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Process of change during play and art therapy Reeves, Jocelyn Diane 1996

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A PROCESS OF CHANGE DURING PLAY AND ART THERAPY By JOCELYN DIANE REEVES Dipl. Ed., Simon Fraser University, 1980 B.A., Simon Fraser University, 1981 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA July 1996 © Jocelyn Diane Reeves, 1996 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia Vancouver, Canada DE-6 (2/88) II ABSTRACT This retrospective study explored the life experience of a child with conduct disorder. The nature of the child's primary attachment pattern and re-attachment was explored over a two year period. The case study approach was employed, utilizing the participant-observation and interviewing techniques for collecting data. The intention was to explain and influence the attachment pattern of the child in the study. Specifically, the intention was for the child to develop a more positive internal working model of himself through creating a therapeutic environment where a secure attachment could be formed. The process of change the child went through, as depicted through his play and art, indicated that significant change occurred in his attachment pattern over the two year therapeutic period. The child's behavioural and interpersonal patterns went from being negative, oppositional, and aggressive to being more positive, compliant, and controlled. The nature of the therapeutic relationship, including the phases of the therapeutic process both in terms of play and art, are presented. As well, implications for special education teachers and school counsellors involved with this type of child are suggested. Ill TABLE OF CONTENTS Abstract ii Table of Contents iii Acknowledgments vi Chapter I: INTRODUCTION 1 Background to the Study 1 Research Question 3 Approach 4 Chapter II: LITERATURE REVIEW 5 Historical Overview of Play and Art 6 The Infant in Relationship 10 Mahler 10 Stern 18 Brazelton 24 Attachment Theory 28 Bowlby 28 Conduct Disorder 42 Theoretical Perspectives 43 Therapeutic Implications 48 Chapter III: METHODOLOGY 51 General Overview 51 Design 51 iv Procedures: Selection of the Participant 52 Setting 53 Therapeutic Interventions 54 Play Therapy 58 Initial Phase 59 Working Phase 65 Ending Phase 71 Art Therapy 73 In-Depth Interview 75 Analysis 76 Reliability and Validity Issues 76 Chapter IV: RESULTS 80 Initial Phase 82 Working Phase 90 Ending Phase 97 In-Depth Interview 104 Mother 104 Childcare Worker 109 Chapter V: DISCUSSION 111 The Process of Change 111 Verbal Interventions 115 V Implications for the Educational Field 118 Special Education Teacher 119 School Counsellor 125 Review of Methodology 129 Summary 131 References 132 Appendix A (School Observation Rating Scale) 136 Appendix B (House-Tree-Person: Initial Phase) 146 Appendix C (House-Tree-Person: Working Phase) 150 Appendix D (House-Tree-Person: Ending Phase) 154 vi ACKNOWLEDGEMENTS I would like to acknowledge the many people who have participated in this project along with me offering encouragement, support, understanding, and growth. Firstly, I would like to thank the child and his family who agreed to participate in this study. Particularly, I would like to thank the child participant for allowing me to enter his world. He was a tremendously valuable teacher to me. I shall never forget him. I would also like to thank the members of my committee for their time and interest in my study. In particular, I wish to express a sincere and heartfelt thanks to my advisor, Dr. John Allan. I feel very fortunate to have had the opportunity to work with such a patient, kind, and guiding professional. I consider him to be a true teacher. I would next like to thank my parents for providing a life-long secure base for all of their children so that we were able to explore, grow, and go out into the world with confidence, energy, and vitality. They have provided a model of the family from which we can shape our own young families. I would also like to thank my parents-in-law for all their support and willingness to grandparent their two young grandchildren when I needed the uninterrupted time. Finally, I thank my husband and my best friend for the daily encouragement, support, and co-operation it took to complete this paper. It has truly been a joint effort. 1 CHAPTER I INTRODUCTION Background to the Study The quality of the emotional feedback children receive from their parents or caretakers has far reaching effects on how the social environment comes to be mentally represented by those children. This ultimately affects behaviour not only through childhood, but through adolescence, adulthood, and on the parental behaviour of that person also (Bowlby, 1988; Greenberg, Cicchetti, & Cummings, 1990; Mills & Allan, 1992). Attachment theory postulates that if young children experience a consistently positive, supportive and emotionally available relationship with their caretakers they will develop a positive internal working model of themselves as that of being competent and loving. In contrast, if they experience a neglectful, abusive, rejecting or frustrating relationship with their caretakers during their infant years their internal working model of self will be negative, unworthy and unlovable. On the one hand they develop feelings of security; a secure attachment pattern. Such an attachment allows the child to trust, to be curious about the world, to be calm and confident while moving through life. The other produces an insecure attachment whereby the child develops a distrusting, anxious, avoidant or disorganized pattern of behaviours. The more positive and secure ones internal working model of self is the more likely one is to react to the world in a full, safe and competent manner. The child is able to develop and maintain positive interpersonal relationships. Conversely, an 2 insecure attachment pattern causes one to perceive the world as dangerous and untrusting. The child is more likely to react to the world in an emotionally and behaviourally incompetent manner having difficulty developing meaningful interpersonal relationships. Because one of the main drives of human behaviour is to form relationships, an insecurely attached child seems to be destined to have an unhappy existence. Children with relationship problems, and aggressive and acting out behaviours, are increasingly becoming a concern within the public school system. In the classroom, displays of aggressive and non-compliant behaviour cannot be ignored as such behaviour undermines the learning, socialization and sense of safety for all the children in that school population. Also, the disruptive, aggressive child is at serious risk of developing adult psychopathology later in life if the problem is not addressed (Kernberg & Chazan, 1991). As a special educator and counsellor in the public school system I had the opportunity to become involved with a very challenging group of children labelled Severe Behavioural Disordered (SBD). The dangers that these children had created in their neighbourhood school settings (both for themselves and for others) often had resulted in the implementation of techniques such as restraining and suspension in order to maintain safety and control. Although such techniques had the effect of temporarily reinstating harmony and calm to the school environment as a whole, (which perhaps was the objective), the out of control child was still just that. The cycle was perpetual. It seemed to me that in order for any real change to occur in these 3 conduct disorder children the adults that worked with them needed to gain an understanding of why they related to life with such negativity, and work from there. Having become familiar with attachment theory and its postulates regarding healthy emotional development I wanted to implement the constructs of attachment theory in a therapeutic setting to create a stronger, more positive internal working model of self and self in relation with others for a child labelled SBD. It seemed to me that if internal working models of self determine how one relates to the world, and if internal working models are dynamic entities, then by exposing a conduct disorder child to a positive, understanding adult in a consistent, safe environment (the therapeutic environment) transformation would occur in his internal working model, therefore, affecting change in overt behaviour. That is to say that, the expectation would be one of decreased aggression and increased control and positive interactions for the child. The purpose of this retrospective study was to explore and understand the "lifeworld" (Van Manen, 1990, p. 16), the life experience, of a child with conduct disorder and the nature of re-attachment. That is to say that, my intention was not only to understand this child's perception of his world, but it was equally as important to help him deal with and learn to control his socially unacceptable behaviour. This, in turn, would allow him the opportunity to relate to his world in a more positive, joyful manner. Research Question This study examined the primary attachment experience of a child with conduct 4 disorder and the nature of re-attachment. By introducing a therapeutic attachment figure into his life, and by using attachment sensitive therapeutic techniques such as play and art, how would the child's internal working model (his view of himself and himself in relation to others) change. Would there be enough change in his insecure attachment pattern to allow him to develop friendships, to attend school in a regular class, and to control his aggressive behaviour. The purpose of this study was to explore these postulates. Approach The approach taken for this study was through field work research methodology, specifically the single case study, in order to gain an understanding of the day-to-day life experiences and their meanings to the participant. The research was explanatory in nature, utilizing the participant-observation and interviewing techniques for collecting data. It's aim was to not only capture the essence and complexity of the real-life experience of the participant, but also to influence his environment to create change. This story is unique just as the participant is unique; the exact combination of biological, psychological, social and cultural factors that interacted to create this child's experience can never be duplicated. This story is one expression of the human potential and it is intended as a contribution to the amelioration of conduct and severe behaviour disorders in children. Attempting to understand this child's experience may provide insight into how we in the educational field may better approach this societal concern about our citizens of the future. 5 CHAPTER II LITERATURE REVIEW To understand the life experience of the child in this story it is important to begin with an exploration of the birth of the primary relationship. Studies show that children, adolescents, and young adults who are most stable emotionally and making the most of their opportunities in the world are those who have parents who, while always encouraging their children's autonomy, are none the less available and responsive when called upon (Bowlby, 1988). It is this initial link between the parent figure and the infant that is the cornerstone of emotional development. The concept of the parent figure as a secure personal base from which first the infant, then the child, adolescent, and even adult explores and perceives the world is "crucial to an understanding of how an emotionally stable person develops and functions all through his life" (Bowlby, 1988, p.46). Therefore, it is essential to understand and explore the roots of emotional experience in the primary relationship if we are going to succeed in understanding and transforming the life experience of a conduct disorder child. A review of the literature that addresses the early development of the parent-child relationship, focussing primarily on the writings of Mahler (1968; Mahler, Pine & Bergman, 1975), Stern (1977; 1985) and Brazelton (1979; Brazelton & Yogman 1986; Brazelton & Cramer, 1990) will be presented. The work of Bowlby (1969; 1973; 1988) in the area of attachment theory will also be reviewed, as well as current literature which focusses specifically on children with conduct disorders (Kernberg & Chazan, 1991). Also, a description of the historical roots of contemporary theory concerning 6 children's play and art will be described and presented. It seems appropriate to begin with such an historical overview, as play and art are the mediums used in the path to healing for the troubled child. HISTORICAL OVERVIEW OF PLAY AND ART The classical theories of play, born in the late nineteenth and early twentieth centuries, include the surplus energy, practise, and recapituation theories (Rubin, 1982). The belief that play is essentially "blowing off steam" dates back to the Ancient Greek and Aristotelian concept of catharsis. However, it is in the writings of the eighteenth century German poet and philosopher, Friedrich von Schiller, that the first classical treatment of play theory may be found. Schiller defined play as "the aimless expenditure of exuberant energy" (Rubin, 1982). Play was viewed as the product of superfluous energy left over once primary needs were met. Because children were not responsible for their own survival they were considered to have a total energy surplus which was depleted through play. The purpose during play, as Schiller saw it, was to transform and transcend reality thereby giving new symbolic representations of the world. Spencer, a nineteenth century British philosopher and psychologist, also wrote about the surplus energy theory of play. He saw play as being the unconscious product of such life-satisfying, inborn instincts as the desire for conquest and dominance (Rubin, 1982). When there was little demand for the literal activities of the instinctively based behaviours in childhood, the children produced nonliteral analogues. He made the distinction that the play phenomenon took on different forms. 7 Those being the superfluous activity of the sensorimotor apparatus, artistic-aesthetic play, the higher coordinating powers of games, and mimicry. The roots of Piaget's cognitively oriented theory of play as having a functional, constructive, symbolic, or games and rules orientation, and Tolman's idea of the organism's inability to remain in a state of physiological homeostasis without expending unspent energy, arise from the surplus energy theory of play. The second classical theory that has bearing on contemporary play as a therapeutic intervention for children is the practise theory of play, first articulated by Groos in 1898. He postulated that childhood existed in order that the organism could play. The length of time the organism spent in an immature state, the longer the length of the play period (Rubin, 1982). The longer periods of immaturity in more complex species were considered necessary to allow the pracitse of those instinctively based skills which were necessary for survival during adulthood. For some animals instinctive behaviours arrived fully developed on the first trial, thus there was no need for a period of play practise for them. However, for more complex organisms, instincts emerged in an undeveloped fashion during the childhood period. Play allowed for the exercise, elaboration, and perfection of these behaviours. Groos (1898), and Baldwin somewhat later (1906), saw the early formulation of play to emanate from imitation. Through elaboration and practise during play intelligence and nonreflective behaviours emerged (Rubin, 1982). Therefore, a direct consequence of play in children was the development of intelligent behaviour. 8 Experimental play, which included sensory and motor pracitse and the practise of higher mental powers, served the purpose of developing self-control. Socionomic play, which included fighting and chasing, and social and family games, aided in the development of interpersonal skills. It is apparent that Groos' view that play existed to allow the practise of adaptive activities is in keeping with contemporary developmental theory today, such as Erikson's psycho-social theory of development. The final classical theory of play is the recapituation theory first presented in 1920 by the North American psychologist Hall. To Hall, the function of play was cathartic in nature. Children used play to "retrace" their racial instincts. For example, games involving running and throwing were viewed as modern extensions of earlier racial hunting activities. Through "playing out" these behaviours their instinctive origins would weaken, thereby allowing the development of more complex forms of activity more typical and appropriate for present day society (Rubin, 1982). Hall's view that play served a cathartic role in normal development is linked to present day psychoanalytic views of play. Play was thought to provide an avenue for the weakening of childhood tensions, anxieties, and aggressive impulses (Rubin, 1982). One of the purposes of play therapy with children today is to allow the expression and release of anxiety-inducing impulses (Axline, 1969). Thus, the tenets of the classical theories of play, despite their diversity, have all had an impact on the study and practise of play as a therapeutic intervention for troubled children. 9 The use of art for healing is probably as old as humanity itself (Rubin, 1980). Yet the therapeutic employment of it to help heal was not considered until the late 1800's. Freud and Jung and the psychoanalytic movement have greatly influenced the use of art in therapy. Although both men shared the assumption that the psyche included conscious and unconscious parts, their views differed on the function and potential of the unconscious mind. Freud (1958) believed that the unconscious stored up experiences, memories, and repressed material gathered in a person's lifetime. Dreams were the path to the unconscious and it was the responsibility of the analyst to interpret the symbolic content of the dream. Jung (1965) had an expanded view of the unconscious. It was more than a storehouse for "out of awareness" motives, drives, memories, and repressed material (Kaufman, 1979). Jung saw the unconscious as a source of creative energy containing guidance and meaning, and in itself, curative (Allan, 1988). The Jungian analyst helped to unlock the personal meaning of ones dream symbols, and that could have a profound healing effect (Allan, 1988). Jung believed that the act of creating the image and externalizing the symbol had healing value. The use of art with children was pioneered by Naumberg in the 1940's. He stressed that the expressive use of art was an avenue to the unconscious (Rubin, 1988). Art was used as a focus for free association, discussion, interpretation, and insight. Kramer's work with children in the 1950's focussedon the healing benefits of 10 the art process. Kramer stressed that the creative process itself was a way of channelling otherwise intolerable impulses into socially acceptable and aesthetically pleasing forms (Rubin, 1988). Although Naumberg's traditional approach emphasized the insight gained from the art, while Kramer's emphasized the creative aspect of the art experience, both saw the healing potential this medium offered. Many contemporary writers agree that art expression allows the unconscious to speak through symbols, images, and fantasies (Allan, 1978; Betensky, 1973; & Kellogg, 1970). Allan (1978) has suggested that art expression offers the child a symbolic process that reaches a greater depth of emotional expression than words do. Therefore, given the importance of art in a child's life and development, the drawings produced can be very helpful in gaining a better understanding of the inner world of a particular child. THE INFANT IN RELATIONSHIP To understand emotional development in the human being we will now begin an exploration of the birth of the primary relationship. Mahler Margaret Mahler (1968; 1975) was an ego psychologist in the psychoanalytic tradition. Her work addressed the individuation process by which the infant separates from mother to become an individual. Her work focussed on the stages of development during the early years of life; birth to 30 or 36 months. She saw the biological birth of the human infant and the psychological birth as being profoundly different. The former was a dramatic, observable, and well-circumscribed event; the 11 latter a slowly unfolding intrapsychic process (Mahler, Pine & Bergman, 1975). Her interest was in this internal journey of the infant in the acquisition of a psychological self. This psychological birth process she referred to as "hatching" and it was seen to have great influence on all subsequent relationships (Mahler et al., 1975). Mahler's work rested on observations of interactions between mothers and babies. Through her observations she identified a number of phases in the psychological birthing process of the infant. They were categorized into two prepatory or "forerunner" phases, and four working or "developmental" subphases. Though these phases are conceptually differentiated on the basis of clusters of behavioral phenomena, they overlap considerably, and "vestiges of certain phases remain with us throughout the entire life cycle" (Mahler et al., 1975, p. 48). In the "forerunner" phases of normal autism and normal symbiosis, the mother and infant mutually lay the groundwork for the child's psychological birth. The Forerunner Phases Normal Autism The first month or so of life is considered to be an autistic or undifferentiated state. The infant's experience of the external world is one of primary narcissism in which physiological needs outweigh any and all psychological processes. The infant has no recognition of mother as being an external agent of satisfaction. A strong stimulus barrier is erected to protect against external stimuli. The infant's bodily reactions are all of a piece, so every stimulus that can penetrate the barrier is responded to with the entire physical being (Mahler et al., 1975). The stimulus barrier 12 acts as a necessary protection, just as the womb once did, contributing to healthy biological growth. In this earliest stage the infant begins to develop a dim recognition that needs are being satisfied from outside the self. Mahler referred to this as "conditional hallucinatory omnipotence" since the infant experiences his or her own desires as controlling this outside presence (Mahler et al., 1975). The goal in this eariest phase is to gain physiological stability, or homeostasis, in the new world outside the womb. Normal Symbiosis The phase of normal symbiosis occurs from the second month on into the third. As the newborn continually attempts to achieve homeostasis through having hunger pangs satisfied by mother, and through tension reducing functions such as urinating, defecating, regurgitating etc., he or she begins to differentiate between a pleasurable/good quality and a painful/bad quality. With time a dim awareness of a need-satisfying object develops where the infant behaves and functions as though infant and mother are one. This delusion of a common boundary between mother and child is characteristic of the state of symbiosis. Mahler described it as the infant having a "hallucinatory omnipotent fusion" with the representation of the mother (Mahler, 1968). By the second half of the first year Mahler believed that the symbiotic partner is no longer interchangeable. The infant has achieved a specific symbiotic relationship with the mother (Mahler, 1968). The rudimentary ego in the infant has been complemented by the emotional rapport of the mother's nursing care. The quality of 13 this interaction affects the structural formation of the ego of the infant that leads to individual organization for adaptation. If the union is optimal, the development to further psychological expansion of the ego is greatly facilitated. The mother takes on the role of being the auxiliary ego, the "protective shield", by providing gratification of needs and preventing excessive frustrations (Mahler, 1968). Thus, the structural formation of the ego occurs as the infant is more and more able to hold tension in abeyance and is able to wait for and confidently expect satisfaction. Through mutual cuing the mother conveys a mirroring frame of reference to which the primitive self of the infant automatically adjusts. If the mother's mirroring function during early infancy is unpredicable, unstable, anxiety ridden, hostile, or lacking confidence in the ability to parent, then the individuating infant experiences an unreliable frame of reference for checking back perceptually and emotionally. The result is a disturbance in the primitive "self feeling" (Mahler, 1968). The mutual cuing interactive process is a circular interaction. From this circular interaction characteristics of the child's personality emerge (Mahler, 1968). Mahler sees the mother responding selectively to the child's cues and the child gradually altering behaviour in response to the mother's selective response. The unconscious needs of the mother are considered by Mahler to activate, out of the infant's potential, the characteristics that make this infant the unique child of this particular parent (Mahler, 1968). The Working or Developmental Phases Between 5 to 9 months of age, the "hatching" process really begins. The two 14 tasks at this stage of development are the emergence of self as a discrete entity, and the establishing of self as a functioning person through the individuation process. While separation involves forming boundaries of the self, individuation is the internal maturation of independent ego functions in the areas of percpetion, memory, cognition, and reality testing. In effect it is the "psychological process of assimilating one's recognition of physical separateness from the mother into an intrapsychically harmonious acceptance of oneself as an individual" (Monte, 1977, p. 209). Differentiation The first subphase of this period is differentiation and the development of the body image. The baby explores and begins to discover that adult presence and absence are independent of the infant's bodily control. The focus shifts from inward -directed attention to outward-directed attention, with the mother providing a point of orientation. The infant will find pleasure in venturing and staying just a bit of a distance away from the mother. He or she will scan others and then mother in an effort to discern the familiar from the unfamiliar. In children for whom the symbiotic phase has been optimal curiosity and wonderment are the predominant elements of the inspection. However, the hatching process, beginning with differentiation, may be delayed or premature depending on the quality of the symbiotic process (Mahler et al., 1975). Practising The next subphase is practising, wherein infants from ten to fourteen months build on accomplishments of the differentiation subphase (Mahler et al., 1975). In the 15 early practising subphase the infant's locomotion improves allowing a certain amount of freedom to explore and handle objects. Forays away from the parent begin to increase in length, with periodic returns to the "home base" of the mother for "emotional refueling" (Mahler et al., 1975, p. 69). Between 10 or 12 months "the toddler takes the greatest step in human individuation. He walks freely with upright posture" (Mahler et al., 1975, p.71). This accomplishment brings the infant into the practising subphase proper. Substitutes for mother are accepted, although many babies become wary and low-keyed in the presence of strangers. Mahler interprets this emotional state as the child's inward concentration on the mother's image, which helps build resistance to the fear of love-object loss, until emotional individuation catches up with locomotion. Walking creates tremendous exhilaration in the child. It is as though the attainment of independent upright locomotion also means graduation into the world of independent human beings. That is, elation is expressed in the escape from fusion and engulfment by the maternal figure. Games like peek-a-boo and hide-and-seek become a means to express separations and still receive assurance that the parent will pursue the child or that the parent still exists when out of sight. The expectation and confidence that mother exudes as she starts to feel that the child is now able to "make it" out there seems to be an important trigger for the child's own feeling of safety, and his or her own autonomy and developing self-esteem (Mahler et al., 1975). Rapprochement The third subphase, termed by Mahler as rapprochement, occurs between 14 16 months and 2 years. The child begins to recognize both separateness and the limitations of his or her abilities. It is a time of paradox and contradiction. The child's independence grows, as well as his or her need for parental attention and involvement. Ambivalence is central to the child's experience. The wish for reunion and the fear of reengulfment coexist within the child. In the second half of the second year, this push-pull experience intensifies. As the child comes closer to a readiness to assert independence, simultaneously there is an overwhelming fear of separation. This rapprochement crisis (at about age 18 months to 24 months) involves the loss of the delusion of grandeur and the growth of the sense of individuality and separateness. Parental departure may become increasingly problematic and fear of strangers may intensify. The anxiety created by the internal struggle is dealt with by projection on the part of the child. "The desire to function by one's own self may be particularly threatening to the child at the very point in development when one's own feelings and wishes and those of mother are still poorly differentiated. The wish to be autonomous and separate from mother, to leave her, might also mean emotionally that the mother would wish to leave him" (Mahler et al., 1975, p. 96). Projection is employed to defend against the contradictory qualities that the child perceives as exhibited by the love object. This object, which has been part of the infant's sense of self, cannot be viewed as bad or unloving, so the child splits the image of the "good" mother and the "bad" mother. The good mother is the internalized love object that was part of the infant's narcissistic ego during the symbiotic period. The bad mother is projected to the outside world. 