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A case study analysis of thematic transformations in nondirective play therapy Levin, Susan Charlotte 1992-12-31

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A CASE STUDY ANALYSIS OF THEMATIC TRANSFORMATIONSIN NONDIRECTIVE PLAY THERAPYbySUSAN CHARLOTTE LEVINB.A., Brandeis University, 1969M.A., Simon Fraser University, 1980A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF EDUCATIONinTHE FACULTY OF GRADUATE STUDIES(Department of Counselling Psychology)We accept this thesis as conformingeuedTHE UNIVERSITY OF BRITISH COLUMBIASeptember 1992Susan Charlotte Levin, 1992in presenting this thesis inpartial fulfilment of the requirements foran advanceddegree at the University of BritishColumbia, I agree that the Library shall make itfreely available for reference andstudy. I further agree that permission for extensivecopying ‘of this thesis for scholarlypurposes may be granted by the head of mydepartment or by his or her representatives.It is understood that copying orpublication of this thesis forfinancial gain shall not be allowed withoutmy writtenpermission.________________________________Department of Counselling PsychologyThe University of BritishColumbiaVancouver, CanadaDateSeptember 14, 1992DE-6 (2/88)AbstractA multiple case study approach wasemployed in thisintensive thematic analysis of the processof nondirective playtherapy. Using a naturalistic researchparadigm, this studyundertook to identify and describe the principalverbal and playthemes and their transformations emergent over acourse of playtherapy, as well as to identify anddescribe similarities anddifferences between the themes emergent in thosetwo domains.Play and verbalization, two types ofsymbolic expression, wereconsidered routes of access to the child’s evolutionof personalmeaning.The research participants in this multiple case studywere 4preschoolers, aged 3 to 4. Each participantreceived 20 weeklyplay therapy sessions which were videotapedand transcribed.Running notations were made on the verbatim transcriptsas toparticipants’ play activities. Separate codingschemes weredevised for the emergent play and verbal themes.Supplementaldata collection, organization, andanalysis procedures included afield notebook with post hocdescriptions of the sessions,session summary sheets profiling play andverbal themes, charts,and memos.This study, discovery—oriented and exploratory innature,yielded rich descriptions of the intricacies of therapeuticchange on two symbolic levels. From these descriptionswereextracted not only information on the transformations in play andverbal themes but also an understanding of the qualitativechanges which denote the phases of therapy, and insightinto theprocess of evolving meaning across these phases.iiA central finding of this study was thatthe arrays of playand verbal themes and their patterns of transformationswerehighly individualized. However, a numberof themes emerged incommon to all cases: Exploration, Aggression,Messing, Distress,and Caregiving or Nurturance. Participantswere observed to workthrough contrasting themes, with preschoolers’therapycharacterized as an active struggle with suchintense,oppositional forces as birth and death, injury and recovery, lossand retrieval. Typical thematic transformationsincludedmovement from infantile vulnerability to mastery, from grieftoward resolution, from fear to safety and protection.The beginning phase of therapy was found to betypified byexploratory play. The middle phase was typified by intensifiedinvolvement in play and by experiences of disinhibition. The endphase was characterized by two contrasting yet not mutuallyexclusive tendencies, namely, the introduction of asense ofhopefulness, confidence, and integration; and an improvedcapacity to deal with difficult psychological material. Entryinto the middle and end phases was signalled by qualitativeshifts in the child’s attentional, tensional, or relationalstate.The theoretical implications of this study included insightinto the critical role of the child’s initiative and of thetherapist’s permissiveness in the unfolding of symbolicexpression. Each individual case contained specific theoreticalimplications for such classic problem and treatment phenomena asdevelopmental delay and play disruptions.iiiThe practical implicationsof this study include emphasizingthe need for practitionersto counterbalance attentionto thechild’s verbal expressionwith attention to transformationsinplay activity and playmaterial usage. It is suggested thatfurther research extend the ramificationsof this exploratorystudy by examining the themesoccurring in treatment withinhomogeneous populationsaccording to problem configuration.ivTABLE OF CONTENTSAbstractiiTable of ContentsvList of FiguresviiiAcknowledgementsixCHAPTER I. INTRODUCTION1Background of the Study1Rationale for the Study2The Research Questions4Overview of Design and Method5Definition of Terms5CHAPTER II. REVIEW OF THELITERATURE. SECTION I:PLAY AND THE PLAY THERAPYPROCESS8Background on Play Therapy8The Therapeutic Qualities ofPlay 8Historical Overview of PlayTherapy 10Conceptualizations of the PlayTherapy Process 12Jungian/Analytic Play Therapy13Nondirective Play Therapy14Studies of Play TherapyProcess17Empirical Studies of NondirectivePlay Therapy 17Instruments of Play TherapyProcess 33CHAPTER II. REVIEW OFTHE LITERATURE. SECTION II:THE USE OF SYMBOLS TO ELUCIDATEPLAY THERAPY PROCESS36The Nature and Function ofSymbols 36Play and Language as SymbolicSystems 38Their Developmental Convergence38Differences as Symbolic Systems39Similarities as SymbolicSystems 40Empirical Support for DevelopmentalCorrespondence. . .41Therapeutic Play as SymbolicExpression 43Accounts of Symbolic Transformationsin Child Therapy 44Case Studies of Play and/orArt Media 44Case Studies of Sandplay47CHAPTER III. METHODOLOGY.SECTION I:PRINCIPLES, RATIONALE,AND TERMS51Background: Considerations inChoice of Method 51The Naturalistic ParadigmField ResearchParticipant ObservationCase Study MethodThe Rationale for MultipleCases...Criteria for Case SelectionPurposeful SamplingPrinciples of Grounded TheoryThe Narrative FrameworkQualitative Data AnalysisSpecific Data Analysis TechniquesCodingMemoingGraphic DisplaysThe Research Design525354555758596061656666676768VCHAPTER III. METHODOLOGY. SECTION II: THE RESEARCH PROCEDURE. .69Synopsis of Design 69Description of Participants 69Rationale for Participant Selection 70Process of Participant Selection 70The Setting and Access Issues 71Ethical Considerations 72The Researcher as Participant—Observer 72The Therapist’s Intervention Style 73The Data Collection Phase 73The Play Therapy Sessions 74The Field Notebook 74Session Summary Sheets 75The Data Preparation and Organization Phase 75The Data Analysis Phase 76Coding of Play Themes 76Coding of Verbal Themes 77The Written Accounts 78CHAPTER IV. CASE 1. ANNA 80CHAPTER V. CASE 2. BRAD 130CHAPTER VI. CASE 3. CARL 182CHAPTER VII. CASE 4. DAVE 233CHAPTER VIII. DISCUSSION AND CONCLUSION 284The Research Questions 284The Research Findings 285Individualized Paths of Change 285Struggle with Opposites 286Common Themes 287Types of Transformations 290Similarities and Differences in Domains 295Developmental Transformations 299Distinctions Between More/Less Verbal Participants. .300The Play Therapy Phases 301Phase Markers 305Narrative Integration 306Reflections on Choice of Method 310Theoretical Implications of the Study 318Limitations of the Study 329Implications for Practice 331Implications for Future Research 333Summary 334REFERENCES 337viAPPENDIX A:APPENDIX B:APPENDIX C:APPENDIX D:OUTLINE OF RESEARCH PROCEDURE 346RESEARCH INFORMATION AND CONSENT FORMS 347LIST OF MATERIALS AND DIAGRAM OF PLAYROOM 350DATA ANALYSIS FORMS 352viiLIST OF FIGURESFigure 1. Anna:Figure 2. Anna:Figure 3. Anna:Figure 4. Anna:Figure 5. Anna:Figure 6. Anna:Figure 7. Anna:Figure 8. Anna:Figure 9. Anna:FigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigureFigure10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.25.26.27.28.29.30.31.32.33.34.35.36.37.Overview of Play with Principal Materials....83Play Themes with Infant Props 85Verbal Themes Associated with Infant Birth.. .93Verbal Themes During Other Infant Play 97Play Themes with Doctor Materials 102Verbal Themes Associated with Doctor Play. . . 104Play Themes with the Whale 107Verbal Themes Associated with Whale Play....110Play Themes for Painting 114Overview of Play with Principal Materials. . .135Play Themes with Vehicles 137Verbal Themes with Vehicles 145Play Themes with the Doll House and Props...151Verbal Referents Across Play Materials 159Play Themes with Adventure People 160Play Themes with Hospital Figures 163Play Themes with Doctor Materials 164PlayThemeswith Water 165Play Themes with Sand 169Overview of Play with Principal Materials. . .187PlayThemeswith Vehicles 188Examples of Verbal Themes with Vehicles 195Play Themes with Doll House Figures 204Examples of Verbal Themes with Doll HouseFigures 209Overview of Play with Principal Materials...237Play Themes with Doctor Materials 238Verbal Themes with Doctor Materials 241Play Themes with Puzzles 245Verbal Themes with Puzzles 248Play Themes with Puppets 251Verbal Themes with Puppets 252Play Themes During Play-in-the-Dark 253Verbal Themes During Play-in-the-Dark 255Play Themes with Miniature Animals 259Verbal Themes with Miniature Animals 264Play Themes with Dolls and Props 267Verbal Themes with Dolls and Props 271Brad:Brad:Brad:Brad:Brad:Brad:Brad:Brad:Brad:Brad:Carl:Carl:Carl:Carl:Carl:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:Dave:viiiACKNOWLEDGEMENTSI would like to express my appreciation to the teachingstaff and the director of the preschool for permitting thisresearch project to take place on site; to the participants’parents who graciously permitted their children to take part inthis project; and to the preschoolers themselves for their trust,for being so vibrantly alive, and for teaching me so much.My thanks extend to the faculty members who helped to bringthis project to fruition: to Don Fisher for his warm andsupportive guidance and for offering a steady hand and soundadvice throughout the challenging research process; to LarryCochran for his keen insight and for his commitment to meaningfulresearch; and to Bill Borgen, Department Head, who although notserving on my committee, offered unwavering support andassistance throughout my program of studies.It is not possible within a few brief sentences to fullyconvey my feelings of deep appreciation to John Allan. As myresearch supervisor, program advisor, clinical supervisor,teacher, and mentor, his wonderfully compassionate and clearsighted counsel shaped each day of my studies, clinical training,and research program. I am deeply indebted to John, whose deepcaring for the welfare of young children is matched by hisgenuine concern for his students.I would like to express my appreciation to Mike Shepard ofUBC’s Education Computing Services for his invaluable, patienthelp and advice in the preparation of this manuscript. DoctoralFellowship funding from the Social Sciences and HumanitiesResearch Council of Canada is gratefully acknowledged in enablingthis research to proceed.ix1CHAPTER I. INTRODUCTIONBackground of the StudyThis intensive study of playtherapy process emerged frompilot work consisting oftwo years of recent clinicalexperiencewith young children. Duringthat time preschoolers receivingnondirective play therapy movedtoward emotional recovery throughtheir own self—directed play.Each child was observed togradually settle into playwith favored play media.Over time,global changes or transformationswere noted in the children’sinteractions with central playmaterials.Upon reflection, it was apparentthat each child’s playmaterial selection and playstyle were unique. In addition, eachchild’s reliance uponverbal communication was singular.Whilethis may appear to be anobvious comment on individualdifferences, the varyingrelevance of verbal communicationforeach child was intriguing.The children’s patterns ofcommunication throughspeech as opposed to communicationthroughplay activityappeared to be distinctive. Nevertheless,whetherverbally or through their playthe children were at all timescommunicating, expressingfacets of their personalities, theiremotional conflicts, andtheir resources for solving the problemsconfronting them, weavingback and forth between verbaland playexpressions.The observed differences in youngchildren’s verbal and playexpressive style began toprompt questions as to how the changesin the verbal and playcomponents of play therapy might beclarified. The researcher’sfascination with the verbal and playcomponents of this complexform of child therapy also prompted2additional questions about thenature of the process of changeinnondirective play therapyand the child’s own experience ofchange within that process.Retrospective case accounts ofchildren in play and relatedtherapies pointed to thedynamic role of focal play materialsandkey play symbols in catalyzingtherapeutic change (Allan, 1988;Kaiff, 1980; Sikelianos, 1979,1986, 1990). Theoretical work onthe role of symbols inhuman culture and in psychic development(Jung, 1954; Kubie, 1953) describedhow symbols bridge theconscious and unconscious realms,linking emotional experience totangible media (Kubie, 1953),providing routes of access toinnerexperience. An intensive, detailed,fine—grained analysis of thechild’s verbal and play expressionsappeared to offer aproductive avenue of inquiryfor the broader process questions.By systematicallyattending to the child’s emergent verbalandplay expressions, perhapsnew understanding could be garneredabout the process of nondirectiveplay therapy, its particularcomponents, and its meaningfor the child from a phenomenologicalperspective.Rationale for the StudyAs a rich and multifacetedtreatment modality, play therapyenjoys widespread clinical usage bychild psychiatrists,psychologists, social workers andschool counsellors. Havingbeen adapted to many therapeuticorientations and treatmentstyles, from psychoanalyticto behavioral, play therapy isutilized directively ornondirectively in the treatment oftheentire spectrum of childhoodemotional disturbances.3However, research intothe complexities of play therapyprocess has not keptapace with the scope and popularityof playtherapy practice. Meagerprocess research supports thecurrentwidespread practice of playtherapy. Much of the clinicalliterature consists of anecdotalcase reports by practitionerswho tend to focus onthe efficacy of play therapyin specificsettings (e.g., Johnson &Stockdale, 1975) or withspecificpopulations (e.g., Nibs &Reiss, 1982). The need forongoingresearch into play therapyprocess is widely acknowledgedin theresearch literature(McNabb, 1975; Phillips, 1985). Thisstudywas launched in responseto the scarcity of systematicprocessresearch and the pronouncedlack of in—depth process work.The handful of extantprocess studies have for themost partconceptualized the nondirectiveplay therapy process in termsofobservable changes in thechild-therapist relationshipordeducible changes in the child’semotionalized attitudes. Inthese studies, the perspectiveof the researcher, like thatofthe clinician,has been that of “other,” an outsidersearchingfor observable evidenceof specific changes. Thechild’s ownexperience of change hasbeen equally objectified anddistanced.Play therapy process researchto date can be considered largely“third person” efforts,attempts via precategorizedcontentanalysis to classifypredetermined therapeuticevents. Noresearch into thenondirective play therapy processhas yetattempted to conceptualize orto study the process of therapeuticchange by accessingthe perspective of the child.There is anevident need for such a“first person” account of thechangeswhich occur in nondirective playtherapy.4By not superimposing an interpretivevocabulary, by trulylistening to and watching the child,this study endeavored toattune to dual aspects of the child’sevolving personalexpression. By considering the child’sunfolding verbalexpression and play themes as parallelnarratives for analysis,this study set out to produce a richdescription of thenondirective play therapy process asexperienced by the child.By attending to the child’s verbaland play thematic expressions,this study attempted to isolate andidentify key components ofthe play therapy process. Thepurpose of this study was toexplore play therapy as a livedexperience by utilizing twosymbolic systems to access thechild’s experience of change: thethemes emergent in the child1sinteraction with play materialsand the child’s verbal narrative.The Research QuestionsThis study was designed to answer the following researchquestions:1. What themes emerge within play,that is, during thechild’s interaction with play materials?How do these themestransform across sessions of playtherapy?2. What themes are verballyexpressed during play? How dothese verbally expressed themes transformacross sessions of playtherapy?3. What are the similarities anddifferences in thesethemes across participants?4. What are the similarities anddifferences between thethemes which are expressed through playversus those which areverbally expressed by the child?5It was anticipated that theverbal and play themes wouldprovide routes of accessinto the process of change fromtheperspective of the child.It was further anticipated thattheresearcher’s immersion into the detailsof participants’ thematicmaterial would lead to an elucidationof the process of playtherapy as it pertains to thechild’s evolving world of meaning.Overview of Design and MethodThis study utilized principles ofnaturalistic inquiry(Lincoln & Guba, 1985):a field setting; the researcher asparticipant observer; case studyreporting; grounded theoryrationale; and principlesof narrative analysis. There isconsiderable overlap amongthese terms, which are often usedinterchangeably in the research literature.These terms share acommon concern with the researcher’simmersion into livedexperience for the purpose of extractingemergent, as opposed topreconceived, thematic elements.In this instance, theresearcher sought play and verbalthemes emergent in nondirectiveplay therapy.This study employed a multiple casestudy strategy withpreschool participants receivingplay therapy. Participants’play therapy sessions werevideotaped and then transcribed.These transcripts werethen submitted to qualitative thematicanalysis, with the codingcategories emergent from participants’verbalizations and play activities.Definition of TermsThis section identifies the following termscentral to thestudy: play therapy process,play themes, verbal themes, andverbalization.6Play Therapy ProcessPlay therapy process was considered a composite of thetransformations within the child’s verbal and play themes overtime.Play ThemesBased on Bishop’s (1982) definition of theme, a play themewas considered “a series of actions and events . . . which areconnected through a common purpose, sequence, and consequence”(p.39). Play themes generally pertained to patterns inparticipants’ interactions with play materials.Verbal ThemesVerbal themes were the patterns and clusters of relatedmeanings emergent within the child’s verbalization. Verbalthemes consisted of repeated topic or content referents, theirsynonyms, and associated words or sounds.VerbalizationVerbalization, as distinct from the rules and syntax oflanguage, referred during the data analysis phase to the child’sentire vocal output. This included words, phrases, sentences,sounds, noises, shouts, singing, and crying.Format of the ThesisThis document is organized according to the followingformat, Chapter II, which is divided into two sections, reviewsthe literature on nondirective play therapy process and theliterature on play therapy as symbolic expression respectively.Chapter III, also divided into two sections, first presents theprinciples, rationale, and terms underlying the researchmethodology, and then describes the detailed steps of the7research procedure. ChaptersIV through VII arethe core of thestudy, the case accountsof the four research participants,Anna,Brad, Carl, and Dave. Theconcluding ChapterVIII discusses thefindings and sets themin their theoreticaland practicalcontext.8CHAPTER II. REVIEW OF THE LITERATURESECTION I: PLAY AND THE PLAY THERAPYPROCESSThis chapter reviewing the literature isdivided into twosections which present the major theoreticalbackground of thestudy. Section I provides theoreticaland historical backgroundon play therapy. Section II detailsthe theoretical rationalefor using symbolic expressionto elucidate play therapy process.Section II also provides backgroundon play and language assymbolic systems, focusing on their developmentaland functionalsimilarities and differences. SectionsI and II are respectivelysupported by reviews of empirical and/or descriptivestudies,namely, play therapy process studiesand representative studiesdescribing play therapy as unfoldingsymbolic expression.Background on Play TherapyThis section discusses the therapeuticqualities of play; abrief overview of the development ofplay therapy; and theprinciples and predominant conceptualizationsof play therapyprocess.The TherapeuticQualities of PlayThe many and varied therapeutic usesof children’s play spanthe entire spectrum of psychologicaltheories. Each therapeuticapplication of play, such as behavioralplay therapy (Russo,1964), psychoanalytic play therapy (Klein,1955), or group playtherapy (Ginott, l982b), assumesthe theoretical colorationofthe psychological model which has inspiredit. Yet all of thesecreative therapeutic approaches, includingnondirective playtherapy, have in common the fact that therapistsare working witha medium, namely play, which is adaptablefor therapeutic aims.9Winnicott (1971) offered a compelling explanation of how andwhy this ordinary childhood activity is capable of accomplishingtherapeutic tasks. Winnicott referred specifically to theparadoxical nature of play as an activity which does not belongexclusively to either the inner or the outer world of thechild.That is, playing reflects the child’s inner psychic reality, yetit takes place in the external world of objects. Conversely,although playing occurs with objects, it is not an objectiveactivity, but a highly involving subjective experience.Playing,therefore, constitutes a unique experience of intermediationbetween the child’s subjective and objective experience.Assuch, explained Winnicott, it characteristically offerssingularopportunities for self—absorption and concentration.Childrenare often referred to as being “lost in play.” On thecontrary,through play young children are often finding themselves,treading deeply, often unconsciously, back and forthfrom innerworld to outer reality and again returning to inner experience.What transpires quite naturally in play is the workingthrough ofexperience from feelings within to their outer portrayal,frominner experience to the symbolic expression of emotionalandpsychic reality by means of play materials and fantasy—-inessence, therapeutic activity.Smith, Takhvar, Gore, and Vollstedt (1985) summarizedotherqualities of play which contribute to its therapeutic value.Play is a naturally enjoyable activity, offering opportunitiesfor pleasure and for positive affect. Because it is usuallyfunand by definition largely freed from rules, it is intrinsicallymotivating and engaging.10The mere introduction of play materialspromotes conditionswhich are conducive to therapeutic process for severalreasons:(a) the play materials convey to the childthat the specialplayroom is a nonthreatening, child-friendly setting, thushelping to reduce the child’s anxiety; (b) the play materialsprovide the child with marty options for activity which can beused to bridge contact with the therapist (through shared play)or avoid such contact (in solitary play); and (c) the materialsprovide the therapist with a nonthreatening arsenal of enticingactivities for diminishing the child’s defenses.Play is widely accepted in the literature as a stimulus andenhancer of the child’s verbalization. Within play therapyliterature, play is generally understood as the symbolic languageof the child, no less significant than the child’s verbalization.Although the child may not consciously intend for play behaviorsto be communicative, play therapists perceive and respond tothelatent communications in play. The manipulation of playmaterials and the resulting physical representation ofexperiences and emotions help the child express and ultimatelyintegrate, often more graphically and tangibly than in words,personal conflicts and difficulties. For many young clients, theinability to verbalize is an inherent part of their difficulty.For them, play provides a tangible means of communication.Play is also kinesthetically enriching, offeringopportunities for energetic movement and physical involvement(Levy, 1976). Pounding, smacking, banging, and messing with playmaterials are all physically engrossing. At the same time, suchactivities facilitate emotional catharsis. Through the physicala11engagement with play materials, angercan be released, anxietydissipated, tension reduced, and calmachieved. Cumulativelythen, play is a naturally familiar,pleasurable, kinestheticactivity, which encourages verbalization, motivates and elicitssymbolic communication, and comprises a natively rich therapeuticmedium. It is within this stimulating and prolific contextthatthe nondirective play therapist actively strives to maximizetheinterpersonal conditions that will further facilitate emotionalawareness, personal expression, conflict resolution, andgrowth.Historical Overview of Play TherapyThe therapeutic use of play emerged from Freudian insightinto its function. Freud wrote extensively about the functionofplay in human development,characterizing it within the bounds ofthe pleasure principle (Slobin, 1964). He identified repetitiousplay, nonpleasurable and often fraughtwith anxiety, as a form ofrepetition compulsion. He also identifiedregressive play in theservice of the ego, and he cited the usefulness ofplay forexperiences of mastery or symbolic revenge (Freud, 1920).Von Hug-Hellmuth (1921) first promoted the inclusion of playin the treatment of children under seven. Withvery youngpatients she believed that play would “enact an important partthroughout the whole treatment” (Hug-Hellmuth, 1921,p.295).However, it remained for the next generation of analysts andFreud’s daughter Anna to develop the deliberate use of play fortherapeutic purposes.Anna Freud (1946) utilized play to expedite a trustingrelationship with the child. She stressed the play-enhancedtransference to access the unconscious. Her contemporary,12Melanie Klein (1955), established play as a cornerstone of childtherapeutic treatment, using verbal interpretations of play asthe focus of treatment. Offshoots of the psychoanalytic playtechnique, such as release therapy for play cathartic expressionappeared in the 1930s (Levy, 1976).The use of play in child treatment remained solely in thepsychoanalytic camp until Axline’s (1947) extrapolation ofRogerian (1951) principles to the child therapeutic setting.Nondirective play therapy, which offers the child a playenvironment conducive to emotional growth, has engenderedstylistic offshoots. Ginott (1959) emphasized the play therapyenvironment as a re—education for life (reality testing) andfavored a less permissive setting than Axline’s. Moustakas(1959) stressed the importance of building a supportivetherapist—child relationship in the nondirective setting. Ingeneral, psychoanalytic applications of play and nondirectiveplay therapy have remained the dominant divisions of contemporaryplay therapy practice, with newer techniques, such as filialtherapy (Guerney, 1964) or theraplay (Jernberg, 1979),continually appearing.Conceptualizations of the Play Therapy ProcessConceptualizations of play therapy process differ among theschools of practice. This section presents the nondirective andthe analytic (Jungian) conceptualizations of play therapyprocess, which together comprised the theoretical basis of thisstudy.13Jungian/Analytic Play TherapyCompendia of play therapy interventions (Landreth, 1982;Schaefer, 1976; Schaefer & O’Connor, 1983) have not yet denotedanalytical or Jungian play therapy as a discrete area of playtherapy practice. However, the work of Allan (1988) and of sandplay therapists such as Kalff (1980), illustrates the practicalfusion of Jungian theory and play therapy principlesas anidentifiable subset of play therapy practice.Jung objected to what he termed the “reductive causalism”ofthe Freudian outlook, and posited instead the “teleologicaldirectness which is so characteristic of everything psychic”(Jung, 1976,p.xxiii). Jung rejected Freud’s solely sexualdefinition of the libido and considered the libido a positivedriving life force. In contrast to the Freudian unconsciouswhich is singularly a repository of personal memory andrepressedfeeling, the Jungian unconscious is bipartite. The personalunconscious, similar to the Freudian unconscious, consistsofrepressed memories and feelings from the individual’s ownexperience. The nonpersonal or collective unconscious is therepository of universal images, knowledge, and awareness sharedthrough evolution by the human species. From this collectiveunconscious are derived archetypal images or themescommon to allcultures. These archetypes, such as “the hero,” “rebirth,”or“wholeness,” emerge in myths, ceremonies, religiousobservances,and other cultural symbols as well as in the dreams oftheindividual. The personal unconscious and the collectiveunconscious are interactive, and this unique interactionwithineach individual is responsible for the diversity of human14personalities. The third componentof the personality, the Ego,is the experientialconsciousness of the individual:memoriesand feelings, ideas andthoughts. The Jungian conceptualizationof the personality alsoposits a spiritual center of theindividual, beneath and beyondthe Ego and the two-tieredunconscious: the Self,whose nature it is to grow and evolvetoward well-being andwholeness.Applying Jungian theoryto play therapy practice, Allan(1988) observed that “thetask of psychological growth is toachieve a balanced communication betweenthe Ego and the Self”(p. 5). This balancedcommunication between the Egoand the Selfoccurs through symbolicexpression because symbols functionas anonverbal link between theunconscious and the consciousmind ofthe individual (Jung, 1976).