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Play therapy: the patterns and processes of change in maltreated children Mills, Barbara C. 1995

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Play Therapy The Patterns and Processes of Change in Maltreated Children By BARBARA C. MILLS B.Sc.N., University of Michigan 1967 M.A., University of Washington, 1971 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 1995 © Barbar a C. Mills, 1995 In presentin g thi s thesi s i n partia l fulfilmen t o f th e requirements fo r an advanced degree a t the University o f Britis h Columbia , I  agre e tha t th e Librar y shal l mak e i t freely availabl e fo r reference an d study . I  furthe r agre e tha t permissio n fo r extensive copying o f thi s thesi s fo r scholarly purpose s ma y b e granted b y the head o f m y department o r b y his or he r representatives . I t i s understoo d tha t copyin g o r publication o f thi s thesi s fo r financial gai n shal l no t be allowed withou t m y writte n permission. (Signature) Department o f flnjjfLO/M^  tf^jpJfiJfjy The Universit y o f Britis h Columbi a Vancouver, Canad a Date <£E£Z£M&L  (orf99S' DE-6 (2/88 ) ii ABSTRACT This qualitative case study research chronicles the process of change during play therapy of two children who experienced maternal loss and maltreatment during the first two years of life. A t the outset of this study both children presented with evidence of insecure attachment as well as symptoms and behaviour consistent with maltreatment. Ove r the course of a year of therapy, both demonstrated profound change and healing. The study concludes that the children were able to utilize the safety, consistency, and affirmation of the therapeutic relationship to discard old models of relating, and to construct new internal representational models of self and of self in relation to others. Onc e old models were discarded, the children returned to the earliest stage of damage and reworked attachment salient developmental tasks while in relation with the therapist. The projective materials of the play therapy space provided the medium through which the children externalized selecte d trauma and critical incidents that shaped their maladaptive models. A s the therapist gave voice to the previously unacknowledged experiences, the child's authentic self was able to disentangle from the trauma. Th e pattern by which the self emerged and developed over the course of therapy approximated developmental pathways described by prominent self theorists (Bretherton & Beeghly, 1982; Mahler et.al, 1975; Stern, 1985) . Change was exhibited in the classroom approximately 10 to 14 weeks after the children were initially seen in therapy. TABLE OF CONTENTS iii Abstract i i Table of Contents ii i List of Figures v i Acknowledgement vii i Dedication i x Quote x CHAPTER I. INTRODUCTIO N 1 Overview of Case Design Methodology 7 Explanation of Terms 8 Research Questions 1 2 II. REVIE W OF RELATED LITERATURE 1 4 Literature Related to Attachment Theory 1 6 Literature Related to Maltreatment 3 2 Literature Related to Models of Self 4 8 Literature Related to Methodological Issues 5 3 III. Methodology 6 0 Relevant Literature Review 6 1 Overview of the Research Design 6 7 Description of Subjects 6 8 Rationale for Subject Definition and Selection.... 70 Process of Subject Selection 7 1 Setting 7 2 Philosophy and Approach to Play Therapy 7 4 Ethical Considerations 7 5 Research Procedure 7 7 Data Collection During Therapy 8 0 The Research Diary 8 1 Qualitative Data Analysis 8 4 Summary 8 7 IV. Cas e I: Gunther 8 9 Overview and History 8 9 Initial Observations and Teacher Interview 9 2 Tracking the Process of Change During Therapy 9 7 Initial Stage of Play Therapy 10 0 Overview 10 0 Manifestations of Self and Self in Relation ....101 Play Themes 121 Summary and Analysis of First Stage 13 1 Second Stage of Play Therapy 134 Manifestations of Self and Self in Relation ....135 Play and Art Themes 15 3 Summary and Analysis of the Second Stage 15 9 Mid Therapy Interview and Observations 16 2 Third Stage of Therapy 16 8 Manifestations of Self and Self in Relations ...169 Play Themes 17 8 Quality of Child Therapist Interaction 18 0 Artwork Related to Self and Family 18 4 Self Presentation in Artwork 19 3 Final Interview and Observations 19 8 Summary and Analysis of Change During Therapy 20 3 Case #2 : Lea 21 6 Overview and History 21 6 Initial Classroom Observations and Interview 21 1 Tracking the Process of Change During Therapy 21 5 Overview 21 6 The Initial Stage of Play Therapy 21 7 Overview 21 7 Manifestation of Self in Relation 21 9 Self Representation and Its Changes 22 1 Play Themes 23 5 Summary and Analysis of the First Stage 24 7 The Second Stage of Play Therapy 25 1 Overview 25 1 Self Presentation 25 3 Play Themes 26 3 Child Therapist Relationship 27 3 Summary of the Second Stage of Therapy 27 5 Analysis 27 8 Mid Therapy Review and Classroom Observation 27 8 Parent Interview and Early Intervention 27 9 Mid Therapy Teacher Interview and Observations....280 Third Stage of Play Therapy 28 3 Overview and Relevant External Events 28 3 Manifestations of Self and Self in Relation 28 5 Child Therapist Interaction 29 2 Play Themes 294 Summary of the Third Stage of Therapy 30 8 Fourth Stage of Play Therapy 31 1 Overview and Relevant External Events 31 1 Manifestation of Self and Self in Relation 314 Child Therapist Relationship 324 Play Themes 32 7 Summary of the Fourth Stage of Therapy 33 2 Final Teacher Interview and Classroom Observation ...333 Conclusions Regarding Lea's Process of Change 33 5 Discussion and Conclusions 34 2 Findings Related to the Original Research Questions .342 Original Research Questions 34 3 Overview of Findings 34 3 Patterns of Change Related to Both Children 34 7 Commonalties in Play and Art Themes 35 5 V Process of Change Related to Both Children 36 5 Therapeutic Change and Classroom Behaviour 38 6 Final Summary 39 0 Issues Unrelated to Research Questions 39 2 Strengths and Limitations of Qualitative Research 39 9 Implications of the This Study 40 1 Clinical Implications 40 1 Implications to Theories of Psychotherapy 40 4 Implications for Attachment Theory and Research...406 Implications for Child Maltreatment 40 6 References 40 8 Appendix A. Schoo l Observation Rating Scale 42 2 B. Permissio n for Play Therapy and Videotaping 43 2 C. Traumatize d Children: Suggestions for Teacher 43 6 VI LIST OF FIGURE S Figure Pag e 3 .1 Picture s of Playroom 7 4 4 .1 Th e Boy and Dog Surrounded 11 2 4 .2 Firs t House 11 8 4 .3 Tre e Drawing 11 8 4 . 4 Perso n Drawing 11 9 4.5 U s e a s Gunther's Famil y 12 0 4.6 Gunther' s Second Picture of Family 12 6 4 . 7 Gunthe r ' s Family Doing Something 14 0 4 . 8 Thi s is a Picture of Me 14 9 4 . 9 U s e a s Gunther' s Person 14 9 4.10 Gunther' s Self Portrait 15 0 4 .11 Mid-Therap y Tree 15 1 4.12 Sel f as a Rosebush 15 2 4 .13 Th e Rainbow and the Caterpillar 18 1 4 .14 Th e Star Map 18 2 4 .15 Spontaneou s Valentine 18 4 4 .16 Th e House Where Parents Play 18 5 4 .17 Heid i Bitten by a Snake 18 7 4 .18 Th e Mountains an d th e Storm 18 9 4.19 Gunther' s Final House Drawing 19 0 4.20 I  Can't Draw My Family, I  Can Draw My House 19 2 4.21 Th e Child Hit By Bird Eater 19 4 4.22 Gunther' s Sel f a s Tree 19 5 4.23 Gunther' s Fina l Tree 19 6 4.24 Gunther ' s Final Perso n Drawing 19 7 4.25 Gunther' s Fina l Sel f Portrai t 19 7 5 .1 Sel f Portrai t 22 2 5 .2 Tre e Drawing 22 3 5.3 Rosebus h 22 4 5 .4 Th e Graveyard 22 9 5.5 Th e Caterpillar Emergin g fro m th e Egg 2 3 0 5.6 Th e Balloons Breakin g Fre e of th e Grave. 23 1 5 .7 Th e Bird/Animal Hatchin g 23 2 5.8 Mo m and Lea at th e Beach 23 7 5.9 Lea' s Initia l House Drawing 24 3 5 .10 Lea ' s Family Doing Somethin g 24 4 5 .11 Lea ' s Person Drawing 24 5 5 .12 Th e Mommy an d Baby Sun 26 5 5.13 Th e Door with th e Large Handle an d Bell 26 9 5.14A Sexualize d Sel f 28 8 5 .14B Sexualize d Sel f 28 9 5 .14C Sexualize d Sel f 28 9 5.15 A  Revisitation of Mother's Death 30 1 5.16 Th e House, th e Weird Guy and th e Ringer 30 3 5.17 Th e Bug Infested House 30 4 vii 5 .18 Th e Good Church and the Bad Church 30 5 5 .19 th e Church Taking Away the Kids Away 30 6 5.20 Hous e and Family Drawing 30 7 5.21 Thing s That Are Not What They Seem 31 8 5 .22 Th e Girl Wearing The Mask 31 9 5.23 Fina l Person Drawing 32 0 5.24 Sel f Portrait 32 1 5.25 Th e Final Self As Rosebush 32 2 5.26 Th e Final Tree Drawing 32 3 5 .27 Spontaneou s Drawing of Lea and Barb 32 5 5.28 Lea' s Brother's Birthday 32 7 5.29 Fina l House Drawing 33 0 5.30 Fina l Family Drawing 33 0 viii Acknowledgment I would like to express my deep admiration for the children who had the courage to let down their protective armour, and to trust again. I  am honoured by their willingness to share their stories with me. I  am awed by the strength and beauty of their spirits. The y have been my most profound teachers during my learning process. I would also like to thank the staff, teachers, and principal of the children's school. I  do not mention the name of the school in order to preserve the identity of the children, but you know who you are. Yo u are models of caring and giving, and were indeed part of the healing process. Than k you to Maureen for so generously sharing the play therapy space. I would like to especially thank Larry Haberlin for your support and encouragement. Yo u facilitated my process every step of the way. Thank you to my supportive committee, for your careful reading, excellent advice, and patience. Dr . Donald Fisher provided wisdom, an astute eye, a generous spirit, and methodological support. Dr . Robert Krell provided critical insight and inspiration. I would like to express my special gratitude to my mentor John Allan for his many years of guidance, encouragement, and therapeutic wisdom. You r ideas, support, and therapeutic exampl e have been invaluable. Dedication IX I would like to dedicate this thesis to my husband John, whose love, support, humour, editing, and computer skills made this journey possible. X It seems  to  me  that  as  therapists  we  have  been  appallingly-slow to  wake  up  to  the  prevalence  and  far  reaching consequences of  violent  behaviours  between  members  of  a family, and  especially  violence  of  parents.  As  a  theme  in the analytical  literature  and  in  training  programs,  it  has been conspicuous  by  its  absence.  Yet  there  is  now  abundant evidence not  only  that  it  is  much  commoner  than  we  had hitherto supposed,  but  that  it  is  a  major  contributory  cause of a  number  of  distressing  and  puzzling  psychiatric syndromes. Since  moreover,  violence  breeds  violence, violence in  families  tends  to  perpetuate  itself  from  one generation to  the  next.  (Joh n Bowlby, 1988, p.77) 1 CHAPTER I INTRODUCTION The maltreatment of children within the family unit is one of the most urgent and alarming of mental health concerns facing North American society today. It is one of the few pathogenic factors consistently confirmed by research to be related to a wide variety of mental health problems (Alexander & Steele, 1981; Browne & Finkelhor, 1986; Friedrich, Urquiza, & Bielke, 1985; Kempe & Heifer, 1987; Steele, 1980; Wolfe, 1984; Zeanah & Zeanah, 1989). Th e impact of maltreatment upon young children has been shown to affect both short and long term coping, behaviour, and mental health of the individual. Equally alarming is the finding that if this impact is unaltered, there is a significant minority of maltreated individuals who perpetuate the abuse and/or neglect into the next generation (Egeland, Jacobvitz & Sroufe, 1988; Friedrich & Wheeler, 1982; Grossman & Fremmer-Bombik, 1988; Kaufman & Ziegler, 1987; Ney, 1988). It is curious therefore that there is a relative dearth of specific and comprehensive models to guide counsellors and psychotherapists in working with children who have been maltreated. Despite the fact that early psychoanalytic literature, as well as more recent theories (Bowlby, 1988; Fraiberg, 1975; Winnicott, 1965) emphasize the role of early parenting relationships on later psychological health, the majority of treatment programs designed for abusive parents and their children, follow a social learning model and focus almost entirely upon the parent. Cohn and Daro (1987) conducted a four 2 year evaluation study of 89 separate demonstration abuse treatment programs, serving 3,253 families in the United States. Collectively the studies included provision of parent education, parent support groups, lay counselling services, and protective child care. The authors found that the demonstration projects were sorely lacking in the ability to prevent further abuse. They report that one third of the parents served, maltreated their children during the treatment program, and another one-half were judged likely to abuse their children following treatment. Furthermore, they found little evidence of any child directed therapy, other than attempts to remove the child from the home. In a more recent revie w of abuse prevention programs, Coh n (1991) likewise notes that "therapeutic care for victims long recognized as a long-term strategy for breaking the cycle of abuse, has been that prevention strategy slowest to develop" (p.100) . From this author's own review of resources in Vancouver, the situation, except in the cases of sexual abuse, is similar. Treatment programs designed specifically for abusing parents and their children involve preschool situations for the children, while parents are involved in parent support groups, life skills training, and child care and development information. Two therapeutic preschool and treatment centres which include play therapy as an integral part of their treatment, have some maltreated children in their programs, though this is not their sole focus, nor their criteria for admission. Maltreated children in the Greater Vancouver school system are referred to the child and family branch of Social Services, 3 but treatment is not routinely provided, even when the abuse is so severe that the child is removed from the home. The exception to this is when the maltreatment involves sexual abuse, wherein funding for treatment is provided by Criminal Injurie s Compensation. In an informal survey of school counsellors, this author found a vast majority of children allocated to the "behavioral classrooms" to be victims of either historical or ongoing maltreatment. In an attempt to find preventive play therapy treatment for one particular child victim of abuse, the area mental health teams reported waiting lists so long that only those children who were clearly not functioning in the classroom, were accepted for treatment. Another disturbing trend in the Vancouver school system is that child counselling support is most often provided by child care workers rather than professional counsellors. Because many maltreated children are first identified, and later supported exclusively within the school system, it is unfortunate that a model of social support (th e more common model of child care workers) is likely again to be the only option available to the child. When the counselling and psychotherapy literature is reviewed, there is a surprising dearth of specific models of intervention with maltreated children. Articles are most often anecdotal, focusin g upon specific treatment strategies, rather than on clearly defined treatment goals, or models for intervention and therapeutic change. It is not that the abuse literature is sparse. A wealth of research provides an ominous and consistent picture of the long 4 term mental health effects of maltreatment upon the individual. The impact of abuse on the young child reads like a dictionary of psychological disorders of childhood. Victims of maltreatment can clearly be differentiated from their non-maltreated peers attending mental health clinics. A study by Gale, Thompson, and Sach (1988 ) found victims of maltreatment presenting with significantly higher levels of depression, anxiety, withdrawal, and psychosomatic complaints than their clinic counterparts. Observation of abused children in their homes show them to be depressed, passive, dependent, and anxious; or angry and aggressive (Egeland , Sroufe & Erickson, 1983; Martin & Rodeheffer, 1988) . Long term research demonstrates that victims of childhood maltreatment have an increased incidence of depression, suicide, multiple personality disorder, interpersona l and self-esteem problems, aggression, antisocial behaviours, and many others (Finkelhor , 1986; Kempe & Heifer, 1987; Wolfe, 1987) . Without appropriate intervention, young abused and neglected children become increasingly characterized by maladaptive form s of behaviour, and their ability to participate in the school environment becomes severely limited (Egeland , Kalkoske, Gottesman & Erickson, 1990; Lynch & Cicchetti, 1991; Manly, Cicchetti, & Barnett 1994) . Research that focuses on the treatment of victims of child maltreatment is now needed. Such research will assist the therapist who is working with the victim, and might also convince funding authorities of the short and long term value of psychotherapeutic treatment . Recent research in the areas of child development, maltreatment, and psychopathology provide potential direction to 5 therapists working with young abused children. The most provocative studies utilize the theoretical paradigm of attachment to trace the patterns of relationship behaviour, as well as the transmission or interruption of abusive parenting from one generation to the next (Mai n & George, 1984; Sroufe & Fleeson, 1986; Zeanah & Zeanah, 1989). Research also demonstrates that aggressive, avoidant, and antisocial behaviour, learned from maltreating parents tends, to be replicated by as early as two years of age in both child/peer and child/adult interaction s (Main & George, 1985; Sroufe & Fleeson, 1986). Such findings suggest that early intervention with maltreated children is likely to prevent the replication of abuse, as well as the pain of unsatisfying and/or destructive relationships in childhood and adulthood. Equally important are the studies of parents and older children who broke maladaptive relationship patterns. The exceptions to the abusive cycle were found to have accessed alternate supportive relationships that seemed to have provided an alternate model of positive interaction. In contrast to those who continued the cycle of abuse, they were found to have been involved in: (a)supportiv e relationships during childhood, with an adult other than the abusing parent, (b ) therapeutic relationships of one year or more, or (c ) supportive spousal relationships in adult life (DeLozier,1986 ; Egeland et al., 1988) . Such findings suggest that one option for counteracting the impact of early maltreatment, may lie in the fostering of a supportive, consistent, therapeutic relationship, within which 6 the child can develop alternate working models of self and self in relation to others. The above research fits with this writer's experience of how maltreated children change within play therapy (Mill s & Allan, 1991). When documenting clients' therapeutic change process in my own counselling practice, I found that young maltreated children used the play therapy experience to, amongst other tasks, develop new models of relating to others in intimate interactions. Children utilize the supportive and trusting relationship with the therapist to first test, and then discard old modes of relating. When old models were rejected, the children gradually and painstakingly establish new ways of interacting in what appeared to be a progressive, developmental-like process. Furthermore this change appeared to subsequently improve a child's interaction with peers and teachers as well. Thi s pattern fits Bowlby's description of the process of the reworking of internal models of self and self in relation to others. Though Bowlby's theories of psychotherapy have been in existence for at least two decades, there is no research that documents this phenomenon in play therapy. The longitudinal attachment research, cited earlier, may for the first time provide clear enough descriptions of observable differences between maltreated and well treated children to allow us to begin to chart this process of change. If indeed a predictable and identifiable pattern is evident, it would be of great assistance to both the beginning and the experienced therapist. Furthermore, by documenting those therapeutic strategies that accompany such change, consistent models of play 7 therapy could subsequently be developed to guide therapeutic child treatment programs. Because most children who are maltreated remain in the home of the maltreating parent, and because many parents are either unwilling or unable to seek help, the purpose of play therapy would be to strengthen the resilience, as well as the mental and relational health of the child, either in conjunction with, or exclusive of parental treatment. The purpose of this research study therefore was to document the process and patterns of change and healing during play therapy of children who had been maltreated within the family unit before the age of two years. Specia l attention was paid to the following aspects: (a)th e patterns with which the children related to the therapist; and (b)th e interactional, play and developmental behaviours that accompanied the alteration of these relationship patterns. Overview of Design and Methodology A multiple case study design, following the principles and methods of naturalistic inquiry , and qualitative analysis were employed. I n the tradition of naturalistic research, the therapist took the role of both therapist and researcher (participant/observer). Al l play therapy sessions were videotaped and transcribed, allowing detailed documentation of the children's process of change within therapy. Periodic , systematic classroom observations, teacher interviews, and school 8 reports were utilized to track the subsequent impact of therapy upon peer and classroom behaviour. The anticipated outcome of this research will a general understanding of the stages and patterns of change that are observable as the maltreated child heals as a result of child centered play therapy. EXPLANATION OF TERMS Child Maltreatment Any interaction or lack of interaction between a child and his/her parent which results in the nonaccidental harm to the child's physical and/or developmental state (Heifer , 1991). A general term encompassing the categories of physical, psychological, or sexual abuse, and severe and chronic psychological or physical neglect. Child Abuse The application of parenting behaviours that are harsh, punitive, controlling and rejecting in nature (Crittenden , 1992) . Child Neglect The failure to provide appropriate parenting (Crittenden , 1992) Self An internally organized cluster of attitudes, expectations, meanings, and feelings (Cicchetti , 1991) . False self The false self is a term coined by Winnicott (St . Clair, 1986), and is comparable to the Jungian idea of "persona". Th e false self develops when mothering (o r caretaking) is either not 9 safe, or is not responsive to the natural and spontaneous core disposition and tendencies for growth and behaviour of the infant. Th e infant subsequently develops an adapted way of being, or external self that is shaped by, and compliant to parental demands and expectations. "Th e false self hides the true self and cannot act spontaneously. Th e presence of a false self results in the person feeling unreal and futile and unable to be genuine in relationships." (St . Clair, 1986, p.71-72). True or Authentic Self A variety of theorists use this term (Kalff , 1982; Winnicott as cited in St. Clair, 1986). I t implies the core, original self of the individual. Internal Working (or representational) Models The expectations, based upon previous experiences with caretakers, that serve the function of enabling the child to organize his or her behaviour around that of the caretaker. Th e set of behaviours regarding attachment figures constitute the internal working model of others. Th e set of expectations regarding the self constitute the internal working model of self (Bolby,1988). Disorganized Attachment Disorganized attachment is a form of insecure attachment. It is believed to emerge when the caregiver, who evolutionarily serves as a secure base, becomes an elicitor of fear. (Mai n & Hesse, 1990) . Infant s who fall into the disorganized attachmen t category have no consistent way of responding to caretakers. A t age six, "disorganized" children's behaviour is characterized by: (a) high anxiety; (b ) controlling or manipulative behaviour; or 10 (c) compliant parentified behaviour, in which they care for the caregiver (Cicchetti , 1991). Mos t maltreated children fall into the category of disorganized attachment. Avoidant Attachment The avoidant attachment classification is a category of insecure attachment. I n infancy, it is characterized by avoidance of eye contact, body alignment, and proximity with the caretaker. A t age six, children continue to show the above behaviours as well as: (a ) an increase in aggression and avoidance; (b ) a decrease in initiative, curiosity, and creativity; (c ) diminishing I.Q ; (d) poor peer relationships. (Sroufe , 1988) Dvssynchronous Presentation of Self This is a term coined by Cicchetti (1991) . I t relates to individuals whose varying aspects of self presentation convey incongruent of conflicting messages. Dvsfluent Speech This is a term used by Main (1985 ) in describing the speech seen in children who were insecurely attached to caregivers at age six. Speec h was characterized by: (a ) short incomplete thoughts and sentences; and (b ) verbal responses that were unrelated to the verbalizations of the caregiver. Internal State Language Internal state language refers primarily to those words that have explicit reference to internal states, including physiological states, affect, and intention. Interna l state words normally first emerge early in the second year of life and increase dramatically during the third. No t only is there an increase in diversity of toddlers internal state lexicons, but 11 also in the range of social agents (othe r persons, toys, photographs) to which they attribute these descriptions. B y two and one half years of age, words related to sensory perception, physiological states, and emotion are most common (Beeghl y & Cicchetti, 1994) . Procedural Memory Procedural memory is thought to be that memory that encodes information regarding recurrent patterns of sensory stimuli and behavioural responses. Thi s kind of memory operates preconsciously and consist of learned modifications of species specific repertoire of attention and responses with which humans are born (Crittenden , 1992) . Procedura l memory stores everyday events and "how to's". Semantic Memory Semantic memory encodes verbal representations of experience. Word s and language memories are stored with both the denotative and connotative meaning given to young children by caregivers. Episodic Memory Episodic memory consists of remembered episodes of experience encoded by multiple means including verbal, auditory and visual memeory. Unlike the generalized memory of events stored in procedural memory, episodic memory stores unique total memories. Thes e memories are recalled as sequentially ordered episodes with characters, movement, sound, smells etc. Especially important is recall of the feelings experienced (Bowlby, 1980) . Becaus e most events are neither unique nor interesting, most experience is not remembered episodically. Th e 12 few events that are, tend to be selected because they are affectively arousing events that are unresolved (Crittenden , 1992). Model of Change A model is a representation that mirrors, duplicates, imitates or in some way illustrates a pattern of relationship observed in data or in nature. A model can become a kind of mini-theory, a characterization of a process and, as such its value and usefulness derive from the predictions one can make from it and its role in guiding and developing theory and research (Reber, 1985) . Research Questions This research design is planned to answer a number of questions related to the therapeutic change process experienced by a child who has been maltreated within a dysfunctional famil y during his or her first two years of life. It will seek to document the process by which the child changes and develops more adaptive internal models of self, and self in relation to others during the course of 25 weeks of child centered play therapy. It will further relate this process to change in the child's symptoms and relationships outside of the play therapy setting. The research will look at the patterns and process involved in therapeutic change and will ask: 1. Are there predictable and identifiable patterns that a child goes through in the process of healing? 13 2. Is there an observable process by which the child alters his or her model of self in relation to others, that is apparent in interaction with the therapist? 3. Is there an observable pattern or process by which the child alters his or her internal image of self? Does this change correspond to a change in relationship patterns? 4. Are there identifiable play and relationship behaviours that accompany the above changes? 5. How do the child's patterns of representation of self and self in relationship with the therapist in therapy correspond to changes in the child's self confidence and relationship patterns with teachers and peers in th e classroom? 14 CHAPTER II REVIEW OF RELATED LITERATURE It is hard to believe that only 30 years ago, the subject of child maltreatment was still met with disbelief. I n this short time, research has proven, beyond the slightest doubt that child maltreatment is indeed far reaching and pervasive in North American society. I t is however only in the last decade, that developmental psychopathology has helped us to understand the complex mechanisms by which child abuse and neglect create a multitude of long term sequelae. I n recent years, a wide range of excellent research has documented the impact of abusive, neglectful and psychologically unavailable parenting upon the developing child. Much of this research has been fueled by the theories of Bowlby (1988 ) and the research instruments of Ainsworth et al., (1974) and Main (1985 , 1987). Th e studies that have sprung from these rich conceptual and clinical paradigms have served to illuminate the process and mechanisms behind the sequelae of maltreatment, as well as the transgenerational cycle of abuse. With each year, the research becomes more informative and relevant to the practicing clinician. Theorie s relating to internal working models, defensive processes, memory systems, and developmental pathways explain why a significant number of maltreated children have failed relationships, unsuccessful schooling, and maladaptive coping patterns. Other theories explain how the self structure becomes distorted by abuse and neglect, leaving the child's potential essentially unfulfilled. 15 Still others explain how the abusive cycle is transmitted to the next generation. An d yet, despite the fact that attachment theory was created by a clinician, for clinicians (Bowlby , 1988) , there is still scant research that applies this elegant paradigm to the actual therapy serving maltreated children. It is my belief that the recent multifaceted research of trauma, and developmental psychopathology provides the child therapist with much of the necessary information and insights with which to understand and track the process of the maltreated child's healing in therapy. Thi s review will explore a wide variety of literature that has informed my own process of understanding the patterns and mechanisms by which maltreated children heal during play therapy. The review leans heavily on the literature of attachment, maltreatment, trauma, and developmental psychopathology. Mos t helpful are the longitudinal studies that differentiate the developmental pathways of maltreated children in comparison to their well treated counterparts. I t is from these results, that the research questions arise. I t was within the context of seeing the pilot children change from behaviours that were consistent with insecure attachment to ones more consistent with secure attachment that inspired this study, and the subsequent methodology. Literature explaining the complexities of the self and of memory systems were accessed in the analysis stage and helped me to decipher the many facets of the study findings. Finall y the rich theories of healing in psychotherapy provide a link between the inner world of memory and the unconscious; and the more 16 tangible world of relational behaviours and developmental pathways. Literature Related to Attachment Theory Literature Defining Attachment Paradigms Bowlby turned to the task of researching chil d development, attachment, and loss out of sheer frustration with the theories that drove child therapy in his day. Ou t of his research came the beliefs, definitions and paradigms that form present day attachment theory. The plausibility of attachment theory lies not only in the intuitive appeal of its hypotheses, but also in the fact that it has evolved from real life studies (Ainswort h & Blehar, 1978; Bowlby, 1959, 1969, 1973, 1980, 1988). Attachmen t theory posits that the early relationship between infant and caregiver provides the template from which all further intimate relationship are modeled. Attachmen t research demonstrates that the early caretaking relationship has profound and predictable impact on a child's long term interactional patterns and developmental trajectories. This section of the literature review will therefore begin by exploring a variety of studies that link the quality of early parenting to a multitude of behavioural and relationship outcomes. Th e review will begin with a brief explanation of the two research instruments that have spawned a wealth of useful studies. 