17 Consolidation of Individuality The final subphase of the separation-individuation process (roughly the third year of life) is an extremely important intrapsychic developmental period (Mahler et al., 1975). Mahler refers to this subphase as the consolidation of individuality. The tasks of this period are to attain some degree of object constancy and to establish individuality by means of defining the boundaries of the self. The child's sense of individuality emerges with the gradual recongnition of the mother and the self as separate entities. To do this, the child must master emotional object constancy by maintaining an image of mother when she is not present. With the recognition that mother continues to exist when absent comes the belief that her love can also be maintained in her absence. Thus the mother is no longer experienced as "bad" when absent. The necessity for splitting is diminished, and the "good" and "bad" objects can be unified into one whole representation. This achievement is reached by means of two essential steps: the cognitive development of internal representations of external reality, and the establishment of trust in both mother and self through the reliable, immediate, loving gratification of need (Monte, 1977). This constancy of the love object has great bearing on the child's expressions of aggression and hostility. Once achieved, the child can continue to experience the parent as loving and lovable even when he or she cannot provide satisfaction, rather than becoming rejecting (hating) or rejected (hated) because of unmet needs. Mahler conceptualizes normal development as achieving completion of the tasks of these phases of psychological birth. The progressive drive development, the 18 maturing ego, and the separation-individuation process work in a complex circular interaction, the result of which is the differentiation between self and object representations for the infant and child (Mahler, 1968). Psychological disturbance results when trauma during the developmental phases leaves some tasks uncompleted. Therapy must provide the opportunity to re-experience the missed or unsatisfactory phases of development, with the therapist providing a readily utilizable auxiliary ego (Mahler, 1968). Borrowed ego strength from the therapist is necessary in order for the child in therapy to reach higher levels of object relationships. Stern Daniel Stern's (1977; 1985) perspective of the phenomenon of attachment between parent and child is organized around the notion concerning the infant developing a subjective sense about self and other. As new behaviours and capacities emerge in the infant, they are reorganized to form orgainizing subjective perspectives on self and other (Stern, 1985). The result is the emergence of different senses of self. The infant is endowed at birth with these capacities that mature and as they do so transformation about self and other also occur. Each new sense defines the formation of a new domain of relatedness, thus resulting in a shift of social experience for the infant (Stern, 1985). Each phase or "form" of social experience remain intact throughout life. Stern sees this developmental progression of the sense of self to take place in four phases: sense of an emergent self, sense of a core self, sense of a subjective self, and sense of a verbal self. According to Stern subjective social experience 19 results from the sum and integration of experience in all domains (Stern, 1985). Sense of an Emergent Self During this earliest period (0 to 2 months) infants are busy developing the ability of relating diverse experiences in the world around them. The tasks of eating and sleeping and general homeostasis are accompanied by social behaviours of the parents such as rocking, touching, soothing, talking, singing, and making noises and faces. The infant's social capacities are operating with vigorous goal-directedness to ensure these social interactions. Physiologically, their abilities to scan and pay attention to the world visually mature, their motor patterns mature, their sensorimotor intelligence heightens to produce affects, perceptions, sensorimotor events, memories, and other cognitions during these social interactions (Stern, 1985). For example, eight week old infants begin to make eye-to-eye contact, cooing sounds, and shortly thereafter, responsive smiling. As integration between these diverse happenings is made the infant learns. Learning experiences are powerful events in an infant's life. "Connectedness forms rapidly, and infants experience the emergence of organization" (Stern, 1985, p. 28). Mental images, or schema, of the human face, voice and touch, are being organized. The infant begins to discover, within those categories, the specific face, voice, and touch of the primary caregiver (Stern, 1977). Thus, parent and infant use the senses of sight, hearing, and touch as their means of getting to know one another. Sense of a Core Self Stern (1985) sees this period (from 2 to 6 months) as "the most exclusively 20 social period of life" (p. 72). The social smile is in place, vocalizations directed at others have come, mutual gazing is sought more actively, and preferences for the human face and voice are operating fully. The building of both schema (mentioned earlier) and relationship takes place during this time in interactions Stern calls the play period. The play period is "a bounded period of time, anywhere from seconds to minutes, when one or both members focus their attention on the social behaviours of the other partner and react to those behaviors with social behaviours of their own" (Stern, 1977, p. 77). Within this relationship adults develop behaviours, termed "infant elicited social behaviors" that are solely exhibited in interaction with infants (Stern, 1977). Mahler describes a similar interactive process which she termed "mutual cueing". In contrast to the normal adult eye contact time of ten seconds, the interactive pair develops a mutual gaze which lasts an average of twenty seconds during play, and can continue thirty seconds or more in quiet times. The adult's pitch of voice is almost invariably raised, with both loudness and intensity. There is an exaggeration in space and time, usually marked by slow formation and elongated duration of both sounds and actions. Visual and audio repertoire are usually limited to several selected expressions that are performed very frequently and stereotypically. The result is that the adult's behaviour is maximally attended to by the infant (Stern, 1985). During this highly social period patterns of vocalization are developed that include interaction and pauses, and that teach the infant how to take the speaking 21 turns that normal conversational exchange requires. Another vocal activity is "chorusing" or vocalizing in unison, which seems to serve as a bonding function (Stern, 1977). The way the caregiver sequences and times his or her behaviours to create different tempos and themes enhances the infant's understanding of human communication and emotional expressiveness. It is during the sense of a core self period that the infant begins to lay the foundation of one of the most highly developed areas of expertise, which is the "reading" of signals and expressions of other people's behaviours. The infant acquires schema that represent the caregiver's various changes in the expression of different human emotions. Through this the infant learns about different temporal patterning and the meaning of various changes in tempo and rhythm. A central feature that grows from these parent/child interactions is an enduring representation of the other person. This internal representation of "other" results from repetitions of the interactive experiences mentioned above. These interactions need to be thought of not as specific memories, but rather, as multiple specific memories. Through this a structure is created which represents the likely course of events, which is the averaging of the child's experiences. While schema can be formed by sensori-motor experience alone, it is essential for the successful internalization of a unit of experience as a representation to have the three elements of sensory, motor, and affective experience (Stern, 1977). It is the interpersonal and experiential aspects of these episodes that are important and that are averaged and represented preverbally. 22 These representations of interactions that have been generalized have been terme< by Stern (1985) as "RIGs" (p. 110). The infant brings to each interactive event a history of the relationship in the form of these new representations. The history then affects the course of every interaction. Conversely, each new sensori-affective experience as it is internalized may alter the configuration of this history as it progresses. Interna representations may be thought of as similar to Bowlby's concept of internal workinc models to be discussed later in this chapter. Sense of a Subjective Self Sometime between the seventh and nineth month of life, infants begin to realiz< that there are "other minds out there as well as their own" (Stern, 1985, p. 19). Self anc other are no longer core entities of physical presence, action, and affect. They nov include mental states such as feelings, motives, and intentions. The nature o relatedness has now been dramatically expanded because mental states can now b< "read", matched, and aligned with or attuned to, or misread, mismatched, misaligned, o misattuned (Stern, 1985). The caregivers empathy, that process crucial to the infant': development, now becomes a direct subject of the infant's experience rather than bein< outside of awareness. With this development, Stern attributes to the infant the capacit; for psychic intimacy. Psychic intimacy as well as physical intimacy is now possible What is at stake in this developmental phase is nothing less than discovering what part of the private world of inner experience shareable and what part falls outside the pale of commonly recognized human experiences. At one end is psychic human 23 membership, at the other is psychic isolation. (Stern, 1985, p. 126) Mahler would view this period as the "hatching" period from the undifferentiated and fused state of symbiosis to that of object permanence. Thus, each infant and caregiver begins to develop an individual course for their own relationship. Parent/child interactive activities, with their basis being in the delight of being with one another, provide the means for the infant to experience both a prototypic and uniquely individual caring and loving relationship. Sense of a Verbal Self Toward the middle of the second year (15 to 18 months) children begin to imagine things in their minds in such a way that now signs and symbols are possible (Stern, 1985). Symbolic play and language now become possible. This ability creates a change in the sense of self and children begin to see themselves objectively. Symbolic play permits children to "think about" or "imagine" their interpersonal life. This is very significant developmentally in that for the first time the child can now entertain a wish about how reality ought to be. Interpersonal interaction can now involve past memories, present realities, and expectations for the future (Stern, 1985). All these interpersonal interactions can now be reported verbally. This allows for mutually shared meaning to become possible. As a result a "quantum leap" in self-other relatedness occurs (Stern, 1985). Thoughts and words become something to be negotiated between parent and child. The relationship between thought and word is not a thing, but a continual process that moves back and forth. Mutually negotiated meanings (the relation of thought to word) grow, change, develop and are struggled 24 over by two people and are thus ultimately owned by an "us". Stern believes that, not just the beginning of walking but the beginning of talking also, is a critical time for a child. At this time...the mother reorients the child away from the personal order with her, and towards a social order. In other words, whereas their previous interactions were primarily spontaneous, playful, and relatively unorganized for the sake of being together, the mother now begins to require the child to organize his or her action for practical, social purposes: to act on his or her own (getting own ball), to fulfill role functions (feeding self), to behave well by social standards (not throwing glass), and so on. (Stern, 1985, p. 171) Thus the child starts to perform in accordance with a social order, moving away from the personal order with mother. Once verbal relatedness (language and symbolic thinking) has been formed, expanding, almost limitless possiblities for interpersonal happenings open up for the child. Language and symbolic thinking give a child the tools necessary to distort and transcend reality (Stern, 1985). The quality of the primary relationship during the first phases of infant subjective development, prior to this linguistic ability, is an excellent predictor of the quality of relating once language and symbolic thinking have formed (Stern, 1985). Brazelton Brazelton's perspective on attachment comes from his medical background as a 25 paediatrician and his expertise in infant development. A fundamental premise of Brazelton's thinking is that parent and child must be seen and cared for as a unit (Brazelton & Cramer, 1990). He describes four distinct stages in the development of early interactions between parent and child: homeostatic control, prolonging of attention and interaction, testing limits, and the emergence of autonomy. Homeostatic Control The infant's task is to achieve control over both input and output systems, enabling him or her to shut out as well as receive stimuli. Attention to incoming stimuli demands control of motor activity, state of consciousness and autonomic responses. The struggle for control in this disorganized period occurs in the first week to ten days of life (Brazelton & Cramer, 1990). The work of the parent is to contain the baby, to gauge input to the needs of the infant and to fit behavioural responses to his or her particular individual threshold. Prolonging of Attention and Interaction Once some degree of control of stimuli has been achieved (between 1 week and 2 months) the infant can begin to utilize clues from the parent to maintain alertness. As well, the infant's emerging social behaviours (smiling, vocalizing, facial expressions, motor cues) facilitate participation in the "rhythmic give-and-take of a synchronized relationship" (Brazelton & Cramer, 1990, p. 115). The mother is also learning this new language of communication. In her desire to be a successful parent, mother learns the baby's rhythms, and synchronizes herself accordingly. She learns to turn away or to tune down when the baby does. She learns that she can add a little 26 magnification to each behaviour that will lead the baby on. As the baby smiles, she smiles more broadly, teaching the baby how to prolong a smile. As the infant vocalizes, she adds a word or a trill, leading towards imitation. By matching her rhythms, her behaviours to the baby's, she enters the baby's world, offering incentive to reach for her (Brazelton & Cramer, 1990). Testing Limits Once sustained interaction has been accomplished (by the third and fourth month) adult and infant collaborate to develop serial games, also described earlier by Stern as the period of play. By pressing the infant's capacity to take in and respond to information as well as to withdraw and recover, the parent contributes to extension of the baby's repertoire. There is a sense of joy in this play in the successfully developing parent and child. Emergence of Autonomy A spurt in congitive awareness at the age of four or five months allows the infant to be the leader or signal giver in the interactive games as often as the parent (Brazelton, 1979). The infant will also break the established pattern of interaction. The parent's response at this stage is crucial. Such behaviours as gaze aversion, avoidance and turning away can be experienced as rejection or understood as strength by the parent. If negatively interpreted, the parent may redouble efforts to regain the synchronicity of earlier stages, thus reinforcing the infant's need to tune out and withdraw from the adult figure. If accepted as a sign of growth, the infant's ego development will then be well on its way (Brazelton & Cramer, 1990). 27 The Affective Relationship Brazelton states that "since a parent has invested in, and is likely to be deeply affected by, the newborn's behavioural reactions, an assessment of the infant's behaviour becomes a window into the reactions of the parent's responses to him or her" (Brazelton & Yogman, 1986, p. 2). Accordingly, he hasfocussed much of his work on the affective relationship between parent and child. The experience of effectance (that is, of creating a successful effect) for both mother and child is seen to come from social interactions that result in a shared, positive emotional state. The infant learns what he or she can and cannot accomplish. The mother's self-esteem is reinforced by the positive quality of the interaction. The infant actively attempts to shape the interactions by processing the mother's emotional input and acting in terms of this information as well as his or her own goal. From the emotions generated during social interchanges, an emotional mood and interactive pattern becomes internalized within the child. When the parent-child interaction is not successful, there is a sense of ineffectance or helplessness. During a distorted interaction, when the infant's actions fail to result in a positive exchange, the infant begins to look distressed and helpless. This is not a mirroring of the mother's emotional state, but arises out of an active process that has failed. The infant's goal has been one of reciprocity. Repeated experiences of this kind reinforce the infant's sense of failure. On the mother's part, each time she brings about a positive response in the child, her competence as a parent is confirmed. If, on the other hand, the infant's ability to respond is impaired or 28 disturbed, the mother's expectations are violated. Parents, especially new, insecure parents, look for signals from their babies to continually confirm the appropriateness of their parenting (Brazelton & Cramer, 1990). In the infant, reactions are largely determined by immediate external and internal stimuli, while for the mother, historical and social factors modify her self-esteem, and therfore her interactions with the infant. When these forces create anxiety in the mother, it becomes more difficult to achieve the shared positive emotional state. Thus, the success or failure of mutual exchange generates emotional states in the infant which reflect not only the immediate situation, but the effect of historical factors that impact on the mother's behaviour. Thus Brazelton sees that the infant and parent must be considered as one. He has concluded that "without recognizing the issues which parents bring from their childhood experience, and therfore the meaning to them of the child's 'symptom', I could do nothing to change their counterproductive responses" (Brazelton & Cramer, 1990, p. xv). ATTACHMENT THEORY Bowlby Bowlby's work evolved from observations of the ill effects on personality of prolonged institutional care and frequent change in the mother figure during the early years of life (Bowlby, 1988). In situations where babies were removed from mothers by strangers, Bowlby found that the children responded with great intensity, and after reunion, showed either a heightened degree of separation anxiety or an unusual detachment. He began to study the behaviours of the mother-infant unit which came to 29 be identified as attachment behaviours, and found them to have a biological function specific to themselves. Previous theories had explained the mother-child bond to be based in nurturance and dependency. Bowlby's observations led him to believe that dependence is at its most intense at birth, and diminishes with the infant's development, whereas attachment behaviours are absent at birth and not strongly in evidence until after six months (Bowlby, 1969). He understood the goal of the attachment behaviours he observed to be protection. It was in the field of ethology that Bowlby turned to establish a theoretical framework for his observations. In the writings of Lorenz (1935) were findings that indicated the presence in some species of a strong bond to a mother figure that did not involve the intermediary of food. As well, Harlow (Harlow & Harlow, 1965) had studied the effect of maternal deprivation of rhesus monkeys and found that infant monkeys showed a marked preference for a soft dummy "mother", which provided no food, over a hard maternal shape that had a bottle attached. Harlow found that when a cloth mother was available, infant monkeys in a strange room would explore the environment, using the mother as a base to which to return from time to time. In the absence of the cloth mothers, the infants showed signs of distress and would not explore. The cloth mother led to an attachment whereas the hard, food-providing mother did not. In his exploration of infant behaviours that had as their goal maintenance of proximity of the maternal figure, Bowlby identified patterns of sucking, clinging, following, crying and smiling. He considered these activities to comprise a 30 behavioural system and regarded them as a "class of social behaviour of an importance equivalent to that of mating behaviour and parental behavior" (Bowlby, 1969, p. 179). He reported that situations which increased attachment behaviours in monkeys were hunger, separation and alarm. The waning of these behaviours coincided with the increase of curiosity and exploratory behaviour. Bowlby hypothesized that the rate at which attachment behaviours wane is affected by the frequency of alarming events and enforced separations at too early an age (Bowlby, 1969). There were three types of conditions that were seen to activate attachment behaviours in humans and to influence the form it takes. First, the condition of the child, such as fatigue, hunger, ill health, discomfort or pain, greatly influences the intensity of the behaviours. A second factor is the whereabouts and behaviour of the maternal figure, be she close and comforting, departing, or discouraging of proximity. Identified as well are other environmental conditions such as the occurrence of dangerous or alarming events or rebuffs by other adults or children, which is the third type of condition. Bowlby identified two main classes of behaviour which contribute to the development of attachment, which he labelled signalling and approach behaviours (Bowlby, 1969). Signalling behaviours, the goal of which is to bring mother to child, include smiling, crying, babbling, calling, clinging, and raising arms. Smiling and babbling generally affect the maternal figure in such a way that the future likelihood of her responding to the infant's signals promptly is increased. In effect, signalling is the 31 "child's way of advertising his whereabouts and activities" (Bowlby, 1969, p. 246). Approach behaviours, with their goal to bring the child to mother, can include seeking, clinging, following, and non-nutritive sucking. The overall objective of proximity is constant, and the techniques are determined by the child's level of locomotory skills. Phases of Development of Attachment Behaviours From his observations Bowlby (1969) recognized four phases of development of attachment behaviour. Birth to eight to twelve weeks Behaviours include orientation toward another person, tracking movements of the eyes, grasping and reaching, smiling and babbling. Auditory stimuli response begins after four weeks and visual after ten weeks. These actions are directed towards anyone in the infant's vicinity in this first developmental stage (Bowlby, 1969). Twelve weeks to six to twelve months Orienting behaviours are similar to those of the earlier developmental stage, but are directed more specifically to the mother figure. Spontaneity and delight become aspects of these behaviours. By four months, most infants recognize and respond differently to mother as compared to other people (Bowlby, 1969). Six months to two years or older The maintenance of proximity to the attachment figure is achieved by means of locomotion as well as the earlier developed signals. By nine months, stronger and more consolidated attachment behaviours are established, and after this age, the child may follow any familiar adult figure if the mother is not available. Friendliness towards 32 anyone other than the attachment figure and subsidiary attachment figures is lessened. Two years to three years of aae Attachment behaviours continue to be evident in intensity and frequency similar to the last developmental stage. Differences in circumstances that elicit the behaviours result from the growth of the child's perceptual range as well as ability to understand events in the surrounding environment. By observation and interaction with mother, the child acquires insight into mother's feelings and motives. Between the ages of two years and nine months and three years, the child reaches what Bowlby suggests may be seen as a maturational threshold, and is much better able to accept mother's temporary absence and engage in play with other children (Bowlby, 1969). This threshold corresponds to Mahler's concept of object constancy (Mahler, 1975). After age three, the behaviour systems of attachment become less easily activated in most children, however, Bowlby points out that "throughout the latency of an ordinary child, attachment behaviour continues as a dominant strand in his life" (Bowlby, 1969, p. 207). Nor are these behaviours confined to young children. Though less easily aroused, attachment behaviours are evident in the actions of adolescents and adults of both sexes whenever they are anxious or under stress (Bowlby, 1988). Exploratory Behaviour The class of behaviours which provides a counterpoint to the attachment behaviours is the behavioural system of exploration. With its special function of extracting information from the environment, exploration enables the child to build up a 33 coherent picture of environmental features that may be of importance to survival. It is the child's initiation into independent membership in the world. Activated by novelty and terminated by familiarity, the behaviours are characterized by interested approach and alarmed withdrawal which often follow one another in rapid succession. Exploration is fuelled by curiosity, and commonly leads to moving away from the attachment figure. In this sense it is antithetical to attachment behaviour. In healthy individuals the two kinds of behaviour normally alternate. The Attachment Figure: A Secure Base The ability to explore is closely related to the degree to which the child has become attached to a stable adult figure. This person, who has come to be called "the secure base" by attachment theorists (Bowlby, 1988), provides the child with the sense of security essential to allow for both exploration and retreat to shelter when afraid. Bowlby considers this concept of the secure base for children, adolescents and adults alike, to be "crucial for an understanding of how an emotionally stable person develops and functions all through his life" (Bowlby, 1988, p. 46). Promotion of Secure Attachment Ainsworth (Ainsworth, Blehar, Waters & Wall, 1978) has proposed the following characteristics and behaviours on the part of the attachment figure (eg. mother) which promote a secure attachment: - Frequent and sustained physical contact - The ability to soothe the distressed infant by holding - Sensitivity to the baby's signals and the ability to time interventions in harmony with 34 those signals - Creation of an environment regulated so that the infant can derive a sense of consequence to actions - The ability to experience mutual delight in one another The component of mothering care that Bowlby considers most important for healthy development of the infant is not routine care, but social interaction (Bowlby, 1969). When given plenty of social stimulation during the middle and latter half of the first year, an infant will quickly develop a discriminated attachment once given the opportunity to do so. Without social interaction, the child will be much slower to develop attachment. By the second quarter of the first year, the infant is sensitive and ready to make a discriminated attachment. After six months the baby can still form attachments, but as the months pass, this becomes more problematic and "by the second year, it seems clear, these difficulties are already great; and they do not diminish" (Bowlby, 1969, p. 327). A principal reason for this phenomenon is that, in mammals, the reaction to any strange figure is increasingly one of fear and