“In order for the child to maintaincontact with the inner worldand feelings, the axis path betweenthe Self and the Egomust be kept open. If the Self is togrowand the Ego is to mature,some form of symbolic expressionoroutlet is needed” (Allan, 1988, p.7).Play therapy process froma Jungian perspectiveemphasizes the child’s evolving symbolicexpression.Nondirective Play TherapyAxline (1947) developedthis major school of playintervention usingRogerian (1951) principles. Nondirectiveplaytherapy refers to a philosophicallyintegrated complex ofconditions which are consideredby this therapeutic stance to beoptimal for emotional growth (Guerney,1983).The vocabulary of Rogers’ (1951)client-centered therapywith adults wholly applieswithin the nondirective play therapy15setting. The nondirectiveplay therapist communicatesa sense ofgenuine respect for thepersonhood of thechild, as well as animplicit acknowledgementof the self—curativeresources whichreside within eachclient.The task of the therapistis to create optimal conditionsfor emotional growth. Tothat end, the therapistmust becongruent with his/herown emotions, avoidingartificialresponses or tone of voice.The nondirective playtherapist mustalso provide unconditionalpositive regard and a consistentlynonjudgmental attitude,even toward what are regardedoutside theplayroom as misbehaviors.Therapist empathy is thetheoretical and practicalcornerstone of all nondirectiveapproaches to therapy. ByRogers’ (1951) definition,empathy, the catalyticimpetus ofnondirective therapy,refers to the therapist’s assumingtheinternal frame of referenceof the client and perceivingtheworld as the client sees it.Gradually, through therapistempathy, congruence,and unconditional positive regard,a trust—inducing environment, a“nonthreatening psychologicalclimate”(Rogers, 1951,p.346), well-suitedto emotional risk-taking andclient growth,evolves.From the perspective ofthe nondirective playtherapist, thehours of supporting thechild’s self-directed playare neitherindulgent nor unremunerative.They constitute the aim andtheessence of therapeuticprocess. In such a milieu,self—awarenessand even insight can emergeentirely from within thechild(Landreth & Verhalen, 1982).Young clients unconsciously respondwith increasingly expressiveverbalizations and behaviorin an16atmosphere whichis permissive, notin the interests oflaissez—faire for its ownsake, but in theservice of emotionalgrowth.The nondirectiveplayroom providesabundant opportunityforthe child’s selectionand combination of playmaterials as wellas for the developmentof pretend play themes.The nondirectiveplay therapist activelyavoids verbalizationsor even bodylanguage which restricts,disturbs, or otherwisedirects thechild, who experiencesthe freedom to unfoldfrom within. Theopportunity as wellas the onus are onthe child to select anddevelop play activitiesand to make manydecisions. Thus, mini—steps along the roadto growth and self-masteryare nurtured andsupported. Althoughnondirective playtherapy, like its “parent”client-centeredtherapy, employs adifferent theoreticalvocabulary from Maslow’s(1968) self-actualizinghierarchy,nondirective playtherapy is compatiblewith an existentialstance which positsimplicit belief inthe self-actualizingpotential of each humanbeing.In sum, thenondirective therapist,through empathic andneutrally nonjudgmentalreflection of the child’splay behaviorsand attendant speech,creates a receptive environmentthatencourages trustand rapport, and permitsand facilitates thechild’s self-directedexperiences of growth.Therapeutic processconsists of thisquietly powerful behavioraland emotionalunfolding in thepresence of an attuned,supporting therapist.The nondirectiveplay setting, as agrowth-facilitativeenvironment, is thusan optimal context inwhich to observe theprocess of therapeuticchange from the perspectiveof the childand to study thenatural evolution of itssymbolic components.17Studies of Play Therapy ProcessThe handful of extant empirical studies of nondirective playtherapy process are described in this section. Play therapyobservational instruments, which have been devised fortherapeutic or experimental settings, are included for discussionbecause these instruments provide additional conceptualizationsof the play therapy process. Because investigators have exploredvaried notions of the play therapy process, these few studies areunfocused in terms of the process variables considered.Empirical Studies of Nondirective Play ProcessLandisberg and Snyder’s 1946 study is the conceptual andmethodological antecedent of what can be considered the “firstgeneration” of empirical process inquiries (e.g., Finke, 1947;Lebo, 1951). Landisberg and Snyder explored play therapy processmultidimensionally, through the analysis of speech, actions,attitudes and child-therapist interactions,They codified the verbalization content of therapists andboth the content and feeling tone of clients’ verbalizations.They further classified each client verbalization or action intoa “meaning—unit,” which categorized positive, negative, orambivalent feelings. They sought patterns in the client-therapist relationship, trends in clients’ response patterns,patterns in expressed client feelings, and indications thatnondirective play therapy was truly nondirective. Inferred fromtheir codification categories of therapist verbalization (whetherpositive, negative, or ambivalent statements, attitudes, andactions predominated) is a conceptualization of play therapyprocess as (a) intrinsically intertwined between therapist and18client and (b) methodologicallyaccessible through thecodification of speech,actions, and attitudes.Their prominent finding,that three-fifths of allverbalizedresponses were made by thechild, while two—fifths weremade bythe therapist, is often citedin the literature as evidencethatthe nondirectivetherapist’s empathic style encouragesthechild’s more active emergence.Of the total number of clientandtherapist statementscoded, 30% of all statements werenondirective therapiststatements, 25% consisted of clients’giving information,and 24% consisted of clients’pursuingpositive play action.Considering the sequel relationshipbetween particular counsellorverbalizations and the“immediately—following” clientstatement or action, Landisbergand Snyder found that“nondirective responses preceded 84.5percent of the client’s responses”(1946,p.207). Therapistreflection of feelingpreceded over half (57%) of the clientresponses. These twofindings are generally consideredassupport for the nondirectivenature of the therapy.To determine both therapistand child trends in thetreatment process, responsesfor all cases (4) werecombined andthe entire treatmentprocess was divided into fifths.From thisprocedure, the followinginformation emerged. Recognition ofFeeling, the most frequentlyused strategy, comprised 62% oftherapist responses in thefirst fifth of treatment, but droppedto 40% in the next fifth.By contrast, during thissecond fifth,the “Restatement ofContent” increased. The researchersnotedthat this second fifthincrease in the restatement of content“occurs simultaneously witha drop in amount of Action by the19client and an increase in amount of clients’ Giving ofInformation” (1946, p. 208). Therapists were found to beslightly more directive or semi-directive in the latter threefifths of treatment than in the first two fifths. Therapists’statements of “Simple Acceptance” more than doubled in the lattertwo-fifths of treatment in comparison with the first two-fifths.However, Simple Acceptance statements, overall, constituted lessthan 10% of therapist remarks. This latter finding is seen asantithetical to the naive perception of nondirective play therapyas simple acceptance of the child (cf. Guerney, 1983).With regard to changes within the child, Landisberg andSnyder found the rise in physical action by children in thelatter three-fifths of treatment to be most important. Thiscorresponded with “marked expression of feeling” (1946,p.209)accompanying most of that action. Also significant, according tochi square analysis of frequency counts, was the marked rise inexpression of feelings toward other persons or situations.Expression of negative feelings increased from 20% of the totalin the early fifth, rising to 40% later, and leveling out at 33%at the end of treatment, while expression of positive feelingsremained generally fixed at 30% of the responses. Theresearchers directly attributed these findings to the child’sgrowing sense of safety and security in the nondirective playroom: “Until the child feels free to express himself without fearin the play therapy situation, he expresses himself in limitedfashion by simple statements of acquiescence” (1946,p.210).Although this study generated a large number of statements(5,751), Landisberg and Snyder relied on 4 subjects, who were20treated by three different therapists. Inpresenting theresults, Landisberg and Snyder evidently presumed uniformityacross therapists’ styles and responses, leaving their studyvulnerable to the “myth of the uniform therapist” (Kiesler,1967). When Landisberg and Snydercollapsed the data acrosstherapists, they obliterated the distinctions which may haveresulted from differing therapeutic styles or degrees ofeffectiveness. In addition, the fact that they failed to denotethe number of sessions or the time span studied is a frustratingweakness of their discussion. Their observation that “nothing inthe four children’s cases occurred that could be classified asinsight” (1946,p.213) cannot be properly interpreted withoutinformation about the length of the course of therapy.Finke’s (1947) noted Master’s research, carried out at theUniversity of Chicago under Carl Rogers, is often cited as acentral contribution, both conceptually and methodologically, tothe literature on play therapy process. Adopting a perspectivesimilar to Landisberg and Snyder, Finke (1947) reasoned that“predictable trends in verbalized attitudes [should] occur duringa series of non-directive play therapy contacts”(p.12)Nondirective play therapy process was conceptualized as patternsof verbalized attitudes.Finke devised 19 verbalization categories which were adaptedand elaborated in subsequent research (cf. Lebo, 1955). Thesecoding categories included: expressions of curiosity, simpledescriptions of play, statements of aggression, exploration ofplayroom limits, negative and positive self—statements, andevidence of interest in the counsellor. In her multiple case21study, Finke analyzed the completeprotocols of six children(ages 5 to 11), who each received from 8 to 12 nondirective playtherapy sessions.Based on chi square analyses, Finke graphed significantcoding categories across sessions for each child, providing avisual record of frequency changes in, for example, aggressivestatements or negative self—statements across sessions. Herfindings offer greater reliability than those of Landisberg andSnyder in that Finke did not presume a “uniform therapist,” butinstead analyzed the emotionalized attitudes that resulted fromeach distinct client-therapist unit. When she collapsed thefrequencies across clients in a Victor Curve, she deduced threegeneral stages of the child’s play therapy experience:The first stage is characterized by shyness or constanttalking, a great deal of aggression and testing of limits,and with some children an interest in the relationshipwith the counselor. Near the end of this stage the level ofconversation reaches a point that is maintained for theremainder of the therapy. In the second stage aggressionand testing of limits decrease slightly, imaginative storiesconnected with the play become marked, and the child seemsto have accepted the counselor’s neutral role. The laststage is characterized by a suddenly renewed interest in therelationship with the therapist and the rapid decline ofaggression, testing of limits and imaginative stories.(1947, p.49)Finke’s contribution to an understanding of play therapy processwas two-fold: (a) within the individual, play therapy processrefers to patterns of particular verbalized responses; (b) acrossindividuals, global process stages can be discerned.Lebo (1955) concurred with Finke’s (1947) basic codificationcategories of clients’ feelings, but argued that Landisberg andSnyder’s (1946) use of a homogeneous age group (five— and six—year—olds) did not provide information about the relationship of22response categories in play therapy to chronological age. Leboseconded Finke’s conceptualization of play therapy process asverbalized emotional attitudes. To that end, he expanded (to 21)and refined Finke’s coding categories, retaining a broadconception of play therapy process as a composite of self—reflectional, interactional, decisional, and play or personaldescriptive elements (cf. Lebo, 1955).Lebo selected 20 children, divided into equal groups of agesfour, six, eight, ten, and twelve years. Each of these normalchildren were offered three one—hour nondirective play therapysessions. The fifteen pages of “verbatim style” records,representing roughly one-tenth of the statements generated, wereanalyzed (coded) by three experienced play therapists.Lebo found that the older the child, the greater thetendency for the child to be more independent of the play therapysituation. Older children explored the limits of the play roomless, looked less to the therapist for information, and talkedless than the younger participants. At the same time, the olderchildren tended to use the playroom as an opportunity for socialconversation, in contrast to the younger ones who attempted amore personal relationship with the therapist.There were methodological difficulties with Lebo’s work,some of which he acknowledged. For example, Lebo noted that (a)the statistical verification indicated that each of the threetrained judges had employed the coding categories differently;and (b) the categories of Simple Description of Play versusStraight Information about outside events were often confusedduring coding and had to be collapsed.23Lebo’s attempt to study play therapy process over a courseof only three sessions for each age group is questionable. Anymeaningful consideration of play therapy process requires timefor that process to evolve. The fact that none of the five agegroups expressed any statements in the “Insight” category may bea reflection that Lebo’s work could more accurately be describedas a study of therapy inception rather than of therapy process.Moustakas (1955a) considered the quality of the child’semotional adjustment to be the essence of play therapy process.He anticipated that the child’s expression of emotion in relationto the therapist would parallel what he considered the phases ofnormal emotional development of the child within the family:undifferentiated positive and negative feelings becoming morefocused, then becoming ambivalently anxious and hostile. Fromthis ambivalence, Moustakas anticipated a process of emotionaldifferentiation and intensification, with negative feelingsbecoming more specific and more directed at a personal orsituational target. Later emotional ambivalence would include amixture of positive and negative feelings which would, in turn,become more distinct. Toward the end of therapy, positiveattitudes and expression should predominate. Moustakas’ (1955a)analysis of play therapy process as phases in emotionaladjustment relied upon his thematic analyses of portions ofverbatim transcripts of several clients.He concluded that “there is an apparent parallel betweennormal emotional development in the early years of life in thefamily relationship and emotional growth in a play therapyrelationship” (Moustakas, l955a,p.84). He arrived at the24following parallel phases observable in the child’s play: (a)expression of diffuse negative feeling; (b) ambivalent anxious orhostile feelings; (c) more focused expression of negativefeelings; (d) an admixture of positive and negative ambivalentfeelings; (e) the predominance of positive attitudes.Acknowledging that even well-adjusted children show negativeemotion, Moustakas emphasized the increased frequency andintensity of negative emotion in the disturbed child. Above all,Moustakas stressed the role of the therapeutic relationship infacilitating emotional growth. His process description was notan experimental inquiry but a conceptual treatise based on hisown clinical work.In a subsequent process study, Moustakas (l955b) comparedthe frequency and intensity of negative attitudes expressed inplay therapy by well-adjusted and disturbed children. This studyreflects a more focused conceptualization of play therapy processas the transformation of specific emotionalized attitudes (asopposed to global emotional attitude changes in Moustakas,1955a)Nine well—adjusted and 9 disturbed preschoolers eachreceived at least four play therapy sessions by the sametherapist. The negative attitudes expressed in play therapy wereevaluated according to frequency, variety and intensity (minor,moderate, or severe). When the session transcripts andaccompanying notes were analyzed, Moustakas’ twin hypotheses weresupported: (a) disturbed children expressed negative attitudesmore frequently than well-adjusted children; and (b) disturbedchildren expressed negative attitudes with greater intensity than25well-adjusted children. Although not part of the research perSe, an interesting qualitative aspect of Moustakas’ selectionof subjects was his comparison of parents’ versus teachers’verbal description of each child’s problems. While there wasdefinite agreement among teachers and parents that each childsuffered from emotional disturbances, the parents’ descriptionsreflected a near panicked perception of their youngsters’difficulties, while the teachers framed the children’s problemsin serious yet objective terms.Moustakas’ thematic classification of the types of negativeattitudes which emerged (not derived from preconceived codingcategories) resulted in the following themes: developmentalregression; diffuse anxiety; orderliness anxiety; hostilitytoward others; hostility toward family (parents and siblings);hostility toward the therapist; and cleanliness anxiety.Among well-adjusted children, cleanliness anxiety andorderliness anxiety were rare, while the most frequentlyexpressed negative attitude was hostility toward siblings.Disturbed children presented a greater percentage of diffusehostility, hostility to home or family, cleanliness andorderliness anxiety, and developmental regression.In a later comparison of well-adjusted and disturbedchildren, Moustakas and Schalock (1955) analyzed therapist-childinteractions. They asked whether (a) the therapist behavesdifferently in interaction with well-adjusted versus disturbedchildren; (b) there are differences in the interaction behaviorof well-adjusted versus disturbed children; (c) certain therapistbehaviors produce certain child reactions, and/or (d) certain26child behaviors produce certain therapist reactions.Using behavioral categories derived from their coincidentalwork (Moustakas, Sigel, & Schalock, 1956), Moustakas and Schalockassumed that the child—therapist interaction involves “reciprocalstimulation.” Each is influenced by the responses and behaviorsof the other. The 82 adult behavioral categories and 72 childcategories were interchangeable in that each could be applied tochild or adult. The behavior of a single therapist was analyzedin relation to 16 preschool children. Statistically significantdifferences in frequency indicated that the therapist gave helpto disturbed children twice as often as to well-adjustedchildren, as well as gave more information to disturbed children.Therapist forbidding and directing also occurred more frequentlywith the disturbed group.Regarding the child’s approach to the therapist, disturbedchildren more frequently evidenced “Threat of Attack” and“Physical Attack.” Incidents of hostility numbered 418 comparedto 23 for the adjusted group. The adjusted group more frequentlyparticipated jointly in activity, sought help and permission, andresorted to more passive ways of expression of aggression towardthe therapist (e.g., changing the topic). Dependency was morefrequently expressed by the disturbed children, while theadjusted children expressed slightly more anxiety.Based on an analysis of 1,882 interaction sequences, thetherapist most frequently initiated interactions with childrenthat offered verbal information, oriented the child to time,oriented the child to his role, directed by suggestion, andoffered interpretation. Based on the 771 interaction sequences27initiated by children toward therapists, children most frequentlysought information or directed by suggestion or command.In 1950, Axline conducted a follow-up study of the playtherapy experience as described by her child participants.Although not a process study per Se, her intent, to attend to thechild’s perception of the play therapy experience, is of interestto this study. In the first stage of her research, she perusedthe verbatim case transcripts for comments made by the childrenabout their play therapy experience. Children’s comments onfeeling happy at being allowed to express all their feelings, tomake a mess, or to be free of adult constraints predominated. Inthe second stage, Axline contacted some of the clients five yearsafter the conclusion of their therapy to solicit their memoriesof the play therapy experience. In conversation with her, thechildren recalled, for example, feeling happy, making friends (ina group play setting), being allowed to make noise, and a generalsense of freedom. Based on the children’s comments, Axline(1950) stated that the nondirective play therapy experience:raises the questions of the relative position of importancebetween intellectual understanding of cause and effect asdeterminants of present behavior and the immediate emotionalexperience the individual has during therapy as theessential dynamic in the process of reorganization of theself.(p.56)Mary Brown Rogers (1964) conducted a play therapy processstudy which was unique in its monitoring of process usingelectronic recording devices. Rogers furnished two separate butnearby rooms for therapeutic play. One room contained playmaterials conducive to aggresssive play; the other containedmaterials conducive to constructive play. The 12 subjects were28free to wander back and forth between the rooms and to choose thematerials they wished within the 50 minute sessions. The roomsand the toy shelves were electronically wired such that the timespent by each child in each room and the amount of time spentwith each material could be measured precisely. This highlymechanized data collection procedure yielded the followingpicture of play therapy phases: First, a period of explorationand, second, the emergence of aggression, whether displaced ontoplay materials or expressed directly. In the final phase, thechildren were observed to move into more constructive play, inwhich productive goals became more prominent.Two studies of similar intent yielded different versions ofthe nondirective play therapy process. Stover and Guerney (1967)trained mothers in nondirective play therapy skills, a treatmenttechnique known as filial therapy. The treatment group, whosemothers were trained, received 10 one—half hour play therapysessions while the untrained mothers of the control groupinteracted as they normally would in play with their childrenover 4 observed sessions. They hypothesized that the children’sbehavior would change in response to the degree of directivity or(neutral) reflectivity in their mothers’ statements. Theintensity of children’s leadership, dependecy, aggression, andnegative feelings were rated on a 4 point scale which ranged from“0” to intense. Over the course of therapy, Stover and Guerneyfound that the children of trained mothers showed increasedleadership statements, decreased dependency, increasedaggression, and increased negative feelings.Stollak (1968) essentially replicated this study, using29psychology undergraduatestudents rather than mothersas the playtherapist substitutes. Stollakincreased the number of one-halfhour play therapysessions to 10 for both experimentalandcontrol groups. He anticipatedtrends similar to those of Stoverand Guerney (1967).Instead, it was found that(a) thechildren’s leadership behaviorincreased from sessions 1through5 only; (b) dependecyand aggressive behaviors remainedunchanged; and (c)negativity continued to increasefrom sessions1 through 10.Taking a different researchapproach to the question ofnondirective play therapyprocess, Siegel (1972) studied16learning disabled children whowere each given 16 playtherapysessions by the same therapist.She sought to determine howthedegree of therapist offeredconditions of accurate empathy,unconditional positiveregard, and genuineness affectedchildren’s process duringtherapy, as measured by theprocessscale first developed by Finke(1947). Contrasting the 4children who received the highestdegree of therapist-offeredconditions with the 4 whoreceived the lowest degree oftherapist-offered conditions,Siegel found significant behavioralchanges over time. Specifically,children receiving highertherapist—offered conditionswere observed to make moreinsightful statementsand more positive statements aboutthemselves than the childrenwho received the lowest degree oftherapist-offeredconditions.In another study carriedout in the 1970s, Hendricks (1971)explored the patterns of playactivities, nonverbal expressions,and verbal comments withinthe nondirective play therapyprocess.30She divided 10 boys, ages 8 to 10,into 2 groups which received12 and 24 nondirective play therapy sessionsrespectively.Hendricks relied upon verbatim transcripts andnotations of thechildren’s nonverbal expressions and their playactivities. Shedevised a 30—item scale for verbalization, a 14-itemscale fornonverbal expression, and a 16—itemscale for play activities.These scales were similar to those previouslydevised by Finke(1947) and later revised by Lebo (1955).The scales enabledHendricks to rely upon quantitative data, namely, frequencycounts.Hendricks identified 4 major phases of thenondirective playtherapy process. In the first,exploratory, noncommittal, andcreative play predominated. She found thatthe childrencommented on their play and the playroom,and volunteeredinformation about themselves or their families.Anxiety was mostlikely to appear in this phase.Creative play increased while exploratory and noncommittalplay decreased in the next phase.Aggression increased as didverbal comments about self and family. In thethird phase,dramatic and role play increased while creative playdecreased.Subjects’ feelings of anxiety, frustration, and anger became morefocused on specific concerns. In the finalphase, childrenshowed increasing interest in the relationshipwith thetherapist. At the outset, in addition to phases of the therapy,Hendricks had sought phases of emotional andsocial growth. Sheobserved, however, that the children’s feelings and attitudesoverlapped to a great degree, such that noclear stages foremotional and social growth acrosssubjects could be determined.31In 1975 Withee embarked upon a similar quantitative study ofplay therapy process in the treatment of 10 children, who wereseen by 10 different therapists. Seeking to replicate and extendthe work of Hendricks (1971), Withee categorized verbal patterns,play activity patterns, and patterns of other nonverbalexpression for boys and for girls. Dividing the participants’ 15sessions into five 3—session time periods, Withee calculatedaggregate percentages for predetermined content categories acrosstime periods and gender. Sessions 1 through 3 saw high levels ofverbal, nonverbal, and play exploratory activity. In Sessions 4through 6, aggressive play and verbal sound effects peaked. In 7through 9, aggressive play ebbed while creative play peaked. In10 through 12, relationship play peaked while noncommittal playreached a low point. In the final fifth, noncomittal play andverbal relationship with the counsellor peaked. Representativefindings related to gender included noticeably more anger amongstboys, and more creative and relationship play amongst girls.Hannah’s (1986) study of play therapy marked a theoreticaland methodological innovation in process research. Hannah hadobserved that despite good intentions in traditional play therapyprocess/outcome studies, results had been mixed and treatmenteffects small. He attributed this to the customary reliance onbetween—group designs and dependence on parametric statisticalmethods, which he perceived as obscuring meaningful individualchanges. Instead, Hannah employed the time series analysis ofmultiple cases.His subjects were 10 normal children, who each had aparticular behavior problem, according to parent or teacher32reports. “Target” problembehaviors, such as aggressiveacts,poor peer interaction,noncommunicative behavior, oroff—taskbehaviors, were identifiedas unique criterion outcomevariablesfor each child. Behavioralobservations for each child werecarried out before andduring eight 50-minute nondirectiveplaytherapy sessions. Standardizedinterviews of parents andteachers were held at the endof treatment to account forchangesdue to client history. In addition,the subjective observationsof parents and teacherswere used as comparison datawith thetime series analysis results.When the tenth child was withdrawnfrom treatment due toparental request, that child was usedas anontreatment “rough check” forhistorical changes. Play therapyprocess consisted of behavioralchanges over time.The strength of Hannah’s methodologicalbreakthrough lay inhis use of time seriesprocedures, which allowed, statistically,for the inclusion oftime as an experimental variable. However,a major weaknesses of thatstudy may be attributed to thatstatistical approach as well,Hannah reported that 8 of the 9participants exhibited a significantand positive change in theirtargeted behavior. Closerreading of his dissertationrevealedthat the statisticallysignificant results corresponded toparents’ and teachers’ subjectiveimpressions of change in onlyone—third of thesubjects. One-third of the observationswereantithetical to the statisticallyderived results (i.e., parentsperceived a behavioral change,while the time series analysisfound no statistically significantchange). The latter thirdwere mixed or ambivalent (i.e.,parental observations wereambivalent in comparison to statistically—evidencedchanges).33Four of the ten time series analysesrequired sophisticated ARIMAprocedures to verify statisticalsignificance. In general,Hannah’s use of time series raised questions as to theweight tobe given to personal perceptions ofchange in comparison tostatistical evidence. An additional complicationarises from thefact that Hannah employed four different therapists inworkingwith the 9 subjects, each of whom wouldhave differed in levelsof skill, efficacy, and impact with thechildren. This study isvulnerable to the “myth of the uniformtherapist” (Kiesler,1967). The impact of the therapist wouldbe no less importantthan the impact of passage of time.Instruments of Play Therapy ProcessSeeking a method to analyze child-adult interaction in playtherapy contexts, Moustakas, Sigel, and Schalock (1956)developedcoding categories such as Attentional Behaviors(e.g.,recognition of others or offering help), StimulusBehaviors(attempts to elicit particular responses, such asreassurance oraffection), Orienting and Directing Behaviors (directingorrestricting), Criticism or Rejection Behaviors (rangingfrompraise to physical attack), Cooperation and Complianceexpressions, and Interpretation. The resulting interactionobservation instrument of 82 adult behavioral categoriesand 72child behavioral categories was utilizedby Moustakas andSchalock in their 1955 study. (Thedescription of the instrumentand its development was published after thestudy.) The variedcategories of this instrument suggest a conceptualization of playtherapy process as a composite of interactional events.Although a later Play Therapy Observation Instrument (PTOI;34Howe & Silvern, 1981)was developed as a researchtool, itsgenesis is consideredhere because the authorscarried out anexhaustive theoreticalformulation of play therapyprocess indeveloping it. Howe andSilvern intended for thePTOI to depictand analyze theplay therapy process moreefficiently than anyprevious play interactioninstrument (e.g., Dana &Dana, 1969;Guerney, Burton,Silverberg, & Shapiro,1965).Concerned that “most [playtherapy] studieshave focusedonly on therapy outcome,not process,” and thatthese outcomestudies “have beenlargely irrelevant to concernsabout playroomindicators of pathologyand change” (Howe & Silvern,1981,p.169), Howe and Silvernpainstakingly set about todevelop anobservation instrumentof superior constructvalidity, capable of“classifying everychild behavior or càmment,regardless of itspurported significance”(Howe & Silvern, 1981,p.169). To thatend, the authors embarkedupon an exhaustive reviewof the playtherapy literature todetermine the universalitiesof childclients’ responses.Ultimately, they ascertainedfour major components of playtherapy experience:Emotional Discomfort, Competency,Defensiveness or MaladaptiveCoping Strategies, andFantasy Play.These were subdividedinto 31 coding categories suchas frequencyand degree of playdisruption, frequencyof coherent talk,frequency of regressionor withdrawal, or inventiveuse ofstructured or creativetoys. Of the original31 experimentalcategories, 13, after testing,were deemed reliable observationalcriteria of play therapyprocess. To date, however,Howe andSilvern’s contributionto the conceptualizationof play therapy35process lies in the isolation of thefour major experientialcategories identified above. Examination of the SocialSciencesCitation Indices since 1981 revealedno published applications ofthe PTOI. One dissertation studyused the Fantasy, SocialInadequacy, and Emotional Discomfortscales of the PTOI fordiagnostic purposes only, in order todistinguish adjusted frommaladjusted children (Perry, 1989).SummaryThe extant studies of nondirectiveplay therapy processencompass a range of research intentions,variables, andmethodologies. The small number of studies,each with adisparate research focus, offer virtually nooverlapping orcorroborative findings, thus confoundingrealistic cross—studycomparisons. The paucity of the existingliterature provides aspare context for the current studywhich, rather thanreplicating earlier research methodologiesand/or research foci,chose to proceed in a new direction, usingqualitative analysesof children’s symblic expression.36CHAPTER II. REVIEW OF THE LITERATURESECTION II: SYMBOLIC EXPRESSION AND THE PLAY THERAPY PROCESSThis section links theoretical background on symbolicexpression with accounts of child therapy that have focused onthe child’s symbolic expression. It begins with a brief overviewof the Jungian conception of symbols, proceeds to outline thesimilarities and differences between play and language assymbolic systems, and concludes with a review of representativeclinical literature which has focused on therapeutic change as aprocess of transformations in symbolic expression.The Nature and Function of SymbolsJung (1976) equated the symbolic expression of human beingswith the teleological life of the unconscious, describing symbolsas “transformers” which serve to convert the libido or psychicenergy from a lower form to a higher or spiritual form. Hisunique contribution to therapeutic process was the insight thatthe personal unconscious unfolds and evolves through symbolicexpression. Conversely, symbolic expression provides channelsfor psychic and emotional growth.Jung concentrated on identifying archetypal images, such asthe hero and the foe, and on exploring fundamental themes ofdestruction and wholeness, death and rebirth. He linked imagesoccurring in nature to ancient and primal meanings: repressedinstinctual violence as well as fertility and the positive lifeforce. At the same time he cautioned against any simplisticanalysis of the meaning of the symbol, focusing instead on thedepth of the psychic mystery a symbol brings into focus. Symbolscannot be simply defined or unidimensionally interpreted.37Rather, symbols are complex “images of contents” (Jung, 1976,p.77) with many potential meanings. Symbols are not signscorresponding to what is known. Symbols “seek rather to expresssomething that is little known or completely unknown” (Jung,1976,p.222). Symbols do not signify a definite action orevent. They represent and express deep personal meaning. Jung’scorroborative case material (1976) as well as subsequent work byanalytical therapists (e.g., Kalff, 1980) affirm that symbolsappearing in a client’s art, play, or dreams commonly reflect orportend important personal changes.Symbols are capable of representing personal meaning becausethey link objective (tangible) with subjective (emotional andpsychic) experience. Symbols link the conscious and theunconscious (Segal, 1975). Symbolization occurs when “abstractintangible states of affairs are realized in a concrete medium”(Kaplan, 1979,p.220). By Kaplan’s description, symbols act asa “mediator” between the realms of the mental or emotional andthe physical or material. According to Kaplan, symbols perform afluid or a moving and interactive function between these twodomains. They intimate unseen meanings while retaining physicaldimensions. As similarly characterized by Kubie (1953):It is the dual anchorage of the symbol . . . which is thebridge over which these processes take place, i.e., theinternalization and externalization, introjection andsomatization. Without this dual anchorage of the symbolicprocess these familiar transmutations of experience couldnot take place either consciously or unconsciously.