17 Instruments Measuring Attachment Pioneering work by Ainsworth (Ainsworth , Blehar & Waters, 1978), and some time later by Main (1984 , 1985) has contributed research tools that operationalize attachmen t concepts. Ainsworth developed the Strange Situation Assessment (SS ) which provides a standardized, efficient, and reliable means of measuring attachmen t security of infants between 12 and 18 months of age. Based upon a structured caregiver / infant separation and reunion series; the instrument classifies the child into one of three categories of insecure attachment, or into a classification of secure attachment to the parent. Original insecure attachment categories included ambivalent and avoidant classifications. Since that time, a number of researchers have also added a category of disorganized attachmen t that best fits children who have been maltreated in the early years of life (Crittende n & Ainsworth, 1989) . The procedure's ability to operationalize representativ e attachment behaviours, and to confirm their validity in relation to quality of overall parenting interactions, has allowed a burgeoning of research into the quality of the early parent-child relationship, and its subsequent impact on the child's social and emotional development. Further, this ability to classify early relationship patterns has provided a starting point from which 18 longitudinal study into the continuity of relationship patterns in childhood could ensue. The Adult Attachment Questionnaire (AAI ) (George , Kaplan & Main, 1985) also classifies adult response into like categories of secure or insecure attachment. This instrument facilitates the comparison of an adult's attachment status to that of his or her children. The combined attachment classification systems provide an important mechanism for the efficient tracking of relational behaviours over time. Studies fueled by the Strange Situation instrument have generally confirmed the link between the quality of early parenting, and the child's current and ongoing mental health and relationship patterns (Egeland , Sroufe, & Erickson, 1983; George & Main, 1985; Troy & Sroufe, 1987). Infant Attachment Models in Later Childhood If as Bowlby suggests, the early parent-infant attachment relationship serves as an internal, perhaps tacit, model for future relationships, one would expect the pattern to repeat itself in childhood relationships as well, as within later parenting relationships. This hypothesis has indeed been tested in a number of studies, using the Strange Situation as the base. This section will highlight studies that track relationship patterns from infancy into early and middle childhood, in the "typical" as well as the maltreated population. Troy and Sroufe (1987 ) examined the association between 3 8 preschool children's attachment histories and their interaction with peers in a preschool setting. The youngsters studied were 19 part of the larger Minnesota Longitudinal study of an urban poor population of 268 high risk families and children. All children (20 males and 18 females) had been previously assessed using the Strange Situation (SS ) procedures at 12 months of age. A s part of the ongoing mother-child interaction project, these same children attended a preschool in which they were routinely in contact with each other. For this particular study, the children were assigned to same gender play dyads so that all possible combinations of attachment histories were represented. Seven of the 14 dyads had at least one member with a history of avoidant attachment, and in 5 of 7 cases, both children fit into anxiously attached classifications, (i.e . either avoidant or resistant). After at least six weeks of preschool attendance, each pair was observed playing in a specifically designated playroom for seven different sessions of 15 minutes each, spread over many weeks. Analysis of the children's play by three different judges showed a significant difference in quality of play and quantity of aggression between dyads containing insecurely attached children and those containing securely attached youngsters. The analysis revealed that the presence of a child with avoidant attachment history was significantly associated with victimization. Five of seven pairs in which at least one child had an avoidant attachment history showed victimization whereas zero of seven pairs without a history of avoidant attachment showed victimization (p<.01) . In contrast, the presence of a child with secure attachment history was clearly associated with a non-victimizing play relationship. None of eight such pairs showed victimization, 20 whereas victimization was foun d i n five of th e six pair s containing exclusivel y insecurel y attache d childre n (p<.005) . Analyzing th e results fro m a different perspective, al l children who were labele d either victims o r victimizers ha d a n avoidant attachmen t history. Al l childre n with an anxiou s resistant attachmen t history were eithe r not i n a victimizin g situation o r were th e victim i n a dyad. Furthe r qualitativ e analysis o f the transcript s showe d tha t i n the interactio n sequences, th e child who played victim had as active a  role i n sustaining th e pattern of victimization (sometime s eve n more) , than did th e victimizer. This researc h shed s ligh t o n a number o f importan t finding s in th e clinical abus e and attachment literature . Continue d victimization o f maltreated childre n i s a well accepte d fac t i n the clinical literature . Thi s research, however i s th e firs t that documents th e connection between th e quality o f th e earl y attachment relationshi p (rathe r tha n th e specific abusiv e act ) with child' s predisposition towar d continuing both th e victim an d the victimizer role . Thi s findin g alon e has major implication s for early preventive intervention . I t is relevant, not onl y fo r the prevention o f abuse i n further generations, but als o i n relation t o the consistent findin g i n the clinical literatur e that disturbed peer relationship s i n childhood ar e one of th e most powerful predictors o f pathology i n adulthood (Muelle r & Silverman, 1989) . In addition, i f thi s data are assessed strictl y i n relatio n to th e concepts o f interna l working models (Bowlby , 1988 ) i t 21 strongly suggests that the child re-enacts not only the model of self, but also the part of the parent in the relationship model. Though the above study included some abused and neglected children, subjects were selected on the basis of the SS, rather than upon a history of maltreatment. The following study specifically traces relationship patterns of children coming from maltreating homes. George and Main (1985 ) were specifically interested in comparing the behaviour of abused toddlers to their disadvantaged, non-maltreated age mates. Te n physically battered children, and ten disadvantaged peers, all between the ages of one and three years of age were observed during four half-hour observations in a familiar daycare setting. Narrativ e records were collected over a three month period. Analysis of data showed that the abused youngsters were significantly more likely than their peers to show aggressive and avoidant behaviour. Abuse d toddlers assaulted both age mates and adults four times as frequently as did their peers. Seve n of the ten battered children harassed their caregivers, averaging 3. 7 times in a two-hour period. Onl y two of the ten controls ever harassed caregivers, their average being . 4 times in the same time period. Avoidan t patterns were also noted. Avoidanc e was defined as moving the head or body away from the individual when approached. Abuse d toddlers showed marked avoidance of friendly approaches, four times as often as their age mates. A  pattern of approach/avoidance was also noted in response to friendly overtures by adults. Thi s behaviour was noted in all ten maltreated children and none of the controls. 22 The above behaviour i s consistent with observations o f insecurely attache d infant s i n Ainsworth's Strang e Situatio n observation. Th e unexpected behaviour i n this particula r situation however, was i n response t o distress i n age mates. When age mates were distressed, fiv e of th e te n control toddler s showed sadness , concern or empathic response s a t leas t onc e whe n they sa w distressed children . Empathic behaviou r was see n i n none of th e maltreated toddlers . In fact, three o f th e abused toddler s responded t o distressed childre n by being physically abusiv e themselves (slapping , hitting, o r kicking th e crying child) . This stud y agai n support s th e notion tha t early parenting model s of relating ten d t o guide interactions , even of very youn g children with peers. Egeland, Srouf e an d Erickson (1983 ) identifie d 8 0 children , from thei r longitudina l stud y of 267 high risk children, whos e caretaking experienc e fi t into fou r different patterns o f chil d maltreatment. Th e fou r maltreatment group s were divided int o groups characterize d by parenting behaviour histories of : (a ) physical abuse ; (b ) hostile/verbally abusive ; (c ) psychologicall y unavailable; an d (d ) physically neglecting . A  contro l grou p o f children and mothers who provided adequat e car e were selecte d from th e remaining hig h risk sample . Th e tw o groups wer e assessed i n order t o compare th e children's developmenta l pathways an d behavioral patterns during th e firs t fiv e years o f life. In general th e maltreated group s were characterize d b y patterns of : (a ) diminishing I Q scores over time;(b ) increasingl y hostile an d negative affec t an d interactiona l patterns; and (c ) 23 lack of sel f esteem , concentration , creativity , an d ego contro l in comparison t o their non-maltreated peers. Th e authors foun d some significan t difference s between th e patterns o f response , depending upo n th e typ e of maltreatment t o which th e childre n were subjected . Nonetheless , th e most strikin g generalizabl e consequence o f maltreatment was th e ongoing declining leve l o f functioning displaye d by all groups o f abused an d neglecte d children ove r time . When considerin g th e process by which we stud y th e impac t of therap y upon maltreated children , thi s findin g i s of grea t use. I t gives furthe r credence t o the use of a qualitative cas e study methodology, knowin g tha t without interventio n th e pattern s of behaviour an d coping i n maltreated childre n are already show n to be thos e o f negative decline. Thi s data allows us t o conside r such patterns t o be th e norm, thu s enabling us t o loo k at th e pattern o f change fo r each individua l child , with les s need t o compare him o r her t o a control group . Egeland, Kalkoske , Gotesman, an d Erickson (1990 ) documente d another stag e i n the Minnesota Longitudina l study . Their analysi s of data sough t t o determine which symptom s an d behaviours see n i n high risk preschool childre n were predictive o f late r demeanor i n the early schoo l years. They followe d 9 6 of th e preschoo l children, alread y followe d fro m birth, an d continued t o asses s them yearly throug h until th e thir d grade. They foun d a hig h degree o f continuity between th e children's preschool behaviour , and tha t see n i n the firs t thre e years o f school. Childre n wh o had demonstrated relationshi p problems i n preschool, were likel y to also have relationshi p problems i n primary school ; an d 24 children, who were sociall y an d academically competen t i n preschool were als o foun d t o be competent i n their schoo l years. In fact , 80 % of th e children identifie d a s aggressive i n preschool were also identifie d as aggressive t o peers i n two o f their thre e years o f elementary school . Likewise , 71 % of th e youngsters labele d withdrawn i n preschool were als o judge d withdrawn i n primary school . Furthermore , th e children who wer e classified a s aggressive o r withdrawn a t fou r years o f age score d significantly belo w th e academic achievemen t level s o f th e competent children . Although th e continuity o f behaviour i n this study (Egelan d et al., 1990) i s striking, th e exceptions ar e of equal interest . There were a  number o f intervenin g factor s tha t correlated with a decrease i n behavioral problems. Improvemen t i n behaviour corresponded wit h decreases in : (a ) maternal depression ; (b ) stressful famil y lif e events; and (c ) and an increase i n th e quality o f stimulatio n i n the child's home environment . Th e severity o f maternal depressio n appeare d t o directly affec t th e quality o f relationship th e mother had with her child , whil e indirectly impactin g th e quality an d organization o f th e hom e environment. In the most recen t publication fro m the Minnesota study , Sroufe (1991 ) summarize d th e alternate developmental an d relational pathways take n by th e insecurel y attache d children . Data was derived fro m (a ) parent chil d observation sessions ; (b ) preschool observations ; (c ) the firs t thre e years i n grade school, a s well a s (d ) a summer camp experience i n their tent h and eleventh years. H e concludes tha t th e patterns tha t eac h 25 group take s i s reflective o f thei r interna l representation s o f self an d self-in-relatio n t o others. In this work, Srouf e argue s that th e self shoul d be defined as: ...an inner organization o f attitudes, feelings , expectations an d meanings, which arise fro m an organize d caregiving matrix ( a dyadic organizatio n tha t exists prio r to th e emergence o f th e self) and which has organizationa l significance fo r ongoing adaptatio n and experience (p.281) . He furthe r argue s tha t throug h participating i n the earl y parent-child relationship , th e child acquires a n understanding o f self an d others i n relational terms . Thi s sens e i s not jus t of a simple role , but o f an entire se t of "if-the n propositions" tha t guide his o r her functionin g an d responses i n subsequen t relationships. The summarize d finding s o f th e longitudina l stud y t o dat e conclude tha t children who displayed secur e attachment durin g th e 18 month Strang e Situatio n (SS ) assessment tende d t o continue t o exhibit highe r functionin g an d healthier relationshi p pattern s during th e subsequen t te n years o f study. As preschoolers the y were characterize d by greater confidence , resourcefulness, sel f direction, enthusiasm , positiv e affect , and problem solvin g ability tha n thei r insecurel y attache d peers. They were als o mor e likely t o be more curious, resourceful, and forcefu l i n pursuing tasks an d goals. In the preschool an d school years th e secure childre n wer e less likel y t o sit beside th e teacher , were more likel y t o initiate positive contac t with peers, and were more likel y t o greet teacher s an d peers. Whe n confronted with rejection fro m 26 peers, the y were more likel y t o reframe i t into a positive message an d t o continue t o seek contact with other children . As te n and eleven year olds thes e securely attache d childre n were more likel y tha n thei r insecur e peers t o be confident an d flexible, an d were better abl e t o manage impulses , feeling s an d desires. A s i n the earlier years, these preteens were mor e likely t o display positive affec t i n all relations with others. Additionally the y came across a s more sociall y competent, an d better abl e t o establish an d maintain deepe r relationships . Thei r interaction with peers was generally characterize d by reciprocit y and fairness . The contrasting descriptio n o f th e insecurel y attache d children (encompassin g insecurel y attache d childre n classifie d avoidant an d resistant) ca n almost be assumed by contras t t o th e securely attache d ag e groups. Th e specific s a s described by th e author will nonetheless be discussed here. I n general, thos e children who were classifie d a s insecure/avoidan t maintaine d a consistent profile throughou t th e 1 1 years o f th e study . Avoidantly attache d childre n were characterize d a s more aggressive, avoidant , and sensitive t o rebuff a t all stage s o f development. A s early a s th e preschool years, they showe d decreased confidence , les s curiosity, an d were eithe r unable o r unwilling t o engage i n challenging tasks . Thoug h the y were mor e likely t o cling t o teachers, they were als o les s likel y t o ask a counsellor o r teache r fo r assistance when experiencin g difficulty. In th e preadolescent years th e insecure children' s pee r relationships were more often marked by hostility an d a lac k o f 27 commitment. They tende d t o choose friend s who were als o insecurely attached , an d within thos e friendship s ofte n playe d either th e victim or victimizer role . The interaction s tende d t o be characterize d by hostility, teasing , rejectio n an d exploitative behaviour . The play o f insecurel y attache d childre n was als o distinctive a t each age. A s earl y as th e preschool years, thei r play lacke d th e fantas y an d complexit y o f securel y attache d children. Whe n make believe theme s did occur i n later years, an y conflict o r problems tende d t o move towar d unsuccessful o r negative resolution . The profile o f th e insecurel y attache d childre n certainl y fits with previous literatur e describin g som e of th e characteristics o f maltreated childre n (I n & McDermott, 1982; Kempe, 1976 ; Mann & McDermott, 1984 ; Wolfe, 1987) . Thoug h th e profile o f th e insecurely attache d child i s certainl y discouraging, Srouf e concludes thi s article by sayin g that : This stron g data o n the continuity o f adaptation ove r tim e should not lea d t o pessimism concernin g change . Th e organizational perspectiv e (o n the self) i s also useful fo r conceptualizing interventio n an d change. The inne r organization o f sel f i s a derivative o f organized vita l relationships and , a s such most likel y will undergo chang e in the context o f other significan t relationship s (p . 303). Finally, Parsen s (1987 ) used a single case stud y approac h t o trace th e impac t of severe abus e and neglect o n a young infant . He presents a  14 month ol d infan t who was well treate d by hi s family an d developed well until 6. 5 month s o f age, after which, due t o traumatizatio n an d late r abandonmen t o f th e mother by he r boyfriend, th e infan t experience d extrem e neglect an d physica l abuse. He presented a t th e treatment facility , afte r bein g 28 apprehended, place d i n an institution, an d the n placed i n foste r care o f a known, lovin g an d supportive aunt . The chil d presente d at 1 4 months with symptom s o f apathy, depression , distrust an d hyperalert state . The case stud y describes th e infant's chang e i n behaviou r from a healthy, well infant , t o the profile described abov e subsequent t o neglect, abuse and apprehension. I t furthe r provides detaile d description s o f th e infant' s gradua l retur n t o trust an d health under th e guidance o f th e therapist wh o primarily helpe d th e aunt regain th e trus t of th e infant . Th e infant's behaviour durin g therap y transforme d fro m depression an d apathy, t o depression an d bursts o f aggression, t o resocialization, an d finall y t o elements o f trus t and reciprocit y with th e caretaker ove r a  period of fiv e months. Though th e author interpret s th e observations i n term s o f a traditional psychoanalytic paradig m o f "excessiv e unpleasure " unleashed i n response t o injured narcissism, th e data presente d are detailed i n such a way tha t i t could be useful, no matte r what theoretica l framewor k th e reader applies . Th e tracin g o f the process by which th e infan t responds t o maltreatment, an d then moves towar d healing, provides a  clear picture o f damage an d repair o f early infan t caretake r relationships . A n exampl e i s also provided o f th e power o f early therapeuti c intervention . It i s furthe r interestin g t o me tha t i f I analyze th e data fro m an attachment perspective, during th e process o f healing, th e infants behaviour change d fro m interactions characteristi c o f avoidant attachment , t o ones consistent with resistan t attachment, an d finall y t o secure attachmen t behaviour. Th e 29 benefit o f detailed cas e stud y research i s also demonstrated . With thi s mode o f analysis, th e reader i s provided wit h sufficient informatio n t o arrive at his o r her ow n conclusions, according t o a favore d theoretica l paradigm . In summary, th e research reviewe d i n this section support s the attachment hypothesis tha t early interna l working models, formed i n very earl y stage s of parent-child relationships , provide a  clear pattern o f interactio n which tend s t o be replicated by th e child i n subsequent socia l relationship s wit h both adult s an d peers. Furthe r demonstrated i s the conclusio n that childre n who develop insecur e attachmen t patterns wit h parents ca n be clearl y distinguished fro m thos e who ar e securel y attached. Finally , a  single case stud y o f a toddler provide s detailed evidenc e tha t therapeuti c intervention , i n conjunctio n with a supportive caretake r ca n counteract earl y maladaptiv e interaction patterns, and one would als o assume interna l workin g models. Th e importan t conclusio n fro m thes e studie s i s th e confirmation tha t child maltreatment, an d subsequen t insecur e attachments, initiat e a  chain of maladaptive relationshi p patterns that , i f uninterrupted, plac e th e child at serious ris k for ongoing destructiv e an d unsatisfying relationship s problems . This furthe r implie s tha t th e provision o f protection fro m abus e alone, i s insufficient i n preventing futur e patterns o f menta l health problems an d cycles of abuse. Th e logica l next ste p therefore, would be a case stud y approach towar d th e purpose o f documenting th e patterns of , and response t o treatment, o f maltreated childre n at different stage s o f development. 30 Maltreatment and Attachment Classification in Later Childhood A number of investigations have found a relationship between maltreatment and a variety of categories of insecure attachment (Carlson, Cicchetti, Barnett, & Braunwald, 1989; Crittenden, 1985, 1988 ; Egeland & Sroufe, 1981; Main & Goldwyn, 1984) . I n their early years the majority of maltreated children were shown to fall into the avoidant or ambivalent categories of insecure anxious attachment. (Crittenden , 1985; Egeland & Sroufe, 1981; Schneider-Rosen & Cicchetti, 1984) . Longitudinal studies show however that as children mature, those labeled as anxious ambivalent in the early years are more often labeled avoidantly attached by the late preschool years (Cicchetti, 1989; Main & Cassidy, 1985) . More recently researchers have coined new attachment categories that better distinguish maltreated children from their peers. Crittende n (1988 ) first cited an A/C attachment rating, characterized by behaviour that displayed both high avoidance as well as high ambivalence of abused infants in relationship to caretakers. Durin g the same period Carlson, Cicchetti, Barnett, and Braunwald (1989 ) used the term "Disorganized" attachmen t behaviour for maltreated youngsters. Th e disorganized category fit as these children seemed to have no consistent approach for coping with, or relating to parents upon reunion. Childre n often began interaction using one strategy and were found to change behaviour in midstream. Thes e youngsters seemingly had found no 31 consistent pattern that worked to maintain a position of safety, as well as to stay in contact with caretakers. In a follow up study of six year old children, Main and Cassidy (1988 ) scrutinized 12 children who had been rated as disorganized in attachment at 12 months of age. Thes e children's reunion behaviour with mothers was characterized as controlling, either through punitive or overbright, caregiving behaviour. Compared to their securely attached counterparts, their conversation style was also seen as much more dysfluent. Carlso n et.al. (1989 ) speculate that the "parentification of the maltreated child may be better understood as a specific manifestation of a more general developmental course of an underlying disorganized attachment relationship". A variety of longitudinal studies have enabled researchers to test the consistency of attachment classifications in children over time. Mai n and Cassidy (1989 ) found considerable stability in attachment categories for six year olds originally assessed as infants. Childre n who were originally classified as disorganized in infancy displayed a variety of unique behaviours at age six. Disorganized six year olds demonstrated controlling, rejecting, punitive or caretaking behaviours during reunion with parents. Cassidy (1986 ) found the doll stories of six year old children who had been classified as disorganized in infancy paralleled their reunion behaviour with parents at six. Thes e children who fit the disorganized attachment category, created stories depicting bizarre, hostile, disorganized and violent behaviour. Cicchetti (1994 ) points out that disorganized attachment is reflective of conflictual working models of relationships and 32 caretakers. Th e child experience s suc h unpredictability o f caregiver behaviour , tha t sh e i s unable t o develop a  consisten t set o f response (o r defensive) patterns. Th e child i s therefor e left with no predictable model o f how t o behave withi n relationships. Th e frequen t resul t i s anxiety an d hypervigilanc e when i n social situations , and a disorganized respons e t o selected socia l relational patterns. B y six years o f age, th e "disorganized" childre n tak e control of the unpredictability i n their relationa l environmen t by controllin g adults . The y do thi s by developin g patterns o f cohersiveness, caretaker rol e reversal, manipulation, o r coy behaviour tha t nets a  predictabl e response fro m th e caregiver . Literature Related to Trauma The Impact of Trauma on Cognition and Development Trauma researc h has evolved alon g a  path separat e fro m th e literature o f attachment. Indeed , i t is only within th e las t te n years tha t traum a theorist s have seriousl y begun t o consider th e possibility tha t childhood maltreatment might qualify a s a for m of traum a (Herman , 1992 ; Pynoos & Nader, 1993 ; Terr, 1990 ; Van der Kolk, 1993) . Herma n (1992 ) coined th e term "chroni c pos t traumatic stres s syndrome " t o characterize th e montage o f symptoms tha t constitute behaviour o f women an d children who hav e been chronically traumatize d within th e home environment . Johnson (1990 ) characterizes traum a as an event s o overwhelming tha t th e child does not have th e defense mechanism s needed fo r coping with it . He suggest s tha t i t i s not th e even t 33 that defines th e trauma , but instea d i t i s the ability o f th e child t o cope with th e event tha t determines whether i t i s traumatic t o tha t particular child . Som e o f th e factor s tha t influence a  child's respons e t o a potentially traumati c even t ar e his or her age , support systems , temperament, environmenta l stress factors , and previous lif e experiences an d copin g patterns. Som e event s suc h as violence o r sexual assaul t woul d be traumati c t o anyone. In his revie w article, Green (1993 ) summarizes th e painful reality o f a child who i s victimized by a  parent, fro m whom nurturing i s also expected and needed. Becaus e th e paradox i s one tha t canno t be readily bridged, th e child must inevitabl y employ defensive mechanisms o f either repression , splitting , o r dissociation i n order t o survive. H e furthe r observe s tha t because i n th e case of ongoing maltreatment, th e traum a i s chronic, th e child i s more likel y t o sustain a  "pathologica l change i n character an d /o r personality structure" . Herman (1993 ) captures th e cognitive dilemm a tha t a chil d must face : The abuse d child' s existentia l tas k i s quite formidable . Though sh e perceives hersel f a s abandoned t o a power withou t mercy, sh e must fin d a way t o preserve hope an d meaning. The alternat e i s utter dispair, somethin g no child can bear. To preserve he r fait h i n her parents, she must rejec t th e first and most obviou s conclusio n tha t somethin g i s wrong with them . Sh e will go t o any length s t o construct a n explanation fo r her fat e tha t absolves her parents o f al l blame an d responsibility, (p . 101) The necessity o f absolving parents o f blame an d responsibility require s a  host o f defensive processes, an d cognitive distortions . A  number o f authors cit e thi s process a s the reason fo r th e progressive declin e i n I.Q. an d cognitiv e 34 abilities commonly seen in maltreated children (Bowlby , 1988; Green, 1993; Van der Kolk, 1987). Bowlb y speaks of the dilemma of the child who "know s what he is not allowed to know and sees what he is not allowed to see". Donova n and Mclntyre (1990 ) cite this very dilemma as a major etiologic factor in the high rate of learning disabilities in abused children. The y ask how a child can perform effectively at school, when intrinsic to the educational model is the expectation that the child tell adults what he or she knows and has learned, when this is the very thing that is forbidden at home: Family secrets can constitute an incredibly noxious, pathogenic, dissociogenic forc e On e of the simplest examples is the effect of secrets on academic performance. Reduced to its barest essential, school is a place where children tell adults what they know - through oral and written work. A  family secret represents knowledge of which the child cannot even be aware that he is aware. Thi s bizarre situation engenders "cognitiv e blinders" which are difficult to isolate to the home situation. Consequentl y the child ends up not allowing himself to know what he knows or tell what he knows - and academic performance falls, sometimes dramatically.