withdrawal as the animal grows older. In humans, fear of strangers appears as early as twenty-six weeks, is generally evident by eight months, and often as late as two years (Bowlby, 1969). Of course, almost from birth, most children do have more than one caregiver and, therefore, other figures toward which they direct attachment behaviour. However, children do not respond with the same intensity to subsidiary figures. Bowlby assents that the role of the child's principal attachment figure can be filled by others than the 35 natural mother. However, hormonal levels following parturition and stimuli emanating from the newborn may be of great importance, so substitute mothers may be at a disadvantage without the presence of heightened hormonal levels and contact from the moment of birth. Therefore, the substitute mother's responses may be less strong and less consistently elicited than those of the natural mother (Bowlby, 1969). By the end of the first year, there are highly characterisitic patterns of interaction established between parent and child. The attachment figure has come to know and expect the child's unique behaviours and to respond in his or her own typical and unique way. Conversely, the child is familiar with the typical parental behaviours and will respond in predictable ways. As such, "each has shaped the other" (Bowlby, 1969, p. 333). Two significant variables that Schaffer and Emerson (1964) identified as relevant to intensity of attachment were readiness with which the attachment figure responds to the infant's crying, and the extent to which that person initiates interaction with the infant. There was no evidence in their research that attachment to mother was less intense when attachment behaviour was directed to other figures as well. In contrast, the greater the number of subsidiary attachment figures the child experienced in the early months, the more intense was the attachment to mother as the primary figure. Conversely, the infant who begins by showing an intense attachment to a principal figure is reported as significantly more likely to direct social behaviours to other discriminated figures as well. An infant who is weakly attached is more likely to confine all social behaviour to a single person. The more insecure a child's attachment to his principal figure is, the more inhibited the child may be in developing 36 attachment to other figures (Schaffer & Emerson, 1964). Paradoxically, intense attachment behaviours are often observed in children whose mothers have maltreated them. Bowlby considers this to be the "inevitable result of attachment behaviours being elicited by anything alarming" (Bowlby, 1969, p. 216). In the animal world, fear is at times used to provoke attachment behaviour. Dominant males will attack juveniles who are approaching danger in order to elicit proximity-seeking behaviour. This phenomenon is seen by Bowlby as reinforcement of the underlying theory that the function of attachment behaviour is protection from predators (Bowlby, 1969). Ironically, in humans this survival mechanism can develop into an unusually strong attachment to an abusing figure. Fear of Separation From the age of four months, the infant begins to distinguish the strange from the familiar and to become wary of all things unfamiliar. From seven months in some children, and nine or ten months in most, the appearance of a stranger arouses an unmistakable fear response (Bowlby, 1973). This reaction results from the infant's inward concentration on the mother's image, which has not yet achieved a place of permanency in the child's psyche (Mahler, 1975). Fear behaviours include wary watching, inhibition of action, frightened facial expression, trembling, crying, cowering, hiding, running away, seeking contact with another person, and clinging. The two most common responses are crying and turning toward a protective figure. Alarming experiences generally lead to an increased susceptibility to respond with fear to that particular situation only. However, uncertainty about the availability of the attachment 37 figure results in an "increased susceptibility to respond with fear to such a wide range of situations that the person concerned is often referred to as suffering from 'free-floating anxiety'" (Bowlby, 1973, p. 103). Transitional Objects At around the age of nine months, and often considerably after, the infant can allay some of his or her anxiety about separation by the proximity of a favoured toy or cuddly object. Bowlby (1969) sees this attachment as consistent with satisfactory relations to people. That is, whenever the "natural" object of attachment behaviour is unavailable, the behaviour can become directed towards some substitute object. Like a principal attachment figure, the inanimate substitute is sought especially when the child is ill, tired, or distressed. This ability to symbolize is seen by Winnicott (1953) to be a major step towards object relations. Responsiveness of Attachment Figure Only when an attachment figure is accessible and potentially responsive can that person be said to be truly available to the child. In keeping with Stern's internalized representation of "other" (Stern, 1977) and Mahler's concept of the "differentiated" self (Mahler, 1975), Bowlby identifies the development of the representational or working model of the world and the self. A key feature that influences both working models is the notion of the attachment figure, the expectation of response of this person, and therefore, how acceptable or unacceptable the child is in the eyes of the attachment figure. Bowlby describes two variables that are essential in order for the child to be confident that the attachment figure will be responsive: 38 - Whether or not the attachment figure is experienced as someone who responds to calls for support and protection. - Whether or not the self is experienced as someone towards whom others, and the attachment person in particular, will respond in a helpful way. Logically these variables are independent. In practice they are apt to be confounded. As a result, the model of the attachement figure and the model of the self are likely to develop so as to be complementary and mutually confirming. Thus an unwanted child is likely to not only feel unwanted by his parents but to believe that he is essentially unwantable, namely unwanted by anyone. (Bowlby, 1973, P. 204) The Inner Working Model It is these initial expectations concerning the availability of others and, in turn, the self as worthy or unworthy of care, which form the inner working models of self and other in the context of the attachment relationship. These early experiences are abstracted and represented as active constructions, which influence later experiences (Strouf, 1985; Stern, 1977). Being active, they are continually being elaborated and, as such, are subject to change. New experiences are engaged from within the framework of the models already constructed, and change is an active, rather than a passive, process (Stroufe, 1985; Greenberg, Cicchetti & Cummings, 1990). However, these inner constructs become somewhat firm even in early childhood and, therefore, influence both the child's experiences and the processing of these experiences. This creates an inclination for basic continuity in terms of the core features of the 39 representations of self, others, and relationships. Epstein (1973) has likened this process to the construction of a scientific theory. In the early stages, the theorist is open to alterations and even abandonment of the hypothesis in the light of new evidence. However, as repeatedly proven evidence shapes, refines and reinforces the theory, the theorist grows less responsive to disaffirming data. As conviction for the theory grows, change remains possible, but becomes increasingly less likely. Once inner working models emerge, the child becomes a dramatically more active force in the parent-child relationship. When the child's model of the parent is unpredictable, his or her sense of efficacy is limited, resulting in the emergence of difficult behaviours. In turn, these behaviours require an even higher degree of consistency from the parent. This makes positive change in the parent-child relationship more difficult. Even when change does occur in the relationship and the child's responses, prior models are seen as transformed, but not erased (Stroufe, 1985; Mills & Allan, 1992). There remains a tendency to reserve the previous pattern in the face of serious stress of some kind. Some degree of continuity can be expected, as well, from the early years, to middle childhood, to adolescence, and even adulthood. "Basic responsiveness and warmth (and consequent secure attachment) represent a 'core substrate' from which develops the child's inner sense of confidence, efficacy and empathic regard for others" (Stroufe, 1985, p. 28). Patterns of Attachment In his first major work on attachment, Bowlby (1969) identifies the differences in the behaviours of securely and insecurely attached children. He describes the secure 40 baby at twelve months as able to explore freely and avoid distress in the presence of strangers, have awareness of the absence of the mother, and greet her warmly on her return. In contrast, he observed that the insecure baby does not explore even when mother is present, is alarmed by strangers, experiences distress and helplessness in the mother's absence, and does not greet her upon her return. Pursuing this area of research, Ainsworth (1978) developed the research setting of the "strange situation", which was designed to elicit exploratory behaviour in the early episodes, and then, through a series of mildly stressful events, shift the infant's attention to maintenance of contact with the parent. Three distinct patterns of response emerged, which Ainsworth labelled secure, anxious resistant, and anxious avoidant attachment (Ainsworth et al., 1978). Secure Attachment Secure attachment is evidenced by a child's confidence that the parent will be available, responsive, and helpful in the event of a frightening experience. This assurance inspires in the child the courage to explore the world. The attachment figure promotes this by being "readily available, sensitive to her child's signals, and lovingly responsive when he seeks protection and/or comfort" (Bowlby, 1988, p. 124). Anxious Resistant Attachment The second pattern is identified by the child's uncertainty about availability, responsiveness, and helpfulness of the parental figure. This state of doubt results in separation anxiety, clinging, and anxiety about exploring the world. The parent influences this pattern of attachment by being "available and helpful on some 41 occasions and not on others, and by separations and, as clinical findings show, by threats of abandonment used as a means of control" (Bowlby, 1988, p. 124). Anxious Avoidant Attachment The pattern of anxious avoidant attachment is one in which the child has no confidence in the reliability of the attachment figure in times of stress. These children are inhibited in their exploration and will avert their gazes and actively avoid contact with the parent after a separation. The behaviour of the parent that promotes these responses is continual rebuff and rejection when the child approaches for comfort and protection. Indeed, the child has no confidence that he or she will be reponded to helpfully but, "on the contrary, expects to be rebuffed" (Bowlby, 1988, p. 124). These patterns of attachment are not limited to infant behaviour. The interactive effect of adverse experiences during infancy has such a strong influence on the psyche of the infant that it increases the likelihood that there will be more (Bowlby, 1988). Thus, adverse childhood experiences result in heightened vulnerability to later adverse experiences, and a higher likelihood that the person will meet with further such experiences. Whereas the earlier adverse experiences are likely to be wholly independent of the agency of the individual concerned, the later ones are likely to be the consequences of his or her own actions, actions that spring from those disturbances of personality to which the earlier experiences have given rise. (Bowlby, 1988, p. 37) Such experiences shape the internal working model of the child, thus determining how 42 the individual is going to relate to the world through the life span. CONDUCT DISORDER Conduct disorder, aggression and severe acting out behaviour are often used synonymously in the literature (Csapo, 1989). Which ever term is being used, it refers to a constellation of behavioural symptoms. The American Psychiatric Association's Diagnostic and Statistical Manual III (1980) divided conduct disorder into a non-socialized subtype and a socialized subtype. Non-socialized refers to the child or adolescent who has not developed sufficient social bonding with other human beings. This type of child shows no affection or empathy for others, displays overt anti-social behaviour, and cannot understand rules, and therefore, has no ability for peer relationships. Usually there is very little guilt or remorse and the child tends to blame others for the consequences his or her behaviour may create (Csapo, 1989). The socialized conduct disorder child does have the capacity for feeling shame, remorse, and guilt, and for social bonding as evidenced through the ability to have a friend or group of friends. Beyond this group, however, manipulative, self-serving, and victimizing behaviours manifest themselves. Although the current American Psychiatric Association diagnostic manual (DSM lll-R) does not make this socialized/non-socialized distinction, current literature on conduct disorder continues to do so (Kernberg & Chazan, 1991; Wells & Forehand, 1985). However, both subtypes of conduct disorder are characterized by persistent behaviours such as aggressive conduct, including both physical violence and verbal inappropriateness, and a negative, oppositional and non-compliant approach when interacting with 43 others in society (Wells & Forehand, 1985). Theoretical Perspectives Despite the negative implications conduct disorder behaviours have for a child they tend to persist. Through integrating the perspectives of the various theories of how infants learn to relate to the world that have already been presented it will help to understand why children with conduct disorder behaviours continue to behave the way they do. To help understand the development of conduct disorder behaviour a look at the earliest manifestations of aggression in the life of an infant is necessary. A newborn infant arrives into the world with a full range of behaviours that allow him or her to be an active participant, interacting with the environment in various ways designed for survival, as has already been mentioned. Interacting with the infant are those caregivers responsible for providing the physical and psychological needs required. Earliest aggression in an infant is not negative in its intentions, but rather, "it is neutralized aggression, or assertiveness, that is part of the organism's program to survive. It manifests itself as a part of the mobilization of energy in the face of a barrier or obstacle" (Kernberg & Chazan, 1991, p. 6). An added push or shove to get through a barrier or past an obstacle is a major source of aggressive behaviour. Even an infant will bulldoze his or her way past an obstacle to reach a favorite toy; a young child will push the one infront to gain the opportunity to go down the slide. Another form of early aggression is the rage reaction in an infant. The urgent crying and screaming state that infants can get in that communicates panic and 44 extreme discomfort is recognized as akin to the stress of extreme provocation (Kernberg & Chazan, 1991). Reaction by caregivers to these earliest forms of neutral aggression affect the concrete physical world, the interpersonal world of human relationships, and intrapsychic world of the infant's developing inner thoughts and feelings. Research has shown that there is an important link between the quality of parenting during early childhood and the occurance and continuation of aggressive behaviour (Mills & Allan, 1992; Egeland, Kalkoske, Gottesman & Erickson, 1990; Wells & Forehand, 1985). The manifest conduct disorder behaviour is the final common pathway for a variety of experiences for these children. Their efforts to cope with the frustrations and the aggressive feelings they have fail because the children have not been able to integrate positive and negative thoughts and feelings into a context that permits them to be expressed in a safe, communicative manner. In turn, their inability to integrate positive and negative feelings may be linked to the quality of early parenting in meeting needs during infancy. Maltreatment in the form of rejection or aggression by the parent, or a stressful, chaotic home causes frustration and a sense of failure of attunement, consistency, and empathy for the child. These experiences cause the child's aggression to "take a deviant path and be counterproductive, rather than to be enlisted toward surmounting the difficulty" (Kernberg & Chazan, 1991, p. 7). The developmental impairments that result from these ubiquitous aggressive feelings cause structural deficiences within the internal world of conduct disorder children. In psychoanalytic terms these structures include the id, ego, and superego. 45 The id is the domain of impulses; the superego, the voice of conscience and self-control. The ego is the executive agent that acts in coordination with the other structures to effect self-regulation and adaptation to the environment. It is the ego that maintains responsibility for reality testing and validation of thoughts and impulses. (Kernberg & Chazan, 1991, p. 4) When considering Mahler's object relations theory and Stern's developmental sense of self theory, conduct disorder children are deficient in the basic personality structures and relationships that ultimately lead to healthy socialization. These children tend to internalize negative parental images associated with negative feelings. As negative feelings such as rage, hostility and anxiety accumulate a negative self-concept and low self-esteem result. This perpetuates itself as these introjected negative representations of self and others tend to be projected onto the outside world. These children begin to perceive the world as they have been perceived themselves. "Identification with good feelings and helpful people is severely hampered as the children's perception of other people (parents, teachers, friends) is distorted by their projection of aggression and also by the aggression they induce in others as a secondary reaction" (Kernberg & Chazan, 1991, p. 5). The specific structural ego deficits conduct disorder children have which make it difficult for them to integrate the world are in the areas of cognitive functioning, impulse control, attention, judgment, modulation of affects, language, and tolerance for anxiety and frustruation. As a result conduct disorder children almost always display other 46 problems in conjunction with their severe behaviour, such as attention deficit disorder and learning disabilities, particularly in the area of reading (Kernberg & Chazan, 1991). Aggression predominates in the domain of the id, making it difficult for the integration of any affectionate feelings. Those children where some positive impulses are able to break through would be considered to be the "socialized conduct disorder subtype" because they are able to show some capacity for remorse, shame, and guilt. Such children are more accessible to therapeutic intervention with a better prognosis (Kernberg & Chazan, 1991; Wells & Forehand, 1985). A lack of ego strength in conduct disorder children makes it difficult for them to understand that peers have motivations and preferences that are different from their own. This omnipotent outlook results in a lack of age-appropriate social skills for peer interaction. When they do not get their own way they act out, unable to contain their feelings of frustration. A core feeling of being unloved and uncared for is common among conduct disorder children. The subjective representational world that is developing in the child is therefore based on rejection and abandonment. This perception may not necessarily have any grounding in a present reality to persist. For example, when conduct disorder children are responded to in a way that is attuned to their needs they are certain that their low self-esteem and sense of worthlessness are what people are really seeing. To terminate this tension they will act out or behave inappropriately promoting what they consider to be inevitable rejection, thus allienating themselves from others while at the same time reinforcing their subjective negative self-image. Children with conduct disorders display a pattern of insecure attachment to the significant persons who are responsible for their care (Bowlby, 1988). As mentioned, Bowlby (1969) posits that through continual transactions with the people and objects in the child's world, the child gradually constructs an internal working model of self and other. This internal working model is dynamic and becomes increasingly more complex as the infant develops. The conduct disorder child's internal working model forms around his or her negative and resistant behaviours because they are being maintained by maladaptive responses by the caregiver(s). The continual incongruence between child and caregiver interaction causes ongoing distortions in the internal working model of the child. As the child gets older his or her internal model solidifies and becomes more and more resistant to change. So long as current modes of perceiving and construing situations, and the feelings and actions that ensue therefrom, are determined by emotionally significant events and experiences that have become shut away from further conscious processing, the personality will be prone to cognition, affect, and behaviour maladapted to the current situation. When yearning for love and care is shut away, it will continue to be inaccessible. When there is anger, it will continue to be directed at inappropriate targets. Similarly anxiety will continue to be aroused by inappropriate situations and hostile behaviour be expected from inappropriate sources. (Bowlby, 1988, p. 48 117) Therapeutic Implications The structural deficiences conduct disorder children have within their internal world make it difficult for them to organize and integrate their thoughts, ideas, and feelings. Because of these organizational deficiencies there are no defensive layers in the child's psyche to be penetrated; there is very little ego strength. The dreaded, unrewarding interactions between the rejecting parent and the disregarded self are expected in any relationship the child has, including that of the therapist. The child has a "rejection fantasy" he or she perceives as real. "It is the deepening of experience to permit new perceptions of self and others to emerge that becomes the essence of treatment" (Kernberg & Chazan, 1991, p. 6). Bowlby (1988) sees the therapeutic relationship as providing a secure base for the child whereby he or she can explore these new perceptions of self and transform. Just as a positive parenting relationship provides a secure base for a growing child from which to separate and individuate, so does the therapeutic relationship. Within the context of a therapeutic play relationship the child is given the opportunity to test out new, more positive internal models of self and self in relation to others. The play therapy relationship is the place where a child can "create alternative adaptive models rather than replacing older models" (Mills & Allan, 1992, p. 7). This restructuring eventually enables the child to adapt and interact more constructively within his or her world outside the therapeutic setting. The one-dimensional, concrete interaction with objects typical of the type of play 49 conduct disorder children display gradually gives way to play full of symbolic meanings (Kernberg & Chazan, 1991). Symbolic meanings emerge as painful and traumatic repressed feelings are projected out through drawing and playing within the safety of the therapeutic relationship. As the child projects these feelings onto the therapist (the process of transference), the therapist responds in an accepting, affirming, and nonpunitive manner. Through responding in this manner "the therapist is able to help the child surface denied aspects of the self and to alter maladaptive behavior patterns" (Mills & Allan, 1992, p. 8). As the child's conflict is recreated and replayed in the therapeutic relationship words that were initially used to name and describe action deepen to words that communicate and share experience. Over time "these children's actions become connected to their thoughts, ideas, and feelings. Thus, the behavior of each child no longer exists in isolation but becomes part of the totality of the child's individuality and his or her unique adaptation to reality" (Kernberg & Chazan, 1991, p. 8). To summarize the therapeutic implications when working with a conduct disorder child, the role of the therapist includes: (a) the creation of a safe and protected space in which the child feels secure enough to explore past pains and embark on new growth; (b) the unconditional acceptance and support of the child and his or her feelings; (c) cautious and tentative interpretation of the child's symbolic play, allowing the child to give words and meaning to painful experiences and feelings; (d) the working of the transference 50 relationship to allow the child to develop alternate modes of intimate interaction; and (e) the eventual assistance in the last stage of therapy to consciously work on acceptable ways of relating in the world. (Mills & Allan, 1992, p. 8) 51 CHAPTER III METHODOLOGY This chapter details the methodology and procedures employed in conducting this study. A general overview of the basic design of the study is outlined first. Following, specific procedures for selecting the participant, the play and art interventions used, the interview process, and the analysis process used in this study will be outlined. Finally, issues of reliability and validity and how they pertain to this qualitative study will be presented. GENERAL OVERVIEW Phenomenological research does not start or proceed in a disembodied fashion. It is always a project of someone: a real person, who, in the context of particular individual, social, and historical life circumstances, sets out to make sense of a certain aspect of human existence (Van Manen, 1990). There is evidence in the literature that early life circumstances and/or experiences have a profound effect upon how a child views himself and how he views himself in relation with others (Bowlby, 1988; Mills & Allan, 1992). Indeed, the "stance" for ongoing relationship patterns is set by the quality of attachment of the child in infancy to the caregiver, including patterns of aggression and/or withdrawl (Mills & Allan, 1992). The single case study method was employed to explore and understand the life experience of a child with conduct disorders. The participant-observation technique for collecting data was used because of the opportunities it presented to be an "active" 52 investigator. Data was collected over a period of 2 years during weekly counselling sessions using attachment sensitive therapeutic techniques such as play and art. Breaks in the counselling process coincided with school breaks. A portrait, a unified written composition that describes a person (Cochran, 1986) was gathered through this data. As well, to help further understand the lifestory of this child and to provide multiple sources of evidence, an indepth interview with his mother was conducted. The data obtained through the interview helped to provide a broader view of historical, attitudinal and observational issues. An interview with the participant's childcare worker was also conducted at the beginning and the end of the therapeutic process. These interviews provided convergent evidence to support what was represented during therapeutic sessions with the child and the investigator. SELECTION OF PARTICIPANT The participant of the study was an eight year old boy who had been assessed as being severely behaviorally disordered by a school district team within the public school system during the latter part of his Grade 2 year. The child had spent time in a special class for SBD children prior to having met with the investigator (one and a half months). He was continuing his placement in the segregated SBD classroom of 8 students upon meeting with the investigator. This child was chosen for the study because of the manifestion of an aggressive socialized subtype of conduct disorder versus the aggressive-nonsocialized subtype (Kernberg & Chazan, 1991). That is to say that upon intitial observation of all the children interacting together within the SBD class for a period of 3 weeks the 53 investigator felt that this child displayed a capacity for peer relationships, social attachments, shame and remorse. Aggressive-nonsocialized children are characterized by overt antisocial behavior and an inability to understand rules or the feelings of others. Although the two categories of conduct disorders are not clearly delineated in the literature they may require different interventions (Kernberg & Chazan, 1991). The investigator felt that a child depicting aggressive-socialized characteristics would benefit more fully from the attachment sensitive therapeutic process that was going to be implemented. According to Kernberg and Chazan children are considered socialized if they exhibit