(p.73)Whether conceptualized as “transformers,” “mediators,” or“bridges,” symbols offer tools of access and insight to inner andouter experience. In this study, the selected symbolic systems38of play and language were understoodto offer access to theinterplay between the material andthe mental, the seen and theunseen, the conscious and the unconscious,the child’s observableactivities with a play object and the intangible yetcomprehensible meanings these objects and activitiesrepresent.Play and Language as Symbolic SystemsBoth play and language are symbolic or representationalsystems (Wolf & Gardner, 1981) which have been shownwithin awide range of psychological literature to sharecommonalities intheir development and in their expressivefunctions.Play and Language: Their Developmental ConvergenceVygotsky’s theories (1966, 1978) on the interrelateddevelopmental course of play and language underlie thisstudy.According to Vygotsky, the development of language andthedevelopment of symbolic play are interrelated and interactiveinthe young child. Vygotsky observed that the developmentoflanguage and activity in the infant at first proceed onindependent, parallel paths. Physical explorationsof theinfant’s world are not linked to specific articulations.Conversely, the spontaneous vocalizations of “babytalk” are notinitially associated with the identification of objects.Earlyspeech is not symbolic. It does notrepresent anything.However, at a critical point in development, the infant’ssoundsacquire meaning. At this developmentalcrossroads, language andphysical exploration become linked. Languagebecomessymbolically, representationally, associated with objects,activities, and events: “The most significant momentin thecourse of intellectual development, which gives birth tothe39purely human formsof practical andabstract intelligence, occurswhen speech and practicalactivity, two previouslyindependentlines of development,converge” (Vygotsky, 1978, p.24).The crucial feature ofVygotsky’s developmentaltheory isthat this criticaldevelopmental event, thepoint at whichlanguage becomes fused withintentional activity, occursin arelational context. Specifically,according to Vygotsky (1978),speech or expressivelanguage derives from thechild’srelationship with themother, in particular, fromplayfulinteraction with her.Vygotsky proposed thatthe infant’s speechat firstfunctions interpersonally,to establish contactwith the mother.Only later, followingsuccessful expressive contact,doeslanguage take on theintrapersonal function ofreflection orthought. That is,the child’s social communicativeexperienceprecedes the development ofinternalized self-talk.This is incontradistinction to Piaget’s(1962) related theories,whichconsidered internal speechan early form of thought andaprecursor to expressive,interpersonal language. AccordingtoVygotsky, the developmentalprocess of speech and activitymay besummarized as follows:The child’s speech is atfirst separatefrom activity. Laterspeech accompanies activity in arelationalcontext, and, finally,it precedes activity (i.e.,the thought ofthe event precedesthe action).Play and Language:Differences as Symbolic SystemsPlay and language arerelated though not identical symbolicsystems (Sinclair, 1970).Specifying the differences,Sinclair(1970) noted, first, thatplay occurs in the tangibleworld,40while spoken languageis an intangiblerepresentative system.Second, play andlanguage differ in themanner in which theypermit the expressionof meaning. Themeanings of a givenplayact are highlyindividualized. Playwith blocks, forexample,can occur in myriadforms, styles, andemotional coloration,indicating meaningsunique to each child.The words thatcomprise language,in contrast, are aconventionally assumedsystem of sharedmeanings. A final differenceconcerns the factthat through play thechild can spontaneouslyand loosely linkmaterials, themes,and events together.In contrast,wordscannot be joinedtogether haphazardly.Language is governed byrules of syntax,grammar, and convention,while a child’sspontaneous playis free of any pre—ordainedform.Play and Language:Similarities as SymbolicSystemsPlay and languageshare functional andconceptual featuresas symbolic systems(Smith, 1979). Both arerepresentationalsystems, enablingthe individual to externalizeand portraythoughts and emotions.Play materialsare representational inthat they act,in Vygotskian terms(1978), as a “pivot,”anobject whichcarries meaning relatedto, but independentof, theobject it is meantto represent. Whena child uses a woodenblock as a car,the block acts as sucha pivot. It bearstheessential meaning of“car.” In play withthis object, the childdemonstrates (a) anunderstanding of asymbolic object, whichcanstand for or representa real objectremoved in time and space,and (b) a facilitywith the representationalnature of language,whereby the word“car” contains meaningwhich links yetdistinguishes thereal object and itsrepresentation. Play41objects as pivotsassist the child to separateobjects from theiressential meanings.As similarly describedby El’Konin(1971),“In play the childoperates with thingsas things having meaning;he operates withthe meanings of words whichsubstitute for thething; therefore,in play there occurs theemancipation of theword from the thing” (p.230).As symbolic systems, bothplay and language permitdecentration. The abilityto decenter, identifiedin the pretendplay literature as adevelopmental turning point(Fenson, 1984),refers to the child’scapacity to play at levels ofexperienceincreasingly removed fromthe self. Early attemptsat pretensein late infancyare directed towardthe self (Lowe, 1975).Later, the childanimates and directs objects,investing themwith the potential forindependent action. At amore complexlevel of abstractionand decentration, thechild is able to adopta role or engagein pretend play independentof the qualities orpresence of physicalprops (Elder & Pederson, 1978;Jackowitz &Watson, 1980; Ungerer,Zelazo, Kearsley, & O’Leary,1981).Language similarly permitsdecentration by enabling thechild toconceptualize, describe, andverbally manipulate persons,objects, and eventsremoved in time andspace.EmpiricalSupport for DevelopmentalCorrespondenceEmpirical studies from thefield of cognitive psychologyconfirm the synchronousonset, interrelated abilities, andassociated deficits inthe child’s play and languagedevelopment.Group comparativestudies with autistic children,whose deficitsin both symbolicplay and language capabilitiesare acknowledgedas extreme (Rutter &Schopler, 1978) has shown thatimpairment in42the capacity for symbolic play is associated with impairment inexpressive language abilities and vice versa (Mundy, Sigman,Ungerer, & Sherman, 1987; Sigman & Mundy, 1987; Ungerer & Sigman,1981).Other studies confirm the correspondence of language andsymbolic play capacities in normal development. Free play withmake—believe content has been positively associated with verbalfluency (Dansky, 1980). Functional and symbolic playcompetencies at age 13 1/2 months have positively correlated withlanguage competencies 9 months later (Ungerer & Sigman, 1984).Reviewing an extended body of the related cognitiveliterature, McCune-Nicolich (1981) noted that symbolic playmeasures frequently correlated positively with languageacquisition in normal infants. She noted a developmentalcorrespondence between the young child’s capacity to representevents in symbolic play and in speech and she cited theliterature as supporting the following synchronous events: “(1)presymbolic behaviors in both domains, (2) initial pretending andfirst referential words, (3) the emergence of combinatorialbehaviors in both domains, and (4) hierarchically organizedlanguage and symbolic play” (p. 795). McCune-Nicolich suggestedthat “symbolic play might provide a useful converging operationfor identifying structural turning points in language” (1981,p.795). An appreciation of the conceptual commonalities of playand language as symbolic systems, their differences as symbolicmodalities, and their developmental interrelationship underliesthis inquiry.43Therapeutic Play as Symbolic ExpressionPlay in therapeutic settings has long been regarded as avital symbolic language of the child. Ginott (1982a) observed:Child therapists . . . make use of toys and play materialsin the . . . treatment of emotionally disturbed children.The rationale for this practice is the belief that play isthe child’s symbolic language of self-expression. Throughthe manipulation of toys the child can state more adequatelythan in words how he feels about himself and the significantpeople and events of his life. To a considerable extent,the child’s play is his talk and the toys are his words.(p.145)Play therapy has also been defined as “symbolic action”(Sikelianos, 1990): “Different mediums . . . are used to createarrangements and rearrangements, creation and recreationsymbolically . . . . Through symbolic action of bringing aboutchanges, transformations, the child also gains confidencein hisability to find resolutions”(p.5). According to her, thechild’s “symbolic action” is both a highly personal languageandthe essence of therapeutic change.Allan and Berry (1987) observed that children in treatmentseem to gravitate toward particular play materials which at firstappear to be merely a function of object preference. “It iscommon for many children to be attracted to one key symbol thatwill, appear, disappear, and reappear throughout their treatment”(Allan & Berry, 1987,p.306). More than a function ofpreference, the experience of these therapists indicatedthatthese objects are often a unique symbolic expression of thechild’s difficulty, or a symbol of the child’s capacityforgrowth and recovery.44Accounts of Symbolic Transformation in Child TherapyCase studies which trace the transformations of children’scentral play symbols are often found on the margins of theestablished body of play therapy literature, namely, in theexpressive arts or sand play literature. These studies, whichencompass play, art, sand, or other expressive media, illustratethe critical role of play symbols in treatment and demonstratethe transformation of these symbols as therapy progresses.Case Studies of Play and/or Art MediaClegg (1984) explored the evolution of a particular symbolictheme in play therapy process, “the reparative motif,” or thetheme of rescue, help, and restoration. He observed that theemergence of this theme marked a significant phase in therapy andpresaged a generally successful therapeutic result. In his in—depth study of two cases, Clegg (1984) documented how this motifemerged, evolved, and moved these children toward recovery. Henoted that nascent forms of the reparative motif, barelydiscernible at first, crystallized into fuller form as therapycontinued. Clegg considered play a “holographic sampling”(1984,p.121) of the personality processes of the child: “It isas if the child were initially teaching the therapist thelanguage of her own unconscious” (Clegg, 1984,p.92).Also working from a Jungian perspective and emphasizing thecurative transformation that can occur as a child workssymbolically through expressive arts media, Allan (1988) hascontributed numerous case studies which document the interplaybetween therapeutic movement and symbolic expression. Accordingto Allan (1988), “In play therapy, children will often45spontaneously work on fantasy themes that have direct relevanceto their psychological struggles” (p.21). As children progressin therapy, Allan has observed that they use play materialsdifferently, often with compelling significance which parallelsand symbolically expresses their inner experience. For example,one child achieved emotional growth which was both catalyzed byand reflected in successive drawings of a tree as a symbol of theSelf——decaying, rotten, eaten away, and sprouting new life(Allan, 1988)In a case study of adapted play therapy treatment (Allan,1988), a five—year-old’s progress from psychosis to emotionalwell-being was expressed symbolically through dual media, drawingand fantasy enactment. The themes of the child’s fantasy play(specifically, her dramatic enactments) and the graphicrepresentations of her inner emotional life followed anintermingled course. Her early psychotic insistence that she wasa sea gull was mirrored in her drawings of herself as a sea gull(a feathered creature). As she became emotionally stronger, herpreoccupation with the sea gull receded while images of feathersremained. In a later stage of therapy, the feather was evidenton the headband of a healthier, graphically represented persona,an Indian princess. In her fantasy enactments as in herdrawings, she adopted different, successive identities whichtransformed across her therapy. Allan’s case study accountssuggest that therapy is a continuous movement of symbolictransformations, a stream of consciousness! unconsciousness thatutilizes a variety of symbolic media as it wends toward emotionalrecovery. He observed that “the language of the Self is that of46pictures, images, metaphors, and feelings” (Allan, 1988, p. 7),Sikelianos, a therapist who has used play media but whoemphasized graphic arts representations in the case study reportsof her psychoanalytically-oriented therapy, has contributedsimilar accounts (1975, 1979, 1986) documenting the role and theinterplay of symbolic changes in therapeutic process. In 1979she described the course of successful treatment of a severelydisturbed boy. This child embarked on a two-year course oftherapy in which symbolic transformations presaged, paralleled,and summarized his progress. The boy “made substantial stepstoward integration through the creation of visual symbols”(1979,p.43). Initially, his drawings of a trailer (which arelinked to sources of power and, in his case, were loaded withfood) reflected his preoccupation and sense of safety withmechanical objects while at the same time presaging his need fornurturance. “To delineate the trailers and the hook—up, [he]used two opposing lines: these may symbolize the opposing forces—-good and bad, positive and negative--whose immobilizing power[he] showed in his bearing and continued to represent in hisdrawings” (Sikelianos, 1979,p.45). Other graphic symbolsemerging and transforming in his therapy were keys, coin phones,and light bulbs.In another case study (1975; revised in 1986), Sikelianosdescribed the symbolic transformations, in this case persistentgraphic symbols, which characterized the progress of a five—year—old girl. Sikelianos specified that “symbolic expression playeda central role in this [therapeutic] process since the core of[her] disturbance was at levels of feelings she could not express47overtly in words” (1986,P.53).Although Sikelianos employed play media, the case accountfocused on three persistent graphic symbols which transformedover the three—and—a—half year course of therapy. Two verticalparallel lines, an abstruse early symbolic communication,eventually merged into a cross. This graphic transformationmirrored the child’s personal transformation from emotionalisolation (parallel and distant) to her later capacity for humancontact and relationship (later represented by intersectinglines). A figure 8, initially upside-down and falling intospace, gained stability, human features (eyes, nose, mouth), andultimately (post-therapy) became an S-shaped mandala, a symbol ofwholeness in the Jungian framework. The V, associated early inher therapy with images of aggression (“Monster V”), developedinto a diamond, another symbol of wholeness (radiance).Sikelianos understood the “8” and the “V” as symbolic of thegirl’s “infantile splitting and aggressive tendencies” (1986,p.59). These graphic representations underwent transformation asher ego and personality became stronger and healthier. Ingeneral, “each of the forms had a particular psychologicalsignificance for her, and over time the forms were modified andcombined in ever—changing ways that reflected her strugglethrough the basic developmental tasks of the young child”(Sikelianos, 1986,p.53).Case Studies of SandplaySandplay, an adjunct and an acknowledged component of playtherapy, constitutes a therapeutic medium in itself. Intended asa nonverbal or minimally verbal, noninterpretive therapeutic48modality (Kalff, 1980; Lowenfeld, 1939), descriptive case studiesof sandplay emphasize the transformations of three—dimensional,tactile representations, and serve as further illustrations ofthe conceptualization of therapy process as a course oftransforming symbolic expression.Buhler’s (1951) “World Test,” an early analysis of sandplaysymbolism, was a projective technique to distinguish fordiagnostic purposes the sandplay of well-adjusted from disturbedchildren. Of interest are the basic styles or themes of sandplaywhich she identified, and her conviction in their symbolicfunction as representative of inner emotional states.Buhler identified disorderly versus orderly, schematicversus scattered, and open versus enclosed arrangements. Sheelaborated other basic styles and the affective dimension theyrepresent as follows: violent play (symbolizing aggression);sparse play configurations (dearth of ideas; escape, rejection);repetitive play (preoccupation or fixation); no people (hostilityor escape wishes); enclosed formations (protection or isolation);chaos (inner confusion, dissolution, ego breakdown); and patterns(primitive or perfectionistic; after Buhler, 1951, p.14).The Jungian psychotherapist Kalff considered the sand tray atemenos, a safe container for the child’s unfolding psyche. Inher work, she paid particular attention to symbols of wholenessand well-being: “The manifestation of the self . . . is the mostimportant moment in the development of the personality” (Kaiff,1980, p. 29). Kalff’s (1980) Sandplay is a compendium of casestudies illustrating the curative influence of symbols centraltoeach child. A child who suffered from a learning inhibition49symbolized feelings of hopelessness with a crashed airplane inthe sand tray. Another symbolized the beginning of a feeling ofwholeness and completeness within herself using tiny trees. Twohalves of her Self were symbolized by fir trees (the West) andtiny blossoming trees (the East).Allan and Berry (1987) noted that the physical properties ofsand allow the child to tangibly resolve difficulties through theexternalization of fantasies. Sand provides opportunities formastery and impulse control over the material, and, in paralleland symbolic fashion, over real life difficulties. Becauseemotional resolution occurs on the unconscious, symbolic level,verbal interpretation is usually neither necessary norrecommended (cf. Kaiff, 1980)The many miniature play objects available to the child eachhas “its own physical structure and symbolic meaning, and eachtends to trigger a fantasy reaction” (Allan & Berry, 1987,p.301). In their case study, cars, trucks, arid jets, symbolized“adaptive movements in the outer world,”(p.305); snakessymbolized “negative external forces” (p. 305); and crocodilessymbolized aggressive forces. A figure of Pegasus, identified asa “symbol of inner strength” (p. 305), underwent a transformationwhich paralleled the boy’s progress: at first buried by heaps ofvehicles, later ridden by a magic helper, and finally emergingwith figures representing the child’s family members seated in acircle, a symbolic representation of wholeness.50SummaryThe case accounts by the above therapists and theorists havein common the retrospective inspection of salient shifts in youngchildren’s play symbolic expression. The notion that children’stherapeutic process would be evident in their symbolic expressionwas central to the present study. This study set out not only tohighlight key events within the child’s symbolic expression butalso to capture as much as possible the rich details of themicroscopic changes in the child’s symbolic expression. Thepresent study, then, differs from these case accounts in thedegree of detail of symbolic expression, and in extending thescope of symbolic expression to include verbalization.This study differs from previous empirical process research,considered earlier, in its departure from a quantitative researchparadigm and in its adoption of an intensive, qualitativeresearch design. Previous empirical process research focusedprimarily on shifts in verbal function, content, and intent. Bytracking transformations in both verbalization and play, thisstudy has attempted to straddle and even to integrate aspects ofboth the content analytical (verbal) focus of previous empricalstudies and the symbolic expressionist domains of the playtherapy process literature.51CHAPTER III. METHODOLOGYSECTION I: PRINCIPLES, RATIONALE, AND TERMSChapter II describes the methodology employed in this study.The chapter is divided into two sections. Section I discussesthe theoretical principles and rationale underlying themethodology. A brief introduction is followed by explanations ofthe major terms pertinent to the study: the naturalisticparadigm, field research, participant observation, case studymethod, principles of grounded theory, and the narrative analyticframework. Section II describes the research procedure employed:the subjects and selection issues; setting and access issues;ethical considerations; data collection methods, and dataanalysis techniques.Background: Considerations in Choice of MethodPredating current burgeoning interest in qualitativeresearch (e.g., Lincoln & Guba, 1985; Lofland & Lof land, 1984;Miles & Huberman, 1984), Vygotsky, whose work of the l930s waspublished in English forty years later, noted the tendency ofresearchers to “treat the processes it analyzes as stable, fixedobjects” (1978,p.61). He broke new methodological ground inpsychology with his ingenious problem-solving experiments,advocating that “a complex reaction must be studied as a livingprocess, not as an object” (1978,p.69). Method must not bedissociated from the essence of the phenomenon under study:The search for method becomes one of the most importantproblems of the entire enterprise of understanding theuniquely human forms of psychological activity. In thiscase, the method is simultaneously prerequisite and product,the tool and the result of the study. (Vygotsky, 1978,p.65)52According to Vygotsky, research must give priority to whathe termed the “unit of analysis.” “Unit of analysis” does notrefer to an operationalized definition in the empirical researchtradition. Rather, a unit of analysis is a living micro-facet ofthe process under investigation. Vygotsky cautioned thatpsychological processes of cognitive learning, emotional growth,and human interactions should not become so particularized intoobjective components in the process of research that they losethe essence of the whole to which they belong. Research units ofanalysis should retain the essence of the process underinvestigation. A reductivist study of water, which analyzes thedisparate hydrogen and oxygen molecules, fails to capture themoving, living reality and taste of water (after Vygotsky, 1978).This study considered participants’ play and language, facets oftheir symbolic expression, as the units of analysis,methodologically accessible through a field research strategy andqualitative data analytic approaches.The Naturalistic ParadigmIn contrast to the dominant research paradigm in whichreality is considered determinate, linearly causal, andobjective, the emergent paradigm of naturalistic inquiryconstrues experience as holistically complex, mutuallyinteractive and causal, indeterminate and subjective(Lincoln & Guba, 1985). Naturalistic inquiry attempts tominimize “the presuppositions with which one approaches theempirical world” (Lof land & Lofland, 1984, p.3) and to becomeattuned to the events and themes which emerge from the site understudy. Terms such as “ethnographic research,” “case study53research,” “field research,” and “qualitative research” have beenused synonymously with “naturalistic inquiry” to describe aresearch strategy which seeks to know and understand humanexperience by immersion in it, followed by description of itsemergent themes (Bogdan & Bikien, 1982; Burgess, 1984; Lincoln&Guba, 1985; Lof land & Lof land, 1984). Despite the proliferationof terms, what the Lof lands (1984) have called a “terminologicaljungle,” there is an essential unity of purpose and overlapinactual ideology among these research strategists. Usually,thedifferences among terms can be reduced to a matter of degreeandemphasis. In this study, the term “naturalistic inquiry,” asexplicated by Lincoln and Guba (1985), was used astheoverarching paradigmatic expression which encompassed thetheoretical and practical components of this study:fieldresearch, participant observation, the case study method,principles of grounded theory, and the narrative framework.Field ResearchNaturalistic inquiry takes place in a natural or appliedsetting (Lincoln & Guba, 1985). The term “field research”emphasizes the fact that the researcher departs fromexperimentally controlled environments and enters humancontexts,the field, in order to study them (Burgess, 1984). Fieldresearch relies upon the researcher’s observations of humanexperience as lived and the subsequent description andanalysisof that experience. Fieldwork, as described by Burgess, isdetailed and intensive. It utilizes the researcher as theprincipal research instrument in the formulation of researchquestions, which are elaborated and developed as theresearch54proceeds. The researcher enters the context to be studied with aminimum of disturbance to its natural functioning and devisesmethods of data analysis which remain true to experience asobserved and which at the same time offer explanatory or analyticinsight. Acoording to Bogdan and Biklen (1982), “Becoming a[field] researcher means internalizing the research goal whilecollecting data in the field”(p.129).Participant ObservationParticipant observation has been described under a varietyof related research rubrics, as an aspect of field work (Burgess,1984), qualitative research (Bogdan & Bikien, 1982), andnaturalistic inquiry (Lincoln & Guba, 1985; Lof land & Lofland,1984). Participant observation is a means of data collection bywhich the researcher functions in a dual capacity: as aparticipant in the actual processes and contexts under study andas an observer of those processes. It is through participationthat “the researcher [can] focus on the process whereby behavioris constructed, and not simply the means or the ends” (Fisher,1990,p.127). Depending upon the degree of detachment orinvolvement within the context under study, there exists a rolecontinuum in participant observation (Bogdan & Bikien, 1982;Burgess, 1984). At one end of the continuum is the completeobserver, who functions discretely from the research subjects andwho observes events from a distance. At the other end is thecomplete participant, whose appearance and behavior differ littlefrom the research participants in the setting. The distance anddetachment required by the complete observer can hamper the easeof communication with participants. Likewise, the complete55participant risks losing sight of the research objective and“going native.” The challenge in carrying out participantobservation research is to find a balance between these extremeswhich is appropriate to each specific study (Bogdan &c Bikien,1982; Lofland & Lofland, 1984).Case Study MethodThe case study is a process of research which “describe[sJand analyze[s] some entity in qualitative, complex, andcomprehensive terms, not infrequently as it unfolds over a periodof time” (Wilson, 1979,p.448). The entity under study can bean event, a setting, an institution, or, as in the present study,a process within an individual. The capability of the case studyto examine events over a period of time is an important advantageof this research approach. Descriptions of real life events andexplanatory or analytic commentaries based on these descriptionsare the results which enable the researcher “to begin determiningthe outer limits and internal workings of functionalrelationships, to find out the possible symbolic meanings ofvarious objects, and the different ways in which objects can beused in relating to the world outside” (Baas & Brown, 1973).Another strength of this method of inquiry is its “abilityto deal with interwoven complexity, multiplicity, [and] detailsof concrete daily life” (Wilson, 1979,p.450). With theintensive focus on the individual, case studies are ideallysuited as a means of probing the particular in the pursuit ofwidely generalizable principles of human behavior. Case studiesoffer understanding of the particular, the detailed extension ofexperience, and an in—depth basis for the increased conviction in56that which is known (Stake, 1978).Case study research in the field of psychology isadvantageous because it is closely allied to clinical practice,which is largely concerned with changes within individuals. Thecase study approach has been central to the development ofpsychology (Kazdin, 1980). The foundational contributors to thediscipline, Freud and Piaget among others, utilized a smallnumber of case examples in conjunction with the forceof theirown subjective insights and inductive reasoning, in establishingthe basic tenets of psychoanalytic and cognitive psychology.According to Dukes (1965):A few studies, each in impact like the single pebble whichstarts an avalanche, have been the impetus for majordevelopments in research and theory. Others, more likemissing pieces from nearly finished jigsaw puzzles, haveprovided timely data on various controversies.