(pp. 74-75) Greenberg & Van der Kolk (1987 ) suggest that the cognitive problems also relate to the way in which various kinds of memory are stored. The y explain that the process of dissociation creates boundaries between different segments of an individual's experience. Th e dissociation of traumatic material therefor e requires the individual to maintain distinct cognitive structures and activities in order to keep dissociated material separate. If boundaries are fixed and long term, then dissociative functions become independent one from another. Greenberg and Van der Kolk (1987 ) likewise hypothesize that dissociated traumatic memories may be encoded exclusively in 35 sensori motor o r iconi c form , an d therefor e not easily translate d into symboli c languag e necessary fo r linguistic retrieval . The y suggest tha t i t i s possible tha t i n situations o f terror , th e experience doe s not get processed i n symbolic/linguistic forms , but tend s t o be organize d o n a sensori motor leve l a s horrifi c images, visceral sensations , or fight/fligh t reactions . They furthe r hypothesize tha t memories ar e not store d i n linguistic for m until th e individual i s between fiv e and eigh t years o f life . The y conclude tha t th e processing o f traum a memories requires , not only th e breaking dow n of dissociativ e barriers, but als o th e connecting o f iconi c o r sensory memor y with languag e an d cognition . Terr (1990 ) studied th e memories an d play o f childre n involved i n the Chowchilla kidnapping . Sh e foun d tha t thoug h th e children had suppresse d many consciou s memories o f th e incident , they all demonstrated post traumati c kin d o f play tha t reveale d aspects o f thei r experience. Ter r describes post traumati c pla y as unlike th e normal play o f childhood. Instea d i t i s repetitive, grim , monotonous, and so litera l tha t you ca n intui t the source o f th e child's traum a with fe w other clues. Therapeutic literatur e likewis e i s replete with evidence tha t abused childre n who are unable t o consciously acces s maltreatmen t memories, play the m out within th e play therap y roo m (Gil,1991 ; James,1990). A quantitativ e stud y int o differences i n the cognitiv e functioning o f abused children was conducte d by th e Trauma Clini c of th e Massachusetts Mental Health center (Lync h & Cicchetti, 1991). Th e result s demonstrate d significan t differenc e i n th e 36 thought processes o f abused children, when compared t o matche d age mates. Abuse d childre n score d lowe r o n scientific an d mathematical logic . Thei r sens e of self an d of self knowledg e was significantl y les s tha n tha t of age mates. Thei r academi c achievement was additionall y effecte d by thei r inabilit y t o utilize resources . Th e control children were more likel y t o as k for help an d revealed much more abou t themselve s i n stories tha n did th e abused children . Finall y when abused childre n sa w projective stor y pictures tha t reminded the m of thei r history , their traum a memories an d responses seeme d t o take over an d hol d them captive . The authors conclud e tha t children's traumati c memorie s see m eradicable. The y sugges t tha t children's traumati c memorie s significantly alte r perceptions, subsequentl y limitin g thei r capacity t o accommodate an d self correct. Inabilit y t o accommodate was blamed o n the child's hyperarousal, while fea r and anticipatory frustratio n was believed t o inhibit th e children's abilit y t o make plans o r fin d alternative approaches . Interface Between Maltreatment. Affect. Language and Cognition Affect an d cognition canno t be separated on e fro m th e othe r in the developing child . Van der Kolk (1987 ) summarizes th e interface between maltreatment, psychological mechanism s an d adaptation. H e notes tha t many traumatize d childre n liv e i n a continuing stat e of vigilance, and hypersensitivity t o environmental threat . H e explains tha t while i n this state, the y lose th e ability t o sublimate, fantasiz e an d symbolize. Th e children ar e consequently deprive d of th e psychologica l 37 mechanisms tha t others use t o cope with th e small injurie s o f daily life . The resultant inabilit y t o tolerate a  variety o f affect, limit s th e capacity t o work throug h normally tolerabl e events. Withou t thi s experience, th e child fail s t o accumulat e the positive experience s o f coping tha t commonl y bolster sel f confidence. Van der Kolk (1987 ) also suggest s tha t because o f th e nee d to "war d off" traumati c memories, victims have an impoverishe d mental life . Whe n th e traum a i s not integrate d int o th e person s life experience , th e individua l remain s fixate d on the trauma . The resul t i s a robotlike existenc e tha t i s devoid o f fantas y an d empathy fo r others. Barahal, Waterma n an d Martin (1981 ) studied th e socia l cognitive aspect s o f empathy i n matched groups o f abused an d nonabused childre n between th e ages o f si x and eight years o f age. Th e children were aske d t o tell a story an d enact a  puppe t play. Abuse d subject s were foun d t o be les s sensitive an d les s able t o identif y appropriat e feeling s i n others. Furthe r th e maltreated childre n were more ego-centri c an d les s able t o identify th e social an d emotional cause s o f specific emotions . Gaensbauer, Mrazek an d Harmon (1980 ) observed childre n wh o had experience d a  variety o f form s of maltreatment. The y correlated affectiv e retardatio n with profound neglect an d deprivation. Childre n who were abl e t o perform task s a t a n ag e appropriate developmenta l level , but appeared withdrawn an d depressed were hypothesized t o have received initiall y adequat e care followe d by a  separation fro m th e caretaker . 38 Erickson, Egeland and Pianta (1989 ) attempted t o compare an d contrast th e developmental patterns an d characteristics o f children classified accordin g t o history o f maltreatment. The y documented social , emotional, and cognitive behaviour o f childre n during thei r firs t 6 0 months o f life. Characteristic s o f children who had experienced neglect, physical abuse , sexua l abuse, an d parental were evaluated . Similaritie s between al l categories o f maltreated children were found . Al l seeme d t o display som e for m of anxiety, a s well a s increase d level s o f anger, withdrawal, an d an inability t o functio n independently . Additionally al l were les s popular tha n thei r securel y attache d counterparts. Some behavioural cluster s were foun d t o be mos t characteristic o f specific categorie s o f maltreatment. Physically abuse d childre n were more likel y t o act out , be aggressive, impulsiv e an d non-compliant. The y furthe r showe d th e most negative affect . Childre n whose caretaker s wer e psychologically unavailabl e showe d a dramatic declin e i n social-emotional functionin g durin g th e preschool years. Additionally , they seeme d les s involve d with sensorimoto r task s i n kindergarten. Thi s stud y foun d tha t parental unavailability an d emotional neglect had th e most profound affect s i f it occurred i n infancy. Th e children who showe d th e most sever e an d varie d problems were thos e who were profoundly neglected . I n th e classroom, the y performed leas t well. I n social situation s the y exhibited both aggressive an d withdrawn behaviour. Whe n asked t o perform, the y were th e leas t attentive, most anxiou s an d relie d most heavily o n the teache r fo r help. 39 Sexually abuse d children could be distinguished fro m other s by thei r anxiety , inattentiveness , an d failur e t o comprehen d what was expecte d o f them . The y displayed a  greater dependenc e upon adults, with s strong need fo r approval an d closeness an d frequent help-seeking behaviour . The maltreated child' s interna l lif e i s likely t o be reflective o f th e impoverishmen t o f thei r external caretakin g environment. Ther e are a series of caretaking interaction s tha t foster th e emergence o f th e self, cognition, curiosity , an d language i n the developing chil d (Bowlby , 1988 ; Mahler, 1975 ; Stern, 1985) . Thes e include , among othe r tasks : (a ) regulatio n of th e environment; (b ) consistent, lovin g an d reliabl e caretaking; (c ) the provision of a secure base; (d ) naming an d acknowledging th e child's affectiv e experience ; (e ) encouragin g exploration an d autonomy; an d (f ) assisting th e preschooler t o respect th e rights o f others. Whe n th e parent i s successful i n these caretakin g tasks , the child i s more likel y t o evolve int o a reasonably positive, articulate socia l being. The use of languag e i s a developmental achievemen t tha t ha s been show n t o be significantl y affecte d by th e presence o f maltreatment. I n a variety o f studies o f th e languag e o f maltreated children , delay s were generally foun d t o be i n expressive rathe r tha n receptive speech . Coster , Beeghly , Gersten &  Cicchetti (1989 ) described maltreated toddler s a s usin g shorter sentence s an d les s relevant an d les s descriptive speech . The childre n were especiall y delaye d i n the verbal expressio n o f their inne r feelings . 40 Beeghly & Cicchetti (1994 ) compared maltreated toddlers use of internal state language to that of their matched controls. The children's language was assessed using four laboratory observations and a maternal interview. The y found that maltreated children spoke significantly less about physiological states, negative affect, and motivational speech than did their age mates. Herman (1992 ) poignantly summarized the dilemma of the maltreated child: Repeated trauma in adult life erodes the structure of the personality already formed, but repeated trauma in childhood forms and deforms the personality. Th e child trapped in an abusive environment is faced with formidable tasks of adaptation. Sh e must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power is a situation of helplessness. Unabl e to care for or protect herself, she must compensate for the failure of adult care and protection with the only means at her disposal, an immature system of psychological defenses, (p.96.) Literature Related to the Resilient Child There is a fair amount of interest in the literature as to the traits that allow a child to survive, or be resilient in the face of an early destructive or psychopathogenic environment. Mahoney (1991 ) summarizes the literature identifying the following to be characteristics of "hardy" or resilient individuals: 1. Early awareness that his or her parents were not functionin g well. (Thi s seems to be an ability to differentiate self concept from that projected by family.) 2. Identification and frequent use of alternate persons as sources of security, nurturance, and developmental identification. 41 3. Early identification and refinement of a special talent (academic, artistic, athletic) that opened new developmental paths and social networks. 4. High motivation to develop, often expressed in unusual tenacity and intensity of activity. 5. A tendency to experience frustration and even trauma as challenges and opportunities for development.(p.161- 162) Maltreated Children and Peer Relationships in the School Years Achieving and maintaining healthy peer relationships is one of the major developmental tasks of the elementary school years. Positive peer relationships are linked to a variety of favorable mental health outcomes. Lynch and Cicchetti (1991 ) evaluated the relationship patterns of 215 economically disadvantaged 7 to 13 year old children during a summer camp experience. Approximatel y half of these children were maltreated, while the other half had received adequate parenting. The y found that the abused children were more likely to show a confused pattern of relatedness, an d non-maltreated children more likely to have optimal patterns of relating to both peers and adults. The children's ability and patterns of relating within a number of different relationships was assessed. Th e authors found a fair degree of continuity between the children's reports of relatedness with their mothers, their teachers and their best friends. Thes e results were seen as evidence that children form both global and specific models of relationships, but that key relationships are most often modeled after primary attachment bonds. The y summarize that maltreated children are at risk for 42 developing globa l models o f relationships, an d of sel f i n relation t o others tha t are predominantly negative . The y conclude tha t th e maltreated chil d i s consequently destine d t o a life of unsatisfactory relationships , i f early interventio n i s not offered . Dodge, Peti t & Bates (1994 ) also assessed peer relationship s in 585 children, 11 % of whom were physically abused . The y followed th e children fo r a period o f fiv e years durin g elementary school . Assessment s were made using yearly paren t interviews, teache r rating , an d peer sociometri c interviews . Maltreated childre n were consistentl y judge d t o be les s popular, more disliked , an d more withdrawn tha n thei r no n maltreated peers. Negativ e rating s were consisten t between al l sources. Th e researcher s conclude d tha t thei r data supported th e notion tha t early maltreatment disrupt s attachmen t relationship s with caregivers , and tha t thes e disruptions the n impai r a  child' s ability t o for m healthy peer friendships . Cohn (1990 ) likewis e foun d similar result s when studyin g 8 9 children durin g thei r firs t year o f school. Sh e foun d tha t insecurely attache d childre n were les s like d by teacher s an d peers, more aggressive , and had more behaviour problems tha n their securel y attache d counterparts . In summary, insecur e attachmen t an d maltreatment hav e bee n highly correlate d with unsatisfactory relationship s with peer s and teacher s int o th e school years. Thi s tend s t o substantiat e the claim tha t early aberran t attachmen t relationships , ten d t o be replicated i n a variety o f interaction s durin g th e schoo l years. Ther e ar e a number o f reasons why thi s findin g i s caus e 43 for concern. Recen t researc h emphasize s th e crucial rol e tha t peer relation s play i n prepubertal children' s schoo l success , mental health , an d ongoing developmen t (Asher , 1991 ; Kupersmidt, Coie & Dodge, 1990) . Pee r rejectio n has also been sho w t o be a strong predictor o f a broad rang e of maladaptive outcomes , including juvenil e delinquency, crime , psychological pain, an d school failure . Thi s findin g add s furthe r credenc e t o th e nee d for early childhoo d interventio n when insecur e attachmen t an d maltreatment ar e evident . Variables Consistent with Interrupting the Cycle of Abuse If a new an d more effectiv e mode of interventio n i s to be found, i n the fiel d of child maltreatment, i t i s useful t o explore th e question o f variables consisten t with interruption s in the abusive cycles . T o date, the articles ar e yet fe w and fa r between. Thre e however were foun d t o be useful, all coming fro m the data collecte d i n the Minnesota Longitudinal Mother-Chil d Intervention Project . Th e chie f researcher s o f thi s project, Byron Egeland an d Alan Sroufe, have appeared elsewher e i n thi s review. Onl y th e most comprehensiv e o f th e thre e articles wil l be reviewe d here. Egeland, Jacobvit z an d Sroufe (1988) , wer e involve d i n a prospective longitudina l stud y followin g 26 7 lowe r clas s mother s from th e thir d trimeste r o f pregnancy throug h th e fift h year o f their child's life . A  variety o f factors , likel y t o affec t th e quality o f parent-child relationship , were studie d including : a ) retrospective report s o f th e quality o f care thes e mother s experienced a s children; b ) observatio n o f thei r behaviour wit h 44 their own children (a t various visits for all study participants; c) as well as yearly scales measuring the degree of life stress experienced by the family. Finally the quality of emotional support, including the quality and consistency of the mother's relationship with her partner and various psychological personality inventories were evaluated on a yearly basis. The retrospective reports of the mother's childhood experiences, coupled with the observations of the mother's care of her child were combined to identify a) those mothers who had been maltreated as children; and b) those who were currently maltreating their own children. Coder s of maternal histories were kept blind to information regarding the mother's behaviour with her own child, and vice versa. Forty-seven mothers were identified as having been either severely neglected or abused as children. Forty-four mothers were identified as currently maltreating their infants based on observations at 3, 6, 9, 12, 18 and 24 months. Fro m this data, the mothers were placed in an "abuse continuity group" (continuin g the cycle of abuse) N=18, or the abuse "exception " group (providin g adequate care) N=12. Seventeen additional mothers could not be definitively labele d either as adequate care or as maltreating and therefore were not included in the analysis. Based on the extensive interviews described earlier the following variables were conceived and coded, independent of knowledge of the mother's childhood history or current child care practices: a) availability of an emotionally supportive relationship during childhood; b) mother's participation in therapy (individua l or family) of one year or more; and c) stable 45 or satisfying relationship s with a primary partner. The analysi s of results sho w a combination o f finding s simila r t o various studies previously describe d i n this chapter. I n contrast t o th e mothers who continue d th e cycle of abuse, a significantly large r proportion o f mothers i n the "exception " grou p reporte d havin g had a supportive relationshi p with some adult i n their ow n childhood (p<.002 ) or having undergone extensiv e therap y (p<.02) . Because "yes " answers o n these tw o variables di d not overlap , al l subjects i n the "exception " grou p experienced on e or th e other o f the emotionally supportiv e relationships . None o f th e mothers i n the abuse continuity grou p had been i n therapy, an d only thre e reported having had an emotionally supportiv e adul t relationshi p during thei r childhood . In describing adul t relationships, significantl y mor e "exception" grou p mothers characterize d thei r relationshi p wit h their partner a s intact, satisfying and/o r stabl e (p<.002) , an d significantly fewe r reported being physically abuse d by thei r mates (p<.02 ) tha n did th e continuity mothers. In relation t o stressful lif e events th e "continuity " grou p experienced significantl y more stressfu l lif e events tha n did th e "exception" grou p (p<.02-.004 ) dependin g upon th e age o f measurement. I t i s of interes t t o note tha t th e majority o f th e life stressors endorse d were item s indicatin g problems with othe r family members and/o r friends . This i s congruent with th e result s indicating tha t relationship problems ar e linke d with continuit y of abuse acros s generations . In summary, i n keeping with Bowlby's attachmen t theory , supportive relationship s eithe r i n childhood, i n the context o f 46 therapy o r i n a love relationship, not only characterize mother s who giv e adequate car e t o their children, but may als o provide a n alteration o f th e internal working model o f abuse lai d down i n the child's earl y maltreatment experience . In summary, th e development o f standardized tool s fo r assessment o f attachmen t i n both adults an d infant s has enable d researchers t o make great stride s i n tracking th e relationship s between parental models an d early experience, and thei r abilit y to provide qualit y car e an d security t o their own children . Further, thes e standardized tool s have allowed us t o develop a base fro m which t o track patterns o f both adaptiv e an d maladaptive behaviour i n relation t o early parent-chil d relationships. Indee d th e attachment paradigm has been ver y productive i n creating a  fram e of understanding fo r this data. In general, th e research studie s reviewe d fo r thi s chapte r demonstrate tha t adults who experienced abusive , neglectful, rejecting, o r insecur e childhoo d relationship s with parents wer e significantly mor e likel y t o have infant s who were als o poorl y attached a t risk fo r futur e maladaptive relationships . Infant s who showe d avoidan t attachmen t i n relation t o maternal figure s showed significantl y more frequen t patterns o f avoidant , aggressive, an d victimizing relationship s with peers. Th e resistant classificatio n o f th e SS was not as consistentl y predictive o f suc h relationships. The research als o tell s us tha t we ca n begin t o predict which parents ar e les s likel y t o continue th e pattern o f maltreatment tha t the y received a s children. Parent s who wer e supported by significan t adult s during childhood , ha d a year o r 47 more o f therapy , ha d a secure and supportive relationshi p with a partner, o r were abl e t o achieve insigh t int o th e detail an d impact o f maltreatment upo n the m tende d t o break thi s cycle. Thi s information allow s us t o screen thes e individual s ou t fo r needin g less intensiv e help with parenting o r with therapeuti c intervention. Perhap s the y also provide us with th e rational e for early secondar y preventive interventio n i n childhood, no t only t o minimize th e impac t of abuse upon th e child, but als o upon th e next generation . Th e answers see m t o lie i n the formin g of intimat e an d supportiv e alternat e relationship s (therapeuti c or otherwise) wit h people othe r tha n th e abuser. Insigh t i s als o a factor . A fina l importan t findin g track s th e impac t o f early non-supportive parenting o n childhood behaviour an d relationships . The behaviour o f children who have been maltreated o r who wer e insecurely attache d i s clearly and distinctly differen t fro m their secur e counterparts . Their behaviour alread y show s a tendency t o replicate avoidant , aggressive, o r victim roles a s early a s th e toddle r years. Thoug h thi s behaviour may reflec t a necessary strateg y fo r survival, i t starts th e child upon a trajectory o f unsatisfying relationshi p patterns fro m early i n life. Although th e excellent quantitative researc h studie s reviewed abov e provide us with importan t insight , ther e remain s insufficient informatio n t o make detailed use of thi s data i n th e process o f counselling an d preventative work. There ar e many questions stil l t o be answered before we ca n translat e thi s 48 information into treatment protocols and intervention strategies for maltreated youngsters. An important research question is whether play therapy has a role in altering the negative or maladaptive internal models of self and self in relationship to others. Can the play therapy situation provide the child with an opportunity to rework these internal models and thus break free of the destructive cycles. Literature Related to Models of Self The Development of the Self in Early Childhood Philosophers and theorists have long shown an interest in understanding th e existence and emergence of the self in the human organism. The attempt to understand the relationship between the mind, soul, and self has captured the interest of ancient and current philosophers alike. Though the study of the self has a history as far back as Aristotle, the literature exploring the development of the self in early childhood is still inconclusive and in the early stages of exploration (Cassidy , 1990). The last two decades has marked an increasing interest by researchers in developmental psychology and psychopathology (Bowlby, 1973; Cicchetti & Beeghly, 1991; Harter, 1983; Mahler, Pine & Bergman, 1978), and the process by which the self emerges in the individual. Psychoanalytic theorist s were among the first to theorize the emergence of self in relation to others and the environment. Freud (1950 ) described the process whereby the infant develops an 49 identity separat e fro m the mother. Mahle r an d colleagues (1975 ) employed detailed observation s t o document th e process by whic h the infan t progresses throug h predictable stage s o f separatio n and individuatio n fro m th e caretaker. They describe th e transformation o f th e child fro m a state of undifferentiate d symbiosis with th e mother t o a sense of th e self as separat e an d distinct fro m th e caretaking figur e Like th e psychoanalytic an d object relation s schools , attachment theorist s view th e early caretakin g relationshi p t o be key i n the pathway tha t self development takes . The interna l working models describe d by Bowlby (1988 ) are also simila r t o th e self an d objec t representation s o f object relation s theory . Th e consistency o f early representationa l model s a s documented i n attachment researc h has been well documented i n this revie w (Crittenden, 1988 ; Egeland, Srouf e &  Erikson, 1983 ; George & Main, Sroufe , 1991) . In the theor y o f attachment then , th e model o f self i s distinguished fro m th e model o f self i n relation t o others. Whereas th e self i n relation t o others i s a socialized self , wh o has adapte d t o a caregiving environment ; th e self model reflect s a sel f tha t i s reflective o f th e original capacities , an d authentic experienc e o f th e child . Stern (1985 ) defines a  core sens e of self tha t firs t become s apparent a t thre e months o f age and i s organized aroun d experiences with th e body i n relationship with a significan t other. Bretherto n an d Beeghly (1982 ) suggest tha t i n infanc y there i s a sense of body sel f tha t i s implicit i n behaviour. Stern notes tha t th e subjective sens e of self begins t o emerg e 50 around nine months o f age when th e infant develops a  capacity t o share attentional an d affective states . Bretherto n an d Beeghl y further sugges t tha t at 1 8 - 24 months o f age, the self o f th e child normally becomes increasingl y observabl e within play an d language. Sroufe (1991 ) describes th e self as an inner organizatio n o f attitude, expectation , an d meaning which aris e fro m an organize d caregiving matrix tha t exists prior t o the emergence o f th e self , and which has organizationa l significanc e fo r ongoing adaptatio n and experience . Lynch and Cicchetti (1991 ) summariz e tha t th e representational mode l o f self i s developed throug h relationshi p with primary caretaker . Interna l representationa l model s may b e the mechanism fo r continuity between self-organizatio n an d relationships wit h others. For each model o f relationship, ther e is a complimentary mode l o f self. Guidano (1987 ) explains tha t th e infan t i s born with buil t in emotional responses , tha t are by nature diffuse, chaotic an d not eas y t o decode o r control. Ove r tim e feeling s acquir e structural connotation s with related perceptions, actions , an d response patterns, labele d emotional schemata . Emotiona l schemata ar e described a s the "structura l configuratio n i n memory representation tha t act as a pattern against which th e ongoin g sensory inflo w i s compared an d made meaningful. I n infancy, i t is the dynamic interpla y between child and caregiver tha t provides th e initia l structurin g o f fundamenta l emotion s and , therefore th e initia l patterns fo r self perception. Repetitiv e 51 experiences with the caregiver provide the foundations of early emotional schemata. He further explains that by the early preschool year, children accumulate a number of what he describes as critical affectively laden nuclear scenes that form a child's early rudimentary conceptualization of self. H e notes that the experiences that go into making this aspect of self definition tend to be repetitive emotionally laden interactions with primary caretakers. It appears from a variety of literature that when the early caregiving experience is attentive , responsive, and supportive of the natural gifts, needs, and disposition of the growing infant, the model of self is very similar to the model of self in relation to others. I f the caregiver / infant relationship reflects the true needs of the infant, rather than the problems of the caretaker, then the relational model reflects the infant's needs and reality. There is little doubt that the final word on the development of the self is still to emerge. There is wide support for the import of the role of the early caretaker in significant aspects of self development. There are also notable data to support the view that the perception of self may alter significantly with cognitive development. The Projected Images of Self The Stories of maltreated children 52 A number of studies compare the stories that maltreated children tell to those told by their well cared for peers. Dean , Malik, Richard and Stringer (1986 ) asked maltreated and non maltreated children to tell stories about kindness and unkindness in a variety of relationship categories. The y found that young maltreated children, between the ages of six and eight frequently told storie s about parents being justified in hurting their children. I n relation to peers, these same maltreated children told more stories depicting physical aggression than did the non maltreated control group. Hanna (1991 ) discovered that the stories of sexually abused children could be distinguished from their peers by the presence of sexual content, anger, aggression and depression. Physicall y abused children's stories were distinctive because of the amount of difficulties in mother-child relationships. In a more recent study McCrone, Egeland, Kalkoske and Carlson (1994 ) gave sixth grade children a projective story telling task as part of their longitudinal study of high-risk children. Fort y three of these children had been identified as having been maltreated at an earlier time. Th e study found that maltreated children told distinctively different stories from those who were well treated. Maltreate d children's stories tended to have high incidence of victimization, negative relationships, aggression, poor boundary maintenance and preoccupation with troubling themes and emotions. In general this research demonstrates that stories of maltreated children tend to be qualitatively different from their 53 sensitively raise d counterparts . Furthe r ther e i s beginnin g evidence tha t thes e children' s storie s a t leas t i n par t mirro r elements o f thei r experience s wit h famil y an d peers . Literature Related to Methodological Issues Currently, th e attachmen t literatur e ha s relie d primaril y upon quantitativ e researc h t o relat e Bowlby' s (1986 ) attachmen t concepts t o th e issue s surroundin g th e impac t o f maltreatmen t upon th e child . Standardize d researc h tool s suc h a s th e Strang e Situation (Ainsworth , 19 7 8) an d th e Adul t Attachmen t Questionnaire (Mai n &  Goldwyn , 1984 ) validat e tha t earl y attachment pattern s ca n persis t int o childhoo d an d late r int o parenting relationships , unles s othe r consisten t an d supportiv e relationships alte r thes e pattern s (Georg e &  Main , 1979 ; Tro y & Sroufe, 1987) . Wha t i s lackin g i n thi s researc h ar e th e detail s of ho w an d whe n suc h relationship s alte r a n individual' s patter n of relating . Mor e specificall y ther e i s a  deart h o f researc h documenting th e impac t specificall y o f th e therapeuti c relationship upo n eithe r th e insecurel y attache d individua l o r the maltreate d individual . Studies Examining Internal Models in Children A numbe r o f studie s hav e sough t t o tes t ou t a  variety o f external measure s fo r identifyin g an d classifyin g children' s internal workin g model s and/o r schemata . Main , Kapla n &  Cassid y (1985) sough t t o determin e si x yea r old s attachmen t classifications b y thei r respons e t o a  serie s o f separatio n pictures, the y foun d tha t secur e childre n smile d a t th e pictur e 54 and commented o n it while insecur e childre n turne d away fro m th e photo, droppe d it , or handed i t to the examiner. Cassidy (1990 ) used puppet interview s an d a story completion tas k t o determin e the child's view of self i n the attachment relationship . Again , this researcher foun d a clear difference i n how securely attache d children represente d themselve s fro m those tha t were insecurel y attached. Sh e was also able t o find a significant correlatio n between th e child's sel f concep t a s measured i n the puppet interview an d doll stor y with standardized sel f concept measures. It appears fro m thes e studie s tha t careful o r structure d observations o f children's response s ca n help t o differentiate a variety o f ways o f viewing sel f and th e world. Plav Therapy Process Research Despite th e fac t tha t play therap y has been th e treatmen t o f choice fo r many prominent theorist s an d therapist s sinc e th e 1940's (Axline , 1969 ; Klein, 1975 ; Landreth, 1982 ; Moustakas, 1955), ther e i s still a relative dearth of useful play therap y process research . Tramontan a an d Sherrets (1983 ) discuss som e o f the problems specifi c t o documenting therapeuti c impac t upo n children ove r time . They note tha t maturation an d developmen t alone may chang e th e manner i n which children manifes t personality trait s an d symptom formation . They als o cite th e profound impac t tha t family , schoo l an d environment have upon th e functioning o f th e child. Thes e certainly ar e importan t caution s and len d added credenc e t o the need fo r detailed documentatio n o f the context within which th e child live s during th e research. I 55 would also note that the detailed documentation of the Minnesota longitudinal study of high risk children (Sroufe , 1991) gives us fair certainty as to the consistency of behavioral and relationship patterns exhibited by non-treated abused children. Indeed this careful documentation in many ways negates the need for a control group, and allows us to focus, in this study, upon the change within each child over the course of therapy. Moustakas (1955b ) was one of the earliest theorists to attempt to differentiate the play of maladjusted children from that of well adjusted children. He developed ten different categories of negative affect which encompassed various qualities of anxiety, regression and hostility. In observing the two groups containing nine children each, he found that the disturbed children demonstrated a greater frequency and intensity of play that exhibited a) diffuse hostility; b) hostility toward family and home; and c) cleanliness and orderliness anxiety. The disturbed children were also more likely to show regression in development during their play. Howe and Silvern (1981 ) developed the Play Therapy Observation Instrument (PTOI ) as a generic instrument for following the process of play therapy sessions. An attempt was made to include behaviours which were representative of concepts common to most theoretical schools of play therapy. From an extensive review of play therapy theorists, they chose four broad behavioral dimensions including 31 discrete behaviours. Their broad categories included: a) emotional discomfort, b) social competence, c) maladaptive coping strategies, and d) fantasy Play. 56 They tested the usefulness of their instrument using raters who coded 76 12-minute sessions drawn from 20 different videotaped play therapy sessions. Analysis of their data demonstrated a number of important conclusions concerning the play therapy process. First they found that two categories of behaviours clustered with other indicators of emotional discomfort. These were "frequenc y of play expressive of conflict" and "frequenc y of talk about worries and feelings". Secondly they found that there was no correlation between fantasy play and maladjustment, unless this play was "expressiv e of conflict". In general they concluded that it was indeed possible to operationalize, code and measure theoretically important aspects of children's playroom behaviour. Perry (1988 ) also used the Play Therapy Observation Instrument, this time to compare the play behaviour of 15 well adjusted and 15 maladjusted children. Each child was observed during an initial play session lasting 3 6 minutes. Analysis showed that the items on the subscale of emotional discomfort clearly discriminated adjusted from maladjusted children. This category specifically measures therapist and child interaction and may be helpful in guiding the coding for this particular study. Without documenting the source of his theory, Moustakas (1955a) also described the stages that the child was going through during the course of therapy. He described six stages of emotional process demonstrated by the child over 24 weeks of therapy. The stages included: a) undifferentiated and ill defined positive and negative feelings; b) the emergence of focused 57 positive an d negative feelin g relating t o parents, siblings an d others; c ) ambivalent feeling s towar d others; d) negative feelin g as primary focus ; e) ambivalent negative an d positive feeling s predominating i n therapy; an d finall y towar d th e end o f therap y f) positive feelin g predominating i n therapy . Allan (1988 ) described thre e stage s tha t children go throug h when a non-directive approac h t o serial cas e drawings i s employed. I n two case studie s he documented th e transformatio n i n each child's drawing s an d affect. Like Moustakas' stages , ther e was no clea r documentation o f th e change manifested by th e children outsid e o f th e session. As with much of th e play therap y literature, we ar e still lef t with questions a s t o how th e progress o f th e child i n therapy translate s o r corresponds t o behaviour an d coping outsid e o f therapy . Plav Therapy Outcome Research Hannah (1986 ) sought t o document th e impac t of play therap y on behaviour outsid e o f th e classroom. Hi s stud y followe d te n children who were referre d t o play therap y because o f acting ou t behaviour i n the classroom. Th e children received play therap y from graduate student s being traine d i n a client centere d approach t o therapy . Eac h of th e nine subject s had a  singl e specific behaviou r monitored i n the classroom settin g t o determine chang e ove r th e 1 1 week tim e period. Using a  Box-Jenkins techniqu e o f data analysis, Hanna h concluded tha t th e children demonstrated positive an d significan t change i n their targete d behaviours a s a result o f play therapy . 