at least two of the following characteristics: sustaining peer-group friendships for at least six months; extending self for others; feeling a minimal sense of guilt; being loyal to companions; and showing some concern for others' welfare (p.3). The participant in this study did manifest some social bonding in that he did extend himself for others and he did show some concern for another's welfare during play, even though it may have been accompanied by disruptive and aggressive behaviour. Another criterion for the selection of the participant was the willingness of the family to participate in the process. Parental consent in writing was required prior to the commencement of therapy. Also, it is important to note, that because the environment this study took place in was a public school, administrative consent was required as well. SETTING The setting of this study took place in a regular size classroom. The classroom 54 was divided into two sections, half of which consisted of school desks and teacher materials and functioned as the "classroom". The other half of the room was the "play area" with a large carpet, shelves of toys, games, art supplies, round table and chairs, large throw pillows, book rack, and sink area. The play area of the classroom, as well as the outside Adventure Playground on the school premises, was used during this study. A hand-held tape recorder was used to record all indoor sessions. It was placed at the center of the round table and given very little attention after an initial exploration of how it worked. The investigator also wrote summary notes after each session. Note taking during a session was never done. THERAPEUTIC INTERVENTIONS Attachment theory, as developed by Bowlby, asserts that children who receive unsupportive, inconsistent, or disrupted parenting early in life are at particular risk of developing psychological disturbance (Bowlby, 1988). Studies have demonstrated that there are important links between the quality of a child's early parenting and the occurrence and continuation of aggressive behavior (Stroufe, 1983; Mahler, 1975). The therapeutic relationship that develops within the play therapy process can offer the opportunity for the aggressive, insecurely attached child to experience a "secure base", similar to that of a positive parenting relationship. Play is the natural medium of expression for children and a symbolic substitute for words (Axline, 1969). Securely attached children use play to dramatize and improvise real life situations and through this exploration find alternate means of 55 handling themselves. In essence, the child "plays out" his or her feelings and problems (Axline, 1969). Aggressive, conduct disorder children frequently demonstrate an impaired capacity to use play to explore how to interact differently in real life situations or for problem solving (Kernberg & Chazan, 1991). Instead, their spontaneous play often serves primarily to express and discharge the anger, the pain, or the frustration and confusion they feel towards their world. It is not the kind of play that invites others to join in and sustain contact easily. The therapeutic relationship within the play therapy process allows the aggressive child to explore and express anger, fear, and hurt in a safe, trusting and supportive environment. Typically, in their play behaviour, conduct disorder children are bound to one-dimensional, concrete interactions with objects (Kernberg & Chazan, 1991). Within the context of the therapeutic play relationship, however, symbolic meanings emerge, and imagination is used creatively to communicate. As ego strength develops impulse control also strengthens, allowing the child to integrate and construct increasingly complex internal working models. The child's actions no longer exist in isolation, but rather, they become connected to his or her thoughts, ideas, and feelings. It is this deepening of experience to permit new perceptions of self and self in relation to others to emerge that is the essence of the play therapy approach to treating aggressive, conduct disorder children. Through the process new and more positive internal working models of self, and self in relationship, emerge that eventually enable the child to interact with the world in a more adaptive way. Through the process dialogue between the ego and the unconscious helps to facilitate acceptance and 56 understanding of feeling (Allan, 1988). Play and art, both non-directed and directed, were used in the play therapy process of this study. The participant met with the investigator once a week for one hour, for a period of two years. Attachment oriented play therapy techniques were used. The treatment and intervention techniques were continually being individuated as the participant went through the three phases of play therapy: the initial contact and assessment phase, the middle working phase, and the ending termination phase. The priorities of the three phases are described briefly below. In the initial phase, the therapist develops rapport and creates a secure base of trust and support from which the child can explore his inner world. Setting limits of safety and showing unconditional acceptance for the child underlines this stage. The therapist follows the child's play without pushing or directing it. The therapist is actively involved in the play through nonverbal interaction to help establish the child's acceptance of her. Gross motor play and structured games often predominate during the initial phase. As a sense of safety is internalized regressive behaviour and symbolic enactment of the source of the child's pain will start to emerge in the play. The positive, hopeful, and calm attitude of the therapist during this stage is vital to holding the treatment to a steady course. Transition to the middle phase occurs in different ways with different children (Kernberg & Chazan, 1991). There may be a period where the initial euphoric compliance of the child will start to be replaced by testing of limits and of the therapist's unconditional acceptance. The child may seem set on alienating the therapist with 57 behaviours heretofore perceived as being unacceptable in the home environment. It is important during this transition that the therapist accept the ambivalent feelings expressed by the child, and give voice to them. Being allowed to express both negative and positive feelings is the first step in achieving an atmosphere in which repressed feelings can be safely expressed (Mills & Allan, 1992). This will ultimately help lead the child toward creative fantasy where play will increasingly fulfill the needs of gratification for the child. However a child makes the transition into the middle phase of treatment, the most important sign of having reached it is that the child communicates in some way that he has established an alliance with the therapist (Kernberg & Chazan, 1991). Once the child has come to view the therapeutic process as worthwhile and the therapist as a valued person the true working stage of therapy has begun. During the middle phase play will become free from repetitive, tense, impulsive actions. The child will gradually access, communicate, and express feelings that heretofore had not been perceived and experienced through his imaginary play. The child will begin to free himself from his egocentric stance and to understand the ideas and feelings of others. The child becomes aware of his capacity to play, to create, to change, and to express his feelings within the context of an "as-if" world. The ending phase of the play therapy process is the consolidation and termination stage. The child shows an ability to share, to begin to consider another's feelings, to begin to make friends and to participate in peer activities. Whereas at the beginning of therapy the child's peer interaction and contact will have been either 58 aggressive or avoidant, he will now show a clear sociability. The initial phase began with an introductory interview at the school between the parents of the child and myself (the investigator). The framework for the structure of the therapeutic process was explained. Issues of time and frequency of visits, possible duration of treatment, parental involvement, confidentiality, and transportation for the child were discussed. What the child should be told about the treatment and who should tell him were also decisions made. The calm and positive attitude taken by the investigator during the initial interview was important. Helping the parents to become acquainted and comfortable with the therapeutic relationship was vital to its success. The initial interview was the first opportunity for developing a collaborative alliance between key people in the child's life. PLAY THERAPY Play sessions took place in the classroom within the school the participant attended as already mentioned. The play materials available included toy soldiers and army equipment, action figures, lego, toy animals, unifix cubes, toy telephones, board games, puzzles, puppets, a doll, blocks, toy cars and trucks and road map, tool box with plastic tools, stuffed animals, and a dry sand tray. An outdoor Adventure Playground on the school property was also used, particularly during the initial phase of the therapeutic process. The Adventure Playground consisted of swings, tire swings, and a wooden climbing apparatus. The soccer field and the school gym were periodically incorporated into the play process 59 as well. Initial Phase During the initial assessment phase play was used mainly to help the child become comfortable with the therapeutic process and to start to explore his inner world through symbolic enactment. During our first session together the child was informed about the rules, limits, structure, and process of therapy. We will be meeting here together every Tuesday afternoon for one hour. This is going to be our special time together to help you with some of the things that make it difficult for you to enjoy school. We are going to do lots of things like play and draw and talk. You can play and draw and talk about anything you like You can ask me any questions you like. Everything we talk about will be private, and nobody is going to know about them except you and me. The only rule we have here is that we don't hit anyone and we don't wreck any of the toys or games. The limits and rules were immediately acted upon and reviewed in a firm, yet calm and quiet way whenever there was any indication that they were about to be broken. It was very important during the inital sessions that I maintain a constant calm, firm yet non-judgemental, demeanor and that the boundaries and limits be strictly enforced. When the play became too reckless and aggressive, ie. the child flipping himself on the ground with intense force, I would immediately intervene. Let's stop. (Hold up hand to indicate STOP) Let's hold on a sec. Remember when we are together we don't hurt anyone or anything. That means ourselves too. For the first 7 or 8 sessions I remained totally non-directive with regard to the content of the play. The only time I intervened with the script was when there was an 6 0 issue of safety or the boundaries of the therapeutic process were being crossed. At the request of the child we spent these first sessions outside on the Adventure Playground. It was a real advantage to have such an open space as the play theme was action packed with a lot of gross motor play (running, jumping, rolling). I used a lot of reflective and supportive verbal language. Non-verbally I was very active, running and jumping, and becoming a valid action character within the child's theme. For the first 8 sessions I remained patient and accepting of the play theme during the repetative gross motor play, and waited until the child was ready to branch out. After an initial social greeting, and perhaps a factual question or two I may have needed some clarification on, at the beginning of each session we went outside and played the "Spaceship Game", as it came to be called. There was a tremendous amount of energy expenditure during this play with all kinds of gunfire and fighting sounds. There was not much depth to the theme other than shoot and kill the enemy forces, however, there was a lot of physical movement. Twenty minutes before the end of each session I would state that our time together was just about over and that it was time to go back inside. Once back inside we would sit down at the round table and draw a picture. At the end of every session the child was offered a glass of water and a granola bar. Then I would walk him to the taxi, thank him for spending time with me, and wave goodbye. By the ninth session I felt sufficiently comfortable with the relationship that was developing between myself and the child that I started to become more directive 61 during our play. I began to put forth ideas and suggestions as to the course of action of the play. How about today I be your engineer on the spaceship? (Rather than an alien who was continually being shot). I could help you get away from the bad guys by putting super turbo jets on the spaceship. Once I assumed the role of "engineer" in our Spaceship Game I was able to begin to make the child aware of his capacity to play and express himself more through the use of language and not just through physical action. I remained nonjudgmental and unconditionally accepting when the child did not like or agree with some of my suggestions. I also remained completely nonpunitive when unpleasant language was used. Verbal Interventions in the Initial Phase of Play Therapy The power of the spoken word is of real significance when communicating with a conduct disorder child. Five types of verbal interventions were characteristic of the initial phase of the play therapy process. Each type of verbal intervention is outlined below with some specific examples of when they were used during this study. For a more detailed account of these interventions see Kernberg & Chazan, 1991. Ordinary Social Behaviour Greetings and other everyday courtesies are considered part of any appropriate social relationship. During every session I used social language in a natural way. Not only was it important to be viewed as a friendly, approachable person, but greetings and other courtesies also communicate to the child that you are not intimidated by his behaviour. 62 Statements Relating to the Therapy During the initial session with the child I clearly explained the boundaries, rules, behavioural expectations, and the objectives of our work together hoping to allay some of the anxieties he may have had about the process. Time, place, frequency, and duration of sessions was also clearly stated. The purpose in talking to the child about these things was not only to make the unknown known, but also to initiate the development of a partnership between the two of us. Requests for Factual Information Only factual information useful to help fill in gaps in my knowledge of the child's history and everyday life was illicited. For example, information on the child's perspective with regard to his older sister was important and necessary to obtain because of the ongoing discord of that relationship. When inquiring about factual information it was important to exercise tact and sensitivity and not to push the child into areas he was not yet able to share. By giving the child the opportunity to clarify issues about himself and his experience with others during the first few minutes of each session during the initial phase of play therapy I was able to begin to weave the fabric of the life story of the child. Supportive Interventions Three subtypes of supportive statements were used during the initial phase of the play therapy process in this study as outlined in Kernberg & Chazan, 1991: 1) education statements; 2) suggestion statements; 3) encouragement, reassurance, and empathy statements 63 Education statements were used to supply factual information and to correct misinformation the child may have brought to the session. Education statements were also used to teach new skills. Yes, I am married. Tie up your runners nice and tight next time and you will be able to kick the ball much better. I did not begin to use suggestion statements until the ninth session. I felt that we had developed enough rapport by then that my suggestions would at least be heard, if not incorporated into the play. The point of using suggestion statements was to help broaden the child's awareness of alternatives in the play theme. By providing other possibilities for problem solving and by presenting new opportunities to break old patterns we could begin to develop a more positive attitude towards the child's environment. Suggestion statements also provided opportunities to help introduce more prosocial approaches to problem solving everyday situations. If somebody is teasing me on the playground you know what I do? I ignore them and walk away. Encouragement implies the suggestion to repeat an approved action. Reassurance refers to the therapist's recognition and expressed approval of the child's thoughts and actions. It confirms the child's own inclinations, relieves his uncertainties, and reinforces his own suggestions to himself. Empathy refers to the way the therapist resonates with the child's thoughts and feelings by labeling or echoing the child's affect (Kernberg & Chazan, p. 62). During the initial phase of play therapy I used a lot of empathy or reflection statements. Such statements allowed me to enter into the 64 "Spaceship Game" in a quiet, inobtrusive way. When you (aliens) attack the Captain's ship it makes him angry. He'll blow you away. It feels good to be in charge and to be the one telling people what to do. During the time that I acted as the engineer on the space ship I used a lot of encouragement and reassurance statements. I called "ship meetings" to discuss how the captain would want to handle the enemy aliens. Discussion provided the opportunity to look at the situation in a variety of ways (suggestion statements), and then I backed up my captain's decision as to what to do (encouragement and reassurance). We stayed in the metaphor of the play during this time. Captain, Captain we need to have a ship meeting. No matter how many times we kill the aliens they keep coming back. We need to devise a plan so that they won't keep coming back. Facilitative Interventions Review statements and invitations to continue with the dialogue were facilitative statements used to help maintain the flow of interactions between myself and the child. Review statements help the ego to synthesize material (Kernberg & Chazan, 1991). Summarizing what the child has said also helps to model logical, sequential thinking. So now I know why you and (sister) had a fight last night. You turned the t.v. on first, then she came along and changed the channel without even asking you. By inviting the child to tell me more I was conveying my interest in what he had to say. Invitation statements were very useful at the beginning of many sessions when the child was relating experiences he had had between sessions. Invitation statements also encouraged him to use his words rather than actions. 65 Can you tell me more about how your lego gun got broken? The above mentioned verbal interventions were predominant during the Initial Phase of the play therapy process. As we moved through the Working Phase and the Ending Phase these interventions continued to be useful to some degree. However they formed the background for other interventions that I will now discuss. Working Phase I did not feel that we had reached the "working stage" until sometime after we had resumed sessions after the Christmas school break (4 months after the commencement of the play therapy process). The typically negative self-image of conduct disorder children and the negative attitude toward adult authority create distrust in these children and make attachment bonding a slow process. Therefore, it was imperative to facilitate the attachment structure during the initial phase by building the child's confidence in the reliability of the therapeutic setting. I was able to do this by physically providing a consistent time and place, and by psychologically providing invariant unconditional acceptance and support. During the working phase the gross motor; running, jumping, rolling behaviour seen while playing the "Space Ship Game" gave way to less active, more detailed play inside. As the child moved from a totally egocentric stance to one that was more socialized and included myself I was able to use the relationship to work out issues. Continued focus was given to the development of the child's capacity to verbalize. This continual focus and improvment in the child's ability to express his feelings in a more adaptive and socially acceptable way gave the child a sense of control. 66 During the working phase I took a more direct approach to help expand the child's awareness of his behaviour, feelings, and thoughts. I encouraged the use of materials in the play area that would give him the opportunity to verbalize feelings and thoughts while in his fantasy world. Sand tray, toy cars, unifix cubes, and paper and felts were made readily available. Often I would initiate play activities with these materials and then ask if the child would like to participate with me. I thought today we might build with the unifix cubes. I'd like to build some stuff. Do you want to join me? By encouraging the use of materials that lent themselves to imaginary play with no set form or rules the child was able to create his own imaginary events. I would adapt to his theme and use it to guide the play. Verbal Interventions in the Working Phase of Plav Therapy The verbal interventions mentioned above continued during the working phase of the play therapy process, however they did take on a different tone and function. Ordinary social behaviour continued and remained unchanged as it served to model a socially acceptable way of greeting and of carrying on other social interactions. Statements relating to treatment decreased significantly as the child became confident with the rountine and continuity of the sessions. Inquiries about factual information became less biographical in nature, but rather, took on an "in the here and now" nature. That is to say that it was important during the working phase to inquire about what was happening in the child's world outside of the sessions. By the time we reached the working phase I had become aware of the poignant issues in the child's 67 life, ie. his relationship with his sister, his father, and his inability to establish friendships at school, and I was able to ask relevant, factual questions. Did you try your joining in skill for soccer this week? How did it go? Supportive interventions continued as in the initial phase. However, their content shifted as play themes expanded. Do you know why I think you get into big fights with other people when you're talking about God? I think it's because you really believe in God and they don't and you can't understand why they don't when you know that he does exist. But not everybody believes in God and that's just the way it is. They have just as much right not to believe in God as you have to believe in God. You don't have to change and neither do they. Facilitative statements inviting the child to continue or to tell me more about the story he was relating and review statements increased during the working phase as I became more familiar with his problems. Facilitative type statements took on the function of helping to expand the child's awareness of the experience he was relating. They would often ultimately offer another way of dealing with a particular situation. Let's think about what you could do next time your sister switches the t.v. channel on you. Two other verbal interventions that were used during the working phase of the play therapy process were directing attention and interpretation statements. Directing Attention Directing attention statements are designed to enhance the child's self-observation and to help him become aware that his thoughts, feelings, and actions are meaningful (Kernberg & Chazan, 1991). In this study I used a lot of directing attention statements. "Look-at" or "Did-you-notice" and "See-the-pattern" are examples of 68 directing attention statements. These statements helped the child focus on particular aspects of his behaviours or feelings. At times these statements referred to immediate behaviours, and at other times past behaviours. Because the child in this study had such a negative emotional tone it was important to emphasize anything positive that transpired either in the session or that he related to me during a session. These type of statements were useful during such times. Have you noticed that when you wear your ski mask at Recess you always play by yourself. Today you didn't wear it and look what happened! Would you like to know what I'm thinking about that? Have you noticed that every time someone puts out their hand to shake yours you squeeze real hard? Let's practise just shaking hands gently. I think people would like that. (We practised a gentle hand shake.) I then made a point of reinforcing the appropriate way to shake hands during our social greetings in subsequent sessions. Interpretation The use of interpretation during sessions was limited because of the nature of the child I was working with. Behavioural disorder children tend to have difficulty seeing themselves as contributing to the problems they have. They tend to externalize the source of the difficulty (Young, R., 1993). Therefore, interpretation statements were only used in the here-and-now of a session and only when the child was in an open, calm frame of mind. I felt that when I did use interpretation I was relying heavily on the strength of our relationship to have it accepted. It is important to acknowledge that my limited experience with the use of this verbal intervention may have also been a factor 69 in its restricted use. Interpretations were aimed at solving internal sources of problem behaviour, therefore they required a certain amount of introspection on the part of the child. They were not used until we were well into the working phase of the play therapy process. Following is an example of interpretation being used during a session in January 1994, more that a year after the commencement of therapy. I noticed that you were wearing your ski mask again at Lunchtime. We talk a lot about how to make friends on the playground and how important it is for people to see your face so that they feel comfortable. A big part of you really wants to make friends, but it's scary too. Maybe they won't want to be your friend. It's just easier to wear the ski mask because then no one will come near you and you won't have to take a risk. The ski mask kind of like protects your feelings. During the latter part of the working phase of the play therapy process (November 1993) I began to actively introduce and include "prosocial skills" into each session. The child's impulse control had strengthened and his ability to verbalize his thoughts and feelings had improved considerably both during play sessions and in the classroom as well. I felt he needed some concrete, step-by-step prosocial instruction. A "structured learning" approach was used to achieve this goal. Structured learning is a behavioural approach for providing instruction in prosocial skills (McGinnis & Goldstein, 1984). Following the format outlined in the McGinnis & Goldstein book, each skill taught was first introduced and then broken down into behavioural steps. I prepared a poster for each skill we did where the steps were clearly stated. The posters were later put up in the classroom for daily reference for all the children. After reading the poster together I would role play an example of a time when that particular 7 0 skill would be used. I would try to create examples of situations that the child had actually been involved in throughout the week. I would role play how he had handled the situation and then show him another "prosocial" way. Finally we would rehearse the prosocial approach in a role play together. He was never asked to role play an inappropriate way of handling a situation, only to observe it, and it was always followed by a more prosocial approach. The prosocial skill we are going to look at today is called "Keep Cool Rules". Let's look at the steps. Keep Cool Rules 1. Tell the person to please Stop. 2. Use a stronger voice. STOP! 3. Ignore, walk away. 4. Tell the person that you will report it. 5. Follow through. Dealing With Disappointment 1. Calm down. 2. Say to yourself: It's o.k. that I didn't... 3. Think about your choices: a) do an activity you like to do b) offer to help someone c) do a relaxation exercise 4. Act out your best choice. The prosocial skills we covered during our time together included: Ignoring, Introducing Yourself, Keep Cool Rules, Joining-ln, Sharing, Playing a Game, Accepting a Compliment, Dealing With Disappointment, Dealing with Your Anger, and Showing Sportsmanship. Because posters were made up for each skill and posted in the classroom we were able to use them for reference during subsequent sessions. It became apparent to me that in order for the child to be able to transfer the prosocial skills we discussed during sessions to the playground he was going to need 71 some support. I began to make myself visible everyday during Lunchtime while the child was on the playground. At times simply my presense was enough to help him think about and use his skills. At other times I would model a particular skill with other children on the playground, or help them problem solve using the language of a prosocial approach we had learned. Can we play?" (soccer) "Who's team are we on? (Joining-ln skill) It really makes you angry when so-and-so doesn't play the game right. I wonder if he knows the rules. Let's decide what they are together right now so that everyone can get on with their play. (Playing a Game skill) Ending Phase The ending phase of the play therapy process is more that a summation of the sessions. Ending, or termination, implies the acquisition of a structure internalized within the intrapsychic life of the child that allows him to conduct his life in a more fulfilling way (Kernberg & Chazan, 1991). The child's internal working model of self, and self in relation to others, is no longer so negatively skewed. The criteria for ending treatment in this study included improved impulse control, enhanced self-esteem as manifested through a more positive affect, and improved peer relations. In March 1994, approximately a year and a half after the commencement of therapy, the child began to show the ability to use adaptive resources with consistency while at school. He was able to engage in play and play activity with others for a sustained length of time while on the playground. He was able to use words to express his emotions rather than actions. Although his learning disabilities prevented him from improving significantly academically, his behaviour had improved 72 significantly enough that he was able to integrate into a regular age/grade appropriate classroom within the school and receive learning assistance. During the ending phase our play changed in tone. The child chose to draw a lot and to express his fantasy of being the hero, of being #1, of being in control, through drawing portraits rather than through active play. He began to express a desire to shoot basketball hoops, to play hockey, or soccer. I brought the sports equipment into the playroom. Soon he was taking the initiative in determining that we would either go to the gym or outside and engage in sports play for the first half a the session and then spend the last part of our time together drawing. The indirect mode of play and metaphor gave way to more direct dialogue. Our time together became relaxed as we derived enjoyment out of just being together and exchanging points of view. Verbal Interventions in the Ending Phase of Plav Therapy Again verbal interventions took a shift in focus during the ending phase of the therapeutic process. An increased focus on review statements and directing attention statements helped the child to continue to be aware of his behaviour. By using review statements it was possible to connect past and present behaviours and feelings for the child and to help him see how certain positive behaviours resulted in positive outcomes. Such statements also helped the child get a sense of history, a sense of the changes that had occurred, and that he was ready to move on. Have you noticed how much more fun Recess is these days? You're joining in and kids want to have you on their team! Remember when it wasn't always like that? Do you want to know why I think it's so much better? 