(p.76)The case study method is appropriate when, as in this study,the research question asks “how” or “why” and when theresearcherhas little control over the behavioral events involved (Yin,1984). By contrast, when the research requires control overevents to be studied, as in a laboratory setting, and/or theresearch questions concern incidence and frequencies, the “howmany” and “when” questions, group comparative or surveyapproaches are preferable.Within contemporary psychology, a reliance on groupcomparative research has resulted in a negative prejudice towardthe study of the individual, according to Rosenwald (1988).Rosenwald observed that “with the jettisoning of the unique, theparticular was lost as well. This leaves us with the definitionof human items by their deviation from the mean” (1988,p.240).57Rosenwald’s claim that “the study of cases—-of lives——is anapproach to the better understanding of social life, not aretreat from it” (1988,p.240) conveys the motivation for theuse of case study methodology in this study.The Rationale for Multiple CasesMultiple case studies are not merely aggregates of singlecase studies (Kazdin, 1980). They are qualitatively richer thanan average of the component cases (Rosenwald, 1988) because theyare capable of answering wider—ranging theoretical questions. Asexplained by Kazdin (1980):Although each case is studied individually, the informationmay be aggregated in an attempt to reveal relationships thatextend beyond more than one individual. . . . Conclusionsdrawn from several individuals seem to rule out thepossibility of idiosyncratic findings characteristic of oneperson. (p.13)Yin (1984) maintained that of the five levels of questionswhich can be answered by case study research, only “questions tospecific interviewees” and “questions asked of an individual” canbe answered by a single case study. However, the multiple casestudy is capable of additionally answering “questions asked ofthe findings across the cases,” “questions asked of the entirestudy in relation to the literature,” and “normative questionsleading to general conclusions.” From Yin’s perspective, “theevidence from multiple case studies is often considered morecompelling, and the overall study is therefore more robust”(1984,p.48) because each case is considered a literalreplication of the other.58Criteria for Case SelectionFrom the perspective of Shapiro (1966), “The first step inthe investigation of processes must logically consist ofinvestigation in a number of individual cases” (p. 5). The useof logical, theoretical criteria in the selection of multiplecases is necessary. Patton (1980) identified six strategies ofcase selection in multiple case research, namely, the selectionof extreme or deviant cases for contrast, typical cases, criticalcases, politically sensitive cases, convenience sampling, andmaximum variation sampling, which documents unique variationsemergent under varied conditions.Yin’s (1984) two strategies for case study subject selectionsynthesize the above options. Yin suggested selecting (a) ahighly typical case, the analysis of which can be consideredrepresentative of many others in the field; or (b) a highlyatypical case, which by contrast illumines cases closer to thenorm (Yin, 1984). Findings of commonalities which arise fromhighly diverse cases can be considered more robust because of thediverse base from which they emerge.The number of cases utilized in a multiple case study shouldalso be based on logical, theoretical principles:The number of cases one chooses to observe depends for itsscientific credibility on the conceptualization of theproblem, the structure of the observation, the significanceof the case chosen, and the use to which the results are tobe put. (Brown, 1974,p.3)The number of cases in this study (4) permitted some diversityfor thematic comparisons and contrasts. At the same time, thenumber was small enough that intensive, even microscopic,analysis could be carried out.59Purposeful SamplingMultiple case studies rely upon replicationlogic (Yin,1984) and utilize purposefulsampling rather than randomsampling. According to replicationlogic, each case isconsidered a literal replication of theentire study. Anindividual in case study research isconsidered not merely asingle unit, but a universe ofresponses.The sampling logic of naturalisticinquiry differs from thatof empirical, experimentalresearch. In that tradition, samplingis based on the statistical premise thatthe selected group ofsubjects represents a random selectionfrom the population atlarge. In case study research, with asmall N or an N of 1,sampling logic does not apply. The dataresulting from these 4subjects were not intended to representthe population at largebut rather to provide insight into andgeneralize to the theoriesunderlying the study.Purposeful sampling is based uponinformational rather thanstatistical factors. Participants are selectedfor theircapacity to generate and maximizeinformation rather than forfacilitating generalizations to thepopulation at large (Lincoln& Guba, 1985). Principles ofpurposeful sampling apply not onlyto the selection of subjectsbut also to the data which areselected for analysis. That is, portionsof the data to beanalyzed may be selected by theoreticalrather than statisticalcriteria. Purposeful sampling isdependent upon the theorydriven needs of the study. That is,it serves a purpose in theenhancement of existing theory or in the developmentof newtheory.60Glaser and Strauss (1967) used a similar term, “theoreticalsampling.” Their term emphasized that a theoretical rationalemust underlie subject selection. In their view, the term“theoretical rationale” encompassed not only subject selectionbut also the criteria by which the qualitative researcher decideswhich data is to be analyzed, how, and when. In “theoreticalsampling,” the sampling of cases, of responses, and of themescontinually undergoes focusing and revision.Principles of Grounded TheoryThe purpose of naturalistic or qualitative research variesfrom providing rich descriptions, at one end of the continuum, toproviding explanations, to the generation of new or expandedtheory. Glaser and Strauss (1967) asserted that the purpose ofqualitative inquiry is to go beyond description to generate newtheory which is anchored, or grounded, in the themes and theevidence which emerge from the data.Grounded theory utilizes research strategies common to mostqualitative research, such as coding, memos, and continualwritten commentaries and analysis. However, the researchvocabulary which Glaser and Strauss introduced emphasizes theorycreation. Coding categories, they maintained, should be morethan adequate descriptions. They should be “conceptually dense,”in that the categories provide analytical and sensitizing handlesfor understanding the data. They identified “core categories” asthose conceptual categories which have the most explanatorypower. These categories are meant to be the theoretical nucleifrom which new theories evolve. In formulating new categories,the researcher working from a grounded theory perspective uses61the method of “constant comparisons”whereby new categories,their rationale, and their propertiesare continually comparedwith existing ones. No conceptualdetail is presumed. Thecategories and their conceptual justifications undergocontinualcomparative analysis. This study set as a primary aimthe richdescription of thematic transformations within theplay therapyprocess. From these rich descriptions, itwas anticipated thatexplanatory insights into the process of play therapyandpossibly even new theoretical understanding of that processmightemerge.The Narrative FrameworkPrinciples of narrative knowing underlie the data analyticstrategy of this study. That is, this study consideredparticipants’ play and their verbalizations as two forms ofemergent narrative, two forms of text orstory. As well, thestudy employed principles of narrativeanalysis in theidentification of emergent verbal and playthemes.Narrative as a means of knowing and as a creativequalitative research perspective rests on the premisethat humanbeings are continually telling stories replete with personalmeaning through their words, their actions, and theirlives.Polkinghorne (1988, 1990), who has advanced the understandingofnarrative, has developed a more complex conceptualizationofnarrative than the ordinary comprehension of narrative as“just”a story: Narrative is the continual unfolding andexpression ofmeaning. As such, narrative expressionis the essence of humanculture and an on—going process within the individual. If words,actions, and lives are considered as a vital story, a living62context of meaning, themeaning of that story, life, action,orwords, can then be accessedin the same manner as with a literarywork, namely, through theidentification of plots and themes.Todescribe a plot in a narrativeis to ascertain the meaning ofthat plot for the individual.Narrative as a perspective inclinical practice is notforeign to the field ofpsychology. The psychoanalytic andpsychodynamic literature iscomposed of numerous client storiesretold by the clinician.Freud was continually searching fordecisive moments in hispatients’ experience to ascertainrepetitive themes, theirsignificant transformations, and theirmeaning in depth (Polkinghorne, 1988).His case studies areillustrations of insightsacquired through what was essentiallynarrative analysis of his patients’discourse and dreams.According to Polkinghorne,Freud contributed two significantinsights into the analytic use of narrative.Both are relevantto this study. First, meaningusually depends upon what happenslater. That is, meaningoccurs in a temporal context. Attimes,it may be immediatelyclear; at other times, understandingmayoccur only in retrospect.Second, the expression of meaningisnot equivalent to theexpression of factual experience. Theclient who fabricates thecontent of a dream, the child whotellsa fanciful story, arestill providing expressions ofpersonalmeaning. Whether or notthe dream or the story is factualdoesnot interfere with thevalidity of its meaning.The narrative framework presupposesthat human meaning,purpose, and intention are knowableand accessible through boththe words and the actionsof the individual. As Polkinghorne63(1990) elaborated, justas words in a series link to assumemeaning greater than thesum of the parts, actions in a seriesform meaningful episodesand plots. Although experience as itisbeing lived may appearsegmented and disjointed, over time thesesegments create a whole of meaningfulplots and patterns. Smallsegments when connected become larger episodeswhich, in turn,depict overarching themes. A beginning,a middle, and an end ofcertain themes may emerge, and the series ofdisjointedexperience forms into a more coherent and meaningfulwhole.Individual events in the narrative thusbecome “comprehensible byidentifying the whole to whichthey contribute” (Polkinghorne,1990,p.94). This thematic identificationis accomplishedlargely by retrospective reflection uponthe narrative material.Adopting a narrative framework forresearch provides “adescriptive structure for integratingthemes into a whole”(Cochran, 1990,p.80). As a research strategy, narrative can beused to provide both descriptions andexplanations. Descriptivenarrative research attempts to accurately portrayemergent themesand plots. The descriptive analysisof a narrative text can becomplex because plots and sub—plots intermingle,requiring thediscernment of latent meanings. Polkinghorne maintained thattheuse of narrative can accomplish causal explanationsbecause thenarrative perspective delves beneath statisticalprobabilities tothe level of the intricacies of humanmotive and purpose. Thisstudy endeavoured to provideessential descriptions of emergentthemes and their transformations in children’s verbalizationsandin their play.The actual interpretation of a narrative text can be64accomplished with scientific rigor(Van Manen, 1990):In the quantitative sciencesprecision and exactness areusually seen to be indications ofrefinement of measurementand perfection of research design.In contrast, humanscience strives for precision andexactness by aiming forinterpretive descriptions that exact fullness andcompleteness of detail, and that exploreto a degree ofperfection the fundamental natureof the notion beingaddressed in the text. (p. 17)Extracting the themes, scripts, or guidingmessages embedded in anarrative can be accomplished by two primarymethods: (a) lettingthe data reveal itself, and (b) askingthe data a question(Alexander, 1988). “Letting the datareveal itself” is not apassive process. It requiresattunement on the part of theresearcher to discern emergentthemes.Alexander (1988) identified nine “principle avenues”fordetermining salient themes in a text. By attendingto primacy,the researcher probes the narrativefor initial themes, assumingthat first themes or expressionsare meaningful to theindividual. Frequency of expressionis another means ofidentifying salient themes. “When frequency iscoupled withother salience indicators it may revealless conscious schemas”(Alexander, 1988,p.271). Unique or unusual expression andcontent can indicate salient themeswithin a narrative, and theindividual’s negation of meaning can also besignificant. Wordslike “always,” “absolutely,” and“never” indicate saliencethrough emphasis. Salience can also beindicated throughomission, a lack of affect or lack of cognitiveclarity in thestream of narrative. Statementswhich reflect error ordistortion can signal important gaps in understandingor theindividual’s self—image. Nonsequitors, or statementsin65isolation, can signal salient themes, as can incompletestatements. In the latter two strategies the narrativeresearcher seeks to uncover the motivation for the isolated orincomplete statements.After employing these principles to identify salient themes,the initial data are sorted and reduced. Salient units in theircompleted form are “microscopic stories with an introduction, anaction, and an outcome” (Alexander, 1988,p.278):My assumption is simply that what is expressed in imageryand the manner in which it is expressed indicates therepertoire of that subject . . . To find repeated fixedinstances of a sequential pattern, despite changes ofcontext, characters, and time, alerts the observer to thepower, in the sense of importance, of that sequence in theexperience of the subject. (Alexander, 1988,p.281)A comparable method by Giorgi (1985) for extracting meaningfrom narrative protocols is to (a) read the entire protocol toget a general sense of the whole; (b) identify “meaning units”;(c) apply psychological insight to these meaning units; and (d)synthesize the meaning units into a “consistent statement” of thesubject’s experience. Giorgi noted that the researcher must beparticularly alert to points of change in meaning within thetext.Qualitative Data AnalysisQualitative data analysis is a continual process of datareduction and organization (Miles & Huberman, 1984). Datareduction refers to the ongoing task of “selecting, focusing,simplifying, abstracting, and transforming the ‘raw’ data thatappear in written-up field notes” (Miles & Huberman, 1984,p.21). Data reduction occurs through systematic, methodical toolswhich begin to streamline a large quantity of data (words) into66smaller and increasingly manageable and meaningfulunits. Datareduction and data focusing occur during both the data collectionand the data analysis phases. Within this research method,reliability and validity are dependent upon the accuracy of thereporting, the generation of rich descriptions with a wealth ofdetail. The construction of a chain of evidence depends uponthis abundant and accurate reporting.Specific Data Analysis TechniquesThe principal data analytic technique utilized in thisproposed study was that of coding. Coding was carried outfollowing data collection. Memos, or analytic notes, werecompleted during the data collection and data analysis phases.Diagrams and displays (after Miles & Huberman, 1984) were alsoused.CodingCoding is the process of conceptualizing the data andcategorizing them according to emergent themes. Codingcategories in this research paradigm are devised from the data,not superimposed upon them. Open coding (Glaser and Strauss,1967), like the “first-level coding” of Miles and Huberman(1984), is an early attempt to organize the data through thematiccategorization. In open coding, the researcher approaches thedata with preconceptions and prejudgments suspended (bracketed).Later, axial coding, or intensive analysis around particularcoding categories by breaking them into component dimensions, canbe carried out (Strauss, 1987). Axial coding is similar to thedimensional coding suggested by Miles and Huberman (1984).Pattern codes (Miles & Huberman, 1984) link the more67particularistic open codes into categories of overarchingthemesand interrelationships.Coding categories may be descriptive,explanatory, and/orinterpretive. They may refer to motifs, themes, patterns,and/orcausal links (Strauss, 1987). In thisstudy, two coding systemswere devised: one for the child’sverbal themes and one for thechild’s play themes.Memo ingMemos are analytic notes written by the researcherthroughout the research process (Miles & Huberman, 1984;Strauss,1987). Memos serve a variety of purposesin qualitativeresearch, such as orienting theresearcher to a new problem,raising a question, recording an insight,or substantiating therationale for a new coding category(Strauss, 1987). optimally,these notes are intended to be taggedto the data which promptedthem. They consist of comments,observations, ideas, questions,clarifications, and analytic insights which arise at anypoint inthe research: before, during, and after data collection.Thepurpose of writing analytic notes is to amass a quantityofanalytic comments which can be sorted,even coded, and utilizedfor building theory.Graphic DisplaysDisplays of the qualitative data, as recommended by Milesand Huberman (1984), can include charts, graphs,tables, and anyother creative diagrams which depict, organize,clarify, andexplain the data. This study reliedprimarily upon the chartingof coding categories across sessions.68The Research DesignIn naturalisticinquiry the researchdesign evolvesfrom thefocusing questionwhich motivatesinvestigation.The design“deals witha logical problemand not a logisticalproblem”(Yin, 1984,P.29). Theresearch designis less a formand morea direction.Early dataanalysis and emergentevidence fortheory buildingprovide the theoreticalscaffold for laterdataanalysis.Prevalent themesor theories emergentearly in theresearch aremodified or replacedand new questionsformulated asadditionaldata become available(Miles & Huberxnan,1984).Although analysisof the data takesplace throughoutall stagesof the study,the more formaland intensiveanalysis and theorybuilding occurin the laterstages (Bogdan& Biklen, 1982).The principlefeature of thequalitative researchdesign isits flexibilityto adapt asnew data and theoreticalconstructsemerge (Bogdan& Biklen, 1982).In qualitativeresearch it isimportant toavoid “goinginto a study withhypotheses totest orspecific questionsto answer, [since]. . . findingthe questionsshould be oneof the productsof data collectionrather thanassumed apriori. The studyitself structuresthe research,notpreconceivedideas or any preciseresearch design”(Bogdan &Biklen, 1982, p.55). Becausenaturalistic researchendeavors togenerate ratherthan to test hypotheses(Marshall &Rossman,1989), guidingquestions ratherthan specifichypotheses wereformulated atthe outset ofthis inquiry.Additional questionswere anticipatedthroughout theprocess of datacollection andanalysis. Adescription of theresearch procedurefollows.69CHAPTER III. METHODOLOGYSECTION II: THE RESEARCH PROCEDUREThis section describes the steps of the research procedure.It begins with a synopsis of the design, then proceeds todescribe the phases of subject selection, data collection, dataanalysis, and write-up. Appendix A outlines the steps of theresearch procedure which are described in summary form in thissection.Synopsis of DesignA multiple case study design was employed, with each caseconsidered a literal replication of the inquiry. Preschoolparticipants received a course of nondirective play therapy fromthe therapist/researcher. From the transcriptions of theirsessions, emergent coding categories for the verbal and playcomponents of the entire course of therapy were devised. Dataanalysis consisted of a process of continual re—organization,reduction, and charting of the codes and supplementarydescriptive material until themes or patterns were identified.Description of ParticipantsFour preschoolers ranging in age (at outset) from 3.1 to3.10 years participated in this study. Preschoolers with diversepresenting problems were selected for participation.Participants’ presenting problems ranged from severedevelopmental delay to a variety of adjustment, behavioral, andemotional difficulties. With one exception, participants wereable at the outset of therapy to play and to communicateverbally. None of the participants had been diagnosed assuffering from any physical handicap or mental disorder. All70children attended thesame preschool and were able to receiveplay therapy on site from thetherapist/researcher.Rationale for Participant SelectionPreschoolers were selected becausethis age group generallypossesses the capacity for bothexpressive language and symbolicplay. Important developmentalcapabilities in language andsymbolic play converge betweenages 2 1/2 and 3 (Lowe, 1975;Ungerer & Sigman, 1984). By thepreschool age of 3 1/2 to 5,basic play and language competenciesare considered thedevelopmental norm. Older latencyage children tend to be lessspontaneously self-disclosing (cf., Lebo,1951) and, in Piagetianterms, depart from a symbolicplay focus to concrete operationalinteraction with materials.Participants with diverse presentingproblems were selectedin accord with the rationalefor participant selection describedby Yin (1984), namely, thatcommonalities found across highlydiverse cases may be consideredmore robust.Process of Participant SelectionThe process of participant selectionbegan with thetherapist/researcher’s observation ofthe entire preschoolpopulation to identify children in needof and believed to becapable of responding to play therapyintervention. Thetherapist/researcher carried outthese observations from behind atwo—way mirror. Observationstook place over a period of 4weeks. To supplement the researcher’sobservations, thechildren’s preschool intake recordswere also consulted indetermining the subject pool. Childrenwho, it was believed,would benefit more fromthe classroom peer milieu or from group71music therapy were not included in the subject pool. Otherfactors, such as consultation with the preschool staff and/orconsideration of parental request, were also taken into accountin the determination of the subject pool.Letters of initial contact were sent by the director of thepreschool to the parents of the children in the subject pool.These letters described the opportunity for their child toreceive individual play therapy and requested that interestedparents phone the school to set up a meeting with the playtherapist for the purpose of exploring this possibility further.In the meeting, the therapist! researcher began by describing theprinciples of play therapy and the possible benefits of playtherapy for their child. The therapist/researcher described theresearch that would derive from the play therapy intervention andprovided parents with a letter outlining the research purpose andbasic procedure. The purpose of this personal meeting was toanswer any questions or concerns the parents may have had aboutplay therapy and/or the research purposes and methods. Thechildren’s availability was a factor in participant selection.Only those children whose parents, subsequent to or during themeeting, provided written consent were selected forparticipation. Copies of the letter to parents describing theresearch objectives and the form for parental consent can befound in Appendix B.The Setting and Access IssuesSubjects were selected from a reputable British Columbiapreschool which included both typical and atypical children inits student population. The play therapy sessions took place at72this preschool.Because the researcher had completed two years of clinicalwork at the preschool during thepilot work for this study, shewas already known to and accepted by the preschooldirector andteachers. Several months before the start of the schoolyear, awritten document, outlining the purpose of the research,wassubmitted to the board of the preschool who grantedinformedconsent for the study to proceed in the fall.Ethical ConsiderationsIn accordance with university ethicsregulations forresearch with human participants, a synopsis of the researchandmethods was submitted to the UBC Behavioural SciencesScreeningCommittee for Research and other Studies Involving HumanSubjects. Approval was received before play therapysessionscommenced. Informed consent forparticipation in the study wassecured in writing by the parent or legal guardianof each child,as described above. The children’sconfidentiality and anonymitywere scrupulously ensured throughout the write—up ofthe projectthrough the use of pseudonyms, the masking of backgrounddetails,and protecting the anonymity of thesetting.The Researcher as Participant—ObserverIn this study, the therapist/researcher functionedas aparticipant—observer as follows. The role andfunction of thetherapist/researcher was well-defined and discrete withinthedata collection and data analysisstages. In the data collectionphase of the project, the researcher maintained aparticipatoryrole as the nondirective play therapist,conveying a specificnonjudgmental, noninterpretive, and empathic attitudetoward the73participants in order for thetherapy to proceed. Reliance onelectronic means of data recording (audio-and videotapes) freedthe therapist/researcherfrom the need for during—session fieldnotes which would have disrupted thetherapeutic focus. Afterthe sessions, the therapistassumed the observer function,completing the field notebook andreflective, retrospective notesor memos. The observationfunction——data reduction and analysis,via the transcription and examinationof videotapes——occurredafter all the play therapysessions had concluded.The Therapist’s Intervention StyleDuring the play therapy sessions,the therapist workedaccording to the principles of nondirective playtherapy, asexplicated in Chapter II, allowing thechildren to determinetheir play initiatives. Within thenondirective approach to playtherapy, the therapist adopted a highlypermissive style ofintervention. Children were permittedto engage in messing andaggressive behaviors well beyond thelimits of socially acceptedbehavior. The therapist operated froma belief that, within thecontained therapeutic setting, (a) theexpression of negativeaffect and behavior diminishesits destructive force and (b) thechild’s positive, self-actualizingenergies can ultimatelyoverride the experiences of dissolutionand regression.The Data Collection PhaseThe videotaping and audiotaping of each child’scourse ofnondirective play therapy sessionsconstituted the datacollection phase. All sessions werevideotaped with anaudiotaped back—up. The video camerawas placed on top of a 3—tiered shelf within theplayroom. In general, it did not prove74to be a distractionto participants.A field notebookandsession summarysheets (describedbelow) were additionalfeaturesof the data collectionprocess.The Play TherapySessionsEach participantreceived a course ofweekly individualnondirective playtherapy sessions.The sessions wereconductedon—site at the preschoolduring school hours ina small roomwhich had beenequipped by the therapist/researcherfor thatpurpose. The therapistaccompanied each childfrom and to theirrespective classrooms.Three of the participantsreceived 20sessions, while thefourth child, whose therapyended at parentalrequest, received17 sessions. Thecourse of therapy spannedroughly 6 monthsof the school year, fromOctober through March.Each session lastedfrom 35 to 45 minutes.A diagram of thetherapeutic playroomas well as a listing ofthe play materialsprovided to participantscan be found inAppendix C.The Field NotebookDuring the courseof the play therapysessions, thetherapist/researcherkept a field notebook.The field notebookor field journalis an indispensabletechnique of field research(cf. Bogdan & Biklen,1982; Burgess,1984; Lincoln & Guba,1984).The field notebookcontained the therapist/researcher’snotes oneach of the playtherapy sessions. Thenotes were in proseformand attempted toprovide a literal record,as recalled as soonafter the sessionas possible, ofwhat transpired withinthesessions. Personalcomments, reactions,insights, and analyticcomments were includedin the field notebookbut were set offfrom the sessiondescriptive notes in brackets.75Session SummarySheetsThe researcherfilled out post-sessionsummary sheets foreach session.Session Summary Sheets(Appendix D) were asecondary aspect of thedata collection process,as adapted fromthe Contact SummarySheets recommended byMiles and Huberman(1984). The purposeof the SessionSummary Sheets was tohighlight the mainverbal and play themesfor each session.These summaries servedto focus the researcher’sthoughts alongthe lines of the inquirybut they were not instrumentalin thedata analysisphase. In a separatefile, the researcher keptmemos or analytic notesrelated to the researchprocedure as wellas other generalobservations, questions,insights, andreflections on the researchin process.The Data Preparationand Organization PhaseBefore emergent verbaland play themes could beidentifiedand analyzed, theresearcher followed a seriesof steps intendedto methodically organizethe vast amount of materialgenerated bythe 77 play therapysessions of the participants.Working on one case at atime, the researcherfirst preparedverbatim transcripts ofthat child’s sessions. The transcriptpage was arranged withthe verbatim verbal materialin the left-hand column. In the right-handcolumn of the protocols, thetherapist noted the playactivities synchronous withtheverbalizations. “Pivots”and “elaborations” in playactivitieswere noted. “Pivots”were major shifts in thechi1ds choice ofplay materials, whichmarked entry into newplay. “Elaborations”were additions of playmaterials to on-goingplay activity. One-minute intervals werenoted on the pages of transcript.A sample76of a transcripted page from the therapy of Anna, showing verbatimverbalization, play pivots and elaborations, and time notations,can be found in Appendix D.The notation of pivots and elaborations proved necessary forthe next step, the construction of “time lines” for each session.Time lines showed in summary form per session all of the majorattentional breaks or pivots as well as play elaborations. Abovethe time line, the therapist noted key play activities. Belowthe time line, the therapist noted key verbalizations. Theconstruction of time lines enabled the researcher (a) to see at aglance the progression of play activities within sessions, (b) tocompare trends in play across sessions, and (c) to identify thechild’s principal play materials. A sample of a portion of atime line is found in Appendix D.The Data Analysis PhaseThe data analysis phase consisted of the coding of playthemes followed by the coding of verbal themes.Coding of Play ThemesCoding of the play themes, or patterns in the child’s playactivities, began with the construction of the time lines.Through the construction of the session time lines the researcherwas able to identify the child’s principal play materials. Theprimary criterion for determining the child’s principal playmaterials was the comparative frequency of play with materialsacross sessions.Using the information on principal play materials generatedby the time lines, the researcher compiled for each play materiala chronological listing within and across sessions of all of the77child’s interactions withthat material. These were calledeventlistings, of which a sampleexcerpt from Anna’s therapy may befound in Appendix D. Asis evident from the example,corresponding verbal highlights werealso noted.With the complex web of the child’splay activities thusbroken down according to playmaterial and chronology of usage,the researcher then sortedeach event listing into themes foreach principal material.To determine the themes, the researcherused a two-fold strategy ofletting the data reveal itself andasking the data a question.Specifically, the therapist pouredover the chronologies, attuning tothe types of distinctions inplay material usage. The therapistrepeatedly asked of thesedata the question: How doesthe child’s use of a given playmaterial differ from precedinguse? For each child, the answersto this repeatedly askedquestion differed. The answers to thisbasic underlying question determinedthe designation of playcategories. The coding categories forplay themes had abehavioral focus, noting the shiftsin the child’s interactionwith a given material. The resultingcategories were thencharted across sessions in orderto portray the succession of thethemes and their transformationsover time. The reader isadvised that within the fourcase accounts nonoperationalizedterms such as aspects, dimensions,facets, and so on, are usedinterchangeably to denote the componentsof a given code.Coding of Verbal ThemesVerbal themes were coded for eachprincipal play material.To determine the verbalthemes, the researcher consulted theevent listings