58 Despite thi s convincing statistica l conclusion , teacher s agree d with thi s conclusion o f positive chang e i n only 17 % of th e cases. Parents concurre d with positive chang e i n 50% of cases. Suc h discrepancy i n finding s may be a result o f a number o f factor s common t o therapeutic research . Children's behaviour i s comple x and often contex t dependent . I t is unlikely tha t th e trackin g o f one behaviour, without includin g context , will adequatel y measur e important change s i n a child. Secondly , ther e i s considerabl e risk i n utilizing differen t therapists , with widely divergen t approaches an d experience t o prove efficac y o f play therap y i n general. Finally , th e validity o f finding s i s certainly enhance d when ther e i s agreement between a  number o f sources o f assessment. Perez (1987 ) was one of th e fe w researchers who specificall y measured therap y outcom e fo r abused children. He divided 5 5 fou r to nine year ol d maltreated childre n int o thre e treatmen t groups. Eighteen o f th e children were involve d i n individual pla y therapy, 2 1 i n group play therap y an d 1 6 i n the control grou p remained o n the wait list . He administered tw o tests , on e measuring locu s o f control, th e other primary sel f concept , t o the children before an d after th e 1 2 weeks o f therapy . He foun d no significan t differenc e between th e outcome o f children i n group therap y an d thos e i n individual therapy . He foun d tha t bot h therapy groups showe d significan t improvemen t i n scores o n bot h scales, i n comparison t o the control grou p i n which n o improvement was demonstrated . This researc h i s an example o f th e use of simplisti c measures used t o analyze complex processes. In looking carefull y 59 at th e tw o measurement scale s used, th e questions aske d hav e little t o do with what th e literatur e an d clinical experienc e supports a s th e child's response t o or experience o f abuse. In conclusion, plotting authenti c an d credible progress an d outcome o f a child i n play therap y i s a complex tas k requirin g attention t o great detai l i n relation t o the child's behaviou r within and outside o f th e context o f therapy . Fo r finding s t o be valid, ther e are a number o f safeguard s tha t th e researcher migh t employ. First , having a  single therapist , seein g al l childre n within th e study, coul d decrease th e likelihoo d o f therapeuti c variables (rathe r tha n actual chang e i n the child) impactin g outcome. Secondly , detaile d stud y of each child's behaviour, bot h within therap y an d within th e outer world, would ensur e tha t th e measurement o f change i s real an d not jus t a measure o f reductionistic convenienc e fo r th e researcher. Finally , i f th e child's progress i n the "rea l world" i s assessed by a  variety o f people o r sources o f measurement, th e resultant conclusion s woul d be more credible . I t seems tha t t o obtain th e depth and breadt h of informatio n tha t would provide rea l insigh t int o th e chang e process, qualitativ e methods i n the tradition of fiel d (naturalistic) researc h ar e the logica l conclusion . 60 CHAPTER III METHODOLOGY I became interested in the research questions posed in this study during my work as a play therapist in one of the inner city elementary schools. A  number of the most troubled children who were referred to me had experienced early maltreatment and subsequent separation from their primary caretakers during the first two years of life. No t surprisingly with such histories, their behavioural presentations were similar to those children labeled as insecurely attached in the attachment focuse d maltreatment literature. As I provided non directive play therapy to these "original" maltreated children, I noticed a number of patterns of change that were best explained by the attachment literature. Though , like most traumatized children, these youngsters used the play therapy time to externalize and process trauma, a great deal of time was also spent playing out what seemed to be missed developmental experiences. Withi n the subtle interactional dance between child and therapist, the children also appeared to be testing, and then reworking old attachment models. Additionall y there seemed to be a concurrent process of reworking certain developmental tasks. O n the surface, these patterns were complex and multifaceted, and I knew that without detailed analysis, would remain tantalizing but unclear. I  began searching for a methodology that would facilitate my enquiry. I t soon became clear that the more reductionistic methods of quantitative analysis would result in a loss of rich detail. Qualitativ e case 61 study methods of research and analysis, with their "thick description", seemed the appropriate method of choice for understanding this intricate emotional and social process of change. Qualitative analysis and a multiple case study design were purported to be the most appropriate methodology for studying and clarifying complicated human and social processes (Lincol n & Guba, 1985) . Th e case study approach allows for the empirical enquiry into a contemporary phenomenon within the context of the "real life" world of the subject (Yin , 1989) . Cas e study was also deemed most useful when the boundaries between the phenomenon studied and the context therein were not entirely distinguishable. Th e process of change, over a significant portion of a child's life is just such a phenomenon. Relevant Literature Review A number of clinicians and theoretician have called for detailed observation of children's change process during therapy (Crittenden, 1992; Freud, 1957; Parsens, 1979). Freud (1957 ) pleaded for the legitimacy of direct child observation within the framework of psychoanalytic investigation . She suggested that children's surface behaviours provide clues to the conflicts and concerns hidden within the mind. Donovan and McIntyre (1990 ) posit that a child's symptoms and behaviour contain within them the answer to the child's unexpressed needs. Likewis e Kohut (1982 ) stated that the psychic organization of the individual is best explicated from the 62 position o f participant observer . An d finall y Parsen s (1979 ) suggests tha t th e richest material fo r theory building has com e through th e process o f direct participant observe r observation . In a metareview o f child therap y research , Tramontana an d Sherret (1983 ) criticized th e experimental desig n of mos t research methodology. The y noted tha t all to o frequently , researchers use d singula r o r gross measures a s dependen t variables, leavin g a n "al l or nothing" qualit y t o th e outcom e effect. Suc h measures were fel t to be insensitiv e t o both th e complexities an d subtleties o f therapeutic change . Thes e author s concluded tha t therapeuti c chang e coul d best be assessed usin g multiple criteri a obtaine d fro m varying source s measured ove r time. Lazarus (1981 ) also argued fo r less emphasis o n shee r numbers an d more upon th e process o f therap y an d th e manner i n which individual s interac t within thei r environment . H e criticized th e traditiona l psychological trai t scales tha t fragment both th e individual a s well as th e results. Bowlby himself was saddene d by th e lack of research relatin g the concepts o f attachment theor y t o the therapeutic process . H e felt tha t i t was: a littl e unexpected that , whereas attachmen t theor y wa s formulated by a clinician fo r use i n the diagnosis an d treatment o f emotionally disturbe d patients an d families , its usage has been mainly t o promote researc h i n developmental psychology. Whil e I  welcome thes e finding s a s enormously extendin g ou r understanding o f personalit y development an d psychopathology, an d thu s as of th e greates t clinical relevance , i t has none th e les s been disappointin g that clinician s have been slow to test th e theory' s uses . (Bowlby, 1988 ; pp. ix-x ) 63 From my origina l observation s with th e children i n the pilot study, I  believed attachmen t theor y t o be a useful paradigm fro m which t o pose th e questions regardin g th e process o f change o f young maltreated children . I  also believed tha t th e naturalisti c method o f inquir y would allo w th e children's actions , pictures, and words t o speak fo r themselves . Naturalistic Research Naturalistic researc h i s described a s involvin g tim e spen t in the fiel d with subject s a s a participant observer . "Th e naturalist choose s t o carry out research i n the natural settin g or context o f th e entity fo r which stud y i s proposed, becaus e naturalistic ontolog y suggest s tha t realities ar e wholes tha t cannot be understood i n isolation fro m thei r context" (Lincol n & Guba, 1985 , p.35). Thi s paradigm attempt s t o minimize th e suppositions wit h which th e researcher approache s th e empirica l environment. I t encourages th e participant observe r t o be acutely attune d t o th e natural world o f th e study contex t (Lofland & Lofland, 1984) . The naturalistic paradig m considers experienc e t o be subjective, mutually interactive , and holistically comple x (Lincoln & Guba, 1985) . Par t of th e research strateg y i s t o understand th e human experience throug h immersio n within it . Thi s approach retain s th e meaning, an d context o f th e subject' s reality, thu s providing ric h insigh t int o human behaviour (Gub a & Lincoln, 1994 ) . Extende d immersio n i n the data allows fo r th e natural an d eventual emergenc e o f theme s an d theor y (Burgess , 1984), retainin g th e "discover y dimensio n o f research" . 64 Detailed observation s an d subsequen t dat a analysi s ar e use d to generate ne w understanding o r theor y o f th e phenomenon bein g studied. Inductiv e reasonin g i s used i n the analysis o f data. As noted by McMillan &  Schumaker: The researcher reflect s o n the finding s fo r meaning abou t humans i n general an d link s finding s t o more general socia l science theory . (It ) provides a n extension o f understandin g rather tha n generalizability. A n understanding ca n provide a configuration o f reasonable expectatio n which might b e useful i n similar situation s (McMilla n & Schumaker, 1989 , p. 105) . The interpretatio n o f data i s accomplished throug h a  process of data analysis an d reduction. Th e answers t o th e stud y questions ar e foun d within th e data, with analysis entailin g a process o f sorting an d rearranging unti l th e trut h emerges. Th e final interpretatio n i s a productive process tha t illuminate s th e multiple meanings o f an event.(Miller &  Crabtree, 1994) . Qualitative researc h values th e voice an d reality o f th e subject. Th e fina l tex t i s written i n a languag e tha t i s clearl y understandable t o the general population. Th e tex t include s a "thick description" o f it s subject, enabling th e reader t o "liv e their way int o th e experience tha t has been described an d interpreted" (Denzin , 1994) . Case Study Design Case stud y methodology i s appropriate when researc h goal s and questions cal l fo r an intensity an d depth o f data collectio n over time . Baas an d Brown (1973 ) make a  distinction betwee n research tha t i s extensive an d tha t which i s intensive i n nature. Whereas empirica l psychological researc h has proceeded almos t 65 exclusively alon g extensiv e line s (i.e . survey , larg e sampl e controlled), cas e stud y an d qualitativ e researc h tend s t o b e intensive i n nature . Th e intensiv e approac h focuse s o n a n in -depth stud y o f mor e subtl e an d detaile d element s o f a  smal l number o f subject s ove r tim e (Yin , 1989) . In cas e stud y researc h th e focu s i s o n th e individua l uni t or entity . Th e natur e o f thi s metho d allow s th e stud y t o capitalize an d focu s o n th e complexit y o f th e proble m o r process , within th e uniqu e characteristic s o f eac h individua l context . Th e full complexit y o f th e proces s o r situatio n ca n b e studie d because th e natura l situatio n i s no t greatl y disturbe d throug h artificially controlle d conditions , intrusiv e assessment , o r similar constraint s o f experimentatio n (Kazdin , 1982) . Th e dat a is ric h an d complex , wit h "eac h individua l cas e stud y consistin g of a  whol e stud y i n which convergen t evidenc e i s sough t regardin g facts an d conclusion s o f th e case . Th e conclusion s o f th e cas e are the n considere d t o b e th e informatio n needin g replicatio n b y other individua l cases " (Yin , 1989 , p . 5 7 ) . Usin g multipl e case s adds t o th e credibilit y o f theor y derive d fro m cas e stud y data . The capacit y t o examin e event s ove r a  perio d o f tim e i s a n important advantag e o f thi s method . Descriptio n an d analysi s o f real lif e detai l enable s th e researche r t o fin d th e possibl e meaning withi n th e element s an d patter n o f behaviou r (Ba s & Brown, 1973) . Th e methodolog y furthe r allow s u s t o probe th e specifics o f on e situatio n i n dept h wit h th e hope s o f findin g illumination int o th e principal s o f huma n behaviour . An instrumenta l cas e stud y i s examine d t o provide insigh t into a n issu e o r refinemen t o f a  theory . Th e choic e o f cas e i s 66 made i n order t o advance understanding o f tha t interest . Th e case researcher analyze s th e case and tel l th e story s o tha t th e readers ca n lear n on their own fro m th e case. From case reports we lear n both prepositional an d experiential knowledge . Certain descriptions an d assertion s are assimilated by th e reader int o memory. Whe n th e researcher's narrativ e provides opportunit y fo r vicariou s experience, reader s exten d thei r memory o f happening s (Stake, 1994 , p.240) Case stud y research has, since th e time of Freud, been a backbone o f psychological researc h an d theor y building. Kazdi n (1980) notes tha t i t allows th e clinician/ researcher t o remai n in touch with th e realities o f clinical practice. Withi n th e last thre e decade s however, contemporar y psychology ha s nearl y abandoned cas e study, i n favor of quantifiable grou p researc h (Rosenwald, 1988) . To o ofte n th e results leav e us with a n understanding o f th e behaviour a s related t o the "mean " rathe r than th e client. Multiple cas e studie s allo w us, within th e rich detail o f the study modality, t o extend finding s an d relationships beyon d the idiosyncrati c finding s o f one individua l (Kazdin , 1980) . Theory derive d fro m multiple case s emerge s throug h a  process o f conceptual refinemen t a s successive case s are considered i n relation t o each other. Eventually ther e comes a time when th e developing conceptua l framewor k seem s complet e an d th e adding o f subsequent case s unnecessary (Bromley , 1986) . Participant Observer The position o f researcher a s participant observe r i s commo n to th e naturalistic paradigm . When th e objective o f th e researc h 67 is to study relationship s ther e seem s no more appropriat e perspective tha n within th e client/therapist relationship . Thi s is especially tru e i n therapeutic research . I t would be difficul t for an external observe r t o gain th e depth of understanding tha t is possible fro m within th e therapeuti c relationship . (Kazdin , 1980) . The naturalistic paradigm see s th e human observe r a s th e most importan t instrumen t o f research. Lincol n and Guba (1985 ) suggest tha t "ther e are compelling reason s fo r conductin g inquiries i n ways tha t maximize rathe r the n minimize th e investigators interactions . Th e quality of interactio n must b e good i f an appropriate balance between factua l theor y ladennes s and theoretica l undetermination i s to be foun d and maintained" . Overview of the Research Design In this research, a  multiple cas e stud y design was utilize d to examine th e process by which tw o children, who had bee n maltreated i n the firs t tw o years o f thei r life , changed an d healed during twenty-fiv e t o twenty eigh t weeks o f play therapy . The researcher functione d a s a participant observe r actin g i n th e role of play therapis t t o both children. Th e role of therapis t included th e broad role of assessment, treatmen t an d consultatio n with significan t others . To thes e usual therapeuti c functions , the tas k of collecting detaile d schoo l observation s an d teache r interviews was added . Thes e provided th e data fro m whic h generalization o f change fro m therapy t o the classroom settin g were determined . 68 A naturalistic, fiel d research model of data collectio n was utilized. Exhaustiv e dat a fro m the playroom, a s well as the school settin g was collected, transcribed , code d and analyzed to determine th e patterns and processes by which each child healed . Each child's stor y and progress durin g therap y was analyzed as a single case . Th e patterns and processes by which both childre n changed were the n compared in order to document the commonalties across cases . Th e commonalties amongs t themes , patterns, and processes the n lea d to a connection of this process of change with literatur e fro m the theoretical areas : of (a ) self; (b) attachment; (c ) therapeutic theory ; and (d) developmental psychopathology; (e ) memory; and (f) trauma. Description of Subjects Three childre n were chose n to participate i n the 25 weeks of play therapy . Two are presented in this document. Criteria for selection stipulate d that : 1. The child's age was 5.0 to 7.5 years at the start of therapy 2. There was a history of maltreatment during the first two years of life, with maltreatment verified by either the parent, guardian, or the Ministry of Social Services. 3. The child attended the designated inner city school. 4. The child's parent or guardian was willing for the child to receive play therapy, to be videotaped, and to participate in the research. 5. There was no recent known acute trauma to the child that would dictate the use of a more directive therapy. 69 6. The child's teacher and parents were willing to complete essential forms and participate in 2-4 hours of interviewing during the course of the study. 7. The teacher would allow researcher or designate to observe periodically in the classroom. The three children who met the above criteria were originally selected, treated, and observed within the classroom setting. Al l three showed significant change as determined by therapist assessment, classroom observations, and teacher interview. Onl y two of the children are actually presented in this thesis. Thi s choice was made during the data analysis stage. Ther e were a number of reasons for this decision. A n important factor lay in the age and attachment differences of the three children. Th e two boys fell into the category of avoidant attachment, and the girl fell into the category of disorganized attachment. I  believed that the analysis would be "cleaner " if there were even numbers in any given category. I  had not expected that the type of insecure attachment classificatio n would make a significant difference in the child's process of change. A s it happened, although their overall patterns were similar, the process of change for the child with disorganized attachment was much more complex than that of the avoidantly attached child. I n addition the choice to present only two children allowed for a more concise process of comparing and contrasting according to the two different attachment types. Further, the two children who are described in this final document are both five years old, while the other child was seven and one half at the start of the study. I n the initial design, I 70 believed thi s ag e range would be reasonable, an d indee d i t was. But with tw o children at one age, and th e other being tw o year s different, I  believe i t would have create d a n unnecessary poin t of confusion. An d finally , th e depth and volume o f data tha t wa s relevant t o th e original question, eve n with jus t tw o children , was suc h tha t t o study an additional child , would hav e necessarily resulte d i n a more shallo w analysis an d presentatio n of th e data. I , and my advisors , opted fo r a greater depth o f data presentation . The tw o children presented i n this multiple cas e stud y me t all stud y criteria , were both fiv e years old , an d i n their firs t year o f kindergarten a t th e start of th e study. Bot h attende d the same inne r cit y schoo l and received play therap y ove r simila r periods o f th e school year. Th e therap y spanne d a  period fro m the middle o f th e kindergarten year t o the middle o f th e firs t grade year. Bot h saw the therapist fo r tw o sessions during th e summer, i n order t o minimally sustai n th e therapeutic connection . In addition t o th e study criteria, both had los t thei r mothe r during thei r secon d year o f life ; one because o f death, and th e other because o f permanent foste r placement. Neithe r ha d received an y therapy . Indee d th e thir d child had also bee n removed fro m his mother's car e at an early age. Thoug h parenta l loss was not part o f th e criteria, i t coincided with all childre n who met th e stud y criteri a i n other ways . Rationale for Subject Definition and Selection The subjec t selectio n criteria fi t th e profile o f th e "pilot" childre n with whom I  worked when I  first bega n 71 contemplating th e questions posed in this research study. These pilot children experienced maltreatment, and often subsequent separation from their primary caretaker during their first two years of life. Their histories were ones of chronic and early maltreatment, and their behaviour fit with those described in the attachment/maltreatment developmental research of insecurely attached children (Egeland , Sroufe and Erickson, 1983; Main and George, 1985; Main and Kaplan, 1985; Sroufe, 1991) . Classroom behavioural change for the two pilot children were significant. Teachers described an increase in self esteem, a greater concentration on school tasks, and an increase in social skills and contact with teachers and peers. On the surface the children seemed to move along a continuum from behaviour that fit Egeland, Sroufe, and colleagues' (1983 , 1985, 1990, 1991) descriptions of insecurely attached children to behaviour closer to those of securely attached children. My intent in choosing the above criteria for selection was to replicate the basic characteristics displayed by the children with whom I first noted these patterns. M y intent was to utilize a methodology that would allow me to explore the details of the above mentioned patterns. Process of Subject Selection The children selected for this research study were enrolled in kindergarten within the designated inner city school. Referral to therapy came from the area counsellor, in conjunction with the teacher and the school based team. I  had initially notified the teachers and school based team of my research 72 criteria. Onc e potential childre n were suggested , th e followin g steps were taken : 1. I observed the child within the classroom setting for the purpose of excluding any children with obvious sensory deficits, major psychiatric disorders, neurological, organic, or chromosomal disorders. 2. I briefly interviewed the teacher to confirm the child's history, presentation, and likelihood of remaining in the school during the study period. 3. The area counsellor then made the initial contact with the child's parents, providing general information about the proposed therapy and research opportunity. 4. I met with the parents, explained the research study, provided written information (Appendi x A), obtaine d permission, and conducted the first interview. Setting The setting was an inner city elementary school that houses grades K through 5. The teachers and staff of this school were committed to creating an environment for the children that was supportive and safe for the children of the school. It is my belief that this outer world sense of safety was an important component to the kind of healing seen in this study. The teachers in this school were open to working cooperatively with me to create an optimal interpersonal atmosphere for the children. The play therapy room is a small permanent room set up within the school. The small room doubles as the office of the 73 school's chil d car e worker , wh o als o offer s pla y therapy . Th e walls are painted a warm white and the trim is painted a mellow turquoise which gives the room a lively fresh look. Th e ceiling is covered with a variety of decorations that create a look of playfulness and optimism. I n the northeast corner, a parasol conceals much of the exit door. I n the southeast corner hangs a butterfly kite, and the northwesterly corner holds a rainbow mobile. Th e childcare workers desk occupies the eastern end of the room and faces into the room. Th e video camera is mounted upon a tripod atop this desk. Th e room is fully equipped to meet the basic goals of play therapy. The room contains six activity centers: (a ) a cozy corner with dolls and puppets, (b ) a sand tray with hundreds of symbolic miniatures, (c ) a fully equipped doll house, (d ) dress up clothes, (e ) a snack table where crystals, and art material lie, and (f ) a shelf with a variety of books, play food, cooking items, and medical equipment. The photographs below provide the reader with a glimpse of the play therapy space. 74 Figure 3.1 Playroom 75 Philosophy and Approach to Play Therapy The pla y therap y approac h use d fo r thi s researc h ca n b e described a s chil d centered , attachmen t sensitiv e pla y therapy . The basi c premis e o f th e therap y i s a  belief i n th e healt h an d healing powe r o f th e child' s psyche . I t i s base d o n th e premis e that give n a  safe , consistent , an d protecte d space , th e child' s psyche will know what he or she needs to do, within the room and relationship, to heal. Thi s philosophical approach recognizes the importance of the relationship in the healing process. Through reflection, acceptance, and affirmation of the children's play and communication within the play therapy room, validation of their authentic affect, experience, and reality is given. Th e therapeutic atmosphere and therapist's attitude is planned to encourage the child to utilize his or her own skills, creativity, and intelligence. Neithe r an agenda, nor a preconceived direction are set by the therapist. I n keeping with encouraging the strengths, and natural abilities of the child, the therapist does not offer help, nor participate in play unless it is at the specific request of the child. I f such a request is made, the child's guidance is sought as to how to fill this role. Limit s are few but consistent. Th e rules are that no one is allowed to hurt anyone or anything within the room. Childre n are also not allowed to take toys from the playroom. The underlying philosophy is that the child will make optimal progress if important figures in his or her outer world are supported, and also supportive of the child. I f the parent(s) are willing and able, consultation occurs on a monthly 76 basis, i f no t mor e frequently . I f thi s i s no t possible , the n another importan t adul t i n th e child' s lif e i s sough t a s a support fo r the m durin g th e healin g process . Durin g th e grad e school years , communicatio n wit h th e schoo l teache r facilitate s additional suppor t durin g a  significan t par t o f th e child' s waking hours . With th e childre n i n thi s study , contac t wit h th e parent s was generall y vi a th e telephone . I  usually consulte d wit h th e teacher a t leas t biweekly . M y goal s wit h th e teacher s included : (a) helpin g the m understan d whic h behaviou r ha d a n unconscious , internal origin ; (b ) givin g the m a  languag e fo r namin g th e child's feeling s an d settin g limit s i n a  wa y tha t wa s no t traumatizing t o th e child ; an d (c ) helpin g th e teache r se e progress i n th e child , beneat h th e ongoin g problems . Appendi x C is a  handou t I  giv e t o teacher s an d chil d car e worker s wh o hel p traumatized children . Ethical Considerations The UB C Ethic s Committe e gav e approva l t o thi s stud y i n accordance wit h universit y guideline s fo r researc h usin g huma n subjects. Th e Vancouve r Schoo l Boar d als o gav e permissio n fo r this study . Informed consen t (Appendi x B ) wa s obtaine d fro m th e paren t or lega l guardia n o f eac h child . Th e consen t wa s obtaine d afte r the researc h wa s explaine d t o th e guardia n verball y an d afte r they ha d rea d th e consen t form . An y question s o r concern s wer e answered, befor e th e paren t wa s aske d t o sig n th e form . 