73 During the ending phase there was also the continued use of supportive statements. Encouragement and reassurance at this point helped the child to realize the permanence of his improved behaviour. Remember that before and after picture you drew. It must feel so good to know that you are under control. You have really worked hard. I'm so proud of you. You know how to stop yourself from getting into fights. Sometimes you'd rather be in the special classroom than Mr. M's room because sometimes it's hard work in there. But you have earned the privilege of integrating and you can do it. ART THERAPY Art therapy was the other therapeutic technique used in this study. A variety of art materials including paint and easel, white paper, construction paper, pencils, crayons, pencil crayons, felts, glue, scissors and clay were always visible and readily availabe during every session. During our second session together in the initial phase of treatment we made a large art portfolio out of bristol board to store the child's artwork in. At that time I told him that all his art work would be kept in the portfolio and that when we finished seeing each other he could take it home with him. Although he never requested to take a drawing home, if he had I would have made a copy of the original for him to keep. The House-Tree-Person (H-T-P) drawing technique was used at the beginning, middle, and end of the therapeutic process. The purpose for employing this direct technique was to get a standard measure that would aide in determining change in the self-image and representational world of the child. Each of the drawn wholes (House, Tree, and Person) is to be regarded as a self-portrait (Buck, 1949). 74 The other art therapy technique employed in this study was the Serial Drawing technique. This indirect technique involved having the child draw regularly in the presence of myself. He was permitted to draw whatever he chose while I sat beside him quietly, or answered or redirected questions back to him. Once the drawing was complete the child would tell me about it. The child in this study was readily able to tell about his drawings. At times, however, it was necessary to help him elaborate on his artwork by asking him open-ended questions. The following open-ended questions were used, as suggested by Allan (1988): Does the picture have a story? Can you tell me what's going on in the picture? Does the picture have a title? What happened before? What will happen next? During the first few sessions I would suggest that we draw during the last fifteen minutes of our time together. Not long into the initial phase of therapy drawing at the end of every session became a natural routine for the child. It not only allowed for a transition time between the active play and the end of the session, but it was also another constant the child could count on. This art technique was sustained throughout all phases of the therapy process. Periodically during the ending phase of therapy I would become directive in the drawing process with the objective of exploring any shift in the child's perception of self at the beginning of treatment and during the ending phase (ie. before and after pictures). At these times I would ask him to draw what he was like on the playground before, for example, and what he was like now. 75 IN-DEPT INTERVIEW An important source of case study information is the interview (Yin, 1989). Lofland (cited in Mishler, 1986) describes the unstructured interview as a "flexible strategy of discovery...Its object is to carry on a guided conversation and to elicit rich, detailed materials that can be used in qualitative analysis" (pg. 27). The interview may be used as a means for exploring and gathering experiential narrative material that may serve as a resource for developing a richer and deeper understanding of a human phenomenon (Van Manen, 1990). For the purposes of this study an in-depth interview with the participant's mother was conducted in the family home during the working phase of the therapeutic process. The interview took place in February 1993, approximately 5 months after the commencement of therapy. The interview was open-ended in nature and assumed a conversational, nondirective manner. However, it was a "focused interview"...it's major purpose was to corroborate certain facts that the investigator already thought had been established (Yin, 1989). A focused interview was appropriate in this case because of the on-going contact by phone between the investigator and the mother during the therapeutic process of her child. The participant's mother was asked to describe her experience of being a mother to the participant starting with her attitude towards her pregnancy. She was encouraged to tell her story, including the joys and the challenges, of what it was like for her to parent her child through infancy, toddlerhood, and childhood. She was encouraged to use examples to explain what she meant. Questions regarding how 76 the father and sibling related to the participant were also presented. Finally, dialogue regarding how the mother saw her child at the present time was initiated. As well, a focused interview was conducted with the participant's childcare worker both at the commencement of therapy and after the termination of therapy. A School Observation Rating Scale was used as the focus of both interviews (see Appendix A). The childcare worker had been assigned to the special classroom of the child on a full-time basis. The purpose of the childcare worker interviews was to collect other sources of evidence to provide convergent sources of data supporting the internal change in the child and how successfully he was able to use the acquired adaptive skills in a typical school setting. ANALYSIS A portrait description based on the process of change that the child went through during the stages of play therapy as depicted through both his art and play behavior was prepared. This portrait discusses the changes in the child's perceptions of self and self in relation to others. The evidence discusses the changes in the child's internal working models and ego strength against the theoretical propositions of the study. The various interviews with the significant adults in the child's life validate these changes. RELIABILITY AND VALIDITY ISSUES The purpose of doing a research design is to create a logical set of statements that can be represented and generalized outside the study. Therefore, major issues that confront any study are those of reliability and validity. Yin (1989) sites four specific 77 case study tests that are relevant for dealing with a qualitative study such as: construct validity, internal validity, external validity, and reliability. Yin further details a number of tactics to be employed throughout the conduct of the case study to deal with these tests. Construct Validity Construct validity deals with the soundness of the results of the study through the establishment of correct operational measures for the concepts being studied. Yin (1989) has identified three tactics to manage this issue. The first tactic is the use of multiple sources of evidence in a manner encouraging convergent lines of inquiry. This was dealt with in this study through triangulation by comparison between the therapist's observations, the literature, and interviews with the mother, and the childcare worker of the child. The second tactic involves establishing a chain of evidence that clearly links the individual case study portrait and the general discussion to specific experiences of the participant. This was managed with cross-referencing of methodological procedures and the resulting evidence obtained through participant-observation counselling sessions and interview data. Finally, the third tactic is to have the draft case study report reviewed by key informants. This involved the participant's mother reviewing the narrative, as well as the childcare worker of the child. Internal Validity Internal validity is relevant to studies that attempt to establish causal 78 relationships or are explanatory in nature. In any study where the investigator is attempting to make a causal statement where event "x" led to event "y" there is the threat of dealing with spurious effects. Yin (1989) describes three tactics to help manage this issue. The first tactic, pattern-matching, compares an empirically based pattern with a predicted one. Internal validity is strengthened if the patterns coincide. In this study the prediction that the participant's aggressive behaviour would decrease as he developed a more positive sense of self did coincide with empirical evidence. The second tactic involves explanation-building where the goal is to analyze the case study data by building a theoretically based explanation about the case. In this study the causal links reflect significant theoretical propositions of Attachment Theory. The third and final tactic is to conduct a time-series analysis where changes are traced over time and compared to a theoretically significant trend. For this study events were traced in detail over a two year period. Theoretical comparison was ongoing. External Validity External validity deals with the generalizability of the study beyond the immediate case study to a larger population. In this study the investigator compared the results to the broader theory of attachment that specifies that a particular set of results should occur, thus developing an analytic generalization. It is important to note, as Yin (1989) points out, that generalization is not automatic. This study presents 79 one account of a particular set of experiences. Theories must be tested through replications of the findings in other similar studies. Reliability The objective of the reliability test is to be sure that, if a later investigator followed exactly the same procedures and conducted the same case study, the later investigator would produce the same findings and conclusions as the study in question. The goal of the reliability test is to minimize errors and biases in a study. This study was so dependent upon the rapport and therapeutic alliance built between the investigator and the particular participant, and this was such an important part of the research process. Also, the interview process in this study was quite unstructured. For these reasons the likelihood of ever being able to exactly replicate this study would be very low. Therefore, the approach to dealing with the issue of reliability here has been to "conduct research as though someone were always looking over your shoulder" (Yin, 1989; p. 45). This requires the investigator to explicitly acknowlegde all assumptions, biases, and perspectives. Through disclosure of thoughts and process and systematic recording of the progress of the study a measure of reliability can be achieved. 80 CHAPTER IV RESULTS This chapter describes the process of change in the participant during the two year therapeutic period. A general case study description of the child will be presented first, including reason for referral to the SBD program, family make-up, educational history, and initial developmental assessment based on the three week observation period prior to the commencement of counselling. Following, a description of the progress made during the initial, working, and ending phases of treatment as indicated through the child's play and art will be presented. Finally, the results of the interviews with the child's mother and childcare worker will be described. Reason for Referral Billy (pseudonym) was referred to the SBD program by the school district team at the age of 7.8 for a composite of behavioural and learning problems. He had consistently displayed oppositional and non-compliant behaviour towards school personnel including punching a teacher when asked to do something. Aggressive and violent behaviour towards his peers such as kicking, punching, swearing, and starting fights was reported as happening almost daily on the school playground. Within the classroom, Billy's present and past teachers had all profiled him as having poor social skills, a general negative emotion, learning problems, and a short attention span. He was described as a student who was off-task, disorganized, easily frustrated, distractible, and overactive. Family Make-up 81 Billy lived with his father (a custodian), his mother (a homemaker), and his twelve year old sister in a rental housing co-op. They had lived at the same residence for the past 3.5 years. Educational History Billy entered Kindergarten at the age of five. He completed his Kindergarten year and Grade 1 year at the same school. During his Grade 1 year a full speech and language assessment was done as well as some informal psychoeducational testing because of the severe learning problems and attention deficit hyperactivity manifestations he was presenting. The family moved to their present residence in a different school district after Billy's Grade 1 year. During his Grade 2 year, in a new school, a complete formal psychoeducational assessment was done. Although his profile indicated severe learning disabilities, he was designated severe behavioural disorder due to the perpetual social and interpersonal problems he was experiencing at school with peers and school personnel alike. By May of Billy's Grade 2 year a place had become available for him in a SBD classroom. Initial Deveopmental Assessment Physical Billy presented as a physically healthy, energetic boy upon initial observation. Height, weight, and strength were normal for his age although his co-ordination was poor (eg. kicking a soccer ball). Vision and hearing were excellent as reported by the school nurse. There were noticeable perceptual and motor skill difficulties as 82 evidenced through slow handwriting speed in class, and difficulty with figure-ground and spatial orientation. Billy also displayed discrepancies in his motor capacities. He was adequate in some areas such as spontaneous drawing, but poor in others such as puzzle completion. Emotional Billy's affect was predominantly angry and aggressive depicting an avoidant, insecure behaviour pattern (Bowlby, 1988). His general demeanor had a negative emotional tone to it. He showed hostility, and a cold toughness towards others, peers and adults alike. However, through this toughness he also showed a desire to interact with the group, albeit inappropriately, rather than be isolated. Initial Phase The goal in the initial phase was to establish a therapeutic alliance in a secure and predictable environment that would allow Billy's concerns to unfold. Play Billy's play behaviour was very aggressive and destructive during our first sessions together. There was no dialogue between us during play time, however Billy did produce lots of sound effects. I was clearly being treated as a spectator of the play while Billy was the star attraction. He would charge around the Adventure Playground in what appeared to be a chaotic frenzy of energy dissipation. However, I felt that his behaviour was goal directed in that he was trying to express to me without words why he was the way he was, and also to see if I would respond to him as others had. For the first eight sessions together I was treated with aloofness while Billy 83 played with intense aggression. By our fourth session I had some sense of what attracted his interest through his drawings (Space) so I parallelled his play with my own. I play my own alien game using the same Adventure Playground space. I only intervened directly in his play when safety was an issue. Billy clearly demonstrated an impaired capacity to play in a reciprocal manner or for problem solving. His aggressive play behaviour was controlling me in that it kept me away from him, therefore potentially away from him being disregarded or rejected. "The fantasy of being rejected by others restricts the children's play to concrete, repetitive themes" (Kernberg & Chazan, 1991, p. 29). By session nine I felt that the therapeutic alliance between Billy and myself had developed enough that I actively introduced more complex and diversified events into the initial play theme that would include myself by creating characters for us. Billy became the Captain of the Spaceship and I was accepted as his engineer. I was careful to maintain a subordinate position. My ideas were gradually accepted more and more as Billy felt his dominant role. Because reciprocity was being established, Billy's play slowed down and he began to verbalize and dialogue with me (the engineer) creating events in our play, not just acting it out physically. Thus, Billy's play behaviour during the initial phase went from being aggressive, violent and isolated, to a shared experience. By my assuming a lesser, dependent, and somewhat helpless role we were able to use play to combine Billy's internal devalued self-representations with their alternate side, the grandiose and narcissistic "I am capable of anything" side. Through this process the negative, rejected self 84 representations were able to become tempered, allowing Billy to develop an increasingly complex internal working model of his world and to strengthen ego functioning between his internal and external world. Billy's realization of my capacity to tolerate the negative self-representations he projected and the sense of safety he felt within the clear limits set indicated we were entering the working phase of the therapeutic process. Art Billy's art parallelled his play during the initial phase of the therapeutic process. His drawings allowed me to further view his internal world. Figures 1, 2, and 3 are examples of drawings he produced during the first two months of counselling. The rage and hostility he projected through his drawings, with evil or bad outcomes, was a consistent theme. Figure 1 Figure 1 is a picture of a rocket blowing up in outer space. Everyone was 85 destroyed. Billy worked intensely while drawing, appearing oblivious to my presence. The sound effects he produced during the explosion were so intense that he was spitting on the paper. The process was noticeably cathartic as Billy discharged his impulses. Figure 2 is a drawing of a spaceship being blown up. Shots, smoke, and fire are all over the place. Again Billy was totally focussed on his drawing and did not speak during the process, except for the intense sound effects. When he was asked about the parachuter he said that that was the Captain of the ship and he was going to fight to the death. When asked how the story ended Billy said that everyone was destroyed. Figure 2 Figure 3 is a drawing of the world's biggest diamond mine being attacked by enemy aliens. The whole mine caved in under the attack. Only the money survived. Figure 3 Figures 1, 2, and 3 all illustrate how Billy's world was full of aggressive and destructive fantasies, with the domain of the id predominating at the expense of integrating these aggressive impulses with any affectionate feelings. As our play proceeded to become more reciprocal and Billy began to verbalize, his free drawings also changed as is apparent in Figure 4. This drawing was done at the end of our 12th session together. A jet is coming home from a secret and very dangerous mission. The jet arrives home safely without any fatalities. Billy talked about the dangerous route the jet had to take as he was drawing. Here we see the theme shifting from being purely evil to a "good" versus "bad" senerio. The drawing also indicates a sequence of events occurring which required some cognitive functioning, not simply a dissipation of impulsive energy. Further evidence of Billy's ego strengthening is noticeable in the outcome of the story in the 87 picture. The outcome is positive and stated clearly in the picture with words. Figure 4 House-Tree-Person I did not administer the H-T-P until our 6th session together when I felt that Billy would accept this directive approach and be able to successfully complete the series of drawings. I told him at the beginning of our session that I would be asking him to draw me three pictures. According to Buck (1949; 1966), the house is usually interpreted as the child's environment, the tree as growth and development, and the person as an expression of the integrative process; all to be regarded as a self-portrait. House Billy worked very quietly while drawing the house (see Appendix B.1). He displayed an uncharacteristically calm demeanor. He spontaneously drew the main part of the house first. He then drew the garage on the right (used as a rock and roll room), and finally the swimming pool and hot tub on the left. At this point he paused in his drawing before completing the picture by adding the mountains, the sun, clouds, 88 and finally the airplane. Billy's story about the house was told during the post-drawing inquiry and flowed as follows: This is not really a house, it's a mansion. It's awsome. The garage is a rock n'roll room and my band plays there. We play rap. This house has everything. There's a pool and hot tub. And a beautiful view. Billy went on to say that he and his friends lived in the house. Then he included his mother. Finally he added his father to the list of occupants, but stated clearly that his sister did not live there. He said it was an awesome place to live because all his friends lived there and they could do whatever they wanted. When asked about what the house needed Billy drew a fireplace in each room with a vent connecting to the already existing chimney. Then he said that now all the rooms would be warm. Discussion Billy's house drawing depicted the antithesis of the environment he lived in. It was his fantasy environment. Money was a very stressful issue in Billy's home and the cause of many arguments. The drawing clearly stated what Billy thought he needed to be happy and to have friends. It was interesting that Billy drew four rooms in the house with four fireplaces. Although he did not acknowledge that all members of his family lived in the house with him, he seemed to indicate metaphorically that with more love and warmth his family would be a happier one. Also, the fact that Billy included a beautiful view indicated to me that some feelings of affection were within him at some subliminal level. Tree 89 Billy again drew quietly and compliantly when asked to draw a picture of a tree (see Appendix B.2). The first tree he drew was the one on the left with all the leaves on the ground. He did not draw the other tree until during the post-drawing inquiry when he was asked what happened to the initial tree. His story was as follows: This tree is dead. See, all the leaves have fallen off. It used to look like this (drew the tree to the right). There was this bench around it and a little boy used to ride his bike there. It was company for the tree, the tree liked it. But the boy moved away and the tree died. Discussion Billy's initial tree was described as dead, with no hope of recovery. Billy's negative emotion and feelings of hopelessness and unworthiness were seemingly being depicted here. Not only was the tree dead, but it was drawn small down in the corner of the page. The second tree Billy drew may have been an expression of what Billy wanted to feel or that he had not always felt so hopeless. Person Billy again drew his person quietly and spontaneously (see Appendix B.3). He drew the face and hair, and then the body. He then added the chains to the torso, the lock on the back, and the key stuck in the hair. Finally he added the words coming out of the person's mouth "Where's the key?" When asked about the picture this is what he said: This guy is a punk. He is really tough, everybody is scared of him. He's really in a bad mood. He can't find his key. Then Billy went on to explain that the punk wore the chains to look tough and to frighten people. He said that this guy didn't have any friends and didn't want any 90 friends. When asked if the punk would ever find the key Billy smiled and said only if he combs his hair. Discussion It seemed easy for Billy to explain metaphorically how he thought others perceived him and that his fragile self was kept safe that way. The tough guy image and the chains were protection for his immature ego; protection from feelings of rejection and failure. But, I felt that he was also telling me that there was another part of himself that didn't want to carry all the heavy weight. It seemed as if Billy was saying that he knew there was a different way to feel, act, and behave. I believe he was showing me where he thought the key lay (in his brain) so that I could help him. Working Phase The goal in the working phase was to help Billy expand his spectrum of coping strategies, to increase his ability to play and talk, and to become more overtly aware of the meaning of his behaviour both within sessions and in experiences outside of sessions. Play During the middle phase of therapy Billy's internal images of himself as negative and "living in hell" started to shift. His ego had developed and matured enough that he was becoming better able to control his impulses. He began to identify with good feelings and saw me as a supportive, helpful person. With the change in weather we used the play space within the classroom rather than the outdoor playground. Billy needed several sessions to explore and 91 manipulate the various toys available, including the toy cars, lego, unifix cubes, telephones, large pillows and tool repair kit. He explored the toys thoughtfully, without reckless abandon. He did not need any reminders about the the rules and boundaries of the play space, further indicating to me that we were in the working phase of treatment. It became obvious that Billy enjoyed building with unifix cubes and lego. He would build robots, jets, guns, and bombs while I would build radar towers and shooting practise targets, as ways of encouraging reciprocal play and dialogue. It was not uncommon for Billy to spend 10 to 15 minutes building guns or other explosive type items and then play with them very physically by rolling around on the floor or jumping off a chair. However, his movements were controlled and his imaginary events were being articulated so that I could also participate. The underlying theme of goodness versus evil was very apparent, but with goodness almost always being victorious. Gradually I became more directive during our play interactions, attempting to extend our theme and to continue to enhance Billy's internal working model. Greenberg et al. (1990) sees internal working models as having the purpose of imitating real or relevant aspects of the world to help the child react in a much fuller, safer manner to his environment. I wanted to construct an internal framework together with Billy that would allow for joy, flexibility, adaptability, and laughter. By staying within his metaphor we began to build "super heros" with the lego and unifix cubes, including space bases where they lived, with the purpose of increasing the amount of 92 communication between us. By our seventh month together Billy was able to build, talk, and play for up to 30 minutes without losing focus. He was identifying with the super heros, showing signs of efficacy and empowerment rather than helplessness and rejection. At the same time I also introduced prosocial strategies that Billy needed to learn if he was going to be able to create and maintain positive friendships and relationships with people in his environment. Billy started to show signs of successful interactions with other children on the playground during Recess and Lunch. By the time we had been together for one and a half years Billy was consistently playing with age appropriate peers without the need for close supervision by the childcare worker. He was also being integrated into an age/grade appropriate class. Art Billy's art during the working phase of therapy that spanned approximately one and a half years is presented in Figures 5, 6, 7, and 8. The drawings show the intrapsychic change occurring in Billy's life. His internal model of self goes from one being negatively skewed, to one with more control, a more positive affect, and an enhanced self-image. In Figure 5 the goodness versus evil theme is further portrayed. This is a fight in outer space. The good guy is on the right without any weapon. The bad guy is on the left and he has a weapon but he hasn't got a chance because the good guy has help all around him. Here we can see that Billy is feeling understood and supported. He doesn't have to act out to protect his developing ego, he is not alone. 