and continually referredto the verbatim session78protocols to ensure that allverbalizations were considered. Thestrategy for ascertainingthe principal verbal themes variedaccording to the degree ofverbal sophistication of theparticipant. For participantswith limited verbal faculties, theresearcher was able to compile foreach material a straightvocabulary listing across sessions.For more talkativeparticipants, the researcher perusedthe event listings and thetranscripts for clusters of relatedreferents occurring inassociation with a given play material.To ascertain a giventheme, the researcher adoptedthe strategy identified above: (a)letting the data reveal itself byreading and rereading thetranscripts and the event listings; and(b) asking the data thequestion: How are these referentsrelated or alike? Todetermine transformations within a giventheme, the researcherasked the data the question: Howdo these referents differ fromprevious referents within the same thematiccategory? Chartingthe verbal themes and their transformationsacross sessionsrevealed their general progression overtime.The Written AccountsThe next 4 chapters contain the case studyaccounts of the 4participants. Each chapter beginswith a case profile, whichgives a brief developmental history andthe basic reason for thechild’s play therapy referral. In orderto safeguard participantconfidentiality and anonymity, only thatbackground which wasnecessary for the reader to makesense of the child’s play andverbal themes has been included. Allnames have been changed,and certain details have been modifiedto protect the identitiesof the children and theirfamilies.79Each introductory case profileis followed by theidentification of the phases of thechild’s play therapy andtheir principal play materials. Thisis followed by a detaileddescription of the transformationsin the play themes with theprincipal materials. The verbalthemes associated with theprincipal materials are then identifiedand their transformationsdetailed.In this study, the phases of datacollection, data analysis,and write-up overlapped and were interactive.Throughout theprocess of writing the accounts and theintricacies of the playand verbal themes, the researcher foundthat consideration of thethematic trends led to a further understandingof each child’sexperience of play therapy. A summary narrativeconcludes eachchapter. This concluding narrativeutilizes the child’s play andverbal themes as tools of understandingto refract and explicateeach child’s experience of play therapy.The reader is advisedof the following stylisticconvention in these accounts: Thefigures given in parentheses, e.g., (6) or (5 through9), referto the session number.80CHAPTER IV. CASE 1ANNA: THE REEXPERIENCING OF INFANTLIFEAnna’s play therapy sessionswere replete with the detailedand often dramaticreenactments of aspects of infant life, frombirth through toddlerhood.Anna was nearly 4 at the outset ofplay therapy. Herpresenting difficulties had perplexed severalspecialists, who had advancedseveral diagnoses in an attempt toexplain some problematic behaviorpatterns, such as tantrums, atendency toward hyperactivity, andoccasional sleep disturbances.Anna sometimes avoided herpeers, preferring solitary play.Anna’s family was very concerned aboutthe difficulties theiryoungest child was encountering.Anna presented as a highlyverbal child, with a well-developed and, as this analysiswill later illustrate,sophisticated vocabulary.Anna possessed a number of otherstrengths. An active andenergetic child, she enjoyed a range ofage—appropriate play activities. Herplay in the classroom wasoften characterized by elaborate fantasysequences, such asdress—up or solitary house play, evidence ofher creativeabilities.With regard to her developmentalhistory, Anna’s birth hadbeen perilous and difficult.Her presenting breech position hadthreatened her life. Throughouther early childhood, Anna hadsuffered frequent upperrespiratory infections. She had requiredongoing medical treatment, whichincluded frequent visits toseveral doctors, repeated medicaltests, many of which werepainful and intrusive, and, on a fewoccasions, briefhospitalizations. Health difficulties,both minor and major,81persisted to some degree throughouther play therapy.Overview of Anna’s Play TherapyFrom the first session, Annaresponded happily andenthusiastically to the nondirectiveplay therapy setting, whichgave virtually free rein toher creative and impulsive energies.Anna quickly established alevel of comfort in the playroom andbasic trust with the therapist. Bythe third session, she hadbegun to surface in her play consequentialpsychologicalmaterial, namely, enacting the birthof the infant. Anna filledthe next 12 sessions with therecreation of many aspects ofinfant life: birth, sleeping,feeding, messing, washing,aggression, and theinfant at play.The concluding 4 sessionssaw a decrease in the intensity,frequency, and duration of herenactments of infant life. Inthese latter sessions, Anna began touse other play materials inthe symbolic representationof her current real—life struggles.Specifically, Anna utilized the figureof a small whale as apatient, while Anna as the doctortended him with painfulinjections, comforting bandaids, andverbal warnings of death.Although Anna’s enactments of infancystill recurred, they nowalternated within sessions withsegments of whale doctor play.Positive developmental gains began toaccrue outside theplayroom. Her progress in school and athome proceeded inspurts. Considerable behavioral improvementmanifested shortlyafter the first 5 sessions, asAnna began to calm at home and toparticipate without behavioral outburstsat some family outings.Behavioral and emotional changes generallyfollowed a “twosteps forward, one step back”pattern throughout her therapy.82“Best ever” adjustmentsat home and at school, asreported by herparents or teachers, wereusually followed immediately bytroubled periods, duringwhich behavioral difficultiessuch astantrums or sleep disturbancesrecurred. Midway through hertherapy Anna was requiredto undergo a battery ofmedical testsin hospital. Thispotentially traumatic event provedto be apositive test of her progress todate. In contrast to earlierhospital experiences, Anna,with the active support of herfamily, was able to toleratethe medical procedures withoutincident. The fact thather return home was not followedbyserious regression into actingout behaviors was an achievementfor her, suggesting someenduring emotional gains.Ultimately, through her therapy,Anna succeeded inremediating some of the effectsof her difficult birth. By latespring, Anna had movedslowly but steadily into a new andstronger relationship withherself, her peers, and her family.She was happier and moreresilient emotionally. She was lesssusceptible to tantrums or tobouts of anxiety, and she had begunto seek out and to enjoyplay with peers.The Phases of Anna’s TherapyAnna’s play therapy advanced inthree broad phases. In thebrief Beginning Phase (Sessions1 and 2), Anna engaged in anumber of activities, whichincluded sustained care-givingsequences, such as preparingfood (playdoh, sand, and water) forthe therapist (1) and givingthe therapist a medical check-up(2). Session 3marked the beginning of the Middle Phase, theEnactment of Infant Life,in which Anna herself was usually therecipient of care. These enactmentsof birth, feeding, sleeping,83messing, aggression, and infant—at—playcontinued in richelaboration through Session 15.Representations of Hurt andHealing thematically dominated theEnd Phase (Sessions 16 through20), alternating with enactments ofinfant life. In this finalphase, a small whale, which had appearedthroughout Anna’stherapy, figured prominently.The Principal Play MaterialsThe recurrence of play materials acrosssessions served asthe principal criterion in determiningthe play materials centralto Anna’s therapy. Theirappearance across sessions issummarized in Figure 1. Infant—relatedprops were the primarymaterials of Anna’s Infant Play. A simplecotton sheet served asthe infant’s receiving blanket, an essential propthroughout thisplay. Other props includedthe doll cradle, baby bottles andsoothers, the tea set, a bib, and assorted objects whichAnnaused as the “baby’s toys.” The DoctorKit, Paints, and the Whalewere also central to Anna’s therapy. Herplay with thesematerials was also submitted to thematicanalysis.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920MaterialINFANTPROPS* * * * * * * * * * * * * * ** * * * *DOCTORMATERIALS* * * * * * * *PAINT* * * * * * * ** * * *WHALE* * * * * * * * * * ** * *Ficure 1. Anna: Overview of Play with PrincipalMaterials84Infant Play: The Play ThemesThe play themes comprising Anna’s InfantPlay weredetermined according to the natural lifeactivities theyrepresented: Birth, Sleeping (in bed and in acrib), InfantAggression, Eating, Drinking, Infant-at-Play,Messing, andWashing. As Figure 2 depicts, Infantactivities were addedincrementally to her play repertoire, until,over time, Anna wasenacting a wide spectrum of infant life.Within each session,infant activities overlapped and interwove in aseamless whole,with the hungry infant Anna pausing to play,then drinking fromher bottle, then climbing into hercrib to read a book, and soon. For the purposes of this study,these thematic threads havebeen teased apart and subjected to discreteanalysis for play andfor verbalization components.Precursors of infant play. Anna’s infant playbegan withtwo fleeting and, at first glance, almosttrifling incidents inthe Beginning Phase. In the first (1),Anna simply handled thetiny crib from the doll house and wordlesslyplaced it on theplayroom table. In the next (2), she buriedthe same crib and init a small baby figure in thesand tray. These segments, thoughbrief, are consequential asthematic precursors to Anna’s laterwell-elaborated infant play.85SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemePRECURSORS* *MESSING* * * * * * * * * * * ** * * * * *BIRTH* * * * * * * * * * * * *SLEEPINGBed* * * * * * *Crib* * * * * * *AGGRESSION* * * * * * * *EATING* * * * * * *DRINKING!BOTTLEWater* * * * *uice* * * * * *INFANTPLAY* * * * * * * * * * *WASHING* * * * * * * * * * * *Figure 2. Anna: Play Themeswith Infant PropsBirth. The dynamic theme whichcharacterized Anna’s therapyfor months was the enactment of thebirth of the baby (3 through14; reprised in 19). Her first enactmentof an infant’s birthwas preceded by the spilling of water. Aftermaking a huge watermess on the floor, Anna crawled intothe therapist’s lap andasked to be wrapped in a blanket. Abrightly colored floweredsheet was adapted for this purpose.Curled in the therapist’slap in a breech (head up) fetal position,and wrapped in her“flowered blanket,” Anna squirmedinside the blanket and madefaint squeaks and infantsounds. From this enclosed posture,Anna tentatively reached out a hand or afoot, and then withdrewit into her blanket cave.Anna then lifted the blanket from offher head and, lookingradiant and happy, exclaimed, “It’s a baby86girl!” This was the genesisof the birth enactments whichconstituted the thematic core of Anna’sprimal play therapy.Within sessions and across sessions,Anna repeated theInfant Birth sequence manytimes. In its most dramatic variation(3, 4), Anna repeatedwhat appeared to be an enactment of abreech birth. She extendedher legs first, uncovered the rest ofher body, emerged feet first from beneaththe blanket, andglowingly announced the birth of thebaby. In other variations(4 through 9; 11), fetal Annaremained enwrapped for longperiods, not wanting to come out. SometimesAnna played a gameof neonatal peek-a-boo,slowly lifting her blanket, or permittingthe therapist to do so,and glancing at the therapist with a lookof happiness mingled withfear. At these times in her play,Anna’s face had the soft andvulnerable cast of a newborn. OftenAnna emerged glowing, playful, andinterested in pursuing otherinfant—related activities, sometimesreturning to more birthenactments following sleeping, washing,or feeding sequences.Anna became attached to the floweredsheet in which shefirst enacted a birth sequence (3).She used this favorite“flowered blanket” throughout hertherapy for birth play oradapted it for use in other infantenactments. It became atransitional object of critical importance (Winnicott,1971), andit figured prominently in the nextdimension of infant life toemerge, Sleeping in Bed.Sleeping in bed. Moving of f the therapist’s lap followingher first birth enactments (3), Annacrawled onto the nearbytable and asked the therapist to providemore blankets so thatshe could create a bed forherself on the table surface. Still87referring to herself asthe “baby,” Anna paradoxically boundoffthe table and capably arranged andrearranged the layers ofblankets on the table, eventuallycrawling under these covers fora pretend sleep (3, 5, 6, 8,9, 11, 14). She usually retainedthe “flowered blanket”from the birth sequences as her cover.Her bed-making activitywas initially carried out withnervous even anxious movements (3).Increasingly, calmnessinfused this activity (e.g., 8).In one transformation, Anna,once in bed, asked for theplayroom light to be turned off (6,11, 14). She soon becameanxious in the dark and asked for thelight to be turned on again.In another variation of theSleeping in Bed theme, Anna incorporatedsequences of being fedimaginary food (9) or a real bottle(11). In Session 9 Anna feltparticularly playful upon awakening. Shefrolicked on herbed/table, engaging the therapistin a game of mimicked babbling.The Sleeping in Bed activityoverlapped with and was ultimatelyreplaced by another neonatal subtheme,that of the infantsleeping in a crib.Sleeping in a crib. Anna enjoyed theconfines of the smallwooden cradle (11, 12, 13, 15, 16, 18,20). Intended for largedolls, this cradle was large andsturdy enough to accommodate herseated upright in it. Wrapped in heroriginal flowered blanket,Anna usually spent her timein her “crib” drinking a bottle ofwater (10 to 14) or juice(after 15).Across sessions, Anna’scrib time was consistently linked tobottle drinking. A fewadditions to this basic activity occurredacross sessions, with somedevelopmental progression discernible:wearing baby “pajamas” (a piece ofcloth); holding smaller play88materials as the infant’stoys (e.g., 10); requesting the lightto be turned off (11);listening to a storybook (13);pagingthrough the book herself (15);and watching the therapist drawher a picture of “baby Anna”(16).Eating. The activitiesof Infant Eating and Infant Drinkingboth emerged following birthsequences in Session 4. For thepurposes of analysis, Infant Eatingwas distinguished from InfantDrinking as follows: When Anna drankor pretended to drinkliquids from her bottle, the activitywas identified as InfantDrinking. When she used tinycutlery to spoonfeed herself, theactivity was identified as Infant Eating,even if she werespooning the mixture from herbottle. This distinction was madein response to the degreeof developmental regression which shepermitted herself through play, i.e.,whether she was enacting aninfant (drinking) or a toddler (eating).The Infant Eatingactivity recurred throughout her therapy (4,5, 6, 8, 9, 10, 20).Neonate Anna’s food was sand, whichshe prepared for herselfin a baby bottle. During Infant Eating, Anna spooned tinyportions of sand from the bottle andeither ate it, pretended toeat it, or fed the therapistthe mixture. Usually this activitytook place with Annaseated on the therapist’s lap, with theflowered blanket wrapped aroundher. In an above—citedexception, Anna ate and was fedsand while on her bed/table (9).When the Infant Eatingactivity reprised at the end of hertherapy (20), it contained anumber of changes. Anna no longerused the bottle or sand as play props.Instead, she set thetable with the tiny teaset and cutlery,sat in the “baby’s chair”and fed herself, a“nice baby,” a water and juice “dinner.”89Drinking. Annashifted from the imaginaryor actualingesting of sand to drinkingwater from a bottle in Session 10.Anna usually drank her bottleof water while seated in thetherapist’s lap or when ensconced inher crib. In both cases,she remained covered inher flowered blanket. Annaenjoyed thisbottle drinking activity,sucking on the bottles at length and/orreturning to drink from herbottle between other infantactivities. This activity remainedconsistent, with notransformations across sessions otherthan the therapist’sproviding juice for babyAnna (15 and following). Once juicebecame available, Anna oftenenjoyed having two bottles (one ofwater and one of juice). Sheheld one while drinking from theother in turn, or she sometimes playfullydrank from both at thesame time. A fleeting transformationof the drinking activityoccurred (18) when Annaused a soother for several seconds.Infant—at—Play. Anna’s Infant—at—Playsequences variedacross sessions and wereembellished with unique details.Lighthearted and even mischievouselements often permeated Anna’sinfant play, which began at the prenatallevel and graduallybecame more developmentally advanced.Anna’s playful sequences began as shemoved and squirmedfrom within the blanketwomb or uttered tiny squeaks and soundsto get the therapist’s attention (e.g.,4). Complex, sustained,exuberant, and interactive sound playlater comprised herneonatal infant play (9). In thissequence, Anna knelt on thetable and wobbled back andforth, as is characteristic of a babylearning to creep or crawl. As shemoved, she uttered a range ofbabbling sounds. The therapist imitatedher playful sounds, and90Anna enjoyed this mirrored baby play withthe therapist/maternalfigure.In later infant play Anna incorporatedvarious playmaterials as the infant’s toys. Early in her therapy (5), Annacuddled in the therapist’s lap, still wrapped in herfloweredblanket, and elicited the therapist’s help in completingapuzzle. In a central session (10), she climbed on topof theshelves and proudly showed the therapist how well the baby couldpound the cobbler’s bench by “himself.”In the latter half of her therapy, Anna incorporatedobjectsas the infant’s toys, which she usually heldas she drank herbottle(s) in her crib or on the therapist’s lap. Theseobjectsincluded a book, a small doll, and, in latersessions, the smallwhale. In one instance (15), Anna clutched a small alligator asan infant’s toy. While she drank from herbottle, the alligatorpretended to “bite” the therapist.Anna was capable of cooperative play with the therapist!maternal figure. In a unique play sequence(12), Anna, asinfant, sat on the therapist’s lap and enjoyed painting the tablewith her. Anna handed the therapist “the big mommy brush” whileAnna used the “little baby brush.”The infant’s play was sometimes kinesthetic, involvingenergetic movement or the physical immersion in materials.Digging in the sand was one example of such play. In Session 6,for example, Anna sat in the sand tray, completelycoveringherself with sand. After climbing out of the sand tray, she laycalmly on a small piece of carpet, grabbing her toes androckingon her back like a baby. In another example of kinestheticplay91(20), Anna repeatedly jumped from abasin of water onto thetherapist’s lap, dousing the therapist with water.Messing. Anna engaged in some type ofmessing activity inevery session. In the role of infant, she used several tactilematerials for her messing activities: painting herself withwater colors; overturning the basin of water onto the floor; or,as noted under Infant-at-Play, climbing into the sand tray andmessing in sand.Washing. Anna denoted theplastic basin of water as the“baby’s bathtub.” Her bathing activity, in which she stood orsat in the basin, recurred in most sessions (6 through 9; 11through 16; 18, 20). Most commonly, Anna took one or two suchbaths within a sequence of infant activities. However, in onecentral session (11), she returned to the washing activity 6times. Occasionally, Anna elaborated the Infant Washing activityby climbing out of the basin and making wetfootprints on thefloor (8) or by painting her feet as she sat in her bath (11).Infant aggression. Anna’s infant persona engaged in anumber of aggressive acts. Some of these, such as spilling wateror throwing sand, overlapped with the Messing activitiesdescribed above. The subcategory of Infant Aggression includedaggression directed against the therapist. At first, this tookthe form of smearing playdoh on the therapist’s hands andoccasionally on her clothing (3 through 6). In Session 9, thesmearing of playdoh on the therapist’s hands served as a pretensefor Anna’s hitting the therapist’s hands. In the next phase (12through 15), Infant Aggression escalated. Following a birthenactment, Anna wriggled out of her blanket and, lying in the92therapist’s lap, kicked the therapist’s arms vigorously.WhenAnna’s attack of the therapist was particularly intenseinSession 14, Anna retreated to the sand tray. Reassuredthat heranger would not harm the therapist, Anna resumed her attack.Soon after, she burst into tears.Infant Play: The Verbal ThemesThe most abundant and varied verbalization occurredin thecontext of Infant Birth enactments. Thisanalysis focuses firston the categories of referents emergent in Birth play. Manyofthe categories, which first emerged in birth play, persistedacross all aspects of infant portrayals as indicatedbelow. Thisanalysis then highlights the principal verbal themesemergent inother infant play categories. Songs and Embedded Storiesarediscussed as special verbal phenomena.Infant Birth: The Verbal ThemesVerbalizations associated with InfantBirth clustered aroundthe following thematic categories, which are described belowanddepicted across play phases in Figure 3:Infant Sounds; InfantIdentity; Prenatal/Perinatal Experience; NeonatalEmotionalStates; and Neonatal Physical States.Infant sounds. Infant Sounds predominatedbefore, during,and immediately after Birth sequences and recurred intermittentlyin most of her infant play. This thematic category comprised3levels of preverbal communication:squeaks, babbling, andcrying.93PhaseBeginning Middle EndThemeSOUNDS* *IDENTITYBaby* *PRE/ PERINATALEXPERI ENCEMovement*Covered*Ambivalence*Birth process*PRE/NEONATALEMOTIONSExcited*Safe*Fearful*NEONATALPHYSICAL STATESick*Hungry*Tired*Clean*Figure 3. Anna: Verbal Themes Associated with InfantBirthAnna emitted faint squeaks from within her floweredblanket,in an attempt at prenatal communication.Babbling or baby talkconsisted of syllables like “goo goo” or “puppa puppa pup.”Sometimes Anna babbled or used baby talk while stillinside theflowered blanket. Often, after being “born,” she snuggledin thetherapist’s lap and babbled happily in this way. Anna alsooccasionally pretended to cry (“waaah!”). Cries usuallycommunicated the infant’s hunger ordistress. These aspects ofpreverbal communication intermingled comfortably withordinaryverbal communication: “Wah bah bah! . .. But he’s just talking94for a little while. Bakaka puutata” (10).Infant identity. Throughouther infant play, Annaidentified herself as a“little baby.” Her verbalizationsrelated to identity consistentlydepicted a positive and happyinfant persona. Anna referredto herself as a “laughing baby”(9), a “magical”baby (11), a “cute” (13) baby,and a “surprisebaby” (14, 19). Inunique instances, she alsoreferred toherself as older thanan infant: “sweet little girl” (5)or “abigger baby” (7, 8). Ingeneral, references to aninfantidentity (“baby”) predominated.Following her firstbirth sequence (3), sheglowinglyannounced, “It’s a baby girl.”With only two exceptions, inwhich she referred to herselfas a “baby boy” (10) and a “babydinosaur” (11), Anna otherwisereferred to herself as a girl babythroughout her therapy.However, when describingthe infant in the third person,sheoften referred to the babyas masculine, e.g., “Baby is makingabed with his mommy rightnow” or “He doesn’t need it on him”(3).At times, feminineand masculine referents occurredwithinsuccessive sentences: “Hewants to curl up in his mummy’s tummy.• . She’s not comingout!” (4)Paralleling and complementing herself—depiction as a “baby”were her continuingreferences to the therapist asmother. Annaunfailingly calledthe therapist “mama.” This conceptwas deeplyembedded in her infant play:“You’re the mummy and I’m the baby”(4). Even in thefinal session (20), Anna commented,“Susan hasa new baby.” At the sametime, Anna was keenly aware that shewas engaged in a dramatizedplay relationship. During her first95infant enactment (3), she informed the therapist: “You’re not myreal mommy. Carol S. is my real mommy.”Prenatal/perinatal experience.Descriptions of prenatalexperience were associated with sequences of birth play.Although these referents varied across sessions, cumulativelythey provided a striking picture of her play persona’s prenatallife and birth experience.A number of referents clustered around the notion of fetalmovement. Anna described herself as “moving” (4), “wiggling”(6), and “turns around” (8). As well, Anna appearedto beintensely aware of the infant’s position: “She’s curl on hermommy; curl curl curl. . . . He wants to curl up in his mummy’stummy” (4).The concept of being covered was also verbally expressed.The baby was described as “hiding” (3, 11) and “covered” (7, 8,).In a similar vein, the flowered blanket was referred to as thebaby’s “cocoon” (3) as well as her “cage” (11).Evidently struggling between a sense of prenatal comfort andsafety (“cocoon”) and entrapment (“cage”), infant Anna expressedambivalence about emerging from the flowered womb. The infantwas “peeking out” (4). She often alternated between “coming out”and “she not gonna come out again” (e.g., 4, 5).Anna’s descriptions of the process of birth were especiallyvivid: “It’s crunching out. Crunch crunch crunch” (4).Similarly, as she lifted the flowered blanket to emerge, shecommented, “The baby went out of there” (4) and “This is openingup” (11)Prenatal/neonatal emotional states. In her play of prenatal96experience, Anna expressed a range of conflicting emotions. Shefelt safe (3) in her cocoon, and she was excited: “Baby’s inyour tummy ‘cause she’s excited” (4). The infantwithin theblanket also experienced some serious, and well—identified,fears: “She’s hiding ‘cause there’s monsters” (3). She furtherelaborated this sense of intermingled distress, fear, as well assome possible solutions to these states (3): “The baby was soupset about something, so the baby went fast a fast asleep.‘Cause something killed him. He’s with his mummy now. He’s notscared any more. He’s in his little cocoon.” References to fearrecurred: “She wants to go back in ‘cause she’s too scared” (5).Neonatal physical states. Anna verbally described theneonate as experiencing a range of physical conditions. Thenewborn was first described as feeling sick (3, 4): “He has acold” (3), and “The baby’s really sick. She has to have somemedicine” (4). When the newborn was hungry, she sometimes madearticulate requests for food: “some dinogettis ‘cause he’sreally hungry” (4) and “breakfast” (10). On occasion, thenewborn was tired and wanted to take a “nap” (10, 12). Anna even“napped” while still inside the blanket/womb: “He’s gonna have alittle sleep now ‘cause he’s too tired” (10). In one instance,Anna referred to the newborn baby as feeling clean following abirth enactment: “Now the baby feel all clean now” (8).Verbal Themes Associated with Other Infant PlayThe verbal themes emergent during other aspects of InfantPlay are summarized by play category in Figure 4. ExternalReferents, Songs, and Embedded Stories are also discussed.97Play CategoryTheme MESSING SLEEPING ANGRY EATING DRINKING WASHING PLAYMuck Mess N/ATiredSickHungry Good food Good foodBad foodP00/Dirt DirtyCleanRemorsePrideDelightPleasure Pleasure PleasureFear FearAnger Hit BiteStormFigure 4. Anna: Verbal Themes During Other Infant PlaySleeping in bed. When Anna enacted the infant in bed,referents to tiredness, wanting to go to sleep or to have alittle “nap,” dotted her discourse. These were the onlyreferents related to this activity which saw some repetitionacross sessions (3, 5, 6, 9). Referents to feeling sick (“cold,”3) or being hungry (“ice cube” dinner, 9) were sparse.Generally, the referents clustered around the notion of physicalstate or condition.As for emotional states, although Anna appeared anxiouswhenever the lights were turned off during this play, sheverbalized this fear only once: “He is scared. Would you turn onthe light?” (6). Enioyxnent typified this play. Generally, Annaseemed to enjoy the bedmaking process as much if not more thanthe “sleeping” aspect. She appeared quite proud of herselfmaking her own little bed: “Baby, let’s get you nice, nicecovered up. That’s good. It’s nighttime now and time for sleep.98Time for having anice sleep. That’s it. You’re allin yournice little bed” (6).Sleeping in a crib.Perhaps because her crib time wasusually linked tobottle drinking, there were few referentsdistinctive to this play. Afew related remarks appeared toindicate a positive feelingabout this activity, e.g., herstressing that the crib was “flybed” (11,12), “I like in mycrib” (11), and thefact that it was “cozy” (13). Unique infant-related referents concerned a requestfor “pajamas” (11) and a“diaper” (13). On oneoccasion, with the lights off, shestruggled with fear: “There’sno monsters in here? . . . There’ssome, there’s, I’m in my bed”(11).Eating.Anna first introduced the topic offood and hungerfollowing a birth sequence (4), translatingher baby talk for thetherapist: “Gaga! Food!”Particularly during the first half ofher therapy, before Anna beganprolonged bottle drinking, Annamost often referred to her sand foodin appealing terms: “Babylikes his food,” which wasalso identified as “good” (5).Positive references predominated inSession 8, when she describedthe sand food as: “breakfast,”“cherry juice,” “dinner,” and“restaurant.” However, to a lesserdegree her sand food was alsodescribed in distasteful terms. Itwas “yukky” (4), “gukky” (5),“p00” (4) and just “dirt” (8)Drinking. When Anna shifted to drinkingwater (rather thanspooning sand) from her bottle, herverbal referents consistentlyexpressed pleasure, e.g.: “Iwant some milk. . . The baby likeher bottle. . . . I have adrink. I think it’s good” (11).References related to oral aggressionsurfaced in the unique99instance of her drinking fromthe bottle while playing with asmall alligator figure (15).While Anna happily drankfrom herbottle, she put the alligatorin the therapist’s shirt pocket,commenting: “He goes insideand he eats something. Yummy. Thatwas warm. . . He drinkssome. . . . Now you have bites all overyou. . ‘Cause he’s onlya monster.”Messing. Anna repeatedlyreferred to her sand and/or watermesses as her muckymess of which she was clearly proud.References to “mucky mucky messes”persisted throughout hertherapy. In a unique instance,she smeared her hands and thetherapist’s clothing with blue playdoh,warning the therapistthat she would “never get away”from Anna’s “gooey hands” (3).Washing. Anna consistentlyverbalized feelings of pleasureand delight in herbath and in being clean. The water basinwasher “special water,”(8), the “baby bath” (9), and once “myswimming pool” (11). Precedingher baths, Anna was aware ofbeing “so dirty” (11, 13).During and afterwards, she was happyto be “nice and washed” (11)and “all washed up” (12). Herpleasure was epitomized in thefollowing self-description: “Sheplayed in her bath and clappedher hands like this” (11).Infant-at-Play. No particular verbal themeemerged duringinfant play. Anna generally describedherself as infant in theprocess of playing: “Babyfound a puzzle,” (5), “The baby’splaying sand!” (6); “This a dry placefor him to play” (10);“Baby this is his toy”(11). In Session 9, preverbal soundsconstituted the play, as Anna andthe therapist played aninteractive game of mirroring eachother’s vocalizations.Infant aggression. Mess—makingoverlapped with Anna’s100aggressive play.Usually she referred tothe results of heraggressive actionssimply as a “mucky mess.”Later in hertherapy, when she beganto physically attack thetherapist, herexpressions of aggressionand anger became more direct.Shecalled the therapist“you sweater” and told the therapist,“I’mgonna hit you!” (12).She also wanted to “bonk” herand then,troubled by this action,added, “I’m so sorry, mommy,‘cause itwas just when I was just,when I was little” (13). Inher mostintense attack on thetherapist (14), she told thetherapist thatshe wanted to “bonk you”but that “I’m afraid you mightgethurt.” Informed that heranger would not hurt the therapist,sheresponded, “I’m glad tohear that,” and resumed her attack,followed by tears.External referents. Anna’ssessions were dotted with anumber of informational and/orself-disclosing statementsrelatedto her life outside theplayroom. These includedher disclosingor describing (a) beinghungry after medical tests; (b)the timeshe broke her arm (5);(c) her video movies at home(6, 8); and(d) her dislikeof spankings (16). Usually hertone during thesedisclosures was one ofintimacy.Songs. Throughout hertherapy, Anna interwove within herplay no fewer than53 little songs. Only a handfulwererepetitions of popularchildren’s songs (e.g., Puffthe MagicDragon; 3). Most wereher own creations; and mostwere briefsung or chanted descriptionsof the play at hand or cheerfulmusical embellishmentsto her play. Simple examplesrelated toinfant play, included:“Baby baby bottle. Baby babybottle.Baby body” (10) or “I took mybath and I had big” (11).101Her most elaborate songrelated to infant play occurredasAnna prepared to liedown for a little sleep. Thecompositionwas rich in imagery (8): “Thelittle whale, and in the morningwhen it’s dry, little baby.When it’s nighttime, in thefallingrain, I’ll sleep in flowers.I want my. I went in to mymum.Hmhmhm. And then the waterfall.Hmhmhm.”Embedded stories. Embedded Storiescharacterized Anna’sdiscourse. These stories, 20 in all,differed from descriptionsof her activities (e.g.,“I’m gonna put this one here”). Rather,for these narratives Annaadopted a special “story telling”voice. She added charactersand imaginary events. She seemedcarried away, talking partlyto the therapist and partly toherself. Embedded in the largersequence of her play, thesestories often contained elementsof narrative structure, phraseslike “and then” or “one day” or otherverbal markers to denote abeginning, a middle, and/or anend to the tale she created. Thefollowing are representativeexamples associated with infantplay:1. While making her bed: “When baby’smaking his bed oneday. Over the hills and faraway, and he like to” (5);2. While sitting in the sandtray, covered with sand (6):The baby’s playing sand.And that’s for my Gramma. Whenshe see that. My Gramma and Nan.And Grandpa will come topick me up and my Mumma too. Yup.And they all hug me andkiss me. And they they come anddo. Remember?3. After emerging from herflowered blanket (11):I’m a baby dinosaur. I’m LittleFoot. Little Foot was sohappy to see his girlfriend namedSara. Sara was so heavy[sic] too. So be careful. So she hadto just. Ah. I’llsave you, Sara. Ooh. His motherdidn’t know what to dowith him so he put him in her bathtub.102In general, Anna’s Embedded Stories mirrored and encapsulatedcertain themes emergent throughout her therapy, such as fear,neediness, vulnerability, and pleasure.Doctor Materials: The Play ThemesDoctor Play was second to Infant Play in frequency acrosssessions and as a dynamic factor in Anna’s therapy. It beganfleetingly, lay dormant for several sessions, and reemerged as animportant and well—developed component of her play in Sessions 16through 20. In virtually all doctor play, Anna retained the roleof doctor, ministering at first to the therapist and later to thesmall whale as her patient. Figure 5 charts the emergence of theprincipal doctor play themes across sessions.SessionMiddle Phase1 2 3 4 5 6 7 8 910111213 1415 1617 181920ThemeEXAMINESINSTRUMENTS* *THERAPISTAS PATIENT*SELF ASPATIENT* *WHALE ASPATIENT* * * * *Figure 5. Anna: Play Themes with Doctor MaterialsExamining instruments. Doctor play appeared initially inseveral distinct and isolated incidents. In the introductorydoctor play sequence (2), Anna as the doctor spent a full 10minutes exploring the doctor kit materials: syringe,stethoscope, blood pressure implement, reflex hammer, medicalchart and others.103Treating therapistand self. Anna treated the therapistwith 4 injections, each followedby a bandaid (2). In the nextbrief segment of doctor play (8), Annarequired treatment for herown hurt. Almost in tears, she complainedof hurt fingers andsought bandaids from the doctor kit.