77 All notes, videotapes, and observations o f th e children hav e remained confidential . They have been store d i n a locke d filin g cabinet. The anonymit y o f th e children and thei r familie s i s maintained within thi s document by th e use o f pseudonyms an d by masking an y details tha t would i n any way identif y th e child o r family. Copies o f th e lette r an d consent for m are i n Appendix B . Research Procedure Each child received between 25 and 28 weeks o f chil d centered play therap y fro m th e researcher/play therapist . Th e therapist functione d a s participant observe r i n the traditio n o f field research. Th e broad rol e of therapis t included : (a ) pre-therapy assessmen t o f th e child; (b ) ongoing assessmen t o f th e child during therapy ; (c ) weekly play therap y while schoo l was i n progress; (d ) ongoing consultatio n with parents an d schoo l personnel; an d (e ) post therap y evaluatio n o f th e child' s progress an d degree o f change. Data Collection Data collection ca n be divided int o tw o major categories . Specific dat a was collecte d fro m sources documentin g th e children's change s i n the "oute r world", suc h as th e classroo m and home. Sources fo r thi s outer world data collectio n included : (a) unstructured observation s i n the school setting ; (b ) teacher's completio n o f school observatio n forms ; and (c ) interviews with parents an d school personnel. This "oute r world" data collectio n occurre d pretherapy, mid therapy , an d pos t therapy. Th e secon d sourc e o f data came fro m th e actual therap y 78 sessions. "I n therapy" dat a source s included : (a ) video recordings o f all therap y session s (wit h audio back up); (b ) therapist fiel d notes complete d a t th e end of each session; an d (c) the child's drawings, stories, and sandtray pictures fro m therapy. Pretherapy and Post therapy Assessment Data In order t o document eac h individua l child' s observabl e change durin g th e 25 weeks o f play therap y th e followin g dat a wa s collected both pre an d post therapy . Selecte d categorie s wer e also assesse d afte r 1 2 weeks a s noted individually . Interviews Interviews with teachers , and relevant othe r schoo l personnel documente d th e child's functionin g i n the interpersona l and learnin g environmen t o f th e classroom. Thes e wer e semistructured interview s followin g th e guidelines o f Mishle r (1987) i n order t o obtain a picture o f th e child and his o r he r behaviour, copin g an d concerns fro m th e viewpoint o f schoo l personnel. Parents o r legal guardians were interviewe d initiall y t o obtain th e child's history . The School Observation Rating Scale The Schoo l Observation Rating Scal e For m (Se e Appendix B ) was complete d by th e teache r pretreatment, a t 1 2 weeks int o treatment, an d post treatment . This rating for m allowed th e teacher t o describe th e typica l behaviour o f th e designated chil d 79 in eight differen t areas . For each area, th e teache r chos e on e category tha t best described th e child as he or she presented i n the classroom. Th e teache r chos e fro m six potential detaile d descriptions o f behaviour. The descriptors ar e numbered fro m on e to six, with one representing th e leas t adaptiv e behaviour an d six th e most adaptive . The scal e was developed by Byron Egelan d and colleagues an d used i n the Minnesota Longitudina l Stud y o f High Risk Families (cite d i n Egeland, Kalkoske , Gottesman & Erickson, 1990) . Classroom Observations Classroom observation s by th e researcher were carrie d ou t pre an d mid therapy . A  post therap y observatio n was made by a trained colleague , who debriefed th e observation dat a immediatel y following with thi s author. Thi s decision was made, because bot h children had evolved t o the point o f attachment with me by th e post therap y session , and i t was believed tha t my presence woul d have altere d thei r behaviour within th e classroom. Th e observations involve d a  running commentar y o f th e child' s behaviour, interaction s with teacher s an d peers, sel f representation, abilit y t o attend t o classroom activities , affect, mood, an d enthusiasm. Observation s occurre d durin g structured clas s activitie s a s well a s tim e spent i n the les s structured centr e time . Observation periods were 20 t o 4 0 minutes i n length . 80 Projective Drawings Projective drawings were requested at the beginning and end of therapy included a) the House-Tree-Person (Buck , 1959); b) Draw your Family (Main , 1986); and a Human Figure Drawing (Koppitz, 1968) . These projective drawings have been found to be revealing of the child's perceptions and feelings about self, family, relationship with others, unresolved trauma, and health of the inner psyche (Allan , 1988; Buck, 1966; Furth, 1988; Main, 1985). These drawings add an intrapsychic component to the assessment process, supplying a multilayered picture of the child's changes. Other projective drawings were used periodically as a natural element of play therapy, and will be discussed and analyzed in the course of therapy. Data Collection During Therapy Transcription of Videotapes The transcription of video tapes was an arduous, and at first confusing process. I  initially viewed and reviewed the whole 25 to 28 tapes in order to determine which categories of verbalizations, play, and behaviours were important, and also changed over time. I  discovered that minute detail to body alignment, facial expression, body posture, and voice tone were as important as the child's play and verbalizations. All verbalizations were transcribed, along with the child's body position, play station, movement and context. Detaile d 81 description of play actions were necessary in order to understand the holistic meaning of the play themes. Case Notes and Memos It is traditional for therapists to make notes after each play therapy session. My notes during this research project contained: (a ) the child's behaviour and conversation on the way to therapy; (b ) subjective overall changes seen in the child; (c ) a general description of the key themes and interactions seen in therapy; (d ) subjective notes on the child therapist relationship; and (e ) any major changes in the child's life either at home or at school. Additionally , I used the top right hand corner of the page to record ongoing hunches, hypotheses and thoughts on the child's pattern of change. Th e left hand upper corner was reserved for comments from teachers, parents and other school personnel. Children's Drawings Like their play, children's projective drawings often speak of their inner fears, feelings, and traumas. Drawings were dated, transcribed, and analyzed as an integral part of the data. As mentioned above certain drawings were solicited at the beginning and again at the end of therapy in order to note changes in the children's representation of their inner and outer worlds. The Research Diary The research diary chronicled issues affecting the research, and decisions made along the way in regard to methodology and 82 data analysis. With each step taken , th e rationale fo r adoptin g the ste p was also recorded . Th e research diary was onl y minimally use d during th e data collection stag e (durin g therapy) . Most memos were recorde d i n the therapeuti c records . I t was during th e transcription , codin g an d analysis stage s tha t th e diary was a n invaluabl e tool . Th e data fo r thi s stud y was s o voluminous tha t I  often fel t overwhelmed by it . A s eac h case wa s analyzed an d written separately , spannin g up t o a year o f tim e for th e ful l scrutinization o f each case, the research diar y wa s essential fo r recording insights , thoughts an d patterns, i n an easily accessibl e location . A s i t was, I filled thre e researc h diaries, with th e result tha t I  had t o create a n inde x fo r eac h of these! ! Assuring Validity, Credibility and Truthfulness Use of th e naturalistic paradig m require s tha t th e participant researche r be convinced both of th e appropriatenes s of thi s approach t o the research question, a s well a s be scrupulous i n ensuring th e credibility o f th e data an d methodology use d (Lincol n and Guba, 1985) . The naturalistic paradig m fit s th e research question s proposed fo r thi s study fo r a number o f reasons. I  was askin g "what" an d "how " questions. Wha t i s the process by which th e child heals an d changes during th e process o f play therapy ? Ho w does th e change i n therapy affec t th e child's functionin g i n his or her oute r world ? I had no doubt tha t th e methodology was appropriat e fo r these questions when I  began. I  believed tha t onl y throug h 83 examination o f th e child's detaile d work within play therap y could I  find th e answers. Thoug h I  had seen th e connectio n between th e pilot children's patterns, and th e results o f attachment research , I  entered data coding an d analysis with a n open and curiou s mind. Thi s attitud e i s the necessary stanc e from which t o conduct qualitative analysis . I t allows th e dat a to speak fo r itsel f an d fo r theor y t o emerge naturally fro m th e data. I  found however tha t when thi s stance i s taken seriously , there are som e seriou s drawbacks. Whe n assuming thi s attitude I found tha t th e truth , as demonstrated by th e details o f th e child's words an d pictures became s o meaningful an d important , that i t was hard t o move t o the next ste p of data reduction an d case "writ e up". Wit h each examination an d reordering o f th e data t o examine patterns an d processes, i t seemed tha t ye t another insigh t was made. Trianqulation Validity an d credibility were furthe r ensure d i n a number o f ways. Firs t an d perhaps most importantly , dat a was collecte d i n a variety o f ways an d fro m a variety o f sources (Triangulation) . Since on e of th e questions aske d whether positive chang e occurre d in the child a s a result o f th e therapy , i t was essentia l tha t sources i n addition t o the therapis t were used. Documentatio n o f change was assesse d throug h interview s with teacher s an d parents, as well a s throug h school observatio n form s and projectiv e drawings. 84 Peer Debriefing During the process of coding and analysis of the actual play therapy sessions, I also utilize d a number of impartia l knowledgeable colleagues with whom I shared the data, my choice of codes, and ultimately my interpretations of the processes of change. Confirming Accuracy of Portrayal With the Source Because I was in frequent contact with teachers, I had the opportunity to confirm the accuracy of both my written summaries of interviews, as well as my observations regarding change within the classroom setting. This was especially important in the final stages when summarizing the overall changes exhibited by the child. Ensuring Confirmabilitv Finally raw written data will be retained for future Confirmability and reference. This is not possible with the videotapes, as confidentiality requires that the videotapes be erased when the study is complete. But transcripts, field notes, research diary, and session notes can be retained and be available for examination. Qualitative Data Analysis Qualitative data analysis consisted of a process of reduction and transformation of massive amounts of data into meaningful units that could be simplified, processed, combined, compared, and ultimately understood. A number of methodological tools were used in this process of data analysis. Most have been 85 alluded t o earlier, but will be briefly describe d i n thi s section. Overview of Data Reduction and Analysis All data was transcribe d int o a word processing program, an d then converted int o file s compatibl e with th e Ethnograp h computer program. Thi s program create d a system fo r coding, an d later sortin g dat a according t o single or multiple codes . Onc e data was transcribed , th e hard copies were rea d and reread t o determine, thos e behaviours an d themes tha t not only persisted , but transforme d ove r time . Eac h piece o f data was the n code d using code s tha t were chil d specific . Lea' s data was much mor e complex tha n Gunther's, initiall y containin g 9 3 different codes . In contrast, Gunther's dat a was coded with 4 2 different cod e words. As eac h therap y sessio n was transcribe d an d coded, th e videotape o f tha t session was the n reviewed t o determine accurac y of th e coding, an d of th e transcription . Thi s was especiall y necessary i n the areas o f non verbal, and affective descriptors . Upon completio n o f coding, a  summary o f each session and it s codes was adde d t o the hard copy. A  simila r synopsi s was als o made o n a sticky "pos t it " note and attached t o a flo w chart o n the wall. Eventually , photograph s o f each child's ar t work an d sand tray s were als o adde d t o this wall tim e line , so tha t a visual picture o f th e image s of change ove r thi s length y tim e period coul d be achieve d without sortin g throug h th e transcript s of 25 t o 28 therap y sessions . 86 This visual tim e lin e was a n essential too l fo r maintainin g a sens e o f th e "large r picture" while being necessarily immerse d in the details. Th e general process o f data analysis involve d a movement from : 1. The initial intuitive sense of each session, and the gestalt of the therapeutic change process to; 2. A focus on data codes and how the details within each showed patterns of change over time, to; 3. A general understanding of the patterns by which behaviour, grouped within broader categories, changed over time, to; 4. Reconstructing this detailed knowledge into a more holistic understanding of the stages within the process of change for each child, and 5. Finally relating these patterns to the relevant theory and research in order to understand the internal process of change. Coding of Data Coding was the primary mode of data reduction and analysis. A code is an "abbreviation or symbol applied to a segment of words - often a sentence or paragraph of field notes - in order to classify the words" (Mile s & Huberman, 1989, p.56). Most codes were obvious, once the transcriptions were read and areas of change over time were determined. I n addition, codes also arose from a relationship between elements of transformation and the key concepts, questions, attachment categories of the research questions. By applying codes to given behaviour, interaction, dialogue, and interpretations of art or play, I was able to ultimately recognize, retrieve, and cluster segments of the data 87 as the y related t o given hypotheses, concepts o r themes . Th e separation an d clustering o f data units create d th e essentia l foundation fo r data analysis. Displaying o r organizing eac h cluster alon g a  time continuum allowed me t o relate change s t o the process o f therap y an d other events i n the child's life . Marginal Reflective Comments As segment s o f data, derived fro m transcript s o r fiel d notes, wer e code d using th e lef t hand margin, ongoin g reflectiv e remarks were noted i n the right hand margin. These remark s were a way fo r me t o document fleetin g thoughts , insights, an d preanalytic connections . The y also allowed me t o i n th e beginning, recogniz e major change s i n any broad category , initially noting tentativ e movement int o th e next stag e o f therapy. Summary The questions aske d i n this research stud y naturally lea d t o the selection o f a multiple cas e stud y design. The complexity o f the research question s dictate d a complex mode o f data collectio n spanning many weeks o f therapy . Th e naturalistic metho d o f inquiry allowe d th e researcher t o enter th e detailed an d comple x world o f th e maltreated child , i n order t o document th e proces s and impac t o f treatment , without creatin g artificia l constraint s upon th e child's reality . Because th e researcher acte d as therapist / participant/ observer, th e need t o ensure validity an d truthfulnes s o f th e data was essential . Triangulation o f data collection and pee r 88 consultation an d review were a number o f methods fo r ensurin g credibility o f th e protocol an d results. Data collected throug h interview , observation , an d a schoo l rating for m provided mechanisms fo r documenting chang e i n th e child's world outsid e o f therapy . Videotape s o f therap y sessions, cas e notes, and the children's drawing s provided th e data fo r documenting th e process o f change within th e play therapy sessions . Methods o f coding, memoing, tim e lin e wal l charts, an d marginal remark s facilitate d dat a reduction. Onc e data was reduced int o meaningful clusters , placing suc h dat a along natural continua , an d analyzing ho w changes occurre d ove r time fo r each chil d assisted i n the fina l case analysis process. Each child' s chang e process was initiall y analyze d a s an isolate d case. Once eac h case was examined separately , commonaltie s acros s cases were noted, an d related t o relevant theory , researc h an d m y own clinical practice. Th e ultimate conclusion s o f th e cas e analysis an d reconstruction resul t i n a more detaile d understanding o f th e patterns o f change durin g therap y o f children who were maltreated, an d experienced maternal los s during th e firs t tw o years o f their lives . Th e process by whic h the children change d als o provides th e beginnings o f a more cohesive theor y int o th e impac t of play therap y upon: (a ) th e structure o f a child's interna l working models; (b ) the child' s developmental pathway ; (c ) the child's memory an d defensiv e structures; an d (d ) the structure o f th e self of th e child . 89 CHAPTER IV CASE 1: GUNTHER Overview and History Gunther wa s a  fiv e yea r ol d bo y wh o demonstrate d significan t changes ove r th e cours e o f hi s 2 6 session s o f pla y therapy . These change s wer e eviden t bot h i n hi s abilit y t o presen t an d graphically portra y a  mor e coheren t an d cohesiv e sel f t o th e world, a s wel l a s i n hi s abilit y t o tolerat e an d participat e i n the comple x socia l milie u o f school . Change s durin g therap y wer e subtle, comple x an d ye t ove r tim e significant . Reasons for Referral and School Concerns Gunther wa s referre d fo r pla y therap y b y th e schoo l base d team o f hi s elementar y schoo l thre e month s afte r startin g kindergarten. Hi s famil y wa s wel l know n t o schoo l personne l a s an olde r siste r U s e ha d attende d th e sam e schoo l fo r th e las t two years . Concern s fo r thi s youn g bo y included : a ) hi s emotional fragility ; b ) a n inabilit y t o compl y wit h simpl e rule s of th e classroom ; c ) a  profoun d inabilit y t o focu s an d atten d within class ; an d d ) a  pervasiv e expressio n o f sadnes s an d anxiety. Research observatio n o f Gunthe r i n bot h th e classroo m an d the playgroun d setting s corroborate d th e school' s concern . Th e initial impressio n wa s on e o f hypervigilance , anxiety , an d dissociation, bot h fro m part s o f himsel f a s wel l a s fro m th e animate an d inanimat e environmen t o f th e school . Hi s eye s consistently appeare d t o b e blan k an d unfocused , o r a t leas t focused inward . Thoug h hi s facia l expressio n wa s no t unpleasant , 90 it was generall y unresponsive t o the activities an d people aroun d him. Eve n during non-demanding activitie s suc h as attending a Valentines party an d playing o n the jungl e gym, Gunther showe d n o ability t o interac t with other children. H e also showe d a  marked avoidance o f adults , approaching the m with eyes lowered , bod y aligned obliquely , an d with no evidenc e o f spontaneou s verbalization. When he was directed o r reprimanded by a n adult h e tended t o either freez e or decompensate. H e was reporte d t o cry , or cling t o his siste r U s e whe n asked t o perform a  variety o f tasks within th e classroom setting . Family History and Concerns Gunther i s th e second of thre e children o f a single mother. Each of th e thre e childre n has a  different father . Hi s mothe r was i n an abusive relationshi p with his fathe r during th e firs t 12 months o f Gunther's life . Bot h parents als o abuse d drug s an d alcohol. Gunthe r an d his older siste r were removed fro m parenta l care due t o profound neglect an d abandonment when he was 1 2 months old . The y resided i n foster car e fo r approximately 8 months, a t which tim e th e current caretake r ( a great aunt ) visited the m and foun d the m to be malnourished, bruise d an d dirty. Sh e applied fo r custody o f th e children, throug h th e Ministry o f Social Services , and has care d fo r them continuousl y since tha t time . A t a  later time , she also applied for , an d obtained custod y o f th e thir d child, a  baby sister , directl y after her birth. This great aun t was 6 5 years ol d at th e onset of Gunther' s therapy. Sh e provided fo r th e children financiall y throug h a 91 combination of social assistance and an old age pension. Sh e was seen walking as far as four kilometers to the food bank with the children in order to meet their basic needs for adequate food. She baked her own bread and cookies and patched their clothes. They were always seen to be clean, well nourished an d adequately dressed in school. Thoug h auntie was known to have problems with alcohol, this did not appear to effect her ability to physically care for the children. While residing in the three different homes in which school personnel visited, Gunther was always known to have his bedroom in the basement, separated from the rest of the family. Durin g a variety of visits, over the therapeutic term, I found this little boy to be generally ignored by the auntie and other adults in his life. Ther e seemed however to be a strong bond between Gunther and his sister Use. Sh e often spoke for him, played with him, and generally "kep t him under her wing". I  further observed that the youngest girl Heidi was clearly favoured both by the auntie, and by the mother, during her infrequent visits. Use , the oldest child, who was seven at the onset of therapy, was seen to play a significant caretaking role of both her siblings and of the great aunt. School personnel reported one incidence of violence, two years earlier in which a man was shot in this family's home. During Gunther's fourth year of life, he had a dog named Kirby who was given to the children by mother on one of her infrequent visits. Gunthe r spent many of his waking hours with Kirby, who also slept in his room. Aunti e "go t rid of Kirby" after three 92 months o f tryin g t o cope with th e increase d work loa d and mes s created by thi s over active puppy . Auntie was understandably vagu e abou t Gunther' s developmental history . Sh e remembers tha t he walked afte r he wa s one year o f age, was slo w t o verbalize (afte r tw o and one half) , and lat e i n being potty traine d (thre e years). He r onl y concer n at outset o f therap y was tha t "hi s grammar was bad". Sh e described hi m as being a  "good , quiet chil d who like d t o spen d time i n his room". Thi s overworked aun t was very clear , fro m th e beginning, tha t Gunther coul d come t o play therapy , but tha t sh e wanted no part o f it . Sh e was equall y reticen t t o become involved with schoo l personnel. Sh e attended no parent teache r conferences, no r an y schoo l activities . Initial Observations and Teacher Interview The initia l teache r intervie w an d classroom assessmen t wer e conducted i n February si x weeks int o Gunther's kindergarte n experience. Assessmen t include d th e (a ) teacher interview , (b ) teacher completio n o f th e School Observation For m (Egeland , 1991 ; see appendix A ) , and (c ) researcher observatio n i n the classroom . Teacher Interview and School Observation Form Gunther's clas s i s part o f a large open area tha t i s home t o two classes, tw o teachers , an d forty-tw o childre n ranging fro m kindergarten t o grade two . Hi s olde r siste r U s e attend s grad e one, als o within thi s open area. Sh e i s officially under th e direction o f one teacher , and he another. Th e tw o classes hav e 93 separate circl e time , and guided lessons , but shar e th e sam e learning centers , and many o f th e same non academic activities . Gunther's teache r report s tha t he has been slowe r t o adap t to kindergarten tha n other childre n his age. He r main concern s revolve aroun d his crying , anxiety , non compliance, an d tendenc y to depend upon his sister . Th e teache r report s tha t wheneve r there i s unstructured tim e or when Gunther i s asked t o do something he dislikes (suc h as cleaning up), he cries and cling s to U s e . Th e teache r i s also concerne d because he does no t respond t o her effort s a t comfort an d support, and therefor e put s undue pressure o n his alread y vulnerable sister . Sh e report s that "a t recess he doesn't hang aroun d with kids his own age, h e just tag s along with Use. " Withi n th e classroom "h e is alway s looking t o se e where sh e is". In relation t o peers, the teacher describes Gunther a s "having no apparen t friends" , and "a t best being tolerate d b y others. I  think he puts the m off because he cries s o much". Th e teacher explain s tha t sh e has children i n her clas s who ar e mor e trouble tha n Gunther because o f thei r aggressiveness , "bu t the y still make friends . H e jus t isn' t able t o make friends. " Sh e reports tha t he "onl y occasionally connect s with others i n appropriate socia l interaction , but usually onl y i n a carefull y structured socia l situatio n or with clear guidance fro m a n adult." Otherwise , a t recess he tend s t o hang ou t on th e periphery o f U s e an d her friends . Gunther i s furthe r described as being highly anxious , "spacey" muc h o f th e time , and seldom focusin g o n classroo m activities. H e frequentl y goe s along with what th e class i s 94 doing, but neither pays attention nor actively participates. Instead, hi s focu s i s either turne d inwar d o r absorbed i n keepin g track o f U s e . Th e teache r reports tha t Gunther will liste n t o stories, but when asked t o do structured tasks , "h e is often no t able t o follo w th e directions, and i f we push at all he cries. During th e activities he i s distracted more tha n not...and yet h e is a nice littl e boy." Initial Researcher Observations The teacher' s descriptio n fit s with my ow n assessment o f this littl e boy. Initia l observation s occu r during a  Valentine s day party, buddy reading , an d a playground vignette . My firs t glimpse o f Gunther i s during a  Valentine party i n the classroom. I t i s the end of th e day after al l childre n hav e given valentines t o each other child i n the classroom. Th e entire clas s i s sitting i n a tight circle, waiting fo r thei r Valentine cak e and drinks. There i s a din of pleasant noise, a s most childre n cha t with eac h other, or watch th e teacher s a s the y prepare th e treats . Som e children are kneeling, other s squatting, while most si t cross legged . Gunthe r i s sittin g between tw o girls, neither o f whom initiat e interactio n with him . One littl e girl i s watching th e teacher , while th e other i s engaged i n intense conversatio n with her friend . Gunther appear s t o be i n a world of his own . Hi s eyes ar e blank, with no apparent focu s on the classroom aroun d him, othe r than occasional attentio n t o the teacher a s sh e give s instructions. H e assumes a  variety o f positions, includin g on e in which he lie s on his back, starin g a t his hands, while hi s 95 legs wave i n th e air. Thi s latte r position last s fo r about fiv e minutes. H e agai n resumes a  cross legge d stance , with his hea d bent towar d hi s lap , as th e "helpers " distribute th e treats . H e is mouthing somethin g t o himself a s he look s at his hands, agai n lost i n his ow n world. H e does not immediatel y respond , when th e helper holds th e plate i n front o f him, s o th e child beside hi m nudges him. Gunthe r look s up, take s a  piece distractedly , without an y apparen t assessmen t o f which i s the biggest o r gooiest. H e gives th e helper a  sideways glanc e but say s nothing . When al l th e children have eaten thei r treats , the teache r moves t o th e outside o f th e circle and asks fo r th e children's' attention. Gunthe r look s up at her when sh e inform s the m tha t those who ar e sittin g properly will be able t o leave first . H e maintains a  quiet, cross legge d sittin g position, with head down, and again plays with his fingers . H e directs a n occasiona l sideways glance a t th e teacher , but no eye contact. Thoug h h e sits as quietly a s any other child , th e teache r does not cal l hi s name until th e end when sh e i s dismissing th e disruptiv e children. H e waits until he i s called, showin g no anxiety , interest o r impatience . Whe n th e teache r finall y call s him, h e gets up an d obediently stand s i n line t o get his notice. A s hi s turn arrives, he approaches th e teacher with his body aligne d t o hers a t a 45 degree angle , glancing a t her periodically. H e takes his paper with an oblique glance a t her and no comment . The secon d observatio n take s place durin g buddy reading . Gunther an d tw o other fiv e year olds ar e paired with tw o olde r boys. On e o f th e older boys i s reading a  book appropriat e t o th e kindergarten readin g level . H e i s reading i n a silly , 96 condescending manner , frequentl y glancin g a t hi s ag e mate , whil e both "crac k up" . Th e younge r childre n remai n uninvolved , certainly no t joinin g i n th e laughter . Gunther' s eye s ar e vacant, an d unfocused . H e keep s hi s hea d dow n durin g th e entir e session, displayin g a n occasiona l hal f smile . A t n o tim e doe s h e look a t th e othe r childre n no r interac t wit h them . H e periodically play s wit h hi s finger s o r clothing . When th e teache r announce s tha t budd y readin g i s over , th e other childre n dispers e an d Gunthe r remain s sitting . H e suddenl y looks up , make s brie f ey e contac t wit h m e an d say s "wh o ar e you" , then look s beyon d me , seemin g no t t o liste n t o m y answer . Whe n he i s calle d t o cente r time , h e leave s m y presenc e withou t further contac t o r conversation . The las t observatio n take s plac e durin g reces s time . H e i s on th e monke y bar s wit h thre e othe r boys . On e chil d fall s of f the bar , a s Gunthe r swing s bac k an d forth , holdin g ont o a vertical post . H e seem s unresponsiv e t o th e falle n child' s plight, a s th e bo y lie s cryin g o n th e groun d belo w him . Th e hur t child dust s himsel f of f an d approache s th e supervisio n aide , pointing i n Gunther' s direction . Sh e call s Gunther , a s wel l a s two othe r boy s ove r t o her . Th e aid e say s "Joh n say s tha t someone pushe d him . Di d an y o f yo u pus h him ? I  need t o kno w what happened. " Al l thre e boy s loo k blank . Sh e ask s agai n a s she look s a t the m pointedly . Th e othe r tw o sa y " I don't know" . Gunther say s nothing , an d put s hi s coa t ove r hi s hea d movin g i t up an d dow n ove r hi s face . Wit h a n exasperate d sig h sh e say s "i f none o f yo u know , the n yo u shoul d al l sa y 'sorry' , Joh n i s upse t and he has been hurt." 97 The othe r tw o boys sa y "sorry " i n reluctant an d insincer e ways, a s the y loo k briefly a t John. Gunthe r keep s his coa t ove r his head. Th e aide pulls th e coat down and again instruct s hi m to say "sorry" . H e look s down at th e ground an d whisper s "sorry". Th e bell ring s an d the y all go i n for recess. To summarize , Gunther's presentation i n the classroom an d o n the playground correspond s closel y with th e teacher's report . The most strikin g characteristi c i s his disconnection fro m th e people an d activities aroun d him. Hi s activitie s ar e predominantly passiv e and seem almost autisti c i n nature, a s he plucks a t his clothes , and focuse s more o n his own body part s than his environment . H e i s able t o follo w commands fro m adul t authorities, an d cues fro m other children, but remain s predominantly distant , avoidant , and with no sig n of affect o r empathy. Th e one instanc e i n which he i s challenged, hi s response i s t o maintain a  stubborn stanc e o f non engagement. I t is interestin g t o note that , when he i s not causing trouble , h e is almost universally ignore d by thos e around him. Ther e i s a n overwhelming sens e o f thi s boy being "th e forgotten child. " Tracking the Process of Change and Healing During Therapy This sectio n documents Gunther' s process o f change an d healing ove r th e course o f a year, spannin g twent y fiv e sessions , of therapy . Thre e stage s o f therap y will be described . Descriptions an d discussion within each stage will be categorize d under th e broad headings o f (a ) child-therapist interaction , (b ) self presentation, an d (c ) play an d art themes . Relevan t 98 description o f environmenta l factors , behaviora l chang e withi n the classroom , an d teache r comment s wil l als o b e examine d withi n each therapeuti c stage . Gunther demonstrate d profoun d chang e an d healin g ove r th e course o f therapy . Thi s chang e wa s eviden t bot h i n th e pla y therapy milie u a s wel l a s withi n th e classroo m setting . Chang e occurring i n therap y tende d t o generaliz e t o th e classroo m setting, approximatel y 1 0 t o 1 4 weeks later . Gunthe r initiall y used therap y a s a n opportunit y t o experienc e ne w way s o f trustin g and connectin g withi n clos e relationships . I n late r session s h e used th e safet y an d affirmatio n o f th e therapeuti c relationshi p to: (a ) develo p socia l skills ; (b ) build eg o resilience ; an d (c ) work throug h a  variety o f painfu l an d traumati c experience s i n his pas t an d presen t life . Over th e cours e o f therapy , thi s chil d progresse d fro m a n original interactiona l stanc e tha t wa s profoundl y anxiou s an d avoidant t o on e tha t showe d th e beginning s o f appropriat e interactive sociability . H e furthe r move d fro m a  stat e o f bein g entirely dependen t upo n hi s siste r U s e fo r an y consciou s direction an d identit y i n his oute r world , t o showin g autonomou s initiative an d creativit y wit h bot h peer s an d teachers . Once thi s smal l bo y learne d t o functio n o n hi s own , an d t o begin t o trust , h e wa s abl e t o utiliz e th e therapeuti c spac e t o externalize an d wor k throug h hi s painfu l experience s o f rejection, neglec t an d fea r withi n caretakin g relationships . I t is m y conclusio n tha t th e growt h show n b y thi s youn g bo y ove r this yea r o f therap y launche d hi m ont o a  healthie r developmenta l pathway. 