93 Figure 5 Figure 6 is "Ram Man", a super hero. This picture was drawn nine months after the commencement of therapy. Billy stated that he was Ram Man after drawing this picture. It was the first drawing he did where he actually articulated that it was his fantasy to be the super hero. In March, a year and a half after the commencement of therapy, Billy (now 9.5 94 years old) drew the picture illustrated in Figure 7. This is a picture of Billy at age 29. He is a member of the "Canadian Special Forces" team. The job of the Canadian Special Forces is to keep peace. Billy is very clearly identifying with good feelings and showing hope and optomism for the future. He is also identifying himself as being a member of a group, rather than an isolate. This drawing was also one of the first to use human characters rather than fantasy characters. This became more and more frequent throughout the final stages of the therapeutic process. Figure 7 Figure 8 was drawn a couple of weeks later. Again, it is a picture of the Canadian Special Forces. This time all the soldiers are on a cruise ship going on a vacation. They need a holiday because they have been working very hard. The submarine is following them to make sure no sharks attack. The sun is shining and smiling, the clouds are light and fluffy. There was no sense of aggression when Billy drew this picture. He sat calmly and drew, experiencing enjoyment in the creative process. I felt that Billy was telling 95 me that we were coming to the ending phase of therapy. In this picture Billy was telling me that he was ready to go, but that it was scary too because "who knows what lies in the waters ahead" and "would I be there to help him if he needed it". Figure 8 Ho use-Tree- Perso n The H-T-P drawing technique was administered again one year after administering it the first time, during the latter part of the working phase. House Billy was very relaxed when he drew the house (see Appendix C.1). He talked 96 while he was drawing explaining to me what everything was. His story during the drawing process and during the post-drawing inquiry was as follows: This house is 300 miles away, that gives you an idea of how big it is. It's a very happy house - look at all the stuff - big pool, big fountain, private helicopter pad, huge balcony, radar screen. You live in the house with me and all my friends...and my family. Cathy (psuedonym for sister) is the maid. You can only enter the house with an authorization code. The punishment for being there without the code is for my dad to sit on you and fart. My enemies tried to burn the house down once but it has a special force field around it so there was no way. Discussion Again Billy depicted an elaborate house with all kinds of luxuries. Such dreaming helped to compensate and escape from the deprived environment he felt he lived in. The fact that Billy included me as a member of the house indicated that we had established a strong therapeutic relationship. I was now being incorporated into his internal model of self in relationship. Billy's sense of humour had also started to emerge and was present in the dialogue about his father. Billy's ambivalent feelings for his father seemed to be coming out. He deeply wanted to respect and gain the respect of his father. However, his father did not present himself to Billy in a way worthy of respect. Billy also stated that the house was well protected from his enemies. It seemed that Billy was feeling safe and supported in our therapeutic alliance. This allowed him to explore some of his ambivalent feelings about his natural environment. Tree Billy drew his tree in the middle of the page, after which he drew the space 9 7 person and the space ship (see Appendix C.2). Again he took pleasure in telling me about the picture and his story flowed easily. This is a tree in autumn. An alien is using a fazer gun to kill the tree. He wants to burn it down. The tree got burned and then the space ship came and took the alien back to his own planet. Some of the leaves survived so the tree lived. It became a treehouse for a little boy and he put guns all around it to protect it from enemies. That little boy was me. Discussion The theme of goodness versus evil, the struggle with positive and negative emotions was apparent in this drawing. Billy seemed to be saying that although he felt and acted differently than he did before, those bad and scary feelings were still there. He still needed me (support) to feel confident that he would make the right choices. Person Billy's person drawing parallelled the play and spontaneous drawings he had been producing in many of the previous sessions (see Appendix C.3). It was a super hero. This is the leader of the Time Fighters. It is B.X.Y. (Billy's initials) at age 11. He has a huge squadron of men. They've received 300 medals of honor for fighting the intergalactical forces. He's heading home after a big day. Discussion It seemed that Billy's negative and hostile internal model had given way to a more positive and empowering image as was depicted in this person drawing. Billy was able to put himself on the side of goodness, which indicated that he was having feelings of worthiness. Ending Phase 98 The goals in the ending or termination phase were to consolidate and strengthen the gains Billy had made. Billy needed to establish a clear sense of internal control and autonomy, and to decrease his reliance on me. Play During our final two months together the fantasy play gave way to play that reflected what Billy did and wanted to do in his natural environment with his peers. We enjoyed playing board games, hockey, soccer, and basketball together in a relaxed manner. Enjoyment was derived from the activity itself and from being able to play with another person. We were able to exchange reactions and impressions about the play without feeling threatened or crushed by defeat. Such play also allowed for more direct dialogue between the two of us to problem solve those moments when the play wasn't going Billy's way. By continually providing Billy with opportunities for self-observation of his play behaviour he was able to gain more and more confidence in his ability to control his impulses. His ego strength had developed sufficiently that he was able to discharge impulses in sublimated, or socially acceptable, ways. Art Billy chose to draw for longer periods of time during the ending phase of the therapeutic process. It was not uncommon for him to want to spend the first part of a session drawing and talking about the things that he was doing outside of therapy before choosing to play some sport activity. He started to depict himself in the "here and now" in his drawings. Figures 9 and 10 are both self-portraits of Billy playing basketball and hockey 99 respectively. Billy had been integrating into a regular class for some time and one of the real pleasures in that for him was engaging in the different sports that class played. He enjoyed playing with children who followed the rules of a game fairly without exploding at any given moment. Figure 10 100 Figures 9 and 10 illustrate the pleasure Billy was getting out of being part of a predictable and productive group, a new experience for him. Figure 10 also includes Billy playing with a friend. These drawings reflect a sense of mastery, self-control, and worthiness. Figure 11 is titled "My Triumph". The motorcycle is Billy's and, although he has not drawn himself on the bike, the story that goes with the drawing is of him riding all over the "Big City". Again the drawing reflects feelings of competency and freedom. Billy is "cruising". His daily experiences are calmer rather than explosive. The drawing shows his central self-symbol as being able to control his impulses. The jet plane at the left of the picture and the small rocket just above the handle bars of the motorcycle may be thought of as protective images for Billy. With increased ego strength these defensive mechanisms are fading away. House-Tree-Person During our second to last session together the H-T-P was again administered. Figure 11 101 House Billy's final house drawing again depicted a grandiose mansion (see Appendix D.1). He drew it fairly quickly and quietly and then stated that he was finished. Following is what he had to say about it upon post-drawing inquiry: As you can see this is a mansion. No one is at home right now but the security system is on. You need a handprint id to get inside. It's my house, I live here with my family. My friend Kevin comes to visit all the time. It's a happy house because it's awesome - the P.N.E. is right behind it. We get in free. Billy went on to say that his family was at the P.N.E. and that's why no one was home. After going on all the rides his family returned home and they ordered pizza for supper. Discussion Billy spent very little time on detail when drawing the house compared to the initial house he had drawn nearly two years previous. The theme of a mansion, of wealth, of having the luxuries money could buy, remained a consistent wish. However, the need to detail and spend time drawing and fantasizing about them seemed to be less. This indicated to me that Billy was accepting a more realistic view of his own world. Billy's father had told him that when Playland opened he would take Billy there. The wish for his family to have a great day at the P.N.E. was in anticipation of this event. It seemed that Billy had a real desire for his family to do something nice together, despite the fact that so often any attempt at a family outing had resulted in great disappointment for Billy. Another interesting shift that was represented through Billy's house drawings 102 was that he went from a house full of his friends, and only with hesitation did he include his mother and father (but definately not his sister), to a house that included friends, myself, mother, father, and sister being the maid, to finally a house that included only his family. This indicated to me a significant shift from an egocentric stance to a more mature ego. His internal self was changing and adapting more positively to the external circumstances of his environment. His perception of himself in relationship with his family was starting to emerge. He was developing a sense of being part of this group, not just someone that this group victimized. By not including myself in the group also indicated to me that his reliance on me had decreased. He still needed to know that I would be there if he really needed me, hence the elaborate security system. Tree Billy's final tree drawing (see Appendix D.2) was drawn with a quiet confidence and once completed this is what was said: This is a very old tree, 200 years old, you can tell because of all the moss on it. Lots of things have happened to it. Like one time a logger tried to cut it down with an ax and chainsaw, but he only cut off a little bit of bark. For 24 years a bear has lived there. He protects the tree - he's a "bearonator". He makes sure the tree gets lots of water and sun. Billy also stated that the tree needed some branches. He said with a smile and a humorous tone that that was another thing the bear was working on for the tree. Discussion It seemed that Billy was saying in this drawing that a lot of things have happened, some not so good, but that things were getting better. It was as though he 103 were summarizing his life through the metaphor of the tree and the bear. There was a sense of hopefulness and anticipation as to what lay in the future. The bear may have been the metaphor for this new sense of self that Billy had recently experienced. We may think of the "bearonator" as Billy's strengthening ego mediating between his internal and external world. The fact that Billy thought the tree needed some branches may be interpreted as his desire to take a risk and reach out to make friends and experience the joys of childhood. Person Billy's final person drawing was a self-portrait (see Appendix D.3). It depicted Billy himself at 29 years old. It was interesting that Billy did not draw a complete body in the picture, but rather cut the portrait off at the waist. Here we may be getting some sense that although intrapsychically Billy has experienced much growth and emotional development he is still somewhat frightened about how he is going to respond to the world. The post-drawing inquiry was as follows: This is the sheriff, it's B.X.Y., it's me at 29 years old. My job is to keep the peace in this town even if it means I have to die. I get a lot of respect in this town. Discussion Although Billy's perception of himself was still that of being tough it seemed clear that the anger and rage within himself had dissipated enough that he was able to identify with goodness rather than evil and to express a sense of humour. I felt Billy was reinforcing in himself confidence in his ability to do the job of acting appropriately, of making good choices, in this drawing. He seemed to have a sense that although 104 there may be others around him not making good choices he didn't have to follow suit. A sense of his own individuality resonated in this drawing and that by his own actions he could make a difference to how things went. Billy was feeling proud and good about himself, someone worthy of respect. In-Depth Interview Mother The results of the interview with Billy's mother helped me to develop a richer and deeper understanding of his world. Our meeting assumed a conversational, non-directive manner which included tea, cookies and looking through photo albums. However, despite this overt gesture of friendliness, I did not feel that Billy's mother was relaxed during our visit. Interestingly, Billy's father had chosen to take the day off work and, although he acknowledged my presence when I arrived, he did not include himself in the interview. I strongly felt that Billy's mother was somewhat anxious about having her husband home during the interview. During her story Billy's mother expressed tremendous love for Billy. Although the pregnancy was "a bit of a surprise" Billy's mother said that she was delighted to have a boy because she thought that would make her husband happy. They had already produced a girl who was four years old when Billy was born. They had not been married at that time. It was unclear as to when they actually did get married. Billy was described as a happy, easy baby compared to her first child who was described as having been "colicky". However, Cathy (pseudonym for Billy's sister) did not respond well to the new addition to the family. Billy's mother said that she had to 105 watch Cathy whenever Billy went down for his nap because Cathy would try to sneak into the crib and hurt him. She said that on time she caught Cathy in his crib hitting Billy. I felt so sorry for the poor little guy. He couldn't have been 2 months old yet. She climbed right into his crib and was hitting him in the head. Did she ever get it. And they still battle. It seems they've been at it forever. I don't know what to do, I've tried everything. Now I just let them try to work it out themselves. Billy's mother described him as being very busy as a toddler, never able to sit still. She described a time when he was four and ran away from her towards a moving train. We went to a park near the tracks. I was chatting with my girlfriend and suddenly Billy was gone. I looked up and I could just see his head. He was heading straight for the train. I just prayed. There was no way I could have caught him. Then, thank God, some woman saw him and grabbed him by the arm. He would have run straight into the train. He was always doing dangerous things. Even now when he rides his bike he'll just ride right out onto the street. Right now he's grounded from riding his bike until he can be safer. Billy's mother said she never thought too much about Billy being extremely busy and oblivious to dangerous situations until he went to Kindergarten. At that time Billy's teacher expressed some concern to her about his inability to sit still and focus. The school put Billy on a "special program" for that, but Billy's mother said that she didn't think it worked becuase his Grade One teacher expressed the same concerns. It got so bad that when I used to pick Billy up I used to hide in the bushes across the street. I didn't want to talk to the teacher. I used to whisper from the bushes for Billy to get over here. Then they told us that Billy couldn't bring his toy guns and knives to school anymore. And they didn't want him to wear his army clothes either because they said he had such a vivid imagination and that he thought he was a soldier all the time. I remember his dad had just bought him those clothes and Billy 106 was so proud of them. I had to hide all that stuff because it was such a fight to get him to leave it at home. Billy's mother went on to say that she could see the school's point about not taking the guns to school, but that Billy's father had just laughed and said that they were just toys. She said that Billy's father liked guns and one of the things Billy did with his dad was to go to the shooting range. I did not get the impression that this activity was a consistent pasttime for Billy and his father however. Indeed, later in the interview it became clear that Billy and his father actually spent very little time together. When Billy's mother was asked how she sees and feels about her son now she responded by saying that he made her laugh, that he really was a good kid. She was greatful that people like myself were around to help Billy at school, that he enjoyed going to school now, and that it wasn't the battle it used to be to get him there. She said several times during that segment of the interview that "Billy really makes me laugh". She was not forthcoming with any other descriptors of her son however. During the interview we also touched on Billy's relationship with his father and his sister. It was stated that because of the work hours of the father Billy actually spent very little time with his dad. Billy's mother said that sometimes on the weekend they'd go to the shooting range together, but that the dad didn't really know how to handle Billy very well so she did most of the parenting. He's always at work when the kids come home from school so I'm the one who has to put up with their fighting and punish them. By the time he gets home they're in bed, and then he's still asleep when they leave for school in the morning. So Billy doesn't really see much of his dad. He doesn't have much patience with their fighting all the time anyway...so maybe it's better that he's not here. Hey, listen, if you've got any ideas about how the kids could get along 107 better I'd like to know them. We ended the interview by talking about what a learning disability was and what attention deficit hyperactivity disorder was. Billy's mother acted as though she had never heard of these terms before. This surprised me as all of Billy's previous school reports had made reference to such terms in relation to Billy. Discussion The information gathered from the interview with Billy's mother supported my observations of Billy during therapeutic sessions. Billy's lack of impulse control seemed to have been manifesting itself over time in every aspect of his life. He had experienced aggressive behaviour from infancy in the form of sibling rivalry at the least. Other social family interactions during infancy, toddlerhood and early childhood did not appear to take on a positive tone. There seemed to be inconsistency and incongruency in the early parenting. It is questionable whether Billy's father was even around during that time. The present parenting experience for Billy also appeared to be devoid of clear and consistent boundaries. Bowlby (1969) considers the quality of social interaction between parent and infant to be most important for healthy emotional development of the infant. The emotional mood and interactive pattern experienced by the infant becomes internalized and these form the basis of the inner working models of self and self in relation to others for the developing child. The lack of congruence between the parents and their inability to support each other in their parenting roles would affect Billy's experience of their availability to him when in need. This, in turn, would create an insecure behavioural pattern in Billy. 108 This inconsistent availability and modelling seemed to cause frustration and anger in Billy which contributed to his difficulty in learning how to problem solve effectively. Over time, Billy's frustration and feelings of failure and unworthiness, developed into a negative emotional affect full of hostility and rage. Billy's less than fulfilling relationship with his father was also apparent in the contents of the interview. During sessions together when Billy spoke about his father he would say that his father was a real grouch and was always getting mad at his mom for spending money on cigarettes and things like that, yet his dad bought cigarettes also. He talked about his parents keeping him awake at night with their "arguing and screaming". Billy would also talk about his father promising to enroll him in sports like hockey and karate "when he gets the money together". Then he'd go on to say that the only thing his dad cared about was his broken down bike (motorcycle). The interview clarified for me that Billy's attempts to get the attention of his father through showing an interest in the types of things that he perceived impressed his father (ie. guns) were in vain. His father seemed to periodically express an interest in Billy but was unable to sustain interest in his child. Billy's experience of his father was one of never kept promises, of never having time for his son. Some of Billy's inappropriate interests and behaviours seemed to be connected to his desire to get his father's attention and approval. It was also clear from the information obtained during the interview that Billy's relationship with his sister was a volatile one. The continual conflict between the two of them seemed to reinforce Billy's negative emotion. Billy's mother seemed 109 genuinely concerned about the sibling fighting, but appeared to lack the skills to deal with it effectively. The lack of success Billy constantly experienced in his primary relationships gave him no sense of worthiness or respect for his feelings. Childcare Worker The results of the School Observation Rating Scale (see Appendix A) as rated by the childcare worker assigned to Billy's special classroom are presented as follows: Enthusiasm: Initial: 2 End: 4 Attention Span: Initial: 1 End: 3 Social Skills: Initial: 1 End: 3 Popularity: Initial: 2 End: 3 Help Seeking/Dependence: Initial: 4 End: 5 Compliance: Initial: 2 End: 5 Negative Emotion: Initial: 2 End: 4 Anxiety: Initial: 3 End: 5 Billy showed growth and improvement across all eight scales which supported that there had been internal change in Billy. The childcare worker felt Billy's high level of compliance resulted from the feelings of security and support offered to Billy during his school day. Because Billy had learned he could rely on and trust in the helping adults in his school he was able to maintain control over his aggressive impulses when he was experiencing a difficult time. He was not yelled at during these times, but rather listened to. Then problem solving could begin. Such results indicated very strongly that Billy's internal working model of self, self in relation with others, and ego strength had grown and transformed sufficiently to permit Billy to experience new perceptions of himself and others. This internal change manifested itself through a more positive self-image, a growing confidence in Billy that 110 he could control his behaviour, and a curiosity and motivation to learn while at school. This enabled him to adapt and interact more constructively in his school environment, with peers and adults alike. 111 CHAPTER V DISCUSSION The purpose of this study has been to explore and understand the etiology and management of a child with severe behaviour disorders. This chapter will present the main findings of this exploration as depicted through the process of change over a two year therapeutic period for a child with severe behaviour disorders. Included will be a discussion on verbal interventions used, as such interventions were significant in influencing the process of change for this child. Following, a discussion of the implications of these findings for those working in the educational field, specifically for the special education teacher and school counsellor who work with this type of child, will be presented. Finally, a review of the methodology used for this study, including recommendations for the future, will be presented. The Process of Change The initial assessment picture Billy presented revealed that his experience of the world was one of ongoing frustration and failure, both in his interactions with others (adults and peers) and concerning his own competence. Because of his impulsiveness, aggressiveness, lack of social skills, and associated learning problems he had not been able to master school situations or family interactions. This had created an angrily dispondent child, full of negative emotion. Conflicts were dealt with through acting out in socially unacceptable ways. The frustration and anger he induced all around him caused his fantasies of being unloved, uncared for and misunderstood to become actualized. 