(The hurt may have beenreal or reflective of emotional hurt, asshe had been upset andanxious from the beginning of the session.)She calmed and wasable to resume play with other materialsas soon as bandaids wereapplied. The power of bandaids to comfortand to ease pain wasparticularly conspicuous in the concluding,recurrent segments ofher doctor play.Whale as patient. Doctor Play emerged as a sustained andwell—elaborated play scenario in Session 16, lasting 17minutes,or one third of the session. Anna repeatedlygave her newpatient, the whale, injections followed by bandaids. Shetookhis temperature and blood pressure, and readhim his prognosisfrom the medical chart. This sustained,intense examination andtreatment of the whale constituted the core of her doctor play inall successive sessions.Minor variations or additions to this basic playactivitywere discerned. These variations suggested the notionofrecovery. First, the whale waspermitted to return betweeninjections to his water basin to swim (18), suggesting thathistreatment over two sessions was beginning to have curativeforce,restoring him to his normal activities. Next (19), playfulelements emerged as Anna tickled the whale when she finishedtreating him. Finally (20), shekissed him when concluding histreatment. These latter examples (tickling, kissing)contained104an affectionate tone.Doctor Materials: The Verbal ThemesAnna’s initial Doctor Play (2) introduced the nuclei of theprincipal verbal themes——”hurt,” “crying,” “shots,” and“gettingbetter”—— which received elaboration and detailed development inthe final 5 sessions. To these central thematic concepts of Hurtor Pain, and Recovery were added the themes of Fear andDeath aswell as Help through Friendship (of. Figure 6).SessionMiddle Phase12345678 91011121314151617181920ThemeHURT!PAIN* * * * * * * *RECOVERY(*) * * * * *DEATH* * * *FRIENDSHIP* *FEAR*Ficiure 6. Anna: Verbal ThemesAssociated with Doctor PlayHurt. Anna as doctor was shocked at Roo’s “hurt tail” (16).Roo was “hurt, she can’t swim” (16) and “sometimes [he] get hurt”(20). Many references to his Hurt condition interwove this play.Sometimes the notion of hurt related to the treatment itself,which was usually a “shot” or “owie” (16, 17, 19, 20). Annavacillated within sessions and across sessions as to the degreeof hurt the injections might cause Roo. Injections “hurt alittle bit I think” (16), they “really hurt” (16), and it“doesn’t hurt” (16, 17, 19). They also contained “poisonmedicine” (18). Sometimes “hurt” reached the whale’s imaginaryextended family: “Your mommy’s hurt, she can’t swim” (16).105Fear. Though few, Anna’s references to fear aresignificant, as references to fear had dotted other elements ofher play (Cf. “monsters” during infant play).Anna expressed asense of her own fears around the whale’s hurt: “I’m afraid youmight get hurt” (16). Paralleling her contradictory commentsaround the concept of “hurt” and “doesn’t hurt,” Anna’s directadmission of fear was expressed together with its negation:“It’s not afraid. I’m afraid” (16).Death. The theme of Death appeared dramatically in herDoctor Play. Pretending to read the medical chart (16), Annasuddenly read Roo the news that he was going to die (16).References to Death recurred, and the topic appearedto befraught with fear and often confusion for Anna: “You gotta die‘cause you might get hurt”; “She doesn’t feel when she’s dead.She, when she’s dead. That’s when you die” (16);“When Roo dies,she’ll be sick” (17). “Remember something of dying? . . Roowhen she’s dying, and Roo’s hurt, she dies. All about Roo whenshe dies” (20). She gave him terrifying news: “Your mommydied,” (16) “poor little whale, his mommy dead. She can’t swim.She’s hurt” (16); and “doctors kill you” (17).Friendship. Some references to Death were linked toattempts at solutions to this problem: “When you die, I’m gonnahelp your and you some bandaids to make you better.” Bandaidsappeared to offer some hope to these persistent fears, as didFriendship. Involving the small fish figure in this play, Annatold Roo, “You gotta die, Roo, ‘cause you might get hurt. Yourfriend will help you” (16). When the little fish arrived, Annaremarked, “No more dying, Roo” (16). On the other hand, the106whale’s friend remained vulnerable: “I’m gonna make you afriend. . . . Now your friend is hurt too” (20).Recovery. The notion of Recovery was composed of a numberof thematic strands. This was evident in Anna’s role. Shereferred to herself as the healer, the “doctor whale,” (16), a“good doctor” (16), and “the nurse” (20). Injections werefollowed by bandaids, which were invariably described as a“special treat” or aIlsurprise.HThere was evidence ofaffection, as when she kissed her patient (18, 20) on his “cutelittle eye” (20). She referred to the recovery process itself.Anna told Roo “you’re fixed” (16). She reassured him, “That’smuch better now, Roo” (17), and told him she was making him“better” (20). At the same time, Anna was not completely certainthat he was better. Some anxiety about his condition persisted.Many times throughout her medical care of him, she asked him withintermingled hope and fear, “Are you all right?” or “Are you muchbetter now, Roo?”The Whale: The Play ThemesPlay with the whale interwove much of Anna’s play therapy.At first, its incorporation in her play was brief and subtle, butin later sessions, whale play surfaced into prominence, stronglylinked to both Doctor Play and Infant Play. In general, thewhale underwent the following metamorphosis: Introductory PlayObject; Marine Creature; the Doctor’s Patient; the Infant’s Toy;and the Focus of the Mural. Figure 7 depicts this progression,in which there was some overlap amongst these thematic elements.107SessionMiddle Phase1 2 3 4 5 6 7 891011121314151617181920ThemeHELDOBJECT* * * * * *MARINECREATURE* * * * * * * * * * * * **MEDICALPATIENT* * * * *INFANT’STOY* * * *MURALFOCUS*Figure 7. Anna: PlayThemes with the WhaleIntroductory play oblect.Across 6 early sessions (1; 3through 7) Anna consistently soughtout the whale immediatelyupon her entry into the playroom.She usually placed him inwater and did not return to play withhim for the remainder ofthese sessions. These brief contactswith the figure of thewhale, overlooked by the therapistduring the therapy, acted asprecursors to her later extensiveuse of that figure.Marine creature. This subcategoryrefers to the whale’snatural identity as a swimmer. Inevery session in which thewhale figured in her play, Anna animatedthe whale, having himswim in the basin of water. Therewere two variations withinthis theme. First, in the early sessions(to 7) the whale swamonly in clear water. In later sessions(13 and following) Annaadded sand to the basin,creating a murky habitat for him.Second, in later sessions (13 andfollowing) the whale wasoccasionally joined by the figure ofthe little fish, whofunctioned as a companion for him.108Medical patient. Thewhale shifted frombeing a literal,biological creature toacquiring an anthropomorphic,fantasyidentity. As doctor Anna’spatient, the whale wasthe recipientof sustained, intensivemedical care, as elaboratedabove,throughout the concludingsessions (16 through 20). Hewassubjected to painful treatmentsas well as care, comfort,andaffection. Sometimes thepainting of his tail, ascited above,appeared to be part ofthe recovery process.Infant’s toy. InfantPlay alternated with DoctorPlay inthe final play phase (16through 20). The whalefunctioned inboth these majorthematic categories, accompanyingAnna back andforth from her infant personainto doctor play. Annasimply heldthe whale as theinfant’s toy, as she cuddledin the therapist’slap and drank from herbottle. In one variation,she clutchedhim playfully betweenher feet while she drank. Inanothervariation, Anna treatedhim as a playmate, sharingher bottlewith him (18) or spoonfeedinghim some juice (19).These latterinstances of cuddlingand offering nurturanceto the whaleparalleled Anna’s simultaneousactivity of receiving physicalandemotional nurturanceherself.Focus of the mural. Thetheme of the whale began andconcluded Anna’stherapy. The penultimate playact of hertherapy was topaint the playroom wall. Annaidentified some ofher large purple swirlsas a whale, getting “biggerand bigger.”In this activity, Annadid not utilize the physicalobject of thewhale. His two-dimensionaldepiction was sufficient forher tokeep the essence of thewhale active and alive.109The Whale: The Verbal ThemesVerbal themes related to play with the whale assorted underthe following categories, as depicted across play phases inFigure 8: Identity; Attributes; Setting; Hurt, Death, andTreatment; Relationship; and Nurturance. Embedded Stories andSongs recurred in all phases of whale play.Whale identity. The whale was first identified as a “babywhale” (1) and at the end of therapy was still (20) a “nicelittle baby whale.” During the Middle Phase, he was occasionally“Mr. Whale” (5, 13). However, when whale play resurfaced in theFinal Phase, he received a more personal name, “Roo,” whichpersisted in Sessions 16 through 20. Even when Anna in oneinstance assigned Roo the role of mother, it was superimposedupon his basic identity of “Roo”: “Roo, you’re the mommy” (19).Whale attributes. In his first appearance (1), the whalewas described as “black,” “hungry” and “thirsty.” He was “allright” and had to “be good.” Anna also called him a “poorwhale,” denoting suffering or misfortune. This single referentprecursed later references to the whale as “poor”: “poor littlestuff” (14), “poor little whale” (16, 19), “poor little thing”(18). The aspect of smallness embedded in these referents alsosaw some repetition: “little small whale” (14); “be a goodlittle fellow” (16).PhaseBeginning Middle EndThemeIDENTITYBaby* * *Mr. Whale*Roo*ATTRIBUTESPoor* * *Hungry!Thirsty*Little* *SETT INGAquarium* *Pool*Dark water* *Bathtub*HURT* * *RECOVERY*DEATH*RELATIONSHIPOffspring* *Friend* *Sister*NURTURANCE*STORIES* * *SONGS* * *110Figure 8. Anna: Verbal Themes Associated with Whale PlayThe whale, like Anna, experienced a sense of conflictbetween wanting to express anger and having to be good: “Well, Idon’t think I can get mad because I’m a whale. I always be agood whale” (13). Other descriptors of the whale ran a completegamut of human attributes, with virtually no repetition: “happy”(13), “scared” (13), “has big teeth” (13), “only a whale” (15),“so happy she can swim,” “silly” (16), “beautiful” (17), “dirty”(18, 19), “the greatest” (20), and “a dirty little animal” (20).She also referred to Roo as “a girl” (16).111Perhaps the most unique verbalizedreferents concerned theway in which Anna verbally broughtthe whale to life. In Session13, Anna picked up the whale and told thetherapist: “Mr.Whale’s gonna say something.” However, he was notquite ready tospeak, as Anna moved on to other play materials.Later (15),Anna conunanded him, “Come alive!” In Session 16,the whale atlast functioned as a dynamic, interactional character. Annahanded the whale to the therapist and asked her,“Would you helpher talk, and the whale song is gonna come.” Thistime Annapursued extensive play and verbal interaction withthe whale,with the therapist speaking for Roo.Setting. Roo’s natural habitatwas a basin of water whichwas referred to as his “aquarium” (1, 14),his “swimming pool”(16), and his “bathtub” (18). However, Annamost often referredto the basin of water to which she had addedsand as his “darkwater” (15 through 19).Hurt, death, and medical treatment. Verbal references tohurt, death, and medical treatment proliferatedwhen the whaleserved as a prop within doctor play. The description of thesereferents has been considered under Doctor Play.Relationship. A string of assorted referents suggested athematic cluster around interpersonalrelationships, particularlyduring the End Phase. There were repeatedreferences to thelittle fish as Roo’s “friend” (16, 17, 20) who would “helpyou.”Roo learned that the little fish was his“baby sister” (19).There were consistent references to Roo’smother: “Hello, I’m alittle small whale. Do you know where my big mother is?” (14);“He has to have more dark water, so he canmake his mother” (15).112Nurturance. Referents which suggestedvarying degrees ofnurturance toward the whale involved affectionand food. Annaoffered him “a big hug” (16) and a“kiss” (17, 20). Sheplayfully “tickled” him (17, 19). Sometimes,her care of himincluded tasty food: “juice” (17, 18),“dinner” (18), “soup”(19), “cake” and “whale food” (20). Roowas also offered a toxicsubstance, “poison” (19).Embedded stories. A number of Embedded Stories interwoveAnna’s play with the whale, of which the examplesbelow arerepresentative. An early story emerged when Anna handled thewhale for the first time (1). This story containedprecursors ofthe themes of Whale, Mother, Baby, and Fearwhich were to unfoldin greater detail as her therapy advanced:One day the mother took the little babysomewhere. And thebaby said, “WahI I’m just a little baby. I’min heresomewhere. Get me out of here!” This one was next. Andbig bad. Grrr! Me too, me too, littlewhale.A later story highlighted the whale inhis struggle betweendirtiness and cleanliness (15):“Yippee!” he said. My, he wants. He’s going to get somemud. Erh erh erh. So he jump inside the mud and he just alldirty. And he had to get him all clean in some tub of waterto make him all clean.A final example contained themes of hurt andrecovery (16):Roo was so hurt. She went out of the swimmingpool. Ohright here. And Roo was so happy. She wasn’thurt anymore. She got a fish. She was way up into thesky, ok.And Roo didn’t come down. There’s Susan.Songs. Songs interwove Anna’s whale playfrom the outset tothe conclusion of her therapy. Like the Embedded Stories, hersongs about the whale reflected the themes of her own play. Herfirst whale song was very brief (1): “Up we go. Up the whale.”113Another example reprised her doctor play themes (16): “I won’tbelieve the no whales. And then then Roo hurts her tail. Shegets a bandaid and a shot. She swims.” The following song, anadaptation of a contemporary children’s song, described a playfulRoo (17)It’s the way for Roo. It’s the way for her. It’s the whaleare home. Nice, so heavy. It’s the whale. Do—do—do. Swimso wild and swim so free. It time for her to have somewater. Wo-wo-wo. Whale all full of mud. Do-do-do.A song near the end of therapy (20) distinguished betweencreatures (whale and fish) which were “hurt” or “not hurt”:“Swimming little Roo. Swimming on her bum. Swimming swimmingswimming swimming, swim two whale. One has bandaids and onedoesn’t. Swim swim swim.”Painting: The Play ThemesDuring the course of therapy, Anna’s painting activitiesappeared to be play interludes of minor importance. However,thematic analysis of these activities (cf. Figure 9) revealedinteresting transformations reflecting developmental changes.Painting changed from being a body- or self-focused to an objector other—focused activity, and, ultimately, to a representationalactivity. Painting also progressed from being an autonomous, toan associative, then to an independent yet cooperative activity.Virtually all of Anna’s painting, throughout her therapy, wascarried out in purple.Anna’s painting was initially highly tactile and selffocused. In its earliest and most frequent manifestation, Annapainted her arms, legs, feet, and sometimes stomach with thewater colors (1, 2, 3, 10, 11, 20). In the middle phase of114therapy, Anna began painting objects other than her own body.She painted the table with the water colors, smearing circles onits surface. In one instance (11), this painting occurredininteraction with the therapist. As noted underInfant Play, thissequence was noteworthy for her inclusion ofthe therapist insustained, interactional fashion.SessionMiddle Phase1 2 3 4 5 6 7 8 9101112 131415 1617181920ThemePAINTSelf* * * * **Table* * *Whale* *Paper* *Wall *Ficrnre 9. Anna: Play Themes for PaintingIn the end phase, when treating the whaleas the doctor’spatient, she occasionally painted thewhale’s tail (17, 20)and/or (17) a “happy face” for him.The painting of the whaleseemed to be part of the whale’smedical treatment (much like theapplication of mercurochrome) andat the same time an aspect ofhis improvement or beautification.Also in the end phase (18, 19), Annainitiated two artactivities which at first appearedto be mundane. She began bypainting (18) and by colouring with crayons(19) on paper on thefloor. However, in both instances, destructionimmediatelyfollowed creation, as she pouredwater on one drawing(18) andripped the other in pieces which she then floatedin the whale’swater basin (19).115Anna’s culminating painting activity,occurring in the finalsession (20), was the creationof a large mural on the playroomwall. This activity was unique interms of the size and scope ofher work with the paints; large circularswirls filled onesection of the playroom wall. Annaverbally explained that sheintended this mural to be a representation ofmarine life. Annaidentified herself as the infant asshe painted with thetherapist. Yet this painting sequence differedfrom her earliercooperative painting activity with thetherapist at the table.In that case, Anna had actedthe dependent and attached infant,seated on the therapist’s lap. In thisfinal painting sequence,Anna still played the baby, but shewas no longer the infantattached to the maternal figures. She workedapart from thetherapist, taking turns painting the mural withher incooperative yet independent fashion. Thetherapist was enlistedhere more as a partner and playmatethan as a maternal figure.Painting: The Verbal ThemesRelatively meager verbalizations occurred inassociationwith painting. Perhaps thiswas due in part to the fluidity ofthe medium and the calmness and concentrationit induced.Nevertheless, the scant verbalizations still covereda wide rangeof topics. These formed only twothematic clusters with anyconsistency of repetition: Calls for Attentionand References toMother. There was some overlap between thesetwo categories.There were also unique references to Fearsas well as a verbalelaboration of the play theme of the Whale andother marine life.As Anna painted her hands, feet, and sometimesher stomach,Calls for Attention were often repeatedwithin sessions: “My116mommy see this” (1, 2, 11), “mommy will look”(10), and“everybody see me” (2). Suggesting ambivalence about receivingattention, Anna also claimed that “Mommy won’t see this” (10).When the theme of Attention later recurred, it was directed tothe whale. Specifically, after having painted the whale’s tailpurple (20), Anna painted herself, “just like you do,” whale.“What do you think of me?” she asked him.A few verbal referents suggested that during the body-painting activity, Anna perceived the paints as enhancing herappearance. She referred to the paints as her “polish” (2). Theymade her look “so beautiful” (11). However, in one instance (3),she called her painted hands “gooey” and “mucky,” and shethreatened to smear the therapist with them, telling her, “Youwill never get away.” At the same time (3), “They’re not gooey.They have paint on them, and they’re pink.”References to Mother, sometimes overlapping with these callsfor attention, also constituted a thematic category in itself.In the beginning phase, as Anna painted herself, she remarkedthat “mommy wash this” (2, 11). In the middle phase, whileseated on the therapist’s lap and painting with her (10),sometimes hand over hand, Anna persistently addressed thetherapist as mother. She invited the therapist to join her bysaying, “Paint with me, mama.” She repeatedly offered thetherapist the “big mommy brush” while Anna took the “little babybrush.” She sustained the activity with such comments as, “Nowit’s your turn, mommy.” Later in her therapy (19), when shecreated the picture which she then tore in pieces, she called ita “picture for my mommy.”117During a central session (10), having climbed on top of thetoy shelf, using it as a perch on which to play, Anna expressedsome intense fears. While painting, she commented that the baby“likes spankings.” Anna then threatened to “spank your[therapist’s] bum” and “paint you” and soon after asked thetherapist, “Monsters coming out? . . . I get scared when theyhave claws on them.”Other unique verbal referents clustered around the theme ofthe whale and other marine life. As Anna painted the playroomwall in the final session (20), she first called her creation “adesign” and “a giraffe neck.” But she soon identified thecircles as “whale! . . . a really big whale. It’s so fat that itmakes too much fish.” The marine theme continued: “Let’s makeone little tiny little fish. . . . It’s getting bigger and biggerand bigger and bigger. . . because it ate the starfish. You see.This is a starfish. . . . You make a nemone [sic]? . . . I’m in anet.”Thematic Comparison and ContrastThere was strong thematic consistency and overlap betweenAnna’s play themes and the attendant verbal themes. That is,Anna’s verbalizations elaborated and advanced the play at hand.Whether in the context of infant, doctor, whale play, or apainting activity, Anna for the most part tended to talk aboutand describe the play in which she was involved.In general, the major categories of play tended to generatediscrete clusters of thematic material. Anna’s Infant Playcentered around verbal and play themes related to Infant Life,Neediness, and Pleasure. Doctor Play generated play and verbal118themes of Hurt and Healing.Sparse but consequentialreferencesto Fear dotted thesetwo principal play activities.Paintingproduced a cluster of referentsdescriptive of relationships.Through all of these activities,references to the whalewereinterwoven.Contribution of Play Activityto Therapeutic ProcessAnna created a complete, multifaceted,and realistic playidentity for herself as theInfant. She gave birth tothatidentity in play and proceededto elaborate many details ofinfant life: eating, drinking,messing, washing, sleeping,aggression, and playing. Annaalso created a play persona forthe therapist, as mother.The playroom itself became Anna’snursery, the infant’s home,complete with crib, bottles, andfood.In creating infant life, Anna wasable to do more than enactthe infant. She becamethe infant and as such in her playshereexperienced infant life.This reexperiencing encompassed notonly the physical butalso the emotional sensations ofinfancyand babyhood.Specific infant-related activitiesyielded specifictherapeutic benefits. Through thebirth activity, Anna hadaccess to sustained physicalcloseness and cuddling and the senseof security thatprovided against fears. Drinking froma bottlegave her actual nurturance(the juice), emotional nurturancethrough cuddling, as wellas physical pleasure in thesensationsof drinking. Sleepingin a bed or in a crib providedopportunities for movementbetween states of anxiety andcalmness. The aspect ofinfant-at—play enabled the safe119expression of aggression towardthe therapist/maternal figure.Anna benefitted from the kinestheticproperties of playmaterials. She literally immersedherself in their tactileproperties. She experiencedabsolute messiness, being covered insand or paints, as well asthe pleasure of feeling washed cleanin her infant bath.Anna benefitted from the regressiveexperiences which theinfant persona enabled. At times, herdescent into developmentalregression could be perceived with strikingclarity in her playactivities. For example, play in thecrib developed after playin the bed. Drinking from abottle occurred after eatingactivities. In these cases, the developmentallyless matureactivity followed a developmentallymore advanced activity.Anna used her doctor play with the whalefor the depictionand representation of real lifeexperience. Anna as the whale’sdoctor was no longer the vulnerableinfant. She assumed the roleof helper and healer,as well as one of control, power, and theability to inflict hurt. In her treatment ofthe whale, she wasable to depict current reallife concerns of repeated trips tothe doctor, receiving medicaltreatment, and so on. The whale,through the mechanismof projection, now carried thevulnerability, the fears, thehelplessness, and the pain, givingAnna some symbolic distance from herpersistent medicaldifficulties.Contribution of Verbalizationto Therapeutic ProcessOn the level of verbalization, Annaspanned a completedevelopmental range. The authenticityof the sequence of herinfantile verbal development was striking. Shebegan as a120preverbal, prenatal being,making imaginative approximations offetal communication--faintsqueaks from within her blanket inorder to capture the mother’sattention. Later, Anna, like anydeveloping infant, used sound itselfas play and this served thespecific purpose of forming therelationship with the maternalfigure. Vygotsky (1978) hasstated that the impetus for infantspeech derives from the mother-childrelationship, and that theplay between mother and child servesto stimulate and enhancethat development. As Annarocked back and forth on the table andenjoyed mirrored sounds with the therapist,this circularinterrelationship between playful mother-childcontact, theenhanced motivation for infantspeech, and the strengthening ofmother-child rapport was vividlyportrayed.Anna proceeded into overlapping infant andbabyhood stagephases of babbling and baby talk, allof which were interwovenwith her own age appropriate discourse.During later doctorplay, Anna moved to the third—persondescription of difficulttopics, such as hurt, death, and mother’s deathas well as topicsindicative of recovery, healing, help,and friendship.Anna was fluent on the verbal level, not onlyin terms ofher vocabulary, which was oftenquite precocious (cf. the“excited” and “upset” baby). Shealso functioned verbally verycapably, advancing the play on overlappingand sometimessimultaneous levels. That is,she was able to speak as theinfant, while concurrently describingher infant activity in thethird person. She interacteddirectly with the whale, talking tohim and creating his personalityas she did so. In addition,there were Songs and EmbeddedStories which mirrored and which121captured in encapsulated form the themes and concerns whichinterwove her own first—person play. Her songs and stories,noteworthy for their rich and creative detail as well as for thesense of wholeness (beginning, middle, and end) they conveyed,provided windows of insight into Anna’s development.There were instances when Anna verbally departed from theplay before her and raised topics related to her life outside theplayroom. Such external referents, elements of self—disclosure,are an underlying goal of play therapy (Reams, 1987). Over thecourse of her therapy, Anna referred to a number of externaltopics, telling the therapist about her home, friends, doctors,injuries, and classroom life. Following these brief and personaldisclosures, Anna was able to return to her play without a senseof interruption.A number of nonsequitors persisted in Anna’s speech. Theseverbal inconsistencies did not elaborate the play at hand norwere they restricted to a particular category of play. Often astring of related referents were followed by one which wasunusual and sounded out of place, e.g., “my daddy come and allthe fairies.” Her repeated contradictory references to herselfas both a feminine and a masculine infant are another example ofthis verbal inconsistency. Anna also seemed to experiencedifficulty with the relationship between cause and effect. Forexample, her statement that “baby’s in his mommy’s tummy ‘causehe’s excited” is representative of this sort. Anna likely meantthe reverse, that the baby was excited “because.” These types ofverbal nonsequitors are seen as indications of a degree of innerstruggle.122On the level ofverbalization, the naming ofthe whale canbe considered apositive critical incident. In naminghim “Roo,”Anna for the firsttime bestowed upon him a specific,rather thana generic (cf. “Mr.Whale”) identity. This identity wasdynamicin that the whale, followinghis naming, underwent a number oftrials, adventures, healings,and relationships, including anactive and interactionalrelationship with Anna. The whale’sidentity was consistentin that he retained his personaand hisname for the remainderof Anna’s therapy. Anna’s abilitytoverbally bestow a consistent identityupon this play materialreflected her own growthtoward a stronger and more integratedidentity.Summary NarrativeThe following narrativeuses the play and verbal themesanalyzed above as the basisfor a summary story of Anna’stherapy.Beginning phase.Anna entered the play room for thefirsttime as if she had alreadyintuited its purpose--to immerseherself in play of a deeplypersonal nature. Anna displayedneither shyness nor tentativenessin her approach to the playmaterials. She was active,energetic, and thoroughly involvedwith whatever materialshe chose. At times, her play seemedimpelled by nervous energy. Yetshe also appeared happy andexcited to have a play arenain which she could indulge her playwishes.She involved the therapist in her playalmost immediatelyand actively sought relationship withher. The play materialswere at least in part Anna’stools for the formation of contact123and closeness with thetherapist. Using sand, water, andplaydoh, she