99 This sectio n will use descriptions an d analysis o f Gunther' s play themes , artwork, verbalizations, an d interactiona l styl e i n order t o chronicle hi s transformatio n ove r th e 25 weeks o f therapy. Th e thre e stage s o f therap y ar e somewhat artificial . Change i s indee d incremental , gradual an d often spira l i n nature. The reader will note however tha t ther e are key session s tha t mark significan t turnin g points, catapulting th e child int o a ne w stage an d a significantly differen t way of behaving and/o r processing. Movement int o a new stage tend s t o reflect a  major alteration eithe r i n the child's interactiona l style , developmental level , or play themes . 100 The Initial Stage of Play Therapy (Sessions 1-7) Overview The initial stage of play therapy spans sessions one through seven. Gunther's dominant presentation is that of an avoidant, anxious and reactive child. Initially, he seems exclusively focused upon the inanimate objects of the playroom, moving rapidly from one item to the next, never stopping long enough to develop any one play theme in depth. Hi s dominant stance is one that avoids direct contact with me in all aspects of interaction. His body is generally turned away, his head is flexed downward, and his eyes are averted. I f I initiate interaction with him, his typical response is to retreat to the far side of the room. Concurrently, he is also avoidant of most discussions about self, family or relationships. Hi s few comments about family convey a pervasive sense of avoidance and loss. His demeanor is decidedly anxious, paradoxical and confusing. Thoug h his smile seems fixed to his face and his voice is overbright, his play contains predominantly aggressiv e themes, with neutral to negative affect. Gunther presents as a child who is developmentally delayed in the areas of speech, play, and social interactional patterns. Speech is often fragmented, incomplete in sentence structure , and lacks emotional descriptors. Hi s play is more like the isolated play of the early toddler or late infant period, focusing primarily on inanimate objects. Further , the few times that he includes me in play, there is no awareness of my body boundaries. I  am used more as an object than a person to interact with. Towar d the end of the stage, the first remnant of 101 interactional play is a brief toddler like hide and seek sequence. Whereas his surface self reveals little of the experience or substance of this boy, his pictures paradoxically reflect much of what we know about Gunther's history and situation. Althoug h Gunther's play themes are brief and segmented, they convey a profound sense of vulnerability, isolation, confusion, and rejection by a mother figure. I n addition, themes of loss, baby, mother and child, and dogs are prominent. Manifestations of Self and Self in Relationship Child Therapist Interaction Patterns A young child brings to therapy, that mode of relating that he or she has learned through repetitive interaction with consistent caretaking figures. By carefully noting these interactional patterns, a therapist is often able to intuit what behaviours are acceptable at home, and even shaped by parents. Young children are dependent for survival upon the caretaking figure(s), and therefore over time adapt ways of relating designed to keep caregivers in close contact. Whe n the parenting figure is also hurtful or neglectful, the child develops relationship specific behaviours that function to maintain connection with the caretaker, while at the same time remaining emotionally or physically safe. During the early sessions of therapy, Gunther presents as profoundly anxious, avoidant, hypervigilant, and reactive while in interaction with me. H e dons what appears to be a "false 102 self" o r persona tha t seems designed t o keep me "unconcerned" , and/ o r himself disengaged . Thi s fals e sel f manifests a s a brittle appearing , fixed , "happ y face" , accompanied by a n overbright voice , and compulsively clea n and tid y demeanor. A t the sam e tim e ther e i s a profoundly avoidan t an d reactive elemen t to his interactio n pattern. Thi s sectio n will document Gunther' s unique ways o f behaving with me. Hi s interactio n will b e discussed under th e sub headings o f (a ) body alignment an d proximity; (b ) anxiety; (c ) and initiatio n o f interaction . Discussion within each category wil l document th e subtle way s this behaviour change s a s Gunther slowl y develops more trus t i n our relationship . Body Alignment and Proximity Seeking. Gunther' s typica l early stanc e i s one i n which his body i s turned away fro m mine. Most commonly , h e plays o r explores with his back t o me, or angled awa y a t a 90 to 180 degree angle . H e seldoml y approache s me; i n fac t most often , i f I speak t o him or come clos e t o him, he moves t o th e other sid e of th e room. Whe n he must approach , he does s o with body angle d obliquely awa y fro m mine, hea d downward, an d eye s averted . From th e fourt h t o the seventh session , Gunther begins t o lower his defensive posture eve r s o gradually. Hi s bod y alignment i s now more ofte n at a 45 t o 90 degree angl e i n relation t o me. Althoug h his head remains flexe d downward ther e are periodic glance s i n my direction. H e also begins t o risk th e occasional an d tentativ e approach , rathe r tha n th e chroni c pattern o f retreat . A t th e same tim e ,  he begins momentary , indirect effort s a t connection includin g request s fo r help an d a 103 beginning paralle l kin d o f play. Although his requests ar e stil l indirect, he begins t o use interactiv e words. Hi s firs t approach, couple d with a subtle invitatio n t o play, occur s i n th e fourth session . Gunthe r had been making a  sand scene . H e pick s up a small airplane , flie s i t past th e ducks, the n towar d me, landing i t on my head. H e stand s i n front o f me at a 60 degre e angle, with th e airplane i n his hand : G: I  like these . D o you lik e airplanes? (turn s t o fac e m e directly). B: Yes. I like airplane s G: A helicopter. I  had a helicopter, but i t broke. B: I t i s sad when your toy s break. G: (h e puts th e airplane i n my hand an d the n turn s away fro m me) . B: Now we eac h have one. Than k yo u G: (H e puts his i n the water tray . I  do th e same. H e take s his out. I  do too . H e the n starts cleanin g th e wheels o f his helicopter. I  fly mine i n the air but he keep s cleaning.) During thi s interaction , I  first mirror his play, an d the n extend i t slightly t o furthe r th e connection he has begun. Thes e tentative gesture s towar d interactio n continu e fo r the rest o f this stage . H e als o begins making equall y indirec t request s fo r help. Fo r instanc e earl y i n the sixth session, as he walk s toward th e snack tabl e he says : G: U s e alway s wants muffins, and she like s muffins too . B: U s e like s muffins? D o you lik e muffins too ? G: Yeah . Last tim e we had muffins (hi s head i s up but he i s talking t o the wall i n front of him. ) B: Well toda y we have muffins too . They're here when yo u want them . 104 G: Oh . (finall y look s a t th e snac k table) , wha t i s this ? It i s interesting , bu t no t surprising , tha t Gunthe r use s th e ego of his older sister Use i n this round about request for his favorite snack. I  would guess that at home this is a safer method, given that she is the more favored child. Anxiety. Researc h discussing the physical presentation of maltreated children paints a picture of hypervigilance and anxiety, especially around adults (Kempe , 1987; Wolfe , 1987) . In the classroom, Gunther's early anxiety takes the form of body stiffness, frequen t crying episodes, and a tendency to cling to his sister Use. I n the play therapy room, anxiety is manifested through a stiff body posture, avoidance of proximity, and an inability to stay focused on any toy or activity. In fact, during the first four sessions Gunther seems a study in perpetual motion, jumping from one toy to the next, seldom remaining long enough to develop a true play theme. I n addition he seems obsessed with orderliness and cleanliness in the play room. In his early research, Moustaka s (1955b ) discovered cleanliness and orderliness anxiety to be one of the factors that distinguished coping from non coping children. I n the first session he states, "I don't like it messy" as he rearranges some disorderly playroom shelves. Late r in that same session, he volunteers that, "In my bedroom I make everything cleaned up." This compunction for keeping everything clean and orderly persists throughout the first 11 sessions. A t times it appears that he concentrates more intensely on replacin g the felt crayon cap in exactly the right way than he does in creating his pictures. 105 In th e fourt h session , Gunthe r i s carefull y arrangin g hi s sand scene . Whe n h e find s a  hai r i n th e san d box , al l focu s o n his creatio n halt s as , wit h a n ai r o f disgust , h e show s i t t o me. Likewise , i n th e sevent h sessio n h e terminate s hi s pla y i n the dollhous e whe n h e find s a  roo m i n disarra y sayin g "somebod y has pu t thi s th e wron g way" . Agai n h e stop s al l pla y unti l th e room i s arrange d correctly . Th e clea r impressio n i s tha t messiness o r disarra y i s anxiet y provokin g t o him . I t i s possible tha t thi s behaviou r represent s a  compensator y aspec t o f play. I n othe r words , on e migh t surmis e tha t i n th e pla y therap y room, Gunthe r require s orde r an d consistenc y t o counterac t hi s experience o f inconsistenc y an d incomprehensibl e chao s i n hi s external world . Anothe r interpretatio n migh t b e tha t bein g clea n and nea t i s a  wa y tha t h e maintain s a  saf e relationshi p wit h hi s auntie i n a  on e t o on e interactio n a t home . Initiation of Interaction. Thi s categor y document s th e emerging abilit y t o instigat e interactio n wit h me , a s oppose d t o simply respondin g t o m y overtures . Th e abilit y t o initiat e interaction reflect s bot h a  child' s workin g mode l o f sel f i n relation t o others , a s wel l a s th e mode l o f self . Fro m th e viewpoint o f th e mode l o f self , a  chil d require s sufficien t eg o integration (o r a  stron g enoug h persona) , t o b e abl e t o presen t a proposal fo r engagemen t wit h anothe r person . Whethe r th e chil d is abl e t o follo w throug h with , an d sustai n contact , als o reflects th e degre e o f confidenc e h e o r sh e ha s i n th e self . From th e viewpoin t o f th e "sel f i n relatio n t o others" , th e degree o f sel f tha t i s riske d i n th e initiatio n o f interactio n 106 appears directl y relate d t o th e child' s perceptio n o f th e safet y of th e relationship , o r o f th e "other" . Within th e smal l confine s o f th e pla y therap y room , wher e unoccupied floo r spac e fo r movin g i s a t bes t tw o meter s square , interaction o f som e kin d i s unavoidable . Initially , th e hig h volume an d rapi d pac e o f Gunther' s interactiona l exchange s see m more a  manifestatio n o f hi s anxiet y a t bein g i n suc h a  smal l space wit h a n adult , tha n a  invitatio n t o tal k o r play . Durin g the firs t fou r sessions , hi s activit y an d verbalization s ar e unfocused, fas t paced , an d eve r changing . H e move s fro m on e to y to anothe r i n th e playroom , verbalizin g briefl y abou t eac h one , often withou t completin g a  though t o r sentence . Thi s chatte r i s constant, bu t seem s directe d t o th e wall s o r floo r rathe r tha n t o me. In the early sessions, any interaction that Gunther initiates with me is through the medium of inanimate objects. Most verbalizations are in relation to toys. The y are quick, disengaged verbalizations such as: "what is this for?"; "a tractor, car, one, two, three four of them"; "it' s Santa Claus, a spider, this again, Yuk, I hate spiders". Al l are made while his face is turned away from me. Th e one exception involves a series of repetitive intrusive interactions during which Gunther abruptly brings toys to my eyes or nose. Th e majority of these toys are frightening objects such as spiders, monsters, or snakes. Occasionall y they are gentle symbols such as a small baby or a dog with which the gesture is then accompanied by a kissing or slurping sound. Althoug h the latter items appear on 107 the surface t o be benign toys , the y are i n fact th e same object s that also appea r within his recurring traum a themes . In relation t o thi s repetitive play ther e are a number o f interesting therapeuti c interaction s tha t appear t o assis t Gunther's movement fro m th e early impulsiv e pattern t o more appropriate interaction . Th e firs t occur s i n session tw o afte r he find s a  large to y spider and brings i t t o my eyes : Th: He's tryin g t o scare me again . G: No . Th: Then what is he doing? He's coming at my face. What should I do? G: You have to try and kill them. Thes e tarantulas make freezing, and then everybody's dead. Th: So should I bat it off and step on him. (H e had earlier said that this was what he did with the flies that got in his eyes at home) G: Yeah , (ton e relaxed) When I offer this reply, Gunther shows a momentary relaxation response. Ther e is a point of connection, as I link this gesture to his earlier explanation. Fo r this brief instanc e he conveys a sense of feeling acknowledged and understood. Th e second scenario occurs in session three. H e brings a monster to my eyes and makes slurping noises. Thoug h Gunther faces me, his eyes are not engaged: B: He's on my nose again biting it. G: Kissin g it. B: I think the monster loves me and hates me. G: No . B: He tries to scare me and tries to kiss me. 108 G: Bye , bye . (A s h e take s th e monste r t o m y mout h an d make s kissing noise . H e the n bring s a  centiped e t o m y fac e wh o also make s kissin g noises. ) B: Th e centiped e kisse s m e bu t h e i s als o tryin g t o scar e m e away. G: N o B: All of these scary things come up and kiss me, but they're scary and I don't know whether to like them or be scared of them. G: Brings a monster to my face. In both interactions, Gunther's words and gestures are paradoxical, while his emotions seem disconnected from the play. There is no sense of enthusiasm or engagement. Gunther' s interactions appears to come from his unconscious rather than a conscious self. Fro m a therapeutic sense, because his play is intrusive, repetitive and joyless, it appears to be a reenactment of trauma rather than an invitation to play. A s the recipient of these gestures, I feel a sense of aggression and intrusiveness. This child is clearly crossing comfortable body boundaries for me. M y response to him, when the repetitive pattern becomes clear, is therefore to speak from my feelings, assuming that they also reflect the feelings that he has experienced during the original traumatic experience. This is a tentative kind of interpretation, acknowledgin g within the safety of his metaphor, what appears to be Gunther's feelings or experience of fear, intrusion, and questionable relationships. I  am therefore speaking from an intuitive conclusion that he is continually confused by interactions within relationships that are supposed to be nurturing or protecting but are indeed frightening. Additionall y in his relatively new experience of attending school, he is encountering new 109 relationships tha t loo k caring, an d therefor e paradoxically carr y the threa t o f hurting him. Because , he stay s with th e activity , rather tha n disrupting hi s play i n response t o my comments , i t i s likely tha t he perceives the m t o be accurate an d empathic . Sessions fou r throug h seve n mark a  period i n which intrusiv e gestures graduall y diminish , an d his invitation s t o engage i n parallel play became more confident. The fourt h sessio n show s a beginning chang e towar d a new mode o f interaction . Gunthe r approaches me i n a more consciou s manner with a  vague an d tentative invitatio n t o actually play. I n the fourt h session , h e initiates brief play with th e helicopter an d airplane. By th e sixth session , not only i s he engaging i n momentary paralle l play, but he i s also abl e t o maintain shor t reciproca l conversations. Mos t conversation s continu e t o be centere d o n inanimate objects . Th e followin g i s typical o f th e momentar y attempts a t play an d conversation tha t characterize thi s period : G: (Goe s to the doll house an d brings a  small to y close t back i n his hand. H e stands i n fron t of me as he take s th e king's crow n out of th e closet. ) B: The crown . Yo u remembered where i t was fro m las t time . G: I  was keepin g i t in there. B: Yes an d you foun d i t again i n the closet. G: (Turn s away fro m me and trie s t o put th e crown on th e king. Move s back facin g me an d says:) thi s i s poking me. B: Yeah, it s hard t o get on. It hurts when you tr y t o do it . G: (Keep s tryin g while I  say thi s and then holds up his han d to show th e marks o n his hand fro m trying . He says ) loo k a t the dots . B: Yeah, i t makes lot s of dots o n your hand . G: Lik e a  face. 110 B: Yeah, it is shaped like a face. G: (Hand s the crown and king to me and turns to eat his snack while I put crown on the king) B: (hand s the "crowned" king back to him) G: Where's the other one now? (  Hands me the queen and he holds up the king). B: Oh thank you. G: Have to take them over here (h e heads to the doll house). B: O.K. and ones going to sit on the throne [reflectin g his action of placing the king on the throne]. G: He has to sit there, another place, look at this, look at a shovel (become s distracted and begins exploring the doll house). How do you work this anyway? This vignette illustrates his emerging ability to momentarily maintain both play and conversation. H e voluntarily begins a play theme in my presence and further seeks to engage me by handing me a specific character. H e takes one step further then the previous example in that he also selects the house as a context in which we are to play. Onc e we are at the doll house however, he is easily distracted and at no time after that is he again focused enough to actually include me or my character in interactive play. Thoug h he instigates activity and solicits my help in this scenario, it is of note that he does not risk doing either in a direct verbal way. It is also important to note that Gunther is actually approaching me during the brief invitations to play, in contrast to his previous patterns of withdrawal. Despit e this change in proximity seeking he continues to retain his stiff, closed posture, and flat affect until the eighth session. Ill Self Presentation During the Initial Stage of Therapy The overwhelming impression during this early stage is of Gunther as a child whose self is defined more by his defenses than any conscious behaviour. H e presents as anxious, unfocused, and avoidant of any conscious connection with myself, or with his past or present experientia l world. Hi s focus is on the inanimate objects of the playroom, but even within this medium, he is initially unable to attend to a play theme or conversational topic for more than seconds at a time. A s the stage progresses he shows beginning movement towards more sustained play themes and brief connections with me. This section will explore Gunther's self presentation and its progress over the first seven weeks of therapy. Th e categories of (a ) ability to maintain focus; (b ) synchrony of self presentation; (c ) developmental level; (d ) self related statements and (e ) self related drawings have been chosen to illustrate the manifestations of self over the course of therapy. Ability to Maintain Focus. Th e ability to maintain focus reflects the capacity of the conscious self to be in control of the child's concentration and direction. I f the child is able to shut out superfluous external stimuli, he or she will be more able to attend and interact in a self directed manner. I f inner feelings and thoughts can be stilled, then the child is able to interface in an intentional way with the world around him or her. During the twenty-five weeks of therapy, Gunther makes significant change in his ability to focus. H e progresses from the anxious hyperactivity of the first weeks, to highly focused 112 creative play themes lasting up to 20 minutes during the last weeks of therapy. In the first therapy encounter, Gunther's attention to a given toy or topic lasts between two and twenty seconds, seldomly reaching a natural conclusion. Th e one exception occurs in the last few minutes of the session wherein he creates a short two minute scenario in the doll house. The second and third sessions follow similar patterns with no focus or play lasting more than two minutes. In these two sessions much of the play and verbalizations are begun, and then terminate before a cohesive interaction occurs. Th e brief exceptions have been discussed previously. Thes e entail moments of empathic connection between child and therapist. The fourth session represents a clear shift when Gunthe r discovers the sand tray. H e begins by sorting throug h baskets of toys on a table adjacent to the sandtray. Noticin g multiples of certain categories, he begins placing them in groupings according to type in the sand. A  pattern emerges as he identifies groupings of pigs, cows, cowboys, "arrowman" (Indians) , superpower figures, and athletes. H e painstakingly arranges these clusters in the sand during three separate concentrated periods lasting approximately two to four minutes each. H e develops a pattern of Figure 4.1 The Baby and Dog Surrounded 113 grouping a number of figures, followed by a play disruption in order to rummage or eat. A t the end of the session, the groupings form a semicircle around an empty space. T o this center, he adds a lone naked baby, who sits on a chair, accompanied by a dog. (Figur e 4.1). Th e baby's back is to the majority of the figures and the dog is directly facing the baby. As the reader will discover, as Gunther's story unfolds, this scene sets the feeling tone for this little boy's isolated, unacknowledged plight in his world. A s will be noted in the section on play themes, the baby and dog are recurrent characters in this child's play. From this session onward, a significant shift occurs both in Gunther's ability to sustain focus, as well as to tolerate interaction with me. Thi s pattern of adding to a scene in "fits and starts", completing it after three or four disruptions, continues as a pervasive pattern for the remainder of this stage. Predominant Affect and Degree of Synchrony. Durin g the initial attempts at coding Gunther's affect, it soon becomes apparent that both his presentation of self and affect are confusing and dyssynchronous. Thoug h his voice, and many of his verbalizations seem on the surface to be cheerful and positive, his body is stiff and constricted, his eyes are devoid of feeling, and his play behaviours usually belie either a sense of fear or gestures of aggression. I n addition, even when he is communicating within a seemingly friendly context; "  I have one of these. Do yo u like puppies?", both his eyes and his body alignment convey a fear and defensiveness. 114 Gunther's play has an anxious, compulsive nature to it and his interactions portray a predominance of negative gestures, implying feelings of fear, anxiety, and aggression, with frequent elements of intrusive play directed at me. Hi s most common gesture consists of bringing found toys directly to my eyes or nose, with concurrent slurping, kissing, or wiggling gestures. During these gestures, Gunther's body is stiff and aligned obliquely to me, his eyes are watchful or disconnected and his voice has an overly bright sound to it. Such paradoxical behaviour predominates over approximately 95% of each of the first four sessions. Exception s consist of brief moments when Gunther's presentation seems to relax, and show consistency. Thes e occur most often within the context of small disclosures of fear, loss, o r at times when he feels understood. Clien t centered therapeutic theory might characterize these moments as instances of advanced empathy. They seem to occur as a result of an accurate verbal or non verbal therapeutic response in relation to the metaphor of Gunther's play. Suc h a moment of synchrony of self happens during a brief interchange in session three, when Gunther finds a small rubber turtle: G: (Find s a turtle on the shelf, starts to take it to the water tray but abruptly brings it to me) . B: a turtle G: (walk s the turtle up my leg then up my arm.) B: ( I turn my hand over slowly and open it) G: (  Places the turtle gently in my hand.) "don't squeeze it, just pet him." 115 B: you want me to hold him and take care of him. G: Relaxed , momentary eye contact, gentle voice "yeah". To me this interaction seems to be Gunther's metaphoric request that I respond gently and respectfully to him within our relationship. Ther e is a hushed sense to this small interaction, as if this boy is indeed putting his trust in me and watching to see if I will honour it. During sessions five, six, and seven, Gunther additionally shows synchronous behaviour during symbolic expressions of anger (punching the bop bag), or neediness (drinkin g from the baby bottle). Dyssynchron y is still evident in approximately 90% of his actions. Mos t of the dyssynchronous presentation seems to occur during play themes that portray either scenes of aggression, or of small family scenes involving babies, dogs, and avoidant parents. Developmental level of play. Gunther' s play during the first four sessions of therapy can best be characterized as an atypical kind of isolated play. I t is impulsive and unfocussed as he moves quickly from one theme to the next. He shows minimal ability to be creative or even imaginative in the early weeks. It is almost as if he is not able to make a connection between the toys and their counterparts in the outside world. Not only am I avoided, but I am often treated like an inanimate object. Gunther exhibits none of the minimal social awareness expected of a child of this age. Usual respect for body boundaries is breached as he brings toys right up to my eyes, lands airplanes on my head, and drives robots between my legs. This breach of boundaries seems eve n more pronounced due to the 116 absence of playfulness or connection with me. I n many ways his play has the flavor of an overactive, unaware older infant or toddler who uses others as objects to poke, investigate and crawl over. Session four marks the first time that he truly attempts to play with me, and I am left surprised at the infant-like nature of the play. H e stands in the middle of the room, puts a cloth over his eyes and says, "Yo u can't see me". Variation s on this type of hide and seek play also occur throughout the second half of the first stage. The fifth session contains another small shift in his manner of interaction, a s Gunther approaches me with two toys, one for me and one for him, asking which I want. Thi s is the beginning of a very rudimentary parallel type play that occurs periodically through until session seven. Typically, he gives me a toy to hold, and then begins a brief imitative pla y on his own, with no further attempt at interaction. I n order to enhance this process, I use a tentative mirroring play to further a chance of engagement between us. Verbalizations Relating to Self and Others In the first four sessions of therapy, the vast majority of Gunther's conversation entails simple descriptive statements either about the inanimate objects of the play room, or about what he is doing with them. Th e most common statements are "oh, a dog...and a turtle... There's a  pig. A  motorcycle, can it stand up." Occasionall y he will tell me " I like the mask" or "I 117 know what this thing is for". Perhap s once in each session, there is a "rogue" statement that provides a momentary glimpse into his persona l or internal world. Thi s is usually sandwiche d between comments on toys. Fo r instance in session two he said "the bugs go in my eye all the time". I n session four, he informs me that " I had a helicopter but it broke", and in session six he says " I used to have one of these, but auntie threw it away". Th e reader will note that the common themes underlying these tiny disclosures imply either a sense of loss, or aggression. O n the whole, we learn little about this child's feelings, internal states, experience s or relationships fro m his conscious conversation. Rather , it is his defensive gestures, artwork, and rudimentary play that are most revealing of the self of this young boy. Self Representation in Art The clarity with which children's drawings depict a depth of knowing about the self is a constant source of awe to me. I n this socially and verbally inept child, his drawings show a wisdom and knowing that corroborates both his history and our observations in the school. Thi s section will explore Gunther's early drawings of (a)house , (b)tre e (c ) person and (d ) family as a method of understanding his model of self. 118 Figure 4.2 First House The house drawing. Thoug h the depiction of his house will be more extensively discussed under play themes, it must be said that this severely neglected and ignored child most appropriately drew a house in the shape of a tombstone! (Figur e 4.2) To me this house drawing is saying "M y home and family are cold, inaccessible and dead in relation to me. I  am frozen out." Person and tree drawings. With further unconscious awareness, Gunther's early self-related drawings contain neither an environmental context nor a ground (Se e Figures 4.3 an d 4.4). What better way to portray a child who is dissociated (ungrounde d in reality), clearly avoidant of contact, and disconnected fro m the human or material environment around him. Whenever a therapist asks a child to do such projective drawings, there are standard questions that are asked once the drawings are completed. These add to our understanding of the meaning the drawings hold for the child. Typical questions include a query Figurw 4. 