112 Therefore, the problematic experiential world of Billy unfolded against a background of disturbances both in interpersonal relationships and within his internal representational working model of the world. It was necessary for therapeutic interventions to focus on Billy's insecure attachment pattern and his negative internal model of self to help transform his social understandings and experience. Because of deficits in his sociability, aggressive impulses were not being sufficiently processed through inner structures causing Billy's actions upon those around him to result in negative feedback, thus, further leading to an image of himself as rejected and unloved. The cycle was perpetual. The attachment sensitive therapeutic approach used emphasized the need to restructure the life experience of Billy to give him a more positive experience, as well as transform the internal representational model of himself as being worthy and lovable. During the initial phase of the therapeutic process the goal was to establish an alliance in a secure and predictable environment so that Billy's concerns could unfold. By setting basic limits of safety, and by showing unconditional acceptance and positive regard Billy was able to explore his aggressive and destructive inner world. The rage and hostility Billy displayed during his play and art gradually became tempered as he began to feel safe within the therapeutic environment. My conveying of acceptance of the full range of Billy's behaviour and feelings was important during this time so that Billy could also become more accepting of himself. Billy's realization of my capacity to tolerate the negative self-representations he projected and the sense of safety he felt within the therapeutic environment allowed for 113 us to have a shared experience. With that came the opportunity for Billy to develop an increasingly complex internal working model of his world and to strengthen ego functioning. The goal in the working phase was to help Billy expand his spectrum of coping strategies, to increase his ability to play and talk, and to become more overtly aware of the meaning of his behaviour. Whereas Billy had demonstrated an impaired capacity to use play for interacting and sharing with others during the initial phase of treatment, he began to show the capacity to express his play in more constructive ways during the working phase. Play began to increasingly fulfill the needs of gratification and communication for both of us. The repetitive, impulsive actions gave way to an expression of feelings using actions and words. Play was monitored carefully to allow for a gradual increase in material that heretofore had not been experienced. Through continued support, encouragement, and careful suggestion of play activities the goal was to expand the length and scope of play interactions. Billy's play behaviour and art during this time indicated that intrapsychic change had occurred in his internal representational model. No longer did his play and art serve to primarily discharge aggression. Rather, it had a structure around it indicating cognitive functioning and a more complex inner world that could tolerate and identify with the use of words instead of actions. This represented itself through Billy showing greater control, a more positive affect and an enhanced self-image. The goals in the ending phase of the therapeutic process were to consolidate and strengthen the gains that Billy had made. Billy's play and art during the ending 114 phase predominantly reflected a sense of mastery, self-control, and worthiness; of autonomy. He naturally chose to spend time talking directly about issues and engaging in age appropriate reciprocal "sports" play (eg. hockey). He had made a group of friends at school with whom he consistently participated in peer activities without requiring adult supervision. His classroom behaviour had altered significantly enough that he was able to function in a regular age/grade appropriate classroom with learning assistance support. Whereas at the onset of therapy Billy had been aggressive and violent in peer and adult contact, he now showed a clear confidence and sociability. The process of change seen in Billy was a decrease in his pattern of ongoing disruptive behaviour and an increase of adaptive functioning. The therapeutic relationship provided the secure base Billy needed in order to explore and transform his internal working model of self and self in relation to others. By not reacting to his provocations with criticism and hostility our relationship grew, which had the effect of strengthening Billy's ego. The consistent empathy and realistic hopefulness provided in the therapeutic setting gave Billy the opportunity to test out and discard old internal models of self and become aware of distorted perceptions. Billy had to first become aware of his misperceptions of me, and then gradually of others. With this ability to make these new differentiations came the opportunity to express feelings and experiences in relationship with me. My job was to clarify, confront, and to some extent, interpret Billy's experiences to thereby enable him to expand his capacity for play and to channel acting-out behaviours into the realm of symbols and words. 115 The supports to the internal model and ego of Billy stemmed from the experience of being empathized with, approved of, and encouraged by an adult. In the place of internalization of bad images a modification or transformation took place whereby both bad and good images were able to be integrated into Billy's internal model of self. Billy became much more capable of monitoring, correcting, and rewarding his own behaviour. As such, both impulse control increased and self-esteem improved. These achievements enabled Billy to improve his relations with the external world, to enrich his internal world by building new and more positive models of self and intimate relationships, and to increase and improve his social skills and sublimatory activities such as play, language, and sports. The improved ego functions of attention, concentration, memory, anticipation and planning that resulted all enhanced Billy's cognitive activity. Verbal Interventions A discussion of the process of change Billy experienced over the two year period would not be complete without some focus being given to the verbal interventions used during treatment. Language can have a magical, powerful meaning for children with conduct disorder or severe behaviour problems. This may seem surprising because such children are not usually verbal. It is "because of their inability to contain affective experience within the psychological realm, the words describing feelings or painful events may take on a reality that is as painful as the feelings or events themselves" (Kernberg & Chazan, 1991, p. 11). Therefore, the use of a hierarchy of verbal interventions during the therapeutic process was necessary to 1 1 6 help to increase Billy's ability to tolerate affects through the use of words rather than actions. During the initial phase verbal interventions ranged from ordinary social behaviour, such as greeting and leave-taking, statements relating to the therapeutic process, statements relating to useful factual information, to supportive and facilitative statements. Supportive and facilitative statements were not introduced into the therapeutic process right away. Billy's ability to communicate with language during our initial sessions together was very limited. Therefore, I relied heavily on social greeting behaviour, factual information, and statements relating to therapy. Such verbal interventions had the purpose of expressing respect for Billy and also of showing a lack of intimidation of him. As Billy became more comfortable and trusting of me he also became more receptive and tolerant of my use of language. He started to put his tough guard down so to speak. During our ninth session together I introduced supportive statements in the form of making a suggestion as to the direction I wanted our play to go. Billy showed a willingness to listen to my suggestion and to implement it with some modifications. I felt that this was a significant moment for us as Billy was beginning to show a desire to communicate with me through the use of words. Billy's ability to express himself both nonverbally and verbally began to increase. Soon thereafter I began to use facilitative statements to help the dialogue being created between us continue to flow. During the working phase supportive and facilitative statements were used frequently with the purpose of helping Billy to verbalize his thoughts and feelings. Our 117 conversations lengthened as we began to talk about "here and now" issues happening with Billy outside the therapeutic environment. It was important for Billy to begin to develop an appreciation for another person's point of view. To help facilitate this cognitive skill I began to use directing attention verbal intervention statements at this point. Directing attention statements helped to enhance Billy's self-observation and to become more aware that his thoughts, feelings, and actions were meaningful and had a direct impact on others around him. Directing attention statements were very useful during the working phase of the therapeutic process because of the difficulty Billy had with seeing himself as contributing to his own problems. However, interpretation statements were used to a much lesser degree for that very same reason; interpretations require a certain amount of introspection. Because Billy tended to externalize the source of the difficulties in his life he was not often open to interpretative statements. I was careful to use them only when his demeanor was quiet and calm. By the latter part of the working phase Billy's impulse control had strengthened and his ability to verbalize his thoughts and feelings had improved considerably both in the therapeutic environment and in the classroom. It was at this point that I introduced a prosocial instructional lesson into each of our sessions. The various prosocial skills covered with Billy are listed in the chapter on Methodology. Billy needed to learn the language on how to deal with the vicissitudes of school life. Through role play and discussion we practised what to do in different given situations. With support from the childcare worker and myself Billy was able to successfully 118 transfer these prosocial skills out into his natural environment. With each successful prosocial approach taken by Billy his confidence grew until he was consistently showing a clear sociability. During the ending phase of the therapeutic process verbal interventions continued to be directing attention statements, as well as review statements to help Billy see the changes that had occurred in his behaviour. Emphasis was placed on how positive behaviours resulted in positive outcomes. Also, supportive statements that offered encouragement and reassurance that his improved behaviours were permanent were used. All of these verbal interventions had the purpose of helping Billy to see that real change had occurred for himself and that he was ready to move on. The verbal interventions used throughout this study modelled a respectful way for human beings to communicate and relate with each other. This manner of verbal communication, in and of itself, conveyed the message to Billy that he was worthwhile and valued. Implications for the Educational Field The public school system is developing an increasing awareness and sense of responsibility for children who exhibit extremely inappropriate behaviour given the slightest situation. Such children cause emotions to run high. The stress that these severe behaviour disordered children cause, if not dealt with constructively, can take its toll on everyone in that school population; children and adult personnel alike. The energy, enthusiasm, and tolerance for ambiguity that adult personnel working with 119 severe behaviour and conduct disorder children must have is only the beginning of what is required to effectively maintain control and teach the essential skills these children need in order to grow in self-confidence, self-control, and trust in others. The climate of the school, and particularly the classroom, is extremely important to ensure effective learning for severe behaviour disordered children. It must be positive, supportive, healthy, and productive. Such children are typically insecurely attached and come from homes in which they have had to continually guard against physical hurt, rejection or psychological abuse. "In order for the child to feel safe enough to drop the usual patterns of defending against such assaults, then he or she must perceive an unconditional atmosphere of physical safety and acceptance" (Mills & Allan, 1992, p. 15). The special education teacher and school counsellor are in focal positions within the public school system to create the necessary atmosphere for growth for these children. Special Education Teacher Components of classroom climate that the special education teacher needs to address to ensure effective learning for severe behaviour or conduct disordered children are setting limits, safety (both physical and psychological), acceptance, and a sense of purpose. Setting Limits Clear and consistent rules and procedures must be established for the children to follow. As the children's ability to comply with the limits set increase, then limits may be refined. However, underlying these limits, one rule that must be enforced from the 120 very beginning by all school personnel is that "People are not for hurting" (Rockwell, 1993, p. 5). Any acts of physical aggression by these children toward other children or adults must be stopped. The school must establish guidelines for handling physical aggression. By using de-escalating strategies such as physical proximity, verbal interventions, and redirecting of attention, the teacher may do a great deal to prevent the physical aggression. Also, by arranging the classroom supplies and furniture in a thoughtful, creative way, by remaining calm in spite of the upsetting behaviour, and by being constantly alert for signs of potential trouble the teacher may be able to prevent physical aggression from occurring. Safety Safety must be the number one priority in a classroom for severe behaviour or conduct disordered children. Because these children have such poor impulse control, a low tolerance for frustration, and act out with physical aggressiveness, the classroom can be a potentially hazardous place. Physical Safety The physical environment of the classroom can help prevent problems. By arranging desks so that children have adequate space around them may help. If children are seated close enough so that they can touch each other without getting up then hitting and stealing problems could escalate. Also, items not in immediate use in the room need to be kept on shelves or in cabinets away from the children. Angry children may throw whatever they can get their hands on; the more they throw the more rewarding (and potentially harmful) is the tantrum experience. Scissors and 121 other sharp school supplies need to be kept out of reach of the children. By making it clear that certain areas of the room are used for specific activities the children will also get a sense of physical safety. For example, desks are for work, the rug is for group discussion or play for a maximum of two people, the painting area is for painting for a maximum of one person, the round table is for instructional group activities or play for a maximum of two people, the time-out area is for cooling off and thinking, etcetera. Pychological Safety Psychological safety and trust are interrelated and inseparable. In order for a child to learn effectively as a member of a classroom group, a sense of trust and safety in self and others must be established. A highly structured and predictable routine is very helpful in developing a sense of trust. Because many children with severe behaviour disorders also have learning and attention problems, daily routines must be predictable in order for a sense of trust in the teacher and in themselves to develop. Every effort to follow the daily routine must be made and any changes in routine need to be clarified in advance whenever possible. Other ways of establishing trust in the classroom include being honest and as good as your word, being consistent with handling non-compliant behaviour, using language that conveys understanding and acceptance, structuring academic assignments for success, and using rewards and consequences that relate logically to actions. Just as consistency, predictability, and acceptance are imperative to developing a trusting relationship in a therapeutic sense with these children, such is 122 also the case in the classroom. Acceptance It is not only important to accept the different temperaments, abilities, and personal strengths and weaknesses of the children with whom a teacher is working, but it is also important to accept the limitations of the environment. That is to say that to the severe behaviour children, a teacher's acceptance of them means that he or she is fair, consistent, and professional and predictable even when they have tested his or her tolerance unmercifully. But acceptance also means a willingness to provide mutual support to co-workers such as childcare workers, learning assistance teachers, or counsellors who are also often involved with these children. Acceptance also means that the individual teacher working with such children be aware of his or her own personal strengths and weaknesses. These children require a great deal of mental and emotional stamina and signs of stress need to be heeded. Acceptance in the classroom of the children by the teacher will gradually lead to acceptance by the children of themselves and each other. One way the teacher may convey acceptance in the classroom is through using language to describe unacceptable behaviour but refraining from using language that attacks the child's sense of self-worth. For example, "I can tell that you are very upset right now because you are kicking the chair. Chairs are ment for sitting on. I wonder if you could use your words to help me understand why you are so upset?" The importance of the type of language, of verbal interventions, used with these children has already been emphasized. These verbal interventions are very useful as a way of developing 123 acceptance and trust between the special education teacher and these children. Another important way a teacher can show acceptance is when a class is having difficulty accepting other classmates due to their inappropriate behaviour, give them time to vent their feelings in appropriate and constructive ways, for example, through a class meeting with the teacher as the facilitator. By respecting their right to feel the way they do, the teacher will have a much better result when enlisting their co-operation to help deal with the inappropriate child. Rewarding the class for responding appropriately to the child who is acting inappropriately, along with repeating the discussion process as needed, will strengthen the tolerance of the class for disruptive behaviour. The children will learn quickly to remain in control in spite of another's actions. Being out of control is a frightening and well-known experience for them all. By creating this kind of atmosphere for these children they will begin to internalize that they are safe and, no matter what, they will not face humiliation. With time, problems will not escalate as quickly, and they will be resolved more effectively with the use of language rather than action. Some other ways a teacher may convey acceptance to severe behaviour children is by recognizing special occasions such as birthdays with a card or cake, making periodic phone calls home to discuss positive behaviour, taking an interest in their personal interests, or by writing a note to a child complimenting a positive behaviour. There are many stresses involved in managing a class of children with severe behaviour disorders and a teacher has a very powerful tool in the ability to show acceptance, both verbally and non-verbally. 124 Sense of Purpose Children with severe behaviour and conduct disorders bring many negatively charged preconceptions about themselves, teachers, and school into the classroom. By creating a sense of purpose, that is, that the classroom is a place for learning and that participation in learning activities is expected, is important. It must be done through positive, constructive activities and assignments that are tailored to ensure the children experience success in learning. A time table clearly visible and consistent from one day to the next will help the children learn to know what is expected of them. By structuring lessons to resemble those in regular classrooms the children will also get a sense of achievement. The lessons must be designed with success in mind however, or the child is likely to shut down and become defiant with statements like "make me" or "I can't". In essence, the more secure children feel in their environment the more curious and, therefore, motivated they will be to learn. Behaviour Management Another effective intervention a teacher working with severe behaviour children may use is a classroom behaviour management plan. Such a plan needs to be used on an ongoing daily basis and is very helpful in ensuring that the above mentioned components of a positive classroom climate are actualized when trying to meet the needs of severe behaviour and conduct disorder children in school. A point system, play money, tokens, bank accounts, a classroom store, time-outs, and special activities are all possible techniques that may be used within a behaviour management plan. The general guidelines for a behaviour management plan include: 125 1. Keep it simple, clear, and concrete. 2. Make all positives contingent on appropriate behavior. 3. Keep students' responsibility and power of choice at the core of each part of the plan. (Rockwell, 1993, p. 29) The purpose of the behaviour management plan and the techniques involved in implementing it are to act as reinforcers of appropriate behaviour. The emphasis is on prevention of inappropriate behaviour through the rewarding of appropriate choices. The children all need to be told and made aware before a problem arises what rewards and consequences are available to them. They then decide which one they want to earn. Behaviour management techniques are very useful in helping a teacher avoid power struggles, deal with profanity, and in giving the children a sense of their own responsibility and choice in how they behave. The above mentioned strategies, techniques, and interventions will all go a long way in creating a positive and supportive school setting for these children. But, of paramount importance for a teacher of severe behaviour and conduct disorder children to remember, is that the real growth for these children occurs through relationships. School Counsellor The school counsellor is also in a position to create a positive and supportive school experience for children with severe behaviour and conduct disorder. In discussing the role of the counsellor I will address individual treatment for the child, how the counsellor can support the special education teacher, and parent involvement. 126 Individual Counselling A school counsellor working with a severe behaviour child must be prepared to commit to the therapeutic process for an undetermined length of time. Unlike other children that a counsellor may also be working with, these children have built up so many ego defenses against their pain and trauma that they do not readily enter into a therapeutic relationship. These children often enter the therapeutic environment showing little ability or will to initiate conversation or interactive play (Mills & Allan, 1992). Therefore, it is important for the counsellor to maintain patience and show an unconditional positive regard for the child as a genuine, valid person. It is felt that one of the strengths in the methodology outlined in this study was in the area of individual counselling for a child with severe behaviour or conduct disorder. It is the opinion of the author that if school counsellors working with severe behaviour children used a similar approach with regard to individual counselling they would experience success in helping these children become more self-confident and show a greater ability to concentrate and learn in the classroom. It is felt that the primary focus when working one-on-one with this type of child needs to be that of creating a positive attachment figure for the child. "The alive relationship between the therapist and the child is the essential dimension, perhaps the only significant reality, in the therapeutic process and in all interhuman growth" (Moustakas, 1959, p. ix). Teacher Support The school counsellor may support the special education teacher working with severe behaviour children through the individual counselling process, but also by 127 implementing and co-facilitating in a prosocial skills group for these children. Prosocial skills need to be taught to these children just as reading and math need to be taught. Through collaboration with the teacher the counsellor can determine which skills are weaker than others for the group. A consistent schedule where the counsellor introduces and teaches the skills would need to be established. Because these children manifest such severe social skill deficits, a biweekly schedule would be preferable to a weekly schedule if it were at all possible. Along with being responsible for implementing a social skills program the counsellor is also in a position to help reinforce the transference of these skills out onto the playground. Children with severe behaviour and conduct disorders need the opportunity to practise a prosocial approach to the vicissitudes of school life. The counsellor can model and help the children to implement the skills when they are in their natural environment during recess and lunch breaks. These children need this kind of support. As well, such adult support will ensure safety for all. Through maintaining a high profile in the school environment as a whole the counsellor is also in a position to model appropriate verbal interventions when helping a severe behaviour or conduct disorder child. All adult personnel within a school need to understand the importance of approaching these children in a consistent manner. A calm, respectful communicative manner is imperative when helping these children problem solve because of their aggressive, explosive nature. The school counsellor has a responsiblity to create awareness, and possibly instruct adults working in the school, on how to effectively approach and deal with these children, including the 128 administrative personnel. Parental Involvement While individual counselling and teacher support are important roles counsellors may have in their involvement with severe behaviour disordered children, the role of being a liaison between home and school for these children is also extremely important. The inescapable truth is that many of these children are in dysfunctional family situations and that is what they go home to every day. The school counsellor is in a legitimate position to inquire into the sanctity of the home. Through meeting with and developing a rapport with the parent(s) of a severe behaviour disordered child the counsellor is able to assess how to approach the management and monitoring of the defiant child outside school hours. The objective of the counsellor is to guide the parents in their parenting approach so that they too experience a more harmonious and co-operative home life with their child. It may be that the counsellor would work with the parents him or herself, or recommend a parent training program available in the community. As can be seen, the role of the counsellor who works with a severe behaviour disorder child is all encompassing and diverse depending on what aspect of the child's world is being focussed on. The commitment to the therapeutic process can be very long term in comparison with other children that counsellor may also be involved with in the school population. The counsellor, more than any other school personnel, is aware of the significance of early aberrant relationship patterns to long term mental health and that these children are not "bad", but in need of professional intervention. 129 The counsellor is the one who can assist other adults in the child's world to understand this. Review of Methodology In reviewing the methodology of this study a real strength and a lot of emphasis was on the individual therapeutic process. The growth and development of a secure attachment between Billy and myself effectively produced significant change in Billy's inner working model of self whereby he was able to discard old misperceptions and replace them with new, more socially adaptive ones to the extent that he was able to have a more successful school experience. However, an area of weakness in the methodology of this study was that of parental involvement. Some discussion of this is necessary in terms of implications for the future. According to attachment theory maladaptive behaviour is often inadvertently developed within the home and sustained by maladaptive parent-child interactions (Bowlby, 1988). A common result of these maladaptive patterns of interaction is the development of insecure attachments between the parent and child. An insecure avoidant attachment pattern can manifest itself through severe behaviour and conduct disorder. Parents of children with severe behaviour disorders often engage in parenting practises that promote aggressive behaviour and suppress prosocial behaviour. These practises may include directly reinforcing deviant behaviour, making frequent and ineffective use of commands and punishment, failing to attend to appropriate behaviours, and the giving of inconsistent messages, as were the parental practises 130 gleaned from this study. A focus on teaching Billy's parents effective ways of interacting with their child would need to be included in the methodology of this study to help create and enhance the growth of a secure attachment between themselves and their child. Therefore, for the purposes of future consideration, I would have conducted parenting sessions with Billy's parents that included both a general description of how misbehaviour occurs within a family (this would have naturally addressed the sibling discord), and given some direct training in a number of discrete parenting skills using examples from their home situation. Another area of concern that needed to be addressed through parental involvement and was clearly evident through the interview with Billy's mother, was the interpersonal processes between the parents and the parents and their children. Several characteristics of Billy's family life, including a high degree of hostility and negativism during parent-parent and parent-child interactions, criticism and indifference among family members, and low family cohesiveness and positive attention, all may have related to Billy's aggression. This study has made it clear to the author that parental involvement when working with a severe behaviour disorder or conduct disorder child needs to be as much a priority as the individual therapeutic process itself. The hope would be that "as a consequence of the increased competence in parenting skills, it is expected that the parents' frustration tolerance will increase along with their enjoyment of their child. The result would be a heightened sense of parental competence and the development of a secure attachment between parent and child" (Kernberg & Chazan, 1991, p. 117). 