set about inan extremely busy and officious mannerto provide “yummy” foodfor the therapist. Here, Anna enactedthe maternal role ofcaregiver, of nurturer, a role whichfor herwas to be short—lived.Anna used the doctor materials toexaminethe therapist, treatingher with shots and bandaids, an activitythat became prominent muchlater in her therapy. As busy motherand as doctor, Anna retainedthe element of control in her playinteraction with the therapist.From the outset, Anna exhibiteddelight in the physicalinteraction with messy materials.She enjoyed handling the sandand water during herpreparation of the therapist’s food.Shestirred, mixed, and dumpedthe mixture and revelled in thepleasurable sensations of the materials.She similarly enjoyedpainting herself with watercolours and overturning the basinofwater on the playroom floor.The beginning phase contained onlythe faintest precursorsof the themes of the infantand the whale. Anna simply placedthe doll house crib onthe playroom table. By the simple actoftransferring the crib from themargins of the playroom (the dollhouse) to the focal pointof the playroom (the table) Annaappeared to be unconsciously,if microscopically, through a playsymbol, raising the topic ofinfant life. She barely touched thewhale. Yet extensivethematic changes burgeoned from boththeseminute play incidents.Middle phase. Anna’s enactmentof the birth of the infantdramatically marked thebeginning of the prolonged Middle Phase.In this phase Anna gavebirth to the principal play identityfrom124which the rest of her therapy evolved.The reign of Anna as thecontrolling caregiver had ended. Annaas the infant drank inphysical and emotional nurturance justas she drew physicalcomfort from her bottles. She epitomizedgentleness andvulnerability. Cuddled in the therapist’s lap,secure in herflowered blanket and hidden from view,Anna was free to exploreand to express fetal sensations.The physical sensationsincluded “curling” and “moving.”Anna even attempted prenatalcommunication with the maternal figure.She emitted faintsqueaks from within her blanket womb.The as yet unborn Anna experienced deepfears, of “monsters”and of being killed, as wellas the “excitement” of being born.Between her fears and her excitement,Anna was suspended in adeep-seated ambivalence about being born.Her birth playafforded her the opportunity to completelyimmerse herself in andplay out the extremes of thatambivalence. In her enactments ofbirth, Anna could enjoy theluxury of a biological impossibility,returning to the womb. She previewed the worldshe would be borninto, lifting the flowered blanketto peek at the therapist.Free of any biological imperative,Anna was then able to withdrawagain into her blanket to enjoy thesecurity of prenatal life.The playful imitation of birth could advanceunhurried andby degrees, with thetentative extension of an arm or a legfollowed by its withdrawal. Her birthplay often seemed to be arehearsal of that event, as she repeatedly emergedinto andwithdrew from the world.Most striking were the details of her birth playwhichcorresponded to Anna’s own breech birth. On morethan one125occasion, Anna thrust herselffeet first out of her blanket. Hercomments on the baby as being “born”only strengthened thisimpression of Anna’s play as a deep—seatedreworking of her ownbirth experience. Indeed,Anna seemed less to be playing atbirth than to be thoroughlyreexperiencing it. Often she emergedfrom her blanket lookingradiant, with cheeks flushed and eyesgleaming.The rest of this phase of her therapyflowed quite naturallyfrom this core birthexperience. Anna as the “magical baby”claimed the playroom as her nursery,with the therapistfunctioning extensively as thematernal figure. The floweredblanket, which had served as the symbolicwomb, accompanied herplay in bed, in the crib,and on the therapist’s lap. Theblanket functioned as a transitionalobject of criticalimportance, carrying the sense of securityshe had experienced“prenatally” into the expanded worldof the neonate. Themes ofcomfort, care, physical and emotionalnurturance, andrelationship with the maternal figureinfused this phase.Most of Anna’s infant experiencewas pleasurable. Sheexperienced a sense of security inher bed and in her crib,nurturance and pleasure through herbottles. She delighted inthe sheer physicality ofmessing and washing, and she enjoyedenacting--being--the active infantat play with mother. She sanghappy little songs andembroidered her play with short stories.Anna also explored nonpleasurableand difficult aspects ofinfant experience. Anxiety and fears,particularly of“monsters,” surfaced in herinfant play. Anna as infant alsoexpressed considerable aggressiontoward the therapist in the126form of physical attacks.The “magical baby” and theangry babywere equally at home inthe playroom nursery.End phase. Thewhale, who had lain dormantduring theMiddle Phase, suddenlycame to life. Asking the therapistto“talk for him,” Annagave him a name, and in that actof naminghim launched the final phaseof her therapy. Anna createdin thewhale named Roo a peer, afriend, an infant toy, a child,acompanion, and a confidante.However, the whale primarily servedas her medical patient,such that whale play in this phasewassubstantially fused withdoctor play. In a sudden shift ofrolesand identities, Annathe infant assumed the roleof Anna the“doctor whale [whale doctor]”and as such ministered toRoo. Hewas subjected toinjections, and he receivedbandaids, tickles,cuddles, and kisses.Anna was no longer solely thevulnerable infant, afraid ofmonsters or needy of sustainedcare. As the doctor, sheadministered pain and comfort,and regulated their amount andfrequency. Anna hadbecome the dispenser, the subjectofexperience, bothpositive and negative. Roo hadassumed, atleast in part and forthe interim, the role of object,recipient,and victim.Anna’s doctor and whale playfluctuated between themes ofhurt and healing. Thetopic of hurt was elaborated andassociated with the themeof death and the terrifyingnotion that“doctors kill you.” Atthe other extreme, healing waselaboratedto include not onlyliteral solutions (cf. bandaids)but also arelationship component,friendship. Anna created forRoo alittle fish friend who would“save” him and ensure “no more127dying.” Anna’s journeybetween the dimensionsof hurt andhealing was not an easyone. Her doctor playwith the whale wasoften charged withtension, especially whenreferences to deathsurfaced.Whale play fused withdoctor play did not supplantinfantplay. Scenes of infantlife continued in this finalphase. Theydid so in a strikingand almost rhythmicoscillation with thewhale and doctor play.Anna moved back and forthbetween theroles of the infantand the doctor. In onerole, she personifiedvulnerability and neediness;in the other, control,agency, andauthority. She enjoyedregression in the reexperiencingofinfant life, and sheraised topics pertinentto her current lifeexperience——trips tothe doctor, and all theassociations offear, pain, and needfor comfort that thosevisits entailed.Anna appeared to be usingthe retreats into infantlife (birth,feeding, and so on)as respites for emotionalnurturance fromwhich she drew thepsychological strength todeal with theseconcerns.In the final minutesof the last session, Annaabandoneddoctor play and turnedto the creation of a largepurple mural onthe playroom wall.She filled the wall withwhales, an emblem ofher therapy. As shepainted, she retainedthe role of theinfant; however, sheappeared a more capable and self—confident,even mature, baby, paintingcooperatively with the therapist!maternal figure. Themural concentrated many ofthe key themesand activities which hadrecurred throughout hertherapy: herlove of painting andmesses, her involvementin the infant role,the recapitulation of thewhale theme. In that respect,the128mural seemed a fitting,creative closure to hertherapy.However, before leavingthe playroom, Anna sought afinal forayinto infant life.Finishing her mural, shesat on the “baby’schair” and greedilysipped juice from a tinycup. In taking afinal sip of juice,Anna seemed to be conveyingthat she wantedto take with herone last symbolic gulpof nurturance as sheventured forth from theroom.SummaryAnna’s play therapy wascharacterized by her completeandenthusiastic immersioninto play experience.She was fullyinvolved both with thetherapist and with the playmaterials fromthe first moments of hertherapy.Anna plunged intothe reexperiencing of infantlife. Shegave birth to a play identity,and the playroom became hernursery. By degrees,Anna descended into regressiveplay inwhich the myriad facetsof infant experiencecame to life.Anna as the newborn experiencedcomfort, nurturance, joy,and pleasure aswell as anxiety, fear,and intense aggression.Finally, Anna shiftedinto new play depictions, newthemes, andnew developmentalchallenges. In doctor play,themes of hurt andhealing were elaborated.In perhaps the key verbalcommunicationof her therapy, Anna broachedher fear of death and broughttolight the worries andeven terror that had likelyunderlain herown frequent medical care.Moving through virtuallyall of Anna’s playtherapy was theoften silent, but ultimatelyvocal, figure of the whale.Anna’sattachment and commitmentto the whale throughouther therapyrepresented an intriguingchoice of a play material, forwhales129travel at the oceanfloor and at itssurface. In the Jungianframework, theocean may symbolizethe depths of unconsciouslife. The whaleserved Anna asa strong, friendly mammaliancompanion who wascomfortable at the surfaceand at the depths.130CHAPTER V. CASE 2BRAD: THE EMERGENCE OF PLAYAND VERBAL COMMUNICATIONBrad’s play therapy was marked bythe synchronous emergenceof play and verbal capacities,which developed from an initialstate of severely impoverishedfunctioning in both domains.Atthe outset of play therapy,Brad was 3 years and 9 months old.His presenting difficultiesperplexed his parents and histeachers. Although Brad was normalin appearance, irregularitiesin motor coordination weresometimes evident. His gait wasoccasionally unsteady, andhis fine motor skills wereinconsistent. Brad oftenlooked pale, and he suffered fromfrequent and prolonged colds.Most worrisome to his parents andhis teachers was his lackof speech. However, althoughquiet, Brad was not mute. He wascapable of emitting sounds,such as crying and screaming. Ingeneral, his attempts to vocalizewere so unclear and so poorlyformed that his teachers feared helacked the capacity forspeech. They had begun toteach him a few basic signs, whichBrad began to employ.Within the classroom, Brad at firstdid not and, apparently,could not play. He appeared unfamiliarwith many of the playmaterials. During the first fewweeks of preschool, Brad seemedoverwhelmed with both the range ofstimulating activities and thesocial structure of the classroom.For example, the first timethat the therapist observed Brad inhis classroom, all of theother children were seated in a circle onthe floor, listening tothe teacher. Brad, incontrast, scampered around the room.Preschool was Brad’s first experience in a peersetting, and he131was unfamiliar withthe demands and requirementsof this socialmilieu. A family doctorhad suggested that Brad wasmentallyhandicapped, an untestedassessment which had greatlydisturbedhis parents.Brad lived with both parents,who were hard working andsincere individuals.Brad’s mother suffered fromchronic healthproblems which hadseriously affected her vision.Brad’s birthhad been normal, althoughhis mother expressed concernthat someover—the—counter medicationsthat she had taken duringpregnancymay have affected hisprenatal development. Developmentalmilestones had been delayed.Brad walked at 14 months and wastoilet trained very late,at age 3, several months beforeentering preschool. Speechhad not yet emerged. Although acongenital mental handicap hadbeen suggested by one doctor, adevelopmental delay of unknownetiology and extent appeared amore plausible assessment.An Overview of Brad’s PlayTherapyIn the early play therapy sessions,Brad neither played norspoke. However, gradually,Brad attuned to the safety and therelaxed behavioral limits of thetherapeutic playroom. He beganto become involvedwith play materials and to elaborateactivities with them. Gradually,too, phonemes, syllables,words, and short phrases emergedby degree from his presentingunclear and unformed vocalizations.In the final sessions ofplay therapy, Brad took animportant step in his play, with theemergence of person—actionsequences in which Brad playedout, and commented on, a fantasyscenario. This emergence offantasy play was a critical and132culminating developmentalevent within his therapy.Brad’s treatment beganin the fall and spannedsix months.During that time, hemade important social-relationalgains athome and at school. AsBrad began to communicatehis wants andneeds at home, histantrums diminished, andhis parents, in turn,felt more relaxedand less frustrated intheir contacts withtheir son. At school,his teachers investedmuch time and energyto meet and assist hisemergent capacities for playand language.Brad made two strong friendshipsduring the school year.The first friendship, whichbegan early in theschool year andlasted throughout, waswith a highly verbal child,Ray. DespiteBrad’s few and unclearvocalizations, Ray seemed tounderstandBrad, and the two werevirtually inseparable.Toward the end ofthe school year, Brad,who by this time had begunto speakdiscernably, befriendeda moderately autisticboy who did notspeak. When a team ofspecialists assessed Brad inthe earlyspring, Brad testedabove the range of mentallyhandicapped. Adefinitive diagnosiswas deferred as the specialistsconsideredBrad’s abilities to bejust emerging from his developmentaldelay.The Phases of TherapyThree phases were discernedwithin Brad’s course of 20individual play sessions.The Beginning Phase, consistingofSessions 1, 2, and part of 3,was characterized by the totalabsence of both play andspeech. A breakthrough inSession 3, inwhich Brad simultaneouslybegan to play and to emit sounds,marked the beginning ofthe Middle Phase of increasinglyfocusedplay and emergent speechwhich continued through Session20. The133latter three sessions (18, 19, 20), the emergence of fantasyplay, constitute the End Phase. During this phase, rudimentarysentences typified Brad’s speech.The following analysis describes the major transformationsthat occurred in Brad’s activities with focal play materialsacross his therapy. This analysis then identifies the verbalthemes which attached to these focal materials and activitiesand, in addition, considers the development of Brad’s verbalcapabilities. Brad’s increasingly focused play and verbalizationwere all the more striking, given his severely impoverished playand language functioning at the outset of therapy.The First Session: The Absence of Play and SpeechBrad, who had been fearful of leaving his classroom, heldthe therapist’s hand limply as he walked down the hall with thetherapist for his first play therapy session. There was astriking absence of muscle tone and responsivity in his physicalcontact. However, within the playroom, the depth and the extentof Brad’s developmental difficulties soon manifested with anintensity that overwhelmed the therapist.For the entire first two sessions of 40 minutes each, Bradstood silently, virtually immobile, rooted to a position in theplayroom that was midway between the therapist and the shelvesladen with toys—-a total distance of about 20 inches. He did nottouch any play material, nor did he utter a sound throughoutthese two sessions. His behavior appeared to communicate acombination of fear coupled with unfamiliarity as to what wasrequired of him. The result was essentially a paralysis of allplay and communicative functions.134Normally, the colorful appealof the play materialsservesto override or neutralizeyoung clients’ earlysession anxiety.However, Brad remainedstanding throughout thesesessions, notventuring even to touch thematerials. The onlyvariationsduring the secondsession were slight changesin posture. Forexample, having stood for mostof Session 1 with his backto thetherapist, he varied his stanceslightly in Session 2: turningto peek shyly at thetherapist and then ever soslowly and subtlyrotating his body so thathe could face the toy shelf.At thispoint, Brad gazed with interestat the toys. He slowly benthisknees to get a closerlook at them but did not reach outhis handto explore. At theend of both sessions, Bradresponded readilywhen the therapist announcedthat it was time to leave. By theslight start of his bodywhen the therapist spoke, itappearedthat he understood the therapist’sverbal message.The therapist contemplated allowingthese presentingbehaviors to continue untilBrad’s inner tension peakedandimpelled him to take a risk.However, the therapist decidedinstead to initiate blowing bubblesin the third session in thehope that the shimmeringbubbles would attract Brad and gentlyinduce him to begin to play.When the third session began muchas the first two, withBrad only marginally less frozen inoneplace, the therapist took a jarof bubbles and silently beganblowing bubbles away fromBrad. Intently, he watched them floatacross the room. Gradually,as the therapist blew the bubblesnearer to Brad, his frozen postureappeared to thaw. Ever sotentatively he reached out one fingerto burst a nearby bubble.In this simple motion, two therapeuticbreakthroughs135occurred. Brad had begunto play, and the therapist,through themedium of bubbles, hadmade contact with Brad. Withinminutes,Brad was scampering aroundthe room, waving his armswildly andstomping on the floor,trying to burst as manybubbles as hecould. His first vocalizationsaccompanied this firstplayactivity. Brad laughedand yelped with delight. Soonafter, hebegan to play with othermaterials.The Principal Play MaterialsAcross Sessions 3 through20, with few and briefexceptions,Brad utilized thefollowing materials in hisplay therapy:Vehicles, the DollHouse and Furniture, theDoctor Kit, theHospital Bed and Figures,Adventure People, Sand, and Water.Figure 10 summarizesthe occurrence of play withthese materialsacross sessions. Thisanalysis will focus on thetransformationsin play themes andassociated verbalizations inBrad’s play withthese materials. Brad’sunique Sound and Activity MimicsareSessionMiddle Phase1 2 3 4 5 6 7 89101112131415 1617 181920ThemeVEHICLE* * * * * * * * * * ** * * * * * *PLAYWATER* * * * * * * * * * ** * * * * * *SAND* * * * * * * ** * * * * * * *DOLLHOUSE* * * * * * * * * ** * * *DOCTOR* * ** * *HOSPITAL* * * * * * * * *ADV.PEOPLE* * * * * * * * * *Figure 10. Brad: Overviewof Play with Principal Materialsconsidered as a singularplay manifestation, incorporatinghis136play and verbalcapacities and facilitating both.Vehicles: The Play ThemesThe playroom selectionof Vehicles included several smallcars, a motorbike, a towtruck, a fire engine, a plane, adumptruck, a backhoe, and aset composed of a larger woodenhelicopter, train, andflatbed truck. Brad’s play with theseVehicles was a prominent (salient)play activity in that itspanned the 18 active sessions ofhis therapy, while many otherplay materials and themesappeared only intermittently acrosssessions. Similarly, within sessions,Play with Vehicles wassalient in (a) frequency (with Bradoften returning to play withvehicles), (b) duration (with vehicleplay constituting the majorportion of object play in Sessions3 through 20, and (c) qualityof involvement (with Bradclearly familiar with, comfortablewith, and enjoying thesematerials).Figure 11 summarizes the play themeswhich emerged in playwith Vehicles and theiroccurrence across sessions. In order oftheir initial appearance the Vehicleplay themes were: Vehicleson the Floor; Vehicles inWater; Vehicles on the Table; Lines ofTraffic; Collisions; Throwing Vehicles;Parking; Vehicles in theSand; Brinkmanship; and FantasyPlay. The earlier-occurring playthemes were discerned from thelocation of his play and theselection of other materials used with theVehicles. Later playthemes were distinguished bythe type of organized activityassociated with Vehicle usage. Adescription of these themeswith representative session examplesfollows.SessionMiddle Phase1 2 3 4 5 67 8 910111213 14151617 181920ThemeHANDLEFloor* * * * *Table* * * * * * * * ** *Water* * * * ** * * * * *Sand* *TRAFFICLines* *Crash* * * ** *Park* *TOSS* * * *BRINK* *PUZZLES* * * *w/ HUMANFIGURES* * * *137Figure 11. Brad: PlayThemes with VehiclesVehicles on the floor:Motion and kinesthesia. Immediatelyfollowing the critical turningpoint in Session 3 when Bradexuberantly began bursting bubbles,Brad turned to the toy shelfand without hesitation selectedone of the vehicles. Seatedonthe floor, Brad triedseveral vehicles, holding themand movingthem along the floor,and clearly enjoying the motornoises whichthe wheels made in frictionwith the floor. He sat midwaybetween the therapist andthe toy shelf, exactly where hehadstood rooted in the first 2 sessions.His position in respect tothe therapist, whetherfacing, avoiding, or slightly turned,wasvariable and appeared flexible.Play with Vehicles on theFloorin this format spannedSessions 3 through 7. With only abriefexception in Session 8, Brad’splay with vehicles shifted toother locations and more variedactivities, never to return tothe floor.138Vehicles on the table: The emergenceof patterns. Brad’sdecision in Session 6 to bringsome of the vehicles to the tablemarked an important transformation inhis play. Brad hadrelocated from the floor, apart from and lower thanthetherapist, to the small play table, very nearand level to her.His play with Vehicles on the Tablecontinued through Session 14,with recurrences in Sessions 16 and 17. Fromthis base besidethe therapist, a range of activities evolved: Linesof Traffic,Parking, Collisions, and Brinkmanship.While some of theseactivities appeared aimless, they actuallycontained the germ ofemergent play organization. Play with Vehicleson the Tabletransformed from casual interaction withthe vehicles to highlypurposive, focused, detailed, and realistic play,constitutingrudimentary representational play.In its least organized form, Brad’s play withVehicles atthe Table consisted of Brad idly touching andhandling thevehicles (6) and/or moving them across the table surface,appreciating the noises the vehicles made and theengine noiseshe vocalized. In a slightly more developed version,Bradexplored various vehicles one at a time,pointing out with greatinterest to the therapist the vehicles’ doors and windows,and,by the tone of his vocalizations, clearly hopingto find partsthat would open and close realistically (7).In Session 7, Brad arranged a number of vehicles on thetable in a first distinct Line of Traffic. From one end ofthesmall table to the other, the vehicles moved slowly or simplyidled, bumper to bumper. This first realistic representation ofvehicles organized in relation to others contrasts with another139vehicle play transformation whichoriginated in this session; for6 minutes, Brad causedsome of the vehicles to travel fast andcrash in a head—on Collision. SuchCollisions recurred inSessions B and 13. The relatively calmand contained activity ofLines of Traffic recurred only once, inSession 13.Comparable in noise level and emotional tone to theCollisions, Brad’s Throwing of Vehicleswas characterized byangry movements. This variation invehicle play first appearedin Session 8, continued through Session11, and recurred inSessions 13 and 17. Within sessions, Vehicle Throwingwasintermittent. That is, it followed or was containedwithinsegments of Brad’s calmer exploration of vehicle partsor Trafficplay. Typically, Brad would sit quietly,calmly handling orlining up vehicles, then suddenly, impulsively, andangrily tossone or two to the floor. Ordinarily,Brad would return to hisprevious activity at the table, minus one or two vehicles.Sometimes, however, he stretched his arm across the tableandswept all the vehicles to the floor in a noisy clutterand thenmoved on to another activity.Play which reflected even more intentionality on his part,and which involved contact via the Vehicles withthe therapist,emerged in Session 11 with a recurrence in Session13. In theParking activity, Brad had each vehicle, in turn,travel to thetherapist’s edge of the table. He parked many vehicles side byside, in parking lot fashion, facing the therapist. SensingBrad’s symbolic approach to her, the therapist gentlytouchedeach vehicle as he parked it and commented, “Hi, jeep,”“Hi,backhoe,” or “Hi, truck.” Brad parked each vehicle with care140and listened intentlyas each one was acknowledged.Brinkmanship was a uniqueyet rich subtheme of Brad’s playwith Vehicles onthe Table, reflectingwell-developed motorcontrol and containingnew emotional coloration.In thisactivity, Brad would use onlya single vehicle. Sometimesthiswould be an ordinarycar, and at other times alarger vehicle,such as the towtruck or the fire truck. Hemade the vehiclerace to the edge of thetable and then held it teeteringon theedge of the abyss. Thevehicle then raced forward, orinreverse, evidently in retreatfrom this danger, only tocrashinto the wall at theopposite edge of the table. Inthe soleoccurrences of Brinkmanshipin Sessions 13 and 17, Brad’svehicles sped back and forthfrom these two perils, withBradproviding realistic brake screechingsounds and comments on thecar “cash.”Vehicles in sand and water. Atthe outset of therapy, Braddisliked getting his hands dirty.Not surprisingly, his use ofVehicles in Sand was sparing.In Sessions 11, 12, and 16 Bradmanipulated the backhoe todig briefly, but realistically, in thesand. In Session 17,the dump truck momentarily visited thesandtray. By contrast, Brad’splay with Vehicles in Wateremergedearly in his therapy (3)and spanned his course of therapy (cf.Figure 11). In its earliestoccurrences (3, 5), play withVehicles in Water was literallycontained within the water: Braddumped dozens of small objects intothe plastic water basin.Vehicles were included in thisconfusion of objects in the basinbut were by no means thefocus of this activity. Water wasassociated with vehicle play when Bradmomentarily had a vehicle141travel from the table,sometimes through theair, into waterspilled on the floor,and back to the table(12). Sand and Waterin combinationfigured prominently inthe Fantasy Play withVehicles considered below.Transportation puzzles.Brad’s interest in vehicleswas sotranscendent throughouthis therapy that it influencedhisselection of a seeminglyunrelated material——puzzles.With fewexceptions, Brad chose puzzlesof vehicles. For that reason,hispuzzle play is considered hereinas a facet of the Vehicle theme.In Sessions 11 and 14through 16, Brad sat in raptabsorptionplacing the large depictionsof train, plane, car,bike, and soon, in their respectivedepressions of the woodenpuzzles. Withincreasing clarity, henamed the vehicles as he didso.Vehicles and human figures. Anumber of unique events notreadily categorizablewithin the above thematic divisionsarosewithin Brad’s Vehicle Play.In Session 11, whileengaged withVehicles on the Table, Brad,for the first time in his therapy,incorporated human figures intohis vehicle play. He put aman,a woman, and a childfigure from the doll house into thejeep andgave them a brief ride,with one of the figures functioningasthe driver. A similar exampleof a unique play event withVehicles occurred in Session 17,when Brad placed the nurseandpatient (Hospital Figures) in the largedump truck and took themfor a ride on the table. Theseevents suggest that, althoughlacking age-appropriate verbalskills to verbally communicatehisunderstanding, Brad was, nevertheless,a keen and intelligentobserver of his world, capableof communicating his perception ofcertain person-object relationships(e.g., rider-vehicle) through142play.In Session 13, two uniqueevents occurred which exemplifiedBrad’s capacity for attentionto detail. In one instance,Bradcarefully and realisticallyhooked a small car onto thetow truckmechanism and towed it acrossthe table. In the second,Bradplayed with the backhoein a remarkably detailed andrealisticmanner. In preciseimitation of a backhoe at a constructionsite, Brad had the backhoe(on the table) scoop imaginaryshovelfuls of earth from onedirection, then slowlypivot on itsbase and scoop from the otherside, repeating this sequence forseveral minutes.These unique events constitutedrudimentary segments ofrepresentational play. Withinthe context of play with Vehicleson the Table, where play involvingspatial/movement patternspredominated (Parking, Traffic,Collisions, Brinkmanship), theabove play events ofprecision, reflecting attention tosubtledetail, were sporadicallyembedded. Further, within the contextof global kinestheticinterest in the vehicles, humanfiguresbegan fleetingly,but significantly, to be incorporated.Cumulatively, these events are seenas rudimentary segments ofrepresentational play and precursorsto the culminating activityof his vehicular play, anelaborated person—action—objectsequence that constituted his firstfantasy play.Vehicle fantasy play. The appearance offantasy play, aprotracted scenario incorporating humanfigures, a vehicle, and arepeated activity sequence, occurredin the final 12 minutes ofBrad’s last play therapy session (20).In this singular playvignette, Brad knelt on thefloor beside a plastic basin which143contained his self—concocted silty mixture of water and sand.Selecting the man, woman, and child adventure people from theshelf, Brad placed them on a small plastic boat in the basin.The figures travelled on the boat until suddenly a “cash” [sic]occurred and it tipped, spilling the figures into the silt, whichcovered their bodies. These figures occasionally cried, “Huip!”Brad then retrieved them from the water, brushed the sand offtheir bodies, and placed the plastic family unit on the boatagain. He repeated this sequence 5 times with great absorption,while at the same time looking at the therapist and verballydescribing this scene.The developmental import of this play activity is manifold.First, this person—object—action sequence constituted the mostcomplex representational play of his therapy: The miniatureactors were realistically tossed from the boat, covered withsilt, and survived to repeat the experience. Second, these 3miniature figures authentically duplicated his own familyconstellation. Third, this segment contained the consequentialaddition of fantasy to his representational play. That is, theboat crash and rescue activity did not stem from Brad’s ownliteral experience. It required imagination. Lastly, this playactivity was significant in that it contained the most variedemotional content of all his play. In previous representationalsegments with the vehicles, emotional coloration was generallyabsent.With regard to thematic progression, this segment containedelements of earlier Vehicle Play. It recapitulated, in muchelaborated form, Brad’s initial interest in the boat in the basin144(4). At that time, he barely ventured totouch the boat. Thissegment is also mindful of two earlier unique events in whichsmall human figures rode in various vehicles. However, thisFantasy Play segment with vehicles reassembled these elements——interest in the boat and people as passengers——and elaboratedthem. No longer simply a fleeting representational activity,Brad’s vehicle Fantasy Play told a simple but clear story ofdanger and rescue. The ensuing analysis of the verbal themesassociated with Vehicle Play will illustrate that this segmentwas equally consequential, developmentally and therapeutically,not only on the level of play activity but on the verbal level aswell. While his play depicted and in a sense defined a literaldanger, his words communicated more than the figures’ need for“hulp.” Repeatedly, Brad observed with horror, “Oh, no. Papagone. Whus boat?”Vehicles: The Verbal ThemesThe gradual emergence of verbal themes, in fact, Brad’s verycapacity for verbalization, underwent painstakingly slowdevelopment, which evolved from his presenting total silence torudimentary sentences. An outpouring of amorphous and largelyincomprehensible sounds surfaced, following his play breakthroughwith bubbles. This ambiguous jumble of sounds, a virtual wordsalad, which nevertheless uncannily bore the inflections,intonations, and cadence of language, was the elemental vocalmaterial from which verbal clarity and, eventually, verbal themesemerged. The following verbal themes, summarized in Figure 12,emerged in association with vehicle play: Vehicle Noises, Namesof Vehicles, Negation, Names of Parents, and Loss and Danger.145SessionMiddle Phase1234567891011121314151617181920ThemeENGINESOUNDS* * * * * * * * * * * *SPECIALVEHICLESOUNDS* * * * * * * *VEHICLENAMES* * * * * * * * *NEGATION!ABSENCE* * * * * * *LOSS!DANGER* *Figure 12, Brad: Verbal Themes with VehiclesVehicle noises. Vehicle noises were the first unitofcommunicative currency between the therapist and Brad. AsBradenergetically rolled a number of vehicles along the floor(3),the therapist provided an accompanying motor sound:“Rhhnnn.”In response to the therapist’s primitive vocal additionto hisplay, Brad ran the cars along the floor even more energetically,clearly seeking more “verbal” commentary from the therapist.This type of contrapuntal dialogue, between Brad’s playwith thevehicles and the therapist’s provision of themotor sound, wascommon within the first few sessions.Not surprisingly, given Brad’s enjoyment ofand engrossmentwith vehicle play, his first discernible syllableswere his ownversions of car engine noises (3, and ensuing), hereafterreferred to as Vehicle Noises. The soundsof motors constitutedthe basis of Brad’s playroom language. Gradually, theseVehicleNoises evolved and transformed in detailand complexity, edging146toward the formulation of syllables, words, and sentences.Specialized vehicle noises. When Brad’s play with vehiclestransferred from grossly defined movements on the floor topatterned play at the table, a roughly corresponding developmentoccurred on the verbal level, with the emergence of detailedSpecialized Vehicle Noises. From Brad’s first play with vehiclesat the table (6), he began to emit a range of very realisticvehicle—related noises. The “eerrk!” screech of brakes as onevehicle neared the edge of the table and the whine of the fireengine siren were the first such sounds to emerge (6). Later,Brad added such accurate vocalizations as water gushing from thefire engine’s imaginary fire hose (8), and realistic train (10),rocket ship (11), and airplane (13) sounds. Brad’s vocalizationof Specialized Vehicle Sounds culminated in Session 16, with Brademitting a generous range of vehicle noises, and introducing oneof greater sophistication: the rhythmic, monotonous “beep beepbeep” of a truck’s back-up signal. This particular SpecializedVehicle Noise was yet another indication of Brad’s capacity forkeen observation and his emerging capacity for detailed,intelligent representation.Names of vehicles. Emerging from this richly variant rangeof vehicle noises, crude yet comprehensible approximations of theNames of Vehicles followed. Brad’s first comprehensible word,although it was related to play with a vehicle, was not a vehiclename. Pausing in his play with vehicles on the floor (7), Bradpointed out to the therapist a car’s “door, on door” with greatinterest. Later that session, Brad uttered “car” as he swishedsome vehicles in the water basin.147From this simple beginning (7),Brad began to verbalize alimited number of vehicle names, whichrecurred throughout histherapy. Ordinarily, pronunciation was verypoor and barelyunderstandable: “huck” [truck], “hwain” [train],“ham” [plane],“hike” [bike), “boh” [boat]. Interestingly,Brad’s verbalizationof vehicle nouns proliferated not duringactual vehicle play, butas he sat absorbedly removing andreplacing the transportationpuzzle pieces, accurately naming eachone.Brad’s general vocabulary gradually expandedfrom this basiccore of vehicles names. However, virtually allof Brad’semergent vocabulary involved vehicle—relatedtopics. Forexample, “cash” [crash] and such phrases as“oh no” and “bohgone” were all associated with vehicle play.Even Brad’sexpression of “cow” involved a puzzle piece of afreight car,which when removed, revealed cows on board.Negation and absence. Following theemergence of Names ofVehicles, which indicated a comprehension oftangible (present)objects, a theme reflecting the opposite,Negation and Absenceemerged. The word “no” first appearedas early as Session 6.Until much later in his therapy,Brads “no’s” always occurred inthe context of a favoured phrase, “Ohno!” which conveyed theelement of surprise. As a totality, this phraseidiomaticallyconveyed a sense of worry and concern. “No” as a dynamicconveyor of negation did not emerge until Session 13. As hiscars crashed into the wall by the table, Brad commented, “No gohey is houn” [latter segment indecipherable]. In asuccessivetransformation of the negation theme, Brad’s “no” by Session 14conveyed a comprehension of the concept of lack orabsence.148Removing representations of vehicles from a wooden puzzle frame,Brad observed “no hoe” [tractor), “no ike,” “no huck.” A subtleand more complex transformation occurred subsequently(16) asBrad, again during the puzzle activity, elaborated the concept of“no” in crude phrases: “No huh cow,” “Not uh train.” This themeof Negation and Absence culminated with a more generalizedassertion of absence: “Gone.” As various vehicles disappearedunder water (16, 19, and 20), Brad observed, “Oh no. Gone kane[plane] .