3 Tree Drawing 119 about the weather, and if the figure in the drawing has been hurt or needs anything. Despit e Gunther's early hesitancy, a  number of responses accurately parallel his external reality. Fo r instance, the contextual weather of all early drawings, except that of the person, is winter (hi s cold environment) despite the fact that they were drawn during a warm early spring. It is from his tree image that we receive a glimpse of Gunther's emotional vulnerability and yearning for contact. Th e little tree that looks so small and insignificant on the big page, seems to reflect his loneliness and isolation. Whe n I ask Gunther to tell me where the little tree lives and what it needs, his poignant reply is: The tree is in the forest, There are animals around him. He likes the animals. N o one has hurt the tree. Th e tree needs more animals. Gunther's person (Figur e 4.4) i s the most realistic of his drawings, both in its visual representation, a s well as within his accompanying verbal response. Like the tree, the figure is small, ungrounded, off balance, and alone. I t sports a mark below the eye that reminds me of a scar. Thi s mark leads me to wonder whether this is the injury that drives his joyless, compulsive play of bringing frightenin g creatures up to my eyes. Gunther' s response to my questions, leaves an ache in my heart. H e tells me: Figure 4.4 Person Drawing 120 the perso n i s Gunther , h e i s lonely , h e need s kid s an d friends, h e i s sayin g somethin g bu t n o on e ca n hea r him . (note th e smal l dialogu e balloo n abov e th e figure' s h e a d ) . When viewin g sel f fro m th e distan t thir d perso n commentato r perspective, Gunthe r i s abl e t o tel l u s a  grea t dea l abou t himself. I n contras t when , i n th e secon d session , I  as k hi m t o "draw a  pictur e o f yourself" , Gunthe r refuse s saying , " I can' t draw myself, I can only draw Use". Interestingly, when I ask him to draw a picture of his family doing something, he begins drawing without any hesitation. The result, however is again a lone picture of his sister Us e (Figure 4.5). Whe n I ask if he has any other family, he replies "no, only Use". I t is my experience that most children draw their entire family, including an image of self, in such drawings. Wit h a second look at this drawing, I notice a pale yellow smiling face within the sister's belly (se e Figure 4.5). My interpretation is that indeed Gunther is ensconced within his drawing of the only family that he can, at this time, acknowledge. I t is likely that it is his small smiling face that is "gestating" within the comfort of Use's person. It appears to me to be a visual representation of Gunther's current reality that indeed he does not have a conscious autonomous self. Instead, in order to function in the outside world, h e must borrow from Use's direction and ego strength. I n the metaphor of the unconscious, it is as if the Figure 4.5 Use as Gunther's Family (perhaps also container for self) 121 ego, or self of this small boy is still in symbiotic union with his only caretaker; gestating within the personhood of his sister. Plav Themes One of the unique and magical characteristics of play therapy is that the unconscious or repressed issues of the young child client are often worked out through the metaphor of play. The children, therefore, are able to work on their pain and issues without a conscious awareness or retraumatization. Through the projective medium of play and art, the therapist can glean a glimmer of those traumas and patterns which influence a child's sense of self and the world without ever hearing him/her speak a word about them. Guidano(1987) suggests that by the end of the preschool years the child has, within the unconscious, an ensemble of nuclear, emotionally laden, critical scenes that have developed because of repetition and meaning over time. H e explains that these internal scenes add to, and influence the child's stable self perception pattern. Likewise , in play therapy, it is often the repetitive play scenarios that give us clues to the experiences, complexes, and schema's that define the self and the way that self responds to the world. In this section, several of the more dominant and emotionally laden play themes will be discussed, and when applicable related to Gunther's behaviour, and known history. 122 Play Theme: Aggression to Face The most striking play pattern that occurs in the early sessions is the tendency for Gunther to bring frightening figure s up to the bridge of my nose. I  consistently perceive this gesture to be aggressive and intrusive in nature. I  also make a number of interpretations in response to this behaviour that appear to be accepted by this child. Th e first is quoted in the description under "initiation of interaction". Essentiall y the interpretation involves my reflection to Gunther that he wants to see if I a m also scared of these creatures. A  second interpretation occurs after his play takes on an additional variation in which the scary creatures also kiss my face. Afte r this has happened a number of times I respond: "I' m confused. All the scary things come up and kiss me now, but they're scary, and I don't know whether to trust them or to be scared of them." I believe that this response reflects Gunther's own confusion about adults who sometimes scare him but end up being nice. I t could also reflect his confusion about adults who have been in a role to care for him but instead hurt, neglect, or abandon him. Thi s of course is the ongoing double bind of the maltreated child (Heifer, 1991; Newberger & De Vos, 1988; Wolfe, 1987). But there is potentially more specificity behind this play gesture. I n Gunther's drawing of a person in the first session, he depicts a boy with a scar or wound under his eye. A n alternate interpretation may be that this child saw many frightening things in the early years of his life including family violence, drunkenness and a person being shot. 123 Play Theme Dog The dog is a prominent, affect laden play theme that recurs consistently throughout the 25 weeks of therapy. Th e dog theme first appears in session one and is last seen in session twenty-three . In the searching and naming behaviour of the first session, the dog is named more than any other single item. Eac h time Gunther encounters a dog, there is a sense of heightened emotion such as " a puppy, I love puppies!". Th e second encounter find s him picking up a stuffed dog and momentarily hugging it. Thi s random attraction continues until an interactive theme emerges in session four. In session four, as mentioned earlier, Gunther places the dog as one of the two central figure in his first sand scene. The dog sits on the ground facing the naked baby who sits alone on a chair, surrounded by many characters, each in it's own grouping. I n session five, the dog is again a principle character in a more sustained scenario enacted in the doll house: G: moves over to the doll house. "Its a kitchen, there's the dog." He picks up the dog and has it jump on the bed saying "woof, woof" beside an also jumping boy. B: The dogs jumping on the bed with the boy, now he's jumping on the other bed. G: Whose bed is it? B: I don't know. Whose do you think it is? G: Its the dogs B: Its the dogs bed 124 G: "woo f woof" ,  turning toward me and bringing the dog to my face, having it lick my nose. Then takes the dog back to the house and says "h e can stay there". Plav Theme: Baby The baby is also an emotionally laden and repetitive play symbol. Fro m the first session, when naming and sorting is Gunther's predominant play activity, the baby is frequently recognized. Th e baby is cited twice, and is the central player in the only cohesive play scene of the first session: G: (Sit s down in front of the house . Mom doll comes into the room) "H i honey",( and gives the boy doll a kiss. Mom doll goes upstairs and through the door, and sees the girls and the baby. Sh e puts the baby on the rocking horse, and then in the crib. Th e baby falls out of the crib.) Although this is a tiny moment of play, it seems to reflect the reality of his family situation. Mother' s visits are infrequent, and destructive to all three children. Gunthe r is generally ignored during these visits, whereas Heidi is lavished with attention, but soon left behind. Among other scenes in session two, the baby is washed in the tub. I n the third therapy session, the theme of the baby being hurt emerges again. Thi s occurs during my attempt to introduce a series of doll stories designed by Jude Cassidy (1988) , developed to measure the child's level of attachment. I n the first attempt, I ask Gunther to tell a story based on a brief scenario in which a boy brings a present to the mother or grandmother. H e continues the story by saying, "Th e boy's giving her a baby. Sh e says thank you. The n she said 'o h wow the baby's going poop', and the seat drops on the baby's head." 125 Gunther i s able t o tolerat e onl y tw o of thes e scenarios . His respons e t o the second situatio n carries th e same them e o f the baby being hurt. Th e structure d scenari o begins with, "  A boy say s I' m sorr y Mom". Gunthe r readil y responds , "H e fel l dow n at th e dining roo m table , and he say s he's sorr y fo r hurting th e baby." In session thre e and fou r th e baby an d dog appear i n th e same brief play scenario s alread y mentioned. I n session fiv e Gunther specificall y ask s fo r the big baby dol l and gently feed s her a  bottle fo r a total of fiv e minutes. Thi s feedin g the n leads t o his firs t clearly regressiv e play i n which he drink s from th e baby bottle himself. Th e baby bottle subsequentl y becomes a  constant companio n i n the remainder o f th e play therap y sessions. Spontaneous play i n sessions fiv e and six also contai n moments o f aggression directed a t a baby. I n session fiv e h e places a  chair o n th e baby's head. Whe n I  ask "doesn' t tha t hur t the baby?", h e replies "no , she like s it. " I n session si x h e momentarily swing s a  ball an d chain at th e infan t figure , bu t then denies my reflectio n tha t he's mad at th e baby. Throughout th e twent y fiv e weeks o f play therapy , Gunther' s play an d affect i n relation t o th e baby symbo l vacillates betwee n being hurtful , frightenin g an d nurturing. Lik e th e dog figure , it i s difficult t o determine whether th e baby i s a symbol o f himself a s a baby, being hurt; or of his curren t ange r an d wis h to hurt his baby sister . I t i s likely tha t i t is both, a t different times . 126 Art and Verbalization Regarding House and Family A child's play, conversation, and drawings about family will frequently provide a snapshot sense of the interactional patterns that have molded his or her self esteem and interactional style. A child is often referred to therapy because of acting out behaviour. Ofte n such youngsters are expressin g their problems through interactional or behavioural symptoms rather than through words. I n the beginning, Gunther's avoidant and anxious behaviour indicates that he has coped with relationships throug h avoiding them. I t is not surprising, therefore, when he declares, " I don't have a family, only Use". Further , his family related play and drawings present images of being ignored, hurt, disappointed and isolated within the family. Gunther's early therapeutic sessions are characterized by a conscious avoidance of topics related to family. A s discussed earlier, in the first sessio n when I ask him to draw a picture of his family, he simply draws a picture of his older sister Use. Agai n in the second session, I request a family drawing (Figure 4.6). H e once more draws Use, providin g great detail on her features and dress. Whe n he finishes, I say "and that is your family". H e replies affirmatively asking if I would write his Figure 4.6 Gunther's Second Picture of Family 127 story. Whe n I  as k wha t hi s stor y i s h e replie s " I lov e Barb , I love you. " i n a  disconnecte d voic e lookin g straigh t ahead . From a  les s consciou s perspective , Gunther' s famil y relate d pictures paralle l hi s sens e o f detachment . Bot h hi s picture s o f a hous e (refe r t o Figur e 4.2 ) an d o f hi s famil y ar e acontextua l and ungrounded . Specificall y th e pictur e o f a  house , usuall y representing th e child' s sens e o f sel f withi n family , i s shape d like a  tombstone . Ther e i s n o chimney , whic h ma y impl y tha t there i s neithe r warmt h no r fir e within . Furthe r ther e i s n o sign o f lif e o r habitation , an d th e doo r appear s to o smal l i n proportion t o th e res t o f th e hous e t o provid e accessibility . When I  as k wh o live s i n th e house , Gunthe r list s himsel f an d hi s family members . Whe n I  as k wha t th e weathe r i s lik e nea r th e house, h e replie s tha t i t i s winter . I  a m lef t wit h th e impression tha t Gunther' s experienc e i s o f hom e and/o r famil y a s cold an d inaccessible . Th e exceptio n o f cours e i s siste r U s e , whom h e readil y acknowledge s a s hi s family , an d draw s wit h grea t care an d detail . Gunther's sens e o f loneliness , needines s an d los s i n relation t o famil y furthe r emerge s throug h hi s comment s abou t toys i n th e playroom . I n sessio n on e h e pick s u p a n airplan e an d says " I used t o hav e on e o f these , bu t Aunti e thre w i t away" . Likewise i n sessio n six , h e comment s " I sa w a  helicopte r i n th e store. I t spu n aroun d lik e that , an d aunti e couldn' t ge t it" . These ar e th e onl y reference s t o aunti e durin g th e firs t stage . Likewise, ther e ar e n o consciou s discussion s abou t eithe r hi s mother, father , o r bab y siste r Heidi . On e o f th e clea r measure s 128 of Gunther's progress see n i n the latte r session s o f therap y i s his ability t o consciously discus s painful event s fro m home. In summary, durin g thi s firs t stag e of therapy , Gunther' s verbalizations, play, an d drawings revea l a  sense o f isolation , hurt, longing , disconnectio n an d anger i n relation t o his family . Play theme s relatin g t o famil y sugges t tha t thi s child feel s neglected, unlove d an d needy. Ther e are also clues tha t he ha s either hurt his baby siste r or has urges t o hurt her. I speculate tha t his rage at her arises fro m th e reality tha t sh e occupies favorit e chil d position, while he continues t o be th e forgotten child . Plav Theme: Healing and Nurturance When helping hurt an d traumatize d children , baby bottles, play dishes, medical equipmen t an d Band-Aids ar e essential tool s of therapy . Bab y bottles allo w th e child t o regress; and dishe s and te a sets facilitat e th e rituals o f feedin g an d nurturance, often missing i n neglected children . Th e use of Band-Aids, stethoscope, an d various medical equipmen t ca n serve t o symboliz e the healing tha t i s taking place within th e child . As mentioned under th e play them e of baby, Gunthe r bega n drinking fro m th e baby bottle i n the fift h session. Throughou t the remainder o f play therapy , Gunther uses th e bottle a s a frequent companio n i n the playroom. H e holds i t while he draws, he fill s te a cups fo r tea parties with it , and even uses i t as a source o f medicine. The sevent h sessio n marks his firs t use of medica l equipment. Thi s sessio n seems a transition between th e firs t an d 129 second stage . A s I  collect Gunther fro m his classroom , I  explai n to him tha t we will begin th e session with a  special drawin g before he plays. M y plan i s to trace his hands a s a way o f affirming hi s ownershi p o f his body. I  had trace d his whole bod y outline tw o weeks previously, with th e intentio n o f helping hi m establish a  more positive sens e of self an d body boundaries. I will describ e thi s interactio n i n detail a s it exemplifie s Gunther's increasin g trus t i n both himself an d our relationship . It also i s th e firs t tim e he seem s attuned t o his body withi n therapy: G: (Goe s directly t o the sand tra y as he enters th e play room.) B: Oh Gunther, Remembe r tha t we are going t o draw your hand s before we play. G: I  have on e of these . (Put s stethoscope o n his head. ) B: Remember tha t we are going t o draw your hands first . Remember on e week we drew your whole body. Today we wil l draw your specia l hands. G: (Put s his hands ont o th e paper sid e by side . H e i s standing a s fa r away fro m me as he can, and stil l have hi s hands o n th e paper. H e i s also leanin g awa y fro m me) . I want thi s one red and other one black. B: (Drawin g with th e red fel t I outline his hands) Ther e i s your very ow n baby finger . G: And there' s my rin g finger . B: yes. and your lon g finger . A h a very importan t one , your pointer finger . G: (B y this tim e Gunther i s leaning close r towar d th e drawing i n an intent manner) And my thumb . B: Yes your thumb , yo u have suc h nice stron g fingers . The y can do s o many useful things . G: Take s his hands off . B: Now shall we draw th e finge r nails on ? D o you want m e to? 130 G: (H e backs awa y but says ) yeah. (  Putting th e stethoscop e on again but continuing t o look at th e drawing) Yeah . B: What d o fingernail s do ? The y help you pick thing s up, and the y help you scratch . The y help you put tha t o n your head. G: The y ca n help me pick thi s up and write my name. B: They sur e can. The y are very specia l hands. G: (H e approaches me smilin g an d says ) I  want t o liste n t o your heart . (H e listens carefully , seemin g t o be comfortabl e in my presence fo r the firs t time) . I  can hear it . B: I t says " I like you Gunther." G: (H e then listen s t o his ow n heart with th e stethoscope ) B: Can you hear your heart ? G: No. only when I  lie down and it s bumping. B: Let me sho w you another place where you ca n fee l you r heart, (h e readily gives me his hand and I  place i t on his radial pulse ) G: I  can fee l it! ! (Lookin g down at his hand and smiling , speaking i n an excited voice.) I  can fee l i t up here to o (putting his hand on his tummy. ) I  can fee l it!!. B: That's neat t o fee l your nice stron g body . This i s a significant scenari o i n many ways. I t i s th e first tim e tha t Gunther seem s t o tolerate positive affirmatio n o f his personhood an d abilities. H e does not retreat when I initiate thi s activity , i n fact as it progresses h e lean s closer . It appears t o have th e anticipated integrativ e effec t because th e rest of th e session seem s t o flo w more comfortably , wit h Gunthe r more grounded i n his body. Once he has listene d t o my heart, he stays within my reac h and shares a  small vignette fro m home: "w e were a t Safeway, an d 131 we were coming out, and there was a boy that was crying". This is followed by a series of play scenes. He begins in the bedroom of the dollhouse. Th e mother doll is lying on the bed. Noticin g a vanity table and mirror, Gunther spends three minutes positioning the mother at the table so that she can see her face in the mirror. H e says "there , now she can see her face." Followin g this scene, he finds a mother and baby snake and makes a nest for them. Th e large snake then becomes a jump rope. Whil e he twirls it over his head, he relates that "Use has a jump rope, but hers is lost and mine is broken". A s he relates this metaphor of loss and need, the snake becomes a whip with which he hits the "bop bag". A s his sense of anger becomes evident with the whipping motions, his body, eyes, face and voice become momentarily synchronous. Thi s ends when the bop bag inadvertently knocks the baby doll out of her bed. Gunthe r immediately ceases the whipping motions and kneels beside her saying, "poo r dolly, the dolly is hurt". Thi s play sequence that began with a display of maternal narcissism, moving to fear, then loss, and finally rage and hurt is then broken. Gunthe r returns to a sorting of inanimate objects. Fro m this time onward, this young boy presents as more connected to both his inner experience, as well as myself and the playroom. Summary and Analysis of the First Stage of Therapy During this first stage of therapy, Gunther's dominant presentation is one of anxiety, avoidance, and disconnection. His anxiety is evidenced by his inability to focus, his constant motion, and his obsession with being clean and tidy. Despit e the 132 small confine s o f th e play therap y space , he displays a  pattern of avoiding both proximity, ey e contact, an d body alignmen t wit h me. Whe n he does approac h me, his gestures ar e subtly aggressiv e and intrusive , masked by a  paradoxical smil e an d overbrigh t voice. His speech , his play themes , and his drawings sho w a disconnection fro m his family , his environment , a s well a s hi s own experience. H e presents a s the ultimate picture o f th e avoidant child , fearfu l of engaging with others. I n th e beginning, hi s dominant play seem s likewis e t o reflect a n avoidance rathe r tha n engagement. I  find myself feelin g bored a s he spend s lon g periods sorting , naming, an d shuffling toys . Even within his brief moments o f projectiv e play, h e seem s too anxious t o reveal much of his inne r world. Ther e ar e smal l vignettes tha t provide brief an d incomplete glimpses int o th e experiences tha t have shape d him. Hi s joyles s repetitiv e gestures o f bringing frightenin g object s t o my fac e suggests a post traumati c play . Furthe r ther e i s a sense of paradoxica l relationship patterns, i n which thos e tha t are supposed t o be good hurt; and thos e tha t loo k scary ar e nice. Finall y we se e very brief scene s an d statements tha t convey intimation s o f loss , neglect an d parental unavailability . Slowly, ove r th e course o f th e firs t seve n weeks, thi s youn g child becomes les s anxious an d les s avoidant. Littl e by little , as I  reflect hi s play an d make smal l interpretation s withi n hi s repetitive patterns, he begins t o slow down, t o retreat less . M y continuous acknowledgmen t o f his words an d play provides a n affirmation o f his validity an d existence. A  turnin g poin t 133 occurs i n th e fourt h session , wherei n h e construct s a  san d scene , interrupted b y frequen t pla y disruptions . Whe n th e scen e i s finally complet e i t show s a  lon e bab y an d a  do g surrounde d by , but als o disconnecte d from , a  serie s o f grouping s o f lik e characters. Thi s child' s sens e o f lonelines s an d isolatio n i s graphically portrayed . Fro m thi s sessio n onward , Gunthe r displays a  ver y gradua l movemen t towar d increase d proximity , alignment an d engagemen t wit h bot h mysel f an d hi s play . B y th e seventh session , enoug h trus t ha s buil t u p tha t h e listen s t o m y heart, lets me show him how to find his pulse and shares a number of stories from home. 134 The Second Stage of Play Therapy (Sessions 8-13) The secon d stag e o f pla y therap y span s sessio n eigh t throug h thirteen. Thi s stag e i s bes t characterize d a s a  tim e o f emergenc e of Gunther' s physica l an d socia l sel f fro m hi s defensiv e posture . In contras t t o th e predominantl y negativ e interactiona l stanc e o f the firs t stage , hi s presentatio n i s positiv e an d playful . Hi s body ha s als o los t it s close d defensiv e posture , thoug h hi s hea d remains flexe d an d hi s eye s hooded . H e n o longe r position s himself a s stif f an d turne d awa y fro m me . Instead , h e frequentl y approaches me , bod y aligne d t o mine , a s h e initiate s a  variet y o f kinesthetic an d dramati c play . Durin g thi s stag e bot h bod y an d speech become fluid and almost lyrical, as he seems to bask in my attention and affirmation. Gunther's trust and attachment to me become evident in a number of touching repetitive scenes. H e brings me a present in the eighth session, that becomes a medium through which he affirms our relationship throughout this stage. Further , he creates scenarios in which he is able to display a variety of talents and then solicit my praise and affirmation. "Watc h this!" becomes a common phrase. Gunther's inner world likewise becomes more accessible to his play. Ther e are fewer play disruptions, allowing him to maintain a play theme through to a natural conclusion. Th e dollhouse play and drawings begin to reveal more detail of his past and present family life. I n addition, sand tray scenes portray scenes of fear and abandonment. Further , this child's 135 self healing abilit y becomes apparen t a s he utilizes ou r dramati c play t o enact scene s o f healing an d nurturing . Manifestations of Self and Self in Relationship Child Therapist Interaction Patterns Body alignment and proximity. I n many ways thi s stag e seem s like a "honeymoo n phase" i n child therapis t interaction . A s h e lets down som e of his defenses, Gunther basks i n my attentio n an d affirmation. Whereas i n the first stag e he moved awa y fro m m e when I  initiated verbal o r physical interaction , i n this stag e h e actively seek s contact with me, even angling hi s body towar d mine. Whe n he i s in interactive play, he face s me directly an d when he plays a t th e sandtray o r dollhouse hi s body i s angle d toward me. Thoug h his head continues t o be generally flexed , h e makes occasiona l specifi c ey e contact. Help and attention seeking. Ther e ar e other subtl e qualitative difference s i n his interactio n with me. Wherea s i n the firs t stage , Gunther appeare d t o cease al l conversation, an d become stif f an d to y focused , th e instan t he crosse d th e threshold int o th e playroom, i n session eight, he continues t o chatter a s we enter . Whe n he finishe s his conversation , h e bend s down and picks up th e baby doll, an d asks i f I will fee d her fo r him. A s I  sit down and pretend t o fee d her with th e ful l baby bottle, h e makes ey e contact an d says "sav e some fo r me". Ther e is a genuine sens e of connection a t thi s moment. I  also tak e this gesture t o be a metaphoric reques t tha t I  nurture th e baby within him . 136 The abov e i s a n indirec t reques t fo r nurturanc e an d help , but a s th e stag e progresses , h e become s bolde r i n solicitin g m y attention. I n sessio n eight , a s h e joyfull y play s wit h th e bubble solution , h e frequentl y shout s "watc h this , watc h this " confident tha t I  will respon d wit h aw e an d affirmation . In sessio n nin e Gunthe r seek s m y sympath y regardin g hi s sor e throat. H e show s no t onl y hi s trus t i n me, bu t a  greate r sel f consciousness whe n h e says , "D o you kno w wha t I  have... a  sor e throat becaus e I  coug h different" . Late r h e i s i n th e middle o f playin g an d says : G: Ohhh. . I  have t o coug h again . I  alway s hav e a  sor e throat. B: O h dear , tha t i s toug h t o alway s hav e a  sor e throa t (gentle sympatheti c voice. ) G: (i n a  bab y lik e voice ) Yeah . B: No t nice , huh ? G: no It is also in this same session that he brings me a present. We have not seen each other for some time because of the school break. Whe n he enters he says: G: I brought something for you B: Oh look at that, thank you. Yo u made it all by yourself. G: Yeah, out of popcicle sticks. B: And what do you call it. G: A throwing star. B: You did an excellent job. Loo k at this, five points. Thank you Gunther. This is very special. 137 I plac e hi s creatio n i n th e baske t o f treasure s tha t I  kee p on th e snac k an d ar t table . I t contain s crystals , feathers , a Ukrainian eg g an d othe r specia l treasures . I t i s clearl y th e right plac e fo r thi s specia l symbo l o f ou r relationship . A n interesting serie s o f interaction s continu e aroun d thi s sta r fo r the remainde r o f th e 2 5 sessions . A t som e tim e withi n eac h session tha t follows , Gunthe r inevitabl y check s thi s baske t t o ensure tha t I  stil l hav e hi s gift . Periodicall y h e decide s tha t the sta r need s repai r o r alteration . I n sessio n 12 , he add s tap e to th e join t area s becaus e h e decide s i t i s comin g loose . I n session seventee n h e paint s th e points . Mos t ofte n h e jus t ask s do yo u hav e th e star , metaphoricall y askin g "d o yo u stil l valu e me" . Initiation of interaction. Th e second stage is definitively distinguished from the first by the initiative and joy Gunther shows in his interaction with me. Bot h play and conversation show a greater confidence as well as consciousness. Th e eighth session marks a significant shift in how, and through which medium Gunther instigates interaction. A s an example, five minutes into the session, Gunther notices the bubble bottle on the shelf and begins a confident and relaxed period of play: G: (Reachin g for the bubbles) Oh bubbles, can I play with bubbles? B: Sure, just bring them down. G: (  Brings them over to me on the floor, sits facing me directly.) D o you like butterflies? B: Yes I like butterflies. D o you like butterflies? G: No I like stars (indicatin g that he would prefer to have the bubble wand shaped like a star. thi s is said in a genuinely excited voice which is a first. He brings the 138 bubbles an d th e two wands t o me and sits down on th e floo r directly i n fron t of me, mirroring my cross-legge d position . He gets th e bubbles ope n and begins blowing a s he als o look s directly a t me, with his head up ) B: S o you will have th e stars, and I  will have th e butterfly. OOO h (a s he blows a  big bubble towar d me ) G: 0-0-0-H!! ! (i n excitement an d delight a s he continue s blowing bubbles with relaxed flui d speech an d movements fo r 5 minutes) . This interactio n i s a landmark, both i n sustained e n fac e interactive play a s well as in the loss of body stiffnes s tha t typified previous sessions . Ther e i s also a new congruenc e between his body movements, affect, and voice durin g thi s interaction. Gunther's ne w comfort i n our relationship i s furthe r exemplified by a  poignant exampl e late r i n this sam e sessio n whe n he drinks fro m th e baby bottle fo r twenty seconds . H e drink s thirstily with his head throw n back an d eyes closed . Whe n h e finished, h e look s directly a t me an d says "d o you want some?" . This gesture show s both a  sense of connection, a s well a s belief that his offer will not be ridiculed . During thi s secon d phase of therapy , Gunther show s greate r confidence i n both himself an d th e safety o f our relationship . The need t o be indirec t o r tentativ e i n his approac h t o conversation, hel p seeking , o r play activitie s disappears . Fro m session eight onwar d he i s able t o engage i n prolonged conscious , connected play an d conversation . Gunther als o uses th e play therap y tim e t o build skill s an d self esteem . Sessio n eleven marks th e beginning o f a new patter n of solicitin g m y attentio n an d affirmation. A s his confidenc e grows within thi s nurturing environment , he begins experimentin g 139 with a  variety o f toy s and play medium, drawin g my attentio n t o each new insigh t o r achievement. He even begins t o offe r occasional suggestion s an d t o complement himself . Th e followin g is an example o f such an interchange, durin g a  game of catch wit h the punch balloon . G: I  punched you (a s he bats th e balloon towar d me ) B: You punched me. (bat s it back) G: Now you punched me. (th e elastic come s unwrapped fro m th e balloon.) Yo u should put tap e on it. B: We could . That' s a  great ide a Gunther. You sur e do hav e a goo d brain. G: Grinning directl y a t me. Yeah I  know. som e people hav e good brains. (H e brings th e balloon over an d holds i t i n place while I  put tap e on it. ) B: Yup, an d you're on e of them . Let s se e how i t works. G: (H e picks up th e balloon and punches i t towar d me) . I f it goes o n the wall I  have t o punch it . Punch. Oops, oooh , I just kicked i t and thro w it . Watch! I  do thi s the n punch. (He's jumping up and down with excitement) . d o you want t o do this ? B: Sure . Show me what t o do. G: (H e demonstrates an d says) You thro w it. A drawing i n the thirteenth sessio n of therap y illustrate s what ou r relationship ha s begun t o symbolize t o thi s small boy. I as k him t o draw a picture o f his famil y doing somethin g (Figur e 4.7) . 