131 It is clear that the family offers one of the most powerful influences in one's life. It affects past, present, and future development. "The family shapes the fiber of people's beings in a way no other social force can begin to realize" (Framo, 1981, p. 205). It is felt that providing the therapeutic environment necessary for the development of a secure attachment between Billy and myself was only a part of the whole required to give Billy every opportunity to experience a happy existence. Although tremendous change occurred as a result of the experience of a positive therapeutic attachment figure in his life, the ultimate sense of emotional well being for Billy would be the experience of a positive, secure attachment between himself and his parents; between himself and his family. 132 References Ainsworth, M.D., Blehar, M.C., Waters, E. & Wall, S. (1978). Patterns of attachment. Hillsdale, New Jersey: Lawrence Erlbaum Associates. Ainsworth, M.D., Blehar, M.C., Waters, E. & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. 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Paper presented at meeting for Professional Growth for Educators, Victoria, B.C. 136 APPENDIX A School Observation Rating Scale Reproduced with permission by: Byron Egeland from the "Minnesota Longitudinal Study of High Risk Children" * • 137 THE UNIVERSITY OF BRITISH COLUMBIA < Department of Counselling Psychology Faculty of Education 5780 Toronto Road Vancouver, B.C. Canada V6T 1L2 Tel: (604) 822-5259 Fax: (604) 822-2328 Dear Teacher, Thank you fo r agreeing to complete th i s r a t i n g scale on your student. The attached forms provide eight d i s t i n c t categories in which to rate a c h i l d in the classroom s e t t i n g . For each category, read the alternate descriptors c a r e f u l l y and c i r c l e one category/ number that best describes the c h i l d as he or she presents in your classroom and the school s e t t i n g . Your r a t i n g of . now and at two add i t i o n a l times during the year w i l l provide a measure for me to p a r t i a l l y evaluate the impact of play therapy upon t h i s c h i l d ' s sense of s e l f and r e l a t i o n s h i p with others and the learning environment. SCHOOL OBSERVATION RATING SCALE Child's Name Date. School and D i s t r i c t / Teacher Grade Scores; Enthusiasm (p.2) . Attentions Span <p.3) S o c i a l S k i l l s (p.4) Popularity <p.5> Help Seeking/ Dependence(p.6) Compliance Cp.7) Negative Emotion <p.8) Anxiety <p.9> Teachers general observations about c h i l d ' s s o c i a l i n t e r a c t i o n , s e l f esteem and confidence. 138 SCHOOL OBSERVATION RATING SCALE Enthus iasm D e s c r i p t o r s and i n s t r u c t i o n s T h i s ' s c a l e a s s e s s e s the i n t e r e s t * v i g o r and eagerness with which the c h i l d approaches l e a r n i n g t a s k s and c l a s s r o o m a c t i v i t i e s . B e h a v i o u r a l s i g n s of enthusiasm i n c l u d e (but are not l i m i t e d to) q u i c k n e s s to b e g i n work, frequency of v o l u n t e e r i n g to p a r t i c i p a t e or to respond to t e a c h e r d u r i n g teacher-guided a c t i v i t i e s , e n e r g e t i c movements ( p u r p o s e f u l , t a s k - o r i e n t e d ) , v o c a l i n f l e c t i o n , ' f a c i a l e x p r e s s i o n s (e.g. wide eyes, s m i l i n g ) . At the h i g h end of the s c a l e the c h i l d takes an a c t i v e i n t e r e s t i n classroom a c t i v i t i e s , invests' e f f o r t i n them, and appears to enjoy and a p p r e c i a t e h i s / h e r s u c c e s s e s . ( I t i s important to note t h a t h i s s c a l e i s concerned with enthusiasm f o r l e a r n i n g t a s k s and planned a c t i v i t i e s in the c l a s s r o o m , not enthusiasm f o r o f f - t a s k b e h a v i o r s or g e n e r a l p o s i t i v e a f f e c t which i s not focused on classroom a c t i v i t i e s . ) 1) T h i s c h i l d shows v i r t u a l l y no enthusiasm. S/he may seem very h e s i t a n t to engage In c l a s s r o o m a c t i v i t i e s , may not p a r t i c i p a t e a t a l l , o r may p a r t i c i p a t e i n a mechnical f a s h i o n with no evidence of being i n t e r e s t e d . Even i n what would be c o n s i d e r e d fun o r h i g h i n t e r e s t a c t i v i t i e s f o r c h i l d r e n t h i s age. T h i s c h i l d shows no p l e a s u r e or excitement, nor does the c h i l d express p l e a s u r e In h i s / h e r accomplishments. 2) T h i s c h i l d i s g e n e r a l l y not e n t h u s i a s t i c . T h i s c h i l d does take some a c t i v e i n t e r e s t i n a c t i v i t i e s and i n a few i n s t a n c e s (e.g. a p a r t i c u l a r l y s t i m u l a t i n g a c t i v i t y ) may show a glimmer of enthusiasm, but the c h i l d mostly Is r e s t r a i n e d or shows a s u p e r f i c i a l , u n i n v e s t e d a t t i t u d e toward what goes on i n the classroom. 3) T h i s c h i l d shows some c l e a r moments of enthusiasm and a c t i v e engagement in classroom a c t i v i t i e s , but p r i m a r i l y s/he does not engage the s i t u a t i o n i n t h i s way. 4) The c h i l d shows a mixture of enthusiasm and e i t h e r r e s t r a i n e d or s u p e r f i c i a l , u n i n v e s t e d b e h a v i o u r . T h i s may occur because the c h i l d i s slow i n "warming up" to the task or because h i s / h e r enthusiasm waxes and wanes and i s not r e l i a b l y i n v e s t e d i n a c t i v i t i e s . 5) T h i s c h i l d b a s i c a l l y i s i n t e r e s t e d i n the t a s k s and a c t i v i t i e s , showing s u s t a i n e d moderate enthusiasm i n most s i t u a t i o n s and/or r e a l exuberance i n some s i t u a t i o n s . While there may be o c c a s i o n a l s i t u a t i o n s i n which the c h i l d appears bored or d i s i n t e r e s t e d , s/he approaches most a c t i v i t i e s w i t h v i g o r and shows p l e a s u r e and excitement i n what i s g o i n g on. 6) T h i s c h i l d show no t a b l e enthusiasm f o r v i r t u a l l y a l l a s p e c t s of s c h o o l l i f e . The c h i l d d i v e s i n t o t a s k s e a g e r l y , shows c l e a r p l e a s u r e and excitement i n accompllshements, and s u s t a i n s a c t i v e , e n e r g e t i c p a r t i c i p a t i o n i n n e a r l y a l l c l a s s r o o m a c t i v i t i e s . 139 SCHOOL OBSERVATION RATING SCALE Attention Span Descriptors and instructions This scale is concerned with attentiveness as manifest in such behaviours as eye contact when: teacher is t a l k i n g , looking at and working with appropriate materials and objects during academic task3 or classroom s o c i a l a c t i v i t i e s . (Enthusiasm for tasks is rated in another scale and should not influence t h i s r a t i n g ) . 1) This c h i l d has an extremely b r i e f a t t e n t i o n span. S/he is e a s i l y d i s t r a c t e d and/or daydreams frequently. S/he may be r e s t l e s s and fidgety or may simply "tune out" and stare into space. This c h i l d e a s i l y loses interest in t o p i c at hand; even a c t i v i t i e s which are highly structured and those which would seem to be most engaging for a c h i l d t h i s age and even when there are no apparent external d i s t r a c t i o n s . Whenever attentiveness is required of t h i s c h i l d , d i s t r a c t l b l l l t y pervades. 2) This c h i l d has considerable trouble attending to school work and many classroom a c t i v i t i e s . S/he i s e a s i l y d i s t r a c t e d by noise or movement and In f a c t may appear d i s t r a c t e d even when there are no apparent external d i s t r a c t i o n s . Inattentlvene«s does not pervade a l l a c t i v i t i e s , in that t h i s c h i l d occassionally focuses his/her a t t e n t i o n for a limited time (e.g. on a topic of major interest or in a highly structured r e l a t i v e l y d i s t r a c t i o n free task). 3. This c h i l d has some d i f f i c u l t y attending to schoolwork. S/he sometimes concentrates and attends to work, but other times i s r e s t l e s s and fidgety or daydreams. Once d i s t r a c t e d , s/he probably has d i f f i c u l t y refocuslng on the task or a c t i v i t y at hand. 4) This c h i l d generally concentrates on tasks and speakers, but does show a few signs of d i s t r a c t l b l l i t y . These may occur p r i m a r i l y during s i t u a t i o n s which are taxing to the c h i l d , of r e l a t i v e l y l i t t l e i n t e r e s t , or loosely structured and perhaps over-stimulating. Once d i s t r a c t e d t h i s c h i l d may be slow to return to the task. 5) This child- has a good attention span, concentrating well on academic tasks and group a c t i v i t i e s . S/he loses that concentration only occasslonally and then only when there are c l e a r external d i s t r a c t i o n s or when a c t i v i t y is c l e a r l y boring or over-the-head of a c h i l d t h i s age. 6) This c h i l d c o n s i s t e n t l y concentrates on schoolwork and a c t i v i t i e s , remaining engaged in tasks and discussions as long as is expected. Only major Interruptions d i s t r a c t t h i s c h i l d , and even the s/he returns spontaneously to the task at hand. 140 SCHOOL OBSERVATION RATING SCALE S o c i a l S k i l l s Descr ip tors and Instruct ions This scale evaluates the q u a l i t y of the s k i l l s demonstrated by th is c h i l d in s o c i a l s i t u a t i o n s , regardless of the response s/he rece ives from peers (popular i ty Is assessed In another s c a l e ) . S o c i a l s k i l l s Include cour tesy , shar ing empathy, p o s i t i v e I n i t i a t i o n of Interact ion with peers , appropriate response to others .attempts to i n i t i a t e In te rac t ion , e f f o r t s to resolve s o c i a l c o n f l l e t s , -and leadership In group s i t u a t i o n s balanced by a cooperat ive w i l l ingness to cons ider o thers ' ideas . 1) This c h i l d lacks even the most bas ic s o c i a l s k i l l s . This" may be the withdrawn, s o c i a l l y Isolated c h i l d px the c h i l d who Is c o n s i s t e n t l y a b r a s i v e , aggress ive , and of fens ive to others or the c h i l d who behaves In an absurd, s i l l y , or e c c e n t r i c manner to the exc lus ion of appropriate s o c i a l In te rac t ions . For whatever reasons, t h i s c h i l d f a l l s to make appropriate attempts to Interact , responds to peers Inappropriately or not at a l l , and d i s p l a y s no empathy or s e n s i t i v i t y to o thers . Such a c h i l d seems not to p r o f i t at a l l from feedback about h i s / h e r poor s o c i a l s k i l l s . 2) This c h i l d o c c a s i o n a l l y "connects" with others in appropriate s o c i a l i n t e r a c t i o n , but usua l ly only in a c a r e f u l l y s t ructured s o c i a l s i t u a t i o n or with c l e a r guidance from an a d u l t . This c h i l d is inept and/or Inappropriate in l e s s s t r u c t u r e d , more spontaneous s o c i a l s i t u a t i o n s . S/he demonstrates no rea l s k i l l in r e s o l v i n g c o n f l i c t s nor does s/he show age-appropriate shar ing or s e n s i t i v i t y to o thers ' f e e l i n g s . Again , th is lack of s o c i a l s k i l l s may be r e f l e c t e d in over t l y o f fens ive behaviour or in s o c i a l i s o l a t i o n . 3) This c h i l d genrea l ly is not inappropr ia te , but seems somewhat awkward or uncomfortable in s o c i a l s i t u a t i o n s . S/he may be hesi tant or unsure of how to behave in some s i t u a t i o n . S/he may show some lack of s e n s i t i v i t y ( e . g . t a c t l e s s , perhaps harsh behaviour; lack of response when someone is hur or t roub led ) . S/he may in teract wel l when things are going smoothly, but is thrown by complexity or c o n f l i c t . 4) This c h i l d i s r e l a t i v e l y s k i l l e d . S/he i n i t i a t e s and responds to s o c i a l i n te rac t ion in appropriate ways. S/he makes some reasonable attempts to resolve c o n f l i c t s and appears to consider o ther ' s f e e l i n g s , but perhaps does not have a wide reper to i re of behaviours to use In such s i t u a t i o n s . This c h i l d may appear more s k i l l e d with adul ts than with peers . 5) This c h i l d demonstrates good s o c i a l s k i l l s In most s i t u a t i o n s . S/he genera l ly shows a balance of leadersh ip s k i l l s and a w i l l i ngness to consider o thers ' Ideas and f e e l i n g s . S/he Is s e n s i t i v e and empathlc and usua l ly connumlcates that concern to o thers . S/he is e f f e c t i v e in dea l ing with c o n f l i c t , but may o c c a s i o n a l l y show a s l i g h t lack of f inesses ( e . g . g i v i n g In too qu ick ly or. being a l i t t l e too pushy). 1 4 1 6) This c h i l d is remarkably s k i l l e d la s o c i a l s i t u a t i o n s . S/he comfortably i n i t i a t e s and responds to s o c i a l Interact ion with both peers and a d u l t s . S/he is notably cooperat ive and f l e x i b l e , but a l so can stand up for h i s / h e r own ideas and r i g h t s . S/he demonstrates rea l f inesse in negot ia t ing c o n f l i c t r e s o l u t i o n . This c h i l d shows c l e a r concern for the fee l ings and r i g h t s of o thers : s/he share w i l l i n g l y , expresses sympathy and o f f e r s help when someone is hurt or t roub led , and stands up for one who is t reated u n f a i r l y . . i: POPULARITY Descr iptors and Inst ruct ions This scale is concerned with how peers respond to a c h i l d , regardless of the s o c i a l s k i l l s that p a r t i c u l a r c h i l d d i s p l a y s . At the high end of the scale is the c h i l d who is c l e a r l y w e l l - l i k e d by a l l and at the low end is the apparently f r i e n d l e s s c h i l d who e i t h e r is scorned or v ic t im ized or is merely ignored. 1. This c h i l d has no apparent f r i e n d s . S/he may be scorned, v ic t im ized a c t i v e l y avoided, or simply ignored. At b e s t , t h i s c h i l d is to le ra ted by o thers . 2. This c h i l d o c c a s i o n a l l y is accepted by the group or perhaps has a l im i ted r e l a t i o n s h i p with one or two (probably equa l ly unpopular) c h i l d r e n . However, most classmates a v o i d , ignore or r e j e c t t h i s c h i l d . 3. This c h i l d is accepted by peers In some l i m i t e d fash ion . S/he is not t y p i c a l l y r e j e c t e d and may be a "tag along" with the group. This c h i l d is c l e a r l y not a leader and, in f a c t , is sought out by others r a r e l y , i f ever . S/he may p lay a negative ro le in the peer group ( e . g . may only be accepted as a clown or v i c t i m ) . 4. While t h i s c h i l d tends not to be a leader , s /he may be a s s i m i l a t e d into the peer group and has a s i g n i f i c a n t amount of s o c i a l contacts with o thers . T y p i c a l l y s /he ne i ther is re jec ted nor a c t i v e l y sought out . 5. This c h i l d is sought out by others and w e l l - r e c e i v e d when s/he i n i t i a t e s In te rac t ion . While not a " c l a s s s tar" t h i s c h i l d c l e a r l y has a s o l i d place in the s o c i a l s t ructure of the c lassroom. 6. This Is. the c l a s s s t a r . This c h i l d c l e a r l y is admired and sought out by other c h i l d r e n , is popular and w e l l - l i k e d . Other c h i l d r e n f requent ly i n i t i a t e contact with th is c h i l d . Peers f requent ly look at th is c h i l d , c a l l h i s / h e r name, s t r i v e to be near him/her . H i s / h e r i n i t i a t i o n s almost always are accepted p o s i t i v e l y . 142 SCHOOL OBSERVATION RATING SCALE HELP SEEKING/ DEPENDENCY Descr iptors This scale encompasses he lp -seek ing behaviours as well as attempts to engage the teacher in other ways ( e . g . seeking emotional support or sympathy; t e l l i n g s t o r i e s from home; t a t t l i n g on other c h i l d r e n ) . It includes boath a c t i v e , d i r e c t e f f o r t s to engage the teacher , as well as the apparent contingency of the c h i l d ' s behaviour on teacher a t ten t ion ( e . g . the c h i l d who does nothing u n t i l s /he rece ives personal encouragement or a reprimand from the teacher ) . This does not preclude the c h i l d ' s responding well to a t tent ion when i t is o f f e r e d . 1. This c h i l d seems almost t o t a l l y preoccupied with gain ing the teachers a t tent ion in one form or another. S/he r a r e l y , i f ever , works independently, asking ques t ions , seeking guidance, a t t e n t i o n , and encouragement even with the most bas ic t a s k s . And/or s/he f requent ly may seek sympathy or comfort from the teacher v i a p h y s i c a l compla ints , whining about work, t a t t l i n g about other c h i l d r e n . 2. t h i s c h i l d seems extremely dependent on the teacher for help and a t t e n t i o n , tu rn ig almost Immediately to the teacher before attempting anything on h i s / h e r own. Gaining the teacher ' s a t t en t ion in some form (sympathy, comfort , encouragement, advice) seems to be a major ob ject ive for th is c h i l d and e f f o r t s to gain that a t t en t ion in te r fe res with the c h i l d ' s funct ion ing in the c lassroom. 3. This c h i l d e x h i b i t s considerable he lp -seek ing or a t ten t ion-seek ing behaviour, and th is often occurs even dur ing rout ine tasks and when i t seems that the c h i l d should be able to funct ion without adult in te rvent ion ( e . g . questions about assignments; checking answers with the teacher; t a t t l i n g ; asking for in tervent ion when c o n f l i c t s f i r s t a r i se or when s o c i a l b ids are not rec ieved ; complaints about work or mild phys ica l compla in ts ) . 4. This c h i l d appears independent dur ing rout ine tasks and a c t i v i t i e s , but turns to teacher when faced with a cha l l eng ing or f r u s t r a t i n g academic or s o c i a l s i t u a t i o n . S/he probably seeks advice or encouragement before dea l ing with the s i t u a t i o n , but then moves on without much fur ther a t tent ion from teacher . A l t e r n a t i v e l y , t h i s c h i l d may not a c t i v e l y seek a t t e n t i o n , but may just look perplexed or uncer ta in about what to do, p a s s i v e l y wait ing for teacher encouragement before beginning tasks or dea l ing with a s i t u a t i o n . 5. This c h i l d o c c a s i o n a l l y seeks help or a t ten t ion from the teacher , but only In h ighly f r u s t r a t i n g or s t r e s s f u l s i t u a t i o n s and/or fo l lowing some attempts to deal with the s i t u a t i o n independently. 6. This c h i l d funct ions independently whenever capable . S/he exhausts h i s / h e r own resources before turn ing to the teacher . This c h i l d requ i res almost no guidance or s p e c i a l a t ten t ion from the teacher , but may respond favorably when such a t tent ion is o f f e r e d . 143 SCHOOL OBSERVATION RATING SCALE COMPLIANCE This scale measures the degree to which the c h i l d shows wi l l ingness to l i s t e n to the teacher 's ins t ruc t ions and to comply to h i s / h e r suggestions in a reasonable manner. This includes the teacher 's general ins t ruc t ions to the group, as well as ins t ruc t ions to the p a r t i c u l a r c h i l d . It includes p o s i t i v e d i r e c t i v e s as well as p r o h i b i t i o n s or reprimands ( e . g . , stop pushing; i t ' s not-t ime to play with cars now). The c h i l d descr ibed as non compliant may do so by overt r e j e c t i o n accompanied by verbal argument or expressions cf anger, or may simply ignore the teacher , look or walk away, c o n s i s t e n t l y ac t ing contrary to the teacher 's suggestions because of being involved in h i s / h e r own schedule of a c t i v i t y . 1. Very low. This c h i l d re jec ts or ignores near ly a l l d i r e c t i o n s of the teacher , c o n s i s t e n t l y re fus ing to obey. In e f f e c t , the c h i l d does almost nothing demanded of him/her. (This may be accompanied by overt expressions of anger or more s i l e n t res is tance of d i r e c t i o n ) . This c h i l d is of ten h igh ly manipulative or over t ly noncompliant in a r e s i s t a n t manner. 2. Low. There are occassional Instances of compliant behaviour, perhaps going along with teacher -d i rec ted group a c t i v i t y or y i e l d i n g to teacher 's d i r e c t i o n s a f t e r a long power s t r u g g l e , but t h i s c h i l d presents a predominantly r e s i s t a n t , noncompliant a t t i tude toward the teacher . 3. Moderately low. This c h i l d s t i l l shows a notable tendency toward noncompliance, but t h i s is mixed with e f f o r t s to fo l low suggestions and d i r e c t i o n s given by teacher. Though i t may require r e p e t i t i o n , persuasion* or f i rm ins is tence by the teacher , the c h i l d does comply in many instances. 4. Moderate. This c h i l d seems compliant toward most of the teacher 's demands and of ten is w i l l i n g to cooperate with the teachers plans and suggest ions, but the c h i l d ' s own schedule of a c t i v i t i e s s t i l l leads to noncompliance. The c h i l d does not seem s t rongly invested in r e j e c t i n g teacher 's d i r e c t i o n s , and episodes of noncompliance t y p i c a l l y are b r i e f and fol lowed by behaviour ind ica t ive of acceptance of the teacher 's l e a d e r s h i p . 5. High. This c h i l d complies with near ly a l l major d i r e c t i o n s of the teacher , e . g . , conforming to teacher d i r e c t e d group a c t i v i t i e s , making t r a n s i t i o n s from one a c t i v i t y to another when the teacher says to do s o , s tay ing on task or re turn ing to task at the teacher 's d i r e c t i o n , accept ing the teachers ideas on how to do tasks , and stopping an unacceptable behaviour when t o l d to do s o . This c h i l d o c c a s i o n a l l y may not comply with l e s s e r d e t a i l s or may sometimes hes i ta te b r i e f l y before complying, the c h i l d may be b r i e f l y noncompliant under unusual c i rcumstances, such as when hurt or unduly f r u s t r a t e d , but recovers q u i c k l y . 6. Very h i g h . This c h i l d a c t i v e l y or ients toward the teacher 's d i r e c t i o n s throughout the day and complies promptly with a l l h i s / h e r i n s t r u c t i o n s . The c h i l d c o n s i s t e n t l y heeds the teacher 's suggestions with a compliance that suggests a bas ic t rus t In h i s / h e r advice and d i r e c t i o n s and acceptance of h i s / h e r au thor i ty In th is s e t t i n g . The c h i l d may quest ion a d i r e c t i o n or suggest an a l t e r n a t i v e , but these behaviours r e f l e c t autonomy within a compliant o r i e n t a t i o n rather that in tent iona l negat iv ism. 144 SCHOOL OBSERVATION RATING SCALE NEGATIVE EMOTIONAL TONES This Is a p ro fess iona l judgment of the l eve l of negative fee l ings the c h i l d "car r ies around" with him/her . It is indexed by such behavioural s igns a s : interpersonal h o s t i l i t y , coldness toward o thers , d e l i b e r a t e l y noncompliant and uncooperative response to o thers , general demeanor and p lay themes in a c t i v i t i e s alone and with o thers , c r y i n g s u l l e n e s s , whining, pout ing , or somber a f f e c t . This scale whould r e f l e c t the emotional tone of the c h i l d ' s fee l ings rather than the s e v e r i t y of e f f e c t s on others ( e . g . , a c h i l d may be very aggressive but have less h o s t i l i t y than a s u l l e n , withdrawn c h i l d ) . Whether one sees overt d i s p l a y s of n e g a t l v l s t l c behaviour or more d i r e c t and covert forms may be a funct ion of the c h i l d ' s l eve l of ego c o n t r o l . The observer should attempt to judge the underly ing q u a l i t y of the c h i l d ' s in ter and lntrapersonal negative f e e l i n g s over t ime. 1. Very h i g h . This c h i l d d i s p l a y s negative emotion to such an extreme that c l i n i c a l Intervention might be warranted on the bas is of such behaviour. Whether exempl i f ied by extreme aggression and h o s t i l i t y , by s u l l e n withdrawal, chron ic whining, or pervasive sadness and d e s p a i r , t h i s c h i l d ' s outlook on the world appears to be c o n s i s t e n t l y and predominantly negat ive . 2. High. This c h i l d appears to car ry a great deal of negative emotion. These f e e l i n g s may be expressed in strong a n t i s o c i a l inc idents with d i r e c t anger or h o s t i l i t y , px a pervas ive ly c o l d , d i s t a n c i n g s t y l e of i n t e r a c t i o n , or s/he may be unusual ly whlny, pout ing , weepy, s a d . 3. Moderately h igh . This c h i l d conveys d i s t i n c t negative tone. It may not be a pervasive c h a r a c t e r i s t i c of h i s / h e r behaviour, but the negative fee l ings are c lose to the surface and are c l e a r l y r e f l e c t e d in tone of v o i c e , f a c i a l express ions , interpersonal behaviours. 4. Moderately low. Th is c h i l d usua l ly seems happi ly or iented toward people , but subt le s igns of negative emotion may be found. This c h i l d may be somewhat whiny, pout ing , or sad or s/he may o c c a s i o n a l l y refuse to p lay or cooperate with another c h i l d or may be rough and harsh toward someone. A l t e r n a t i v e l y , t h i s c h i l d may be s l i g h t l y subdued in h i s / h e r in te rac t ions and be f r i e n d l y enough but not outgoing. This c h i l d may be not iceab ly s e r i o u s , sober or f l a t a f f e c t i v e l y . Other 's negative behaviour is l i k e l y to a f f e c t t h i s c h i l d n e g a t i v e l y . 5. Low. This c h i l d shows l i t t l e negativism in any form. The c h i l d may exh ib i t some pouting or sadness i f t reated u n f a i r l y or in a h o s t i l e manner. Or there may be occas iona l i r r i t a b i l i t y or rough treatment of o thers . But these are the most inc identa l of events and show e s s e n t i a l l y some lack of courtesy or response to h o s t i l i t y rather than ab id ing negat iv ism. 6. Very low. This c h i l d Is not in any way negative toward people or h i s / h e r approach to l i f e . This c h i l d seems character ized by wholesome expectat ions of good for tune, enjoyment of l i f e , and wi l l ingness to p a r t i c i p a t e with others In cooperat ive f ash ions . Negative emotion is genera l ly not observed and the c h i l d usua l ly reacts n e u t r a l l y to o ther ' s negative behaviour. 145 SCHOOL OBSERVATION RATING SCALE ANXIETY This scale Is designed to provide a g loba l Indicat ion of the amount of s t r e s s or anxiety, the c h i l d appears to experience in s c h o o l . Anxiety or s t r e s s may assoc ia ted with behaviours such as frequent n a i l b i t i n g , h a i r t w i s t i n g , being e a s i l y s t a r t l e d , being p a r t i c u l a r l y watchful or "jumpy", d i s s o l v i n g Into tears e a s i l y , fear of speaking or performing tasks in front of the c l a s s , genera l ly appearing nervous and f e a r f u l or avoidant of o thers . Other more subtle s igns may be i n a b i l i t y to a t tend , non responsiveness to requests , lack of eye c o n t a c t . Since these behaviours a lso may suggest an underlying cause other than anx ie ty , some sub jec t ive judgment is involved in i n f e r r i n g anxiety or s t r e s s . 1. This c h i l d ' s anxiety is pervasive and in te r fe res s e r i o u s l y with h i s / h e r s o c i a l and academic behaviour in s c h o o l . This c h i l d may be extremely s e n s i t i v e , c r y i n g e a s i l y or becoming upset in other ways; s/he may "freeze" or become o v e r t l y upset whenever demands are p laced on him/her; and s/he probably has a very d i f f i c u l t time recover ing from such a s t r e s s f u l exper ience. This c h i l d probably e x h i b i t s severa l of the anxiety symptoms l i s t e d above or s/he exh ib i ts one or two in such i n t e n s i t y that they preclude success fu l funct ioning in s c h o o l . 2. This c h i l d c o n s i s t e n t l y shows mild anxiety or o c c a s i o n a l l y e x h i b i t s a major anxiety ep isode. This anxiety does impair h i s / h e r a b i l i t y to funct ion s u c c e s s f u l l y in s c h o o l , academical ly or s o c i a l l y . This c h i l d may show an extreme reac t ion to s t r e s s f u l circumstances and probably has d i f f i c u l t y recover ing from such r e a c t i o n . 3. This c h i l d may show f a i r l y frequent s igns of anxiety in a v a r i e t y of s i t u a t i o n s px s/he does not of ten appear anxious, but r e a l l y " loses i t" under s t r e s s . Anxiety sometimes i n t e r f e r e s with f u n c t i o n i n g . 4. Under most circumstances t h i s c h i l d shows no c l e a r s igns of anx ie ty , but t h i s c h i l d would not be descr ibed as calm and re laxed ( e . g . s /he conveys a sense of being somewhat uncofomrtable or hes i tant in many s i t u a t i o n s ) . In some instance ( e . g . when pressured or perhaps when faced with a very unstructured s i t u a t i o n ) th is c h i l d probably does show c l e a r s igns of anxiety and those s igns may p e r s i s t for a whi le . However, t h i s anxiety does not in te r fe re with the c h i l d ' s funct ionings in s c h o o l . 5. while t h i s c h i l d may show occasional s igns of anxiety or s t r e s s , these are apparent only in c l e a r l y s t r e s s f u l s i t u a t i o n s and anxiety does not in ter fere with school func t ion ing . A l t e r n a t i v e l y , t h i s c h i l d may show no c l e a r s i g n s , but does not appear t r u l y re laxed in the school s i t u a t i o n s . 6. This c h i l d shows no apparent s igns of anxiety in the school s i t u a t i o n . S/he genera l ly appears relaxed and seems to recover e a s i l y from s t r e s s f u l exper ience. 146 APPENDIX B House-Tree-Person (Initial Phase) 1 4 7 148 B.2 149 B.3 150 APPENDIX C House-Tree-Person (Working Phase) 151 C.1 152 C.2 153 C.3 154 APPENDIX D House-Tree-Person (Ending Phase) 155 D.1 156 D.2 157 

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