child's confidentiality will be carefully protected. No names will be used, and no identifying background information will be included. The treatment agency will be described, but not identified by name. The focus of the study will be on the descriptions of the play and art themes as they emerge and transform, and on how each child's process of change unfolds over time. At the end of the study, you will receive a written summation of what 1 have learned, and a report of your child's individual progress. Each of the play therapy sessions will be video and audiotaped for several reasons. The tapes will enable me to generate transcripts of the play sessions and descriptions of each child's play for the study. The videotaping will also facilitate supervision of my clinical work by my thesis supervisor at UBC as well as consultation with my supervisor, Roger Gale at the Mental Health Agency. The tapes will be erased once my research project is completed. Page 1 of3 T H E U N I V E R S I T Y O F B R I T I S H . C O L U M B I A Parental Consent Form Department of Counselling Psychology Faculty of Education 2125 Main Mall Vancouver, B.C. Canada V6T 1Z4 Tel: (604) 822-5259 Fax: (604) 822-2328 Date: Child's Date of Birth: I give consent for my child_ to receive individual play therapy sessions from Janice Ebenstiner, masters student in Counselling Psychology and to participate in the research project: "The Language of Child's Play: Thematic Representations of Healing through the Process of Play Therapy" at Kitsilano Mental Health. I understand that all my child's sessions will be videotaped and audiotaped for research purposes, for Ms. Ebenstiner's clinical supervision. I understand that my child will receive weekly individual play therapy sessions of approximately 50 minutes, for at least 20 weeks. I understand that my child's anonymity and confidentiality are ensured in all phases of the research and resulting reports in accordance with the Freedom of Information and Protection of Privacy Act. 1 understand that as parent or guardian, I have the right to terminate my child's participation in play therapy, and/or participation in the research project at any point without jeopardizing my child's opportunity for further therapy. Signature of parent or guardian Signature of parent or guardian Date Date Parent: Please keep a photocopy of this signed document for your records i f you wish and check here to indicate that you have done so. Please return the original signed consent form to Janice Ebenstiner at the Greater Vancouver Mental Health Service, Kitsilano Mental Health Team. Page 3 of 3


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