140 When he finishe s drawing his picture he proudly points to the roof saying: G: Those are the vents. An d that is the peak. You can open it. B: And what happens when you open it. G: You can see the stars and you can make a wish. (Direct eye contact and an Figure 4.7 Gunther's Family Doing Something angelic smil e and voice tone) What a nice thing to have on your house. This is going to be you (a s he draws the caterpillar). This one is me? Yes. An d I am the snail. So you are the snail, and I am the caterpillar. And who else is in your family. G: Just you and me. This dialogue is a graphic example of how this little boy has internalized our relationship, using it as an alternative model of close relationships. I t further illustrates how the therapeutic relationship has nurture d a new and emerging alternative view of the world as accessible and hopeful, with himself competent. Gunther's confidence in seeking me out for interaction moves to a new focus in session 14. Whe n I come to pick him up in the classroom, his teacher reveals that has been telling her that he needs to see me. Whe n he enters the play room, he volunteers 141 that today he needs two donuts for his snack. When I broach the subject of him asking for me, he volunteers some painful information: B: How's auntie, Gunther? G: Takin g care of Sally and Freddy. Heidi , my baby sister, she's at my mom's friend's house (lookin g directly at me as he tells me). B: O h really. Ho w come she's away. G: Because she's so bad (wit h a sense of sadness). B: She' s so bad. S o she's away to give grandma a break? G: (Look s down at his lap, and shakes his head yes.) Sh e cries and wakes up all night. B: I wonder if you miss her? G: No. we have a picture of her that we look at. I n the classroom, Heidi came and she was dancing. This session is a striking example of this boys great progress. He has moved from avoiding me in the beginning, to purposefully seeking me out to share an experience that had triggered his greatest fear, the fear of rejection and abandonment. Thi s initial disclosure of Heidi being sent away opens the lid on other fearful experiences. I n this same session he later discloses how lonely he feels in his basement bedroom, separated from the rest of the family. Finall y he shares being hurt by this same friend of his mother's to whom Heidi had been banished. From this fourteenth session onward, toys are no longer the sole medium of interaction between us. H e is now also able to utilize our relationship to verbally express the fears and pains of his current situation. 142 Self Presentation in the Second Stage In the first stage, Gunther seemed merely a composite of defenses and anxiety; a little being, too cautious and defended to risk access to either his inner or outer world. Ther e was little evidence of a unique conscious and purposeful self apparent either in his interaction or his play. A  very different child emerges in this second stage. Fro m the seventh session onward, we see the gradual blossoming and emergence of the unique and purposeful self. Synchrony of self presentation and affect. Wherea s the first stage was dominated by negative or neutral and withdrawn affect; in the second stage, an atmosphere of pleasure and joy prevail as Gunther experiments with, and enjoys a new found sense of self. Ther e is a synchrony of self presentation that dominates over 60-80 percent of each session, and continues for the remainder of the 25 weeks of therapy. As he enters the play therapy room in the eighth session, a significant change is evident. Hi s movements are less frenzied, he makes occasional brief eye contact, and his affect and play tend toward positive themes. H e stays with a conversation or activity longer and there is more often a relaxation in his body. Rather than the tense anxious movements of the first stage, Gunther's limbs frequently break free from his body and he shows a grace and fluidity as he moves. Thi s is especially evident during kinesthetic play. He begins session eight by asking if I will feed the baby doll for him, reminding me to leave some for 143 him fo r later . Ther e i s a  genuin e sens e o f ful l engagemen t an d authenticity no t fel t before . H e the n reache s fo r th e bubble s o n the shelf , sit s directl y facin g m e o n th e floor , an d activel y invites m e t o pla y bubble s wit h him . G: H e blow s bubbl e hig h int o th e ai r an d chase s them , popping the m a s h e goes . H e blow s a  bubbl e a t me , I  blow i t back an d h e catche s it . B: Oh , we'r e playin g bubbl e catch . G: H e start s blowin g th e bubble s awa y an d chasin g the m around th e room . B: You'r e blowin g the m al l ove r G: come s bac k t o m e an d blow s a  bubbl e gentl y int o m y hair. B: (laughing ) On e fo r me . G: (Wit h eye s sparkling , h e blow s a  ver y bi g bubble) . B: O h Gunther , wha t yo u ca n do ! G: H e become s mor e animate d an d chase s th e bubble s dancing around , poppin g them , an d blowin g the m t o me . (A n air o f freedo m an d jo y i n hi s affect. ) It i s durin g thi s kinestheti c play , tha t Gunthe r als o begin s to shar e funn y littl e storie s abou t himself . I t i s a s i f th e jo y he experience s wit h hi s body , allow s som e o f hi s cautio n t o dissolve. I n sessio n eight , a s h e chase s th e bubble s h e pause s suddenly t o sa y "on e tim e I  was talkin g t o mysel f an d actuall y a lady bu g lande d o n m y shirt" . I n th e elevent h session , whil e w e are battin g th e beac h bal l bac k an d fort h h e exclaim s "I' m th e strongest, I  beat th e beac h bal l up" . Soo n afte r thi s h e stop s his enthusiastic , jumping , dancin g pla y an d says , "Di d yo u eve r see a  movi e calle d Booge r Lips? " I  laug h an d repl y tha t i s a pretty funn y name . H e say , "Yeah , i t wa s a  scar y show" . 144 Gunther likewis e show s a  synchrony between his play them e and his sel f presentation th e majority o f th e time . Hi s voice, movements, an d facia l expressio n ar e joyfu l an d fre e during th e kinesthetic play . He show s anger as he beats an d kicks th e bop bag with powerful blows. H e i s gentle an d relaxed an d solicitou s as he serve s tea . I t is only within th e doll house an d san d scenes tha t he returns t o his overbrigh t voice, fixe d smil e an d constricted body . Anxiety. A s ca n be surmised fro m th e above, Gunther show s less evidenc e o f anxiety i n the second stage . H e approache s readily, speak s without caution , and i s able t o focu s o n both kinesthetic an d dramatic play fo r up t o 1 5 minutes a t a time. H e continues t o be neat an d tidy, but gradually thi s take s les s o f his concentration . I t i s in the twelfth sessio n tha t he finall y abandons his obsessio n with order above all else. Whil e he i s sorting throug h a gourd fille d with crystal s an d fossils , totall y entranced with th e beauty o f his finds , he spill s his box o f juice. H e continues t o comment o n the crystals before rightin g the container. Fro m thi s time onward, les s cleanliness anxiet y is shown. H e never reache s a  point o f being messy, but i s finally abl e t o finis h a play them e before worrying abou t disorder, dir t o r spills. Developmental level. Th e isolate d insula r play o f th e firs t stage gives way t o frequen t parallel o r early type s o f interactive play i n this stage. Gunthe r remind s me o f a toddle r in many aspects . H e has internalize d my affirmation s an d attention, an d acts as i f he knows tha t he i s the center o f my world. H e therefor e frequentl y solicit s my attentio n with hi s 145 "watch this" . Hi s play likewis e has tha t joyful , explorator y focus common t o the toddle r stage , as i f newly i n love with hi s mobile body, an d accessible world . The baby bottle continue s t o be his constan t companion . A s he eats his snack , he ofte n alternates between th e bottle an d hi s juice. Whe n settin g up a tea party, he fill s th e te a pot fro m the baby bottle, and i n session 12 , when he finishe s drinking , h e shows his affection fo r me by offering me a drink. Lik e th e toddler, he also love s t o play hide an d seek . Despit e th e cramped quarter s o f our small playroom, h e hides fro m me, alway s with parts protruding, an d giggles while I  search fo r him. I n the eighth sessio n he goes behind th e doll house an d says : G: I  can see you, but you can' t se e me. B: I  can see your nos e G: (Bendin g down further ) Now you can' t se e me. B: Hey where's Gunther (h e bends dow n further) . I  sure mis s him, I  wish he would com e back. Let s see , he's not i n th e muddy water, he's not i n the sand box, let s loo k behind th e house. G: tap s my leg , an d makes a n excited singin g noise . Although thi s i s a slightly more advance d for m of hide an d seek tha n th e firs t stage , ther e i s certainly a  toddler lik e essence t o thi s play. Gunthe r continue s t o initiate a  number o f different variations o f hide and seek play sporadicall y throughout thi s stage. In the ninth sessio n he stand s i n th e middle o f th e room, with a dress up cap e an d head band on . H e pulls th e head band ove r his eyes and say s "yo u can't se e me". A number o f dress up scene s i n front o f th e mirror als o mimic thi s 146 hiding an d rediscoverin g o f th e self, as he raises an d lower s th e mask o r cape an d crows with delight. Verbalization relating to self and family. Th e firs t stag e showed Gunther avoidin g most discussio n regardin g himself o r hi s family. H e expressed littl e o f his interna l state , wants, o r feelings. Thi s slowl y change s i n this second stage , as h e becomes more abl e t o connect with his inne r experience . H e begins t o show a greater pride i n his abilities , a s well a s a body awareness . Jus t as his body i s the firs t part o f sel f t o become expressive , Gunther's initia l feelin g words ar e als o abou t the stat e o f his body. I n session eigh t he tell s m e " I have t o cough, I  always have a sore throat" . I n session nine he tell s m e that " I have a  bump o n my head. I' m goin g t o have a bath when I get home, th e bump i s sticky". I n session thirtee n and fourteen , he i s able t o tel l me tha t he i s hungry an d tha t he needs mor e snack. Expression o f longing , sadnes s an d fea r also begin t o surface. I n session nine he tell s me how his dog was returne d t o the pet store , I  reply tha t i t must have made him sad . H e agree s making his firs t feelin g statemen t "yeah , I was sad , s o sad". A t this moment, his whole sel f convey s a  congruent sens e of grief . His firs t conscious, cohesive disclosure o f painful feeling s about his famil y surfac e i n the tent h session. H e has jus t completed a  spontaneous drawin g o f a treasure map, guarded by a plasticene sword . H e turn s t o me and says : G: We were a t Arthur's house. H e was mean. I  walked home b y myself. B: He hurt you, and you walked hom e 147 G: Yeah. B: and what did auntie say? G: Auntie didn't know. Sh e doesn't care about me. Sh e just likes Heidi. Whereas all previous indications that this small boy felt unloved or unprotected were only implied, this is the first time, he feels safe enough to share this feeling in a poignant conscious conversation. I n session eleven he again conveys his sense of non protection and unsafety, but this time in metaphor. He is rummaging in the baskets and comes across a large bat. H e holds it up with an intense look on his face and tells me: G: I'll get the bat and I'll kill it. B: You want to kill the bat. G: Yeah. W e have a bat at our house. I t always sleeps outside and it goes into a spooky house. B: It sleeps in a spooky house, but no one hurts it. G: And it always comes back in the morning. Gunther seems to be conveying an underlying message in this small scenario that home is not a safe place. I n his anecdote, a fearful creature is allowed to return to the house time after time without being interrupted nor challenged. I t seems the ultimate paradox of the neglected or abused child that the family puts the needs of hurtful or frightening "peopl e or creatures" over the fears or needs of the vulnerable child. Gunthe r is telling me that if he had his way he would kill the bat, rather than let it continue to scare him. Gunther also shows significant change in self concept during this period. Whereas in the first stage, my affirmation of his abilities resulted in a quick retreat, in this stage he is 148 more likel y t o agre e wit h me . I n th e tent h session , I  complemen t him o n hi s repai r jo b an d h e replie s "yeah , thi s i s th e goode r way". H e frequentl y finishe s a  tas k an d proudl y display s hi s achievement. I n th e twelft h session , whe n h e leave s fo r th e bathroom i n th e middl e o f th e sessio n an d return s quickl y I comment, "Yo u wer e bac k fast , yo u mus t hav e ru n lik e th e wind" . He smile s an d say s " I know" . I n th e fourteent h session , h e agai n returns quickl y an d say s "I' m back fast . I' m reall y fast" . I t is clea r b y Gunther' s verbalization s that , a t leas t withi n th e confines o f th e pla y space , h e i s developin g a  ne w sens e o f sel f as lovabl e an d competent . Self representation in drawings. Onc e again , I  as k Gunthe r to dra w picture s o f himself , hi s family , an d th e House-Tree -Person projectiv e drawing s durin g thi s middl e stag e o f therapy . This sectio n wil l examin e Gunther' s image s o f (a ) house , (b ) self, (c ) tree , an d (d ) th e sel f a s a  rosebus h drawings . Whereas al l sel f relate d drawing s i n th e firs t stag e wer e small, monochromatic , isolated , an d devoi d o f context , i n thi s stage image s tak e u p mos t o f th e page , an d contai n a  variet y o f colours, ground , an d evidenc e o f weather . A s th e stag e progresses, symbol s o f sel f becom e mor e revealin g o f Gunther' s inner world . 149 I again ask Gunther to complete the House-Tree-Person drawings in the tenth session. Whe n I ask him to draw a house (Figur e 4.8), he complies with enthusiasm informing me " I am drawing a picture of me I'l l draw a h o u s e f i r s t . " I t i s Figure 4.8 This Is A Picture Of Me. I'll Draw The House First interesting to note that this time, his emphasis begins with the ground and the access to the house. He draws the horizontal lin e for the ground, next concentrating on the stairs leading up to the house. He puts rocks on either side of the stairs, and then draws the house. The reader will note that not only are there stairs to the house, but the door is definitely accessible. The entrance also seems to be one that accesses not only his home, but himself. H e balances his drawing by adding the upper half of himself on the left side of the page. H e is clearly attached to the ground, but only half of him has emerged. H e says "thes e are my hands, That's how I draw". Whe n I ask if he is finished he says "  I need to draw a bush, a little bush". Figure 4.9 Ilse as Gunther's Person Not surprisingly, Gunther's person continues to be an image of U se (figur e 4.9). Whe n I later ask him to draw a picture of himself, he once more replies " I don't know how to draw a picture of myself, I can only draw Use". I  encourage him to try, suggesting that drawing a boy is much like drawing a girl, only with shorter hair. As might be expected with this kind of prompting, his picture (Figur e 4.10) look s like a carbon copy of Use, except with short hair. Th e two important points of distinction though are that: a ) Use's foo t is touching the grass, whereas Gunther's is seven centimeters above the grass; and b) Gunther has large staring eyes and a tentative smile rather than the grin that Use sports . I t is my sense that this is the beginning of Gunther's ability to differentiate his conscious self from his sister. His comments following this self drawing are also reflective of themes already seen in Gunther's previous play. Whe n he finishes the self drawing, he points to the top of his own head and says " I have a bump there. I'm going to take a bath when I get home. Th e bump is sticky." I n reality there is no evidence of stickiness or a bump at that time on Gunther's head. I  have the feeling that this is a body memory evoked by this drawing. As the reader will remember, Gunther's self as "the person" 151 drawing in the first stage showed a mark below the eye. Thi s theme of injuries to his head continues to be prominent. Within the House-Tree-Person series, it is the tree image that is most revealing of Gunther's feelings and experience (Figure 4.11). I n comparison to the pre therapy tree, this depiction is much more "tre e like". It has a sturdy brown trunk, and a small amount of green foliage. A s Gunther draws the tree, his voice becomes dreamy, and for the first time spontaneous conversatio n accompanies his drawing: (He draws the trunk, and then the green top. Draw s a branch hanging down from each side of the foliage) This is the broken branch that is stuck there. This one is something you hang from, its in jungles. (Draw s the ground seven centimeters below the bottom of the tree then makes purple dots). These are the dots, I'll make a sign. How do you spell danger? (  He makes various signs stuck in the ground below the tree with the different letters of the word danger.) I'l l draw the wood now, this is how I draw the broken sticks. This is a balloon from my baby Heidi's birthday. This illustration and dialogue contain many of the themes already seen in play. Ther e are intimations of danger, of being hurt or damaged, and of pain related somehow to his status in relation to his younger sister. Thi s image becomes even more meaningful later, when in the seventeenth session of therapy, 152 Gunther is able to verbally share the pain of being ignored on his birthday, while Heidi's birthday is lavishly celebrated. The ground appearing in the mid-therapy pictures seems indicative of Gunther's tentative movement toward being more connected or "grounded" in his environment. Tha t his symbolic representations of self are at this point still unable to actually touch the ground (o r in one case are only partially emerged), may reflect how early and tentative this progress is. The first drawing tha t shows a complete self symbol connected to the ground occurs in session 11. Thi s picture is a response to my request to draw a rosebush. A  guided imagery that asks the child to imagine what he would look like if he were a rosebush accompanies this request. Gunther' s subsequent drawing is a poignant example of his growth toward a sense of self and self efficacy (Figur e 4.12). For his rosebush, Gunther first draws a teepee, then a snail and finally clouds and raindrops. As he draws, Gunther speaks in a dreamy lyrical voice: I'll do the little tiny snail. That's how I do shells. An d his home right here (pointin g to his back). An d a giant tent. I'l l draw the door, the door right here. His antennas make it open. (make s clouds and dots) D o you know what this is. Its lightning, and some rain. Its raining even on his tent. Then he sits on them and he says, 0000H!. This magical picture has such rich dialogue and imagery. Firs t and Figure 4.12 Self as a Rosebush 153 foremost, thi s creatio n i s a work o f sheer jo y and optimism abou t self an d life . Th e littl e snai l a s a symbol o f self now carrie s his home aroun d on his back. On e cannot imagin e a  bette r solution fo r a small boy who feel s unwelcome an d unappreciated i n his ow n famil y and home. Further , i t is common fo r children t o create a  "vegetativ e representatio n o f self" a s thei r "tru e self" begins t o be accepte d an d recognized i n therapy (Allan : persona l communication, 1992 ; Mitchel l &  Rogers, 1994) . Thi s drawin g also seem s t o harmonize with Gunther's new foun d joyful, sel f confident presentation i n therapy. Th e abilit y o f th e snail' s antennae t o open the ten t door i s indeed consistent with hi s greater confidence , creativity , an d self efficacy . Finally , could ther e be a  more graphi c representatio n o f Gunther's ne w found energy, connection , an d enthusiasm tha n th e image s o f rai n and lightening . Plav and Art Themes Like his verbalizations, Gunther's play i s richer, mor e complex, prolonged an d focuse d during thi s stage . H e i s mor e proactive tha n reactive when engaging i n play themes . Most ofte n he appear s t o begin with a clear vision, an d the n works hard t o create th e context fo r his play. Pla y fall s int o thre e basi c categories: (a ) kinesthetic; (b ) reparative play; an d (c ) projective play relating t o hurt an d trauma . Th e category o f kinesthetic pla y has been described already . I t is a spontaneou s play tha t emerge s a s Gunther becomes comfortabl e both wit h himself an d th e play space . Thi s kind of play serve s a  number o f purposes. I t seems t o build a sense of comfort with his body a s 154 well a s his new foun d identity . I t also appear s t o be a  way fo r Gunther t o connect with me and his environment , therefor e grounding himsel f i n reality . The reparativ e play occur s as interactiv e play involvin g Gunther an d myself. I t appears t o serve th e purpose o f healin g his hurts within th e safety o f th e therapeutic relationship . This categor y encompasse s both medical/healing pla y an d a nurturing, feedin g play. Thoug h interactio n within thi s categor y is usually quit e intense , i t ordinarily convey s a  positive affective tone . In contrast, Gunther's projective play encompasse s th e negative emotion s o f fear , loneliness , and parenta l unavailability, an d i s most ofte n enacted within th e doll house. It is not until sessio n 1 4 that i t moves t o the sand tra y an d assumes a  more ominou s tone . Theme s relate d t o family , dogs , baby, fea r an d danger generall y fal l under thi s category . Plav Themes of Family, Baby and Dog The dog continue s t o be a dominant characte r durin g thi s stage, an d i n session nine we lear n why. I t i s toward th e end o f the sessio n an d Gunther i s once again rummaging throug h th e baskets when he comes upon a dog. H e says : G B G B G B I used t o have a  dog named Kirby . Dogs are specia l t o you. Kirb y was special . (He turns and walks awa y fro m me.) That makes you sa d that he went away . No, back t o th e pet store. I bet you were sa d to see him go. 155 G: (Return s to face me, though he is looking down at his hands instead of at me) I  was sad, ....s o sad. (move s away again) During the twelfth session, th e dog is paired with mother and children in the most complex dollhouse play of this period. Gunther spends a great deal of time arranging the house to exactly fit his specifications. H e puts the baby in the bath, the girl in a bedroom, and the mother asleep on the couch. Onc e the stage is arranged, he fetches the dog and carefully sits it in a chair in front of the TV. H e then gets the mother off the couch and once again arranges her carefully on the stool in front of the vanity table, so she is staring in the mirror: G: Look how nice she looks. B: She looks at herself in the mirror. G: (H e takes the mother downstairs to where the couch and babies are) Oh dear better fix these (a s he puts the baby in the crib) B: She's worried about the baby G: And the two men, the two fathers. (H e puts the baby in a chair in front of the TV, and the dog beside it on a chair) B: The baby and dog are alone, and they are worried about the men. G: Yeah, and the mom has to go to bed. W e need a new mom (He gets a new mother figure and puts it beside the baby.) Oh the baby fell, poor baby. Th e dog fell down too. B: Boy they have a hard time. G: (Take s the boy figure, drops it and then begins hitting the bop bag with the boy) Look he is fighting "boo m boom". (hitting the bop bag with ever greater intensity) right in the eye. G: (h e returns the boy to the house, walking with clear purposeful intent. H e places the boy in a bed near the baby). B: Now the boy has a bed. G: Yeah (wit h a satisfied voice) Look at the baby. (  He puts the boy and the baby on separate rocking horses, rocking them back and forth, singing as he does this, clearly satisfied.) Though we can only guess at what this scene portrays, it seems however to encompass a number of the negative aspects of Gunther's past family life including: (a ) a narcissistic, unavailable mother; (b ) dangerous fathers; (c ) and a perception of being a distant second to the baby sister in his caretakers' affections. Becaus e the scene focuses specifically upon the narcissistic and unavailable mother who does not protect, I speculate that this scene may at least partially relate to Gunther's removal from his mother by social services at the age of 18 months. At the end of the scenario, there seems to be a compensatory anger and a reclaiming of the boys rightful place. I t is difficult to interpret exactly what this dog figure symbolizes, but it certainly has a prominent role. I t is interesting that the baby and dog are again alone side by side, in a stance similar to the sandtray scene in the fourth session. The fourteenth session seems to be the transition session into the last stage of therapy. No t only does Gunther ask his teacher to see me, but he moves into a more conscious discussion of home life and his baby sister's banishment. Althoug h Gunther can speak about Heidi being sent away h e cannot consciously express the terror that this incident seems to provoke in him in relation to his own hurt and abandonment as a baby. Thi s does, however, emerge with graphic clarity, toward the end of the session, in the symbolic world of the sandtray. H e begins 157 collecting th e small aquatic figure s and arranging them , alon g with shell s i n the sand tray . H e holds up th e smallest an d says : G: I  know what her name is. B: th e fish ? G: No, my mothers friend . He r name i s Frieda. B: The one who i s taking car e of Heidi ? G: Yeah. She' s mean too . Sh e sits on me. B: Sh e sit s o n you an d hurts you. G: Yeah . B: I  wonder i f you're worried tha t she'll hurt Heidi ? G: (ignorin g thi s question, he keeps his head down as h e plays with th e sea creatures ) B: It' s scar y when people hurt you lik e that . G: (H e takes th e shark and has i t pound th e smal l aquati c creatures). " I saw an undersea shar k eating on e of these. " (He disrupts play an d goes an d gets th e batman weapon an d begins shootin g i t around th e room. ) Though Heidi's banishment, an d th e memories o f his ow n hur t are to o painful t o discuss i n much detail, this predatory pla y scene speak s volumes abou t what thi s event means, and trigger s i n this smal l boy. I t appears tha t processing throug h th e more symbolic medium o f fis h and sand rather tha n words o r peopl e figures, give s him enough distance fro m reality, t o express hi s fears. Plav Themes of Fear, Aggression and Hiding Most o f th e play theme s i n this category have been discusse d already. I n the ninth sessio n ther e i s a ghost tha t stalk s th e children i n th e doll house. Th e children hide behind a  chair. In the tent h session , Gunther plays ou t a scenario o f fea r tha t 158 the tw o men will hurt th e baby. I n the eleventh session , th e spooky bat tha t returns t o th e house i s mentioned, an d i n th e fourteenth sessio n th e shark attackin g th e fis h is dramatized. I n addition, Gunther uses th e "bo p bag" a t leas t onc e within eac h session t o act ou t his ow n anger an d aggression . Plav Themes of Nurturance and Healing Gunther's ongoin g play and self soothin g with th e bab y bottle has alread y been mentioned an d continues throughou t thi s stage. Ther e i s however a new kind of nurturing them e involvin g the te a set and dishes. I n this play Gunther i s th e caretakin g figure an d I  am th e recipient o f his cooking . I t firs t appear s in session nine when he asks "d o you want t o play tea?" . Whe n I respond affirmatively , h e bustles abou t layin g th e table , fillin g the te a pot an d cups fro m the baby bottle, and putting preten d cookies i n the oven. W e drink ou r te a and he sit s back with a satisfied sig h and says " I have alway s wanted t o play tea. " The healing an d nurturing play most commonly follow s directly afte r discussio n o r enactment o f difficult issues . Th e next te a party occur s afte r Gunther talk s about losin g his do g Kirby. H e expresse s his sadness an d the n says "tim e fo r a te a party." Thi s tim e he engages i n a more elaborat e process o f foo d preparation, stil l supplyin g th e te a fro m his bottle. Whil e busily cooking , h e hands me a  piece o f his real cooki e "t o hold me over" . H e remove s th e items fro m his pretend ove n when h e sings out "ding " t o indicate th e time r has rung. Afte r he drink s his tea , he glances sideway s a t me, grins, and the n gulps th e rest o f th e bottle, finishin g with a satisfied sigh . 159 In th e twelft h session , h e als o use s th e docto r ki t fo r hi s reparative play . Afte r completin g a  comple x famil y scen e i n th e dollhouse, h e pick s u p th e stethoscop e an d announce s " I want t o listen t o you r heart" . H e lean s clos e t o me , listenin g intently . He put s a  Band-Ai d o n m y nose , the n proceed s t o measur e it , followed b y "bonkin g it " wit h a  smal l hammer . I  respon d "you'r e going t o hur t m y nos e lik e yo u go t hurt" . H e doe s no t reply , bu t continues doctorin g me , endin g wit h a n injection . Whe n I  sa y "thanks fo r fixin g m e u p doc" , h e respond s "no w clos e you r eyes , I a m goin g hom e an d someon e els e wil l come...th e bubbl e blower" . He fetche s th e bubble s an d stand s befor e m e grinnin g fro m ea r t o ear. Thi s patter n o f actin g ou t painfu l issues , the n repairin g the pai n throug h a  nurturin g o r doctorin g play , followe d b y a kinesthetic joyfu l i s a  commo n patter n see n i n thi s stage . This smal l vignett e demonstrate s ho w fa r Gunthe r ha s progressed i n hi s us e o f th e pla y spac e durin g th e twelv e week s of therapy . H e i s comfortabl e i n ou r relationship , creativ e an d imaginative i n hi s play , an d clearl y know s ho w t o us e th e spac e and ou r relationshi p t o activat e power s o f sel f healing . Summary and Analysis of the Second stage of Therapy The trust , acknowledgmen t an d affirmatio n tha t wer e buil t during th e firs t stag e o f therapy , allo w Gunthe r t o reduc e hi s defenses durin g th e secon d stage . Withou t th e camouflag e o f hi s defensive posture , w e fin d a  brigh t an d appealin g littl e boy , wh o he i s abl e t o demonstrat e initiative , creativity , an d joy . Hi s body relaxes , hi s fixe d facia l expressio n an d overbrigh t voic e 160 disappear, an d he becomes more interactiv e with both myself an d the toys . Within thi s period we se e tremendou s growt h i n Gunther' s ability t o utilize both th e therapeuti c spac e as well a s ou r relationship. Withi n th e nurturing an d protective confine s o f our relationship he engages i n interactional pattern s more commo n to th e toddle r period. Ther e i s an awareness an d pride i n his body ( a body self ) fo r the firs t time . H e confirms his existenc e and importanc e throug h smal l games o f hide and seek. Withou t th e fear of ridicul e o r censorship, he experiences jo y i n th e movement an d abilities o f his graceful body. H e also generates a variety o f scenario s tha t allow him t o solicit th e ego enhancin g benefits o f my praise an d admiration. A s each week goe s by, w e see him become more sel f confident , creative an d focused . As Gunther develop s a  confidence i n his validity , loveability an d competence, he i s also able t o access inne r feelings an d experience. Wherea s i n the firs t stag e of therapy , he showe d a  clear avoidance o f topic s relate d t o self an d family ; in this stag e his play an d drawings revea l a  tentative connectio n with his inne r world o f experience. He uses th e medium o f art an d play t o begin t o process his early experienc e o f parenta l unavailability, neglect , favoritis m an d narcissism. Dange r related t o intruder s an d fathe r figure s als o begins t o surface. Gunther's drawing s likewis e become contextual , grounded, an d expressive o f his issue s as well a s of growth. Additionally , his speec h becomes more articulate, with a beginning abilit y t o express body states , feelings , needs and ideas . H e solicit s m y 161 sympathy when he has a sore throat, tells me when he needs more snack, and relates his feelings of loss and sadness. Not only is Gunther able to use the play and art medium to begin to externalize and process his past issues and pain, he also engages in a reparative type of healing play. Withi n this medium he enacts the role of a positive caretaking figure who prepares supper, serves tea, bandages and doctors me. Thes e sessions often follow immediately after the processing of painful projective play or drawings. 162 Mid Therapy Interview and Classroom Observations Teacher interviews , classroo m observations , an d teache r response t o th e Schoo l Observatio n for m wer e complete d betwee n the twelft h an d fourteent h session s o f therapy . I t i s interesting t o not e tha t thou