“The emergence of the theme of negation was a criticaldevelopmental occurrence. A two—year—old’s first “no” commonlymarks the onset of a rebellious phase. A positive developmentalmilestone, this “no” marks the rudimentary comprehension of egoboundaries and the ability to distinguish between self and other(nonself). As the child’s emergent ego boundaries clarify theself, as actor and agent, from the nonself, as object and other,the child verbalizes this distinction in a generic but powerful“No!”If Brad’s focal play symbol of the vehicles is taken as arepresentation of the self, then his verbal commentary of “noham” or “no hike” indicates his emergent developmental awarenessof self and other boundaries. That is, just as there is “ham”and “no ham,” there is self and nonself. Further, Brad’sexpression of “gone,” an important extension of the NegationTheme, was accompanied by play in which vanished objects laterreappeared, signalled his comprehension of the enduring existenceof objects removed from sight. Brad, within this play andcorroborated by his verbalization, had edged toward the149developmental capacity for decentration.Names of parents. Brad first elaborated his vehicle playwith the Names of Parents during the same session in which “no”as a dynamic negative first occurred (13). As his (driverless)vehicles repeatedly crashed into the wall in the Brinkmanshipactivity, Brad commented enigmatically, “Mama ha ho mama” andlater “Iya papa hung.” Throughout his entire therapy, “mama” and“papa,” his own name, and a crude approximation of what may havebeen “lady” or “Heidi” [an adult friend] were the only names ofpeople that Brad ever uttered. He never identified other playfigures as “boy” or “man,” for example, as is common for childrenin play therapy.Loss and danger. Precursors to the culminating verbal themeof Loss and Danger can be discerned as early as Session 6 inBrad’s anxious comment, “Oh no,” a phrase which recurredthroughout his therapy. This simple phrase subtly conveyedworry, anxiety, and a sense of pending loss or danger. It oftenoccurred when vehicles crashed or toys were broken. Later (19),in a slightly more elaborate expression of this theme, Brad, uponsubmerging an airplane in water, offered, “Oh no. Gone kane!”The verbal theme of Loss and Danger appeared in its mostcompelling and lucid form in the last 9 minutes of the finalsession (20). As Brad engaged in his sophisticated fantasysequence of the family members being repeatedly tossed from thelittle boat, he verbally described the action:Guh guh. . . . Oh no. Haish mama?. . . Unna go boh. . . Unhaigh goh. . . Oh no. No go boh. Go boh. Phhnn. Cash! .On boh. Hulp! . . . Whuh mama? . . . Whuh papa? . . . Nopapa. Papa gone! Gone gone papa. . . . Mama, no mama!Rhhnn. Cash! Oh, ah, oh no!150Although his verbal facility is terribly impoverished for achild of 4.2 years, this story represented a developmentalachievement for Brad. At a fundamental level, it encompassed thethemes of danger and recovery, loss and retrieval. However, forthe first time in his therapy, the protagonists experiencingdanger and loss in a play sequence were not mechanical, buthuman. Further, they were not merely any people, but parentalfigures. At a deeper level, then, this story is fraught withemotional force and essential object relations content: Theentire family suffered repeated dangers but were repeatedlyrecovered; mother and father were repeatedly lost and retrieved.Brad’s Improved Verbal FunctioningAlthough not the direct concern of this study, both progressand a progression within Brad’s capacity for verbal communicationand the structure of his language were noted in the process ofanalyzing his verbal themes. A mass of prevocal sounds (3, 4, 5)first emerged: laughter, shouts, yelps, and, later, vehiclenoises. Subsequently, nonspecific syllables and single wordsemerged (6), followed by such two—word strings as “oh no” (6) andsimple phrases, “on boat” (7). Virtually unintelligiblesentences began to proliferate in Session 9 and continuedthroughout his therapy. Intelligible noun—verb sequences emergedin Session 19 (“kane gone”) and proliferated in the final session(20) with his commentary on the boat crash.Doll House and Props: The Play ThemesA second focal object in Brad’s play was the doll house, itsfurniture, and the 3 or sometimes 4 resident characters (cf.Appendix C). Four major play themes, summarized in Figure 13--151Exploratory, Bathroom Play, General Play, and Throwing Objects--as well as a series of Unique Events evolved in his doll houseplay. Brad played with the doll house in some fashion inSessions 4 through 13 and 16 through 20.SessionMiddle Phase1 2 3 4 5 6 7 8 9101112 1314151617 181920ThemeHOUSETouch*Climb* * *Deface* * *FURNITUREHandle* *Throw* * * * * * * *BATHROOM PLAYAthouse* * * * * *Attable* * *OTHER ROOMS* * *Figure 13, Brad: Play Themes with the Doll House and PropsExploratory play. Even during his inactive and silentsessions (1, 2, and part of 3), Brad had looked with interest atthe doll house but had not ventured to approach it. His firstplay at the doll house (4) epitomized subtlety and tentativenessas he explored its features and props before moving on in latersessions to engage the materials in limited representativefashion. In 2 brief segments (less than 30 seconds each), Bradsimply touched some of the furniture, including the toilet, anobject which figured prominently in later representative play.Subsequently, he handled some of the furniture briefly, and then,as if testing the strength of the structure, climbed on top ofthe doll house for a few seconds. During this session (4) he152tried to deface the doll house, by pulling off the tape whichheld some of the wooden molding together. He eventuallysucceeded in breaking off a piece of the molding. These foursubthemes of Exploratory Doll House Play--Touching, Handling,Climbing, and Defacing--rarely recurred throughout his therapy.Bathroom play. A conspicuous theme within Brad’s doll houseplay was Bathroom Play, which occurred at two locations: theDoll House and the Table. The miniature bathroom fixtures whichappealed to Brad included a shower stall, a basin with attachedmirror, a tub, and a toilet with attached counter and basin. Thetoilet was realistically equipped with a liftable toilet seat anda toilet paper dispenser.Bathroom Play at the Doll House ranged from simple handlingof the fixtures to including a human figure in a representationalplay segment. For example, Brad merely handled the shower stallin Session 4 and 5 and banged the small toilet on the dollhouse’s bathroom floor (6). In subsequent sessions (7, 8, 9), heput a small baby figure in the bathtub. Later, he placed a boyfigure on the toilet (8, 9). Bathroom Play at the Doll Houseappeared in its most intricate and complex manifestation whenBrad utilized all of the fixtures in a related sequence, givingthe baby a bath, putting it on the toilet, and giving it a shower(12). In the following session (13), Brad repeated a similarsequence with utmost calm and absorption with the variation ofusing a figure of a boy rather than a baby.The subtheme of Bathroom Play at the Table emerged inSession 8, several sessions after the appearance of Bathroom Playat the Doll House. As the boy figure sat on the toilet in this153session (8), Brad provided the sounds of exertion associated withdefecation and the sounds of water flushing. The boy called out“Huip” and “Mama.” Brad then tossed these objects angrily to thefloor. In a subsequent transformation of this play (9), the boyfigure climbed all over the fixture, its toilet, counter, andbasin. When the therapist responded, “Now the boy is standinghere,” Brad moved the figure to a new location and asked her,“Ungh now?” In the final occurrence of Bathroom Play at theTable (11), Brad gave the mother, father, and boy figures showersin the shower stall.Although there is minimal difference in the content of playwith bathroom fixtures (i.e., it always concerned washing ortoilet needs), the transfer of Bathroom Play from the doll houseto the table, nearer the therapist, is seen as a significanttransformation on several levels. First, independent of the playmaterials, Brad, it is inferred, felt generally more comfortableto bring his play closer to the therapist. Second, relatedgenerally to the materials, Brad appeared to be symbolicallybringing the contained and private inner world of the doll houseto the open setting of the playroom table. Finally, Brad’sbringing specifically the bathroom fixtures from the house to thetable is seen as an important play symbolic communication. Bradwas portraying sensitive body and toilet training issues and,literally, bringing them to the therapist’s attention via thematerials.General doll house play. This play theme encompassed dollhouse play with furniture props other than bathroom fixtures.More generalized play with a range of doll house furniture first154appeared in Session 10, several sessions after the emergence ofBathroom Play. Brad played with these props at the Doll Houseor, alternatively, brought selected items to the Table. At theTable, Brad’s General Doll House Play was limited in that hetended to focus on a single object with minimal activityelaboration. For example, when he placed the mother and fatherfigures on the couch (12), the figures simply sat there.However, when kneeling before the Doll House (with his back tothe therapist), Brad was capable of sustained, absorbed, andcomplex play with an assortment of props and figures.General Doll House Play reached its richest elaborationduring Sessions 12 and 13. A comparison of this subtheme acrossthese two sessions reveals that in Session 12 Brad focused on thebaby asleep in the crib, commenting “Shshsh.” He also handledthe kitchen appliances. He then went on to a sustained sequenceof Bathroom Play with the baby figure. However, in the nextsession, Brad engaged in Bathroom Play with the boy figureratherthan the baby and then sat calmly and intently arrangingandrearranging many household furnishings, placing bathroom,diningroom, kitchen, bedroom, and living room props within asingleroom of the doll house. He appeared to be attemptingtoconcentrate the essentials of an entire household intoone smalland manageable space. His deep and impressive concentrationduring this activity was regrettably spoiledby the therapist’sverbalization, “That’s the shower.” Brad reacted toherneutrally descriptive comment as a serious intrusionto his calmand silence. In response, he angrily swept the dollhousefurniture to the floor and moved on to other play.155Throwing furniture. Throwing Doll House Furnitureconstituted a distinguishable, recurring play theme in itself.In its initial manifestation (6), Brad tossed]Jof the dollhouse furniture down the doll house staircase, leaving it in ajumbled and confused pile at the bottom of the ground floor.More commonly (6 through 11, 13, 16), Brad scattered or flung thepieces one at a time from the doll house onto the playroom floor.Sometimes, this throwing activity followed calm and engrossedplay at the doll house (e.g., 13). The resounding crashes andthe resulting chaos served as an angry and abrupt conclusion tohis preceding calm. At other times, Brad simply enjoyed theactivity for its own sake (i.e., throwing was not preceded byfocused play), tossing the furniture all over the room. ThrowingFurniture represented Brad’s least structured or focused dollhouse play and one of his most aggressive behaviors within theplayroom.Unigue events. A number of Unique Events, not readilycategorizable within the above themes, occurred in associationwith doll house play. In Session 10, Brad dumped the water fromthe miniature toilet bowl into the therapist’s lap, an actionthat concurrently suggested a desire to punish, dirty, provoke——and trust——the therapist. In an unrelated unique event laterthat same session, Brad included in his doll house play thefigure of a boy with a bandaged head. Brad’s inclusion of thisHospital Figure with the doll house materials was unusual. InSession 11, Brad selected a square piece of doll house furniturewith many open sides, a type of cupboard, and lifted it off thetable, straight into the air. He provided mechanical sounds as156he did so. Only during the data analysis did the therapistrealize that Brad was depicting an elevator, an act whichreflected his perceptive and his imaginative capabilities. Inthe last session (20), Brad sat quietly at the table near thetherapist playing with the doll house’s standing lamp. Hequietly and deliberately broke it in two. The therapist wonderedat the significance of this occurrence in the last session. Bradwas likely angry at the ending of these sessions, and it isplausible that the breaking of the light unconsciously symbolizedthe disruption he felt with the pending break in therapy.Brad’s doll house play culminated in a richly developedUnique Event in Session 16, when, for the first time in histherapy, characters functioned in rudimentary relationship. Bradbegan the sequence by dragging the heavy doll house to the centerof the playroom, bringing the world of the entire doll housenearer the therapist, and allowing him access to all sides of thehouse. Repeatedly, Brad made the boy and the mother figures moveto and through the doll house windows and door. Sometimes thesetwo figures took turns going to the windows to look outside orinside. At other times, it appeared that one figure waslookingfor the other, as if they were engaged in a subdued chase.Once,the boy said “Boyboy” [bye-bye] to the mother. Later, the motherfigure climbed the doll house chimney twice, falling offbothtimes. Following this complex activity, Brad abandoned thefigures and became absorbed in defacing the house by removingalltraces of masking tape from its window ledges.This sustained 11 minute Unique Event was developmentallysignificant. Brad, for the first time, had portrayedcharacters157in relationship. Further, the relationship was multidimensional, with the figures functioning as a unit (looking outthe windows), in association (chasing each other), and asindividuals (searching for each other, saying “bye bye”). Themother figure alone was depicted as experiencing danger (fallingfrom the chimney.) Brad’s subsequent attention to pulling offbits of masking tape was seen as an emotional retreat, perhaps inreaction to what for him had been an enormously expressive playactivity.Doll House Play: The Verbal ThemesIn contrast to Brad’s vehicle play, in which associatedverbalizations were observed to coalesce into discernible, ifunrefined, themes, the verbalizations associated with Brad’s dollhouse play were minimal and fragmentary. Figure 14, whichsummarizes all identifiable words which emerged during play withmaterials other than vehicles, includes a listing for the DollHouse. The table distinguishes between clearly formed verbalefforts and those which were unclear, but reasonablydistinguishable in context through tone and inflection. Assortednoises (toilet flushing, shower water, defecation, refrigeratorsounds) appear to be the only loosely associated grouping ofsounds. They are only qualifiedly advanced herein as a theme perse. The remaining words appearing in the Table essentiallycomprise a vocabulary list typical of an impoverished 18-month-old child.In the absence of any consistent thematic material, thissection of the analysis comments on the inconsistencies and theimpoverishment of Brad’s verbalizations during Doll House Play.158The paucity of vocabulary associated with the doll house isstriking. One explanation may be that Brad was often quiet, evensilent, during such play. Nevertheless, he just as often emitteda range of sounds, syllables, and words, most of which wereundecipherable. Yet the lack of any continuity of even singlewords across sessions is perplexing. For once Brad had shownthat he could pronounce a word, the question arises as to whatprevented him from repeating it in subsequent sessions. As well,there was at least a sampling of names, nouns, prepositions, andverbal participles. Having shown himself to be capable ofpronouncing these units of communication, the question alsoarises as to why Brad rarely assembled these into phrases orshort sentences.Adventure Peoile: The Play ThemesBrad first incorporated the Adventure People, as distinctfrom the Doll House figures, into his play in Session 9. The 113—inch high plastic Adventure People represented a range of maleand female characters (cf. Appendix C). A “black man,” whichfigured prominently in Brad’s Adventure People play, actually hadCaucasian features, but his black hair, black moustache, andblack clothing lent him a sinister appearance. An inspection ofFigure 15, which summarizes all of Brad’s play with the AdventurePeople, reveals minimal play with these human characters acrossthe entire 20 sessions.Play MaterialDoctor Sand Hospital Adventure Doll WaterFigures People HouseReferent*159door*car* *boh [boat]* *cash [crash]* * *go* * *ouch* *ohoh* *ohno* * * *no*mama* * * *papa* * * *in* *high* *out*ook [look]*oke [broke]* *done*gone* * * * *ung-ung [all gone]*no hi—eelhi—ee gone* *hon [sand]* * * *won /wong/wa—eh/wuh [water]* *esh [splash]*whunna go?[where’d it go?]* *hink hun [drink some]*no want out*huip [help]* * *nie—nie*bye bye*nine [mine]*now*on/off*house*light*eyes*bye-bye*SOUND EFFECTSvehicles* *toilet flushing* *shower*defecation*fridge*sh sh sh [hush]*Figure 14. Brad: Verbal Referents Across Play MaterialsThe four major play themes were the following: Handling,Toileting, Submerging in Sand or Water, and Riding in Vehicles.These themes were so limited in occurrence and development that160they do not require any further description other than thelisting provided in Figure 15.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemeHANDLE* *TOILET*WIVEHICLES* * *SUBMERGESand/Water* * * * *SCENES* * * *Figure 15. Brad: Play Themes with Adventure PeopleBrad’s play with the Adventure People was not onlyinfrequent and brief but, for the most part, it lacked anycomplexity. The figures were the passive victims of a simpleevent: burying, dumping, or submerging. Even when they wereactive, such as sitting or riding, their activities wererestricted representational segments lacking in play development.Brad generally tended to engage these figures in simple,unvarying, and literal representations.Scenes. However, within this general context of simpleusage, devoid of distinctive movements and even emotionalcoloration, a number of scenes, or unique events, stand out.Brad’s making one figure jump from the back of a playroomchairinto the water basin (17) represented a unique and evenimaginative departure in play material usage. In the followingsession (18), an event occurred in play with Adventure Peoplethat was unique on the verbal dimension as well. Brad sat at thetable, not playing at all but holding a female (presumedmother)161figure, who appeared to be the topic of his conversation, asfollows: “Oh no, unna ho. [Vocalized sounds of running water.]!Oh no, oh oh. Oh no, ub oh.! Hon.! Gun.”In the next session (19), the nurse figure jumped into thesand and was buried, Subsequently, Brad engaged in a sustainedand completely engrossed play segment with the “black man.” Inabsolute and absorbed silence, Brad repeatedly had the black manjump from the back of a chair into the water basin, buried theblack man in the silt in the basin, and then brushed off thefigure to repeat the segment many times, sometimes including thenurse figure in the same pattern of activity. Intermittently, hetried to pull the legs of the black man apart, apparently tryingto break the toy. He also appeared interested in hurting thefigure. When the therapist responded “ouch!” as the figure’slegs were pulled, Brad laughed somewhat sadistically.The final session (20) contained a series of unique eventswith the Adventure People, each with different emotionalcoloration. Having observed the therapist (directively) use afamily grouping to enact a scene of a boy receiving a spanking,Brad had the boy figure spank the mother figure and then bury herin the sand. Later (19), Brad repeated the activity ofdelightedly pulling the black man’s legs apart and then buryinghim in silt. In Session 20, he engaged in the boat crash sceneso rich in emotional coloration, as described in detail underVehicle Play. Interestingly, all unique events with theAdventure People occurred in the final 4 sessions. As well, mostplay with single Adventure People involved male figures.162Adventure People: The Verbal ThemesThe reader is referred to Figure 14, which summarizesalldecipherable vocabulary, whether clearlyformed or reasonablydeduced in context, which occurred throughout histherapy withthese figures. No consistent thematicmaterial was discerned,with the exception of his verbalizations duringthe boat crashscene in Session 20. This first, and only, verbalizedstory toldof danger and loss, “Oh no. Gone.Whus mama? Papa gone!” Mostverbalization associated with Adventure Peopleoccurred duringplay with vehicles.Hospital Figures: The Play ThemesBrad, who had never been hospitalized, seemed intrigued withthe white plastic set of a nurse, boy patient (withdetachablehead bandage), and wheeled hospital bed (withremovable blanket).As with the adventure people, play with the Hospital Figuresclustered around the most elementary of activities: Handling(onthe floor, at the table, or in water); Throwing onthe Floor, andBurying in Sand. A subcategory of More Elaborate Handlingrefersto Brad’s placing the boy figure in the bed, covering him withthe blanket, and wheeling the bed and/or giving the nurse a turnin the bed. The “More Elaborate” activities were stillseverelylimited representational play segments. Within this generalcontext of restricted play representation, the few unique eventswhich can be discerned in Brad’s Hospital Play were lessdeveloped than in his play with Adventure People. The Nurse, forexample, simply walked across Brad’s puzzle (14). The BoyPatient lay in bed, entered the water, and briefly rode a boat inthe water basin (17). In Session 17, a slight progression was163discerned in the play with these materials as together the twofigures rode in a dump truck, were immersed in water, and, inturn, took showers. Figure 16 lists these themes and cites theiroccurrence.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemeHANDLEFloor*Water*Table* * * *BURYSand*THROW* * * *SCENES* * * * *Figure 16. Brad: Play Themes with Hospital FiguresHospital Figures: The Verbal ThemesFigure 14 reveals that there were few intelligibleverbalizations and no clear verbal themes during play with thesefigures. As the figures rode in the dump truck (17), Bradcommented: “No. oh no. Gone. Hon [sand?]. Whunna go [Where’d itgo?]. Car cash [crash].” This constituted the largest cluster ofverbalizations during play with Hospital Figures. It issignificant that this occurred in conjunction with Vehicle Play.Doctor Materials: The Play ThemesBrad’s play with the Doctor Materials generally involvedExploratory Handling of the plastic instruments. Once, hebriefly placed a pencil behind his ear while looking at themedical chart, a play detail which the therapist interpreted asan indication of his perceptive and imitative capacities.164In addition to Handling the instruments, Brad occasionallyExamined the therapist briefly. His two examinations of thetherapist indicate some thematic progression. In the firstexamination (6), he used the syringe to inject the therapist’swatch. Later in his therapy (18), Brad ventured to inject thetherapist’s mouth and to place the thermometer in her mouth. Theoccurrence of these themes is summarized in Figure 17.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemeHANDLE*EXPLOREINSTRUMENTS* * * *INJECTTHERAPIST* *Figure 17. Brad: Play Themes with Doctor MaterialsDoctor Materials: The Verbal ThemesNo verbal thematic material emerged throughout this play(cf. Figure 14). Only minimal and unclear verbalizationsaccompanied his doctor play.Water: The Play ThemesPlay with Water occurred in each of Brad’s active sessions(3 through 20). Figure 18 summarizes the kinds of activitieswhich emerged in association with water. These clustered aroundthe themes of Handling Materials in Water; Mess-Making;Representational Play; Pouring; and Feeding.165SessionMiddle Phase1 2 3 4 5 6 7 8 9 101112 1314151617 181920ThemeHANDLEOBJECTS* * * * * * * * * * * * * *MESSSpill* * *Splash* *Dump* * * * * * * * * * *w/HUMANFIGURES* * * *POUR* *DRINKCup* *Bottle*Figure 18. Brad: Play Themes with WaterHandling. Brad’s playwith water began in most tentativefashion as one of his vehicles skimmed the waterin the basin(3). In the next session, the water basin becamea focus of playactivity. Brad tossed many play materials intothe basin,filling it with a chaotic jumble oftoys (3 through 9, 14, 15).A transformation occurred when Bradknelt by the basin full oftoys and calmly handled them (5,7, 9, 13, and 15 through 19).Mess-making. Mess-Making involvedSpilling, Splashing, andDumping. Brad Spilled water on the dollhouse (7), on thetherapist’s feet (12), and on 2 large babydolls (18). He alsoSplashed water in the basin (7) and on thetherapist (11). Themost dramatic messes occurredwhen Brad Dumped the entire basinof water with the small toysonto the playroom floor, creating awet, colorful flood (8 through 11 and 13 through19).Representational play. In his earlysessions, Brad used the166water basin as a container for an indiscriminate jumble of toys.In later sessions, he selectively dipped a small number of humanfigures into the water, occasionally with a vehicle prop, playingwith them in the basin in representational fashion (as vehiclepassengers). These scenarios, which have been already beenelaborated, included the hospital figures going for a ride in thewater (16), and the hospital figures and adventure people beingimmersed in the water (17). In the final instances ofrepresentational play, Brad added sand to the water, creating asilty mixture. The black man and the nurse figure jumped intoand disappeared in this silt (19). The extended boat crash scene(20) was the finale of representational play involving water.Pouring. The therapist introduced the water wheel late inBrad’s therapy in an attempt to intensify his play with water.He used it in two sessions (16, 17), pouring the water from thetea set pitcher and other containers into its funnel, andwatching the trickling water set the plastic gear wheels inmotion. His brief use of the pitcher here led him to use it inthe preparation of make-believe food.Drinking. From the above simple pouring activity with thetea set pitcher, Brad shifted to incorporate the tiny tea cups inhis water play as well (17). He drank from the cups. In thefirst nurturing activity of his therapy, he poured water into atiny cup for the therapist to drink. In the following session(18), this transformed into Brad’s only instance of play with thebaby bottles. As Brad poured water into tea cups for himself andthe therapist, the therapist placed a baby bottle on the table.Brad quickly grabbed it, filled it with water, and then filled167another bottle for the therapist. He not only drank from thebottle, but he also bit off the tip of the nipple from hisbottle. Momentarily, he tried a soother as well, tradingsoothers with the therapist.Water Play: The Verbal ThemesFigure 14 summarizes Brad’s verbalization during play withwater. These verbalizations are classified according to soundswhich were clear, or unclear but reasonably deduced withincontext. Within the listing of more clearly formed words, thefollowing clusters, qualifiedly advanced as actual themes,included: Vehicle related words (vehicle noises, “my car”“doors”); names of parents (“mama,” “papa”); referents suggestingloss or worry (“gone,” “oh oh”). A preponderance of self—conscious and even nervous laughter during water play, especiallyduring Mess-Making activities, was observed. Similarly, apreponderance of Sound Mimics (described below) were also notedduring his water play.The number of unclear but comprehensible words which emergedduring Water Play far exceeded the number of comparable wordsemerging during play with adventure people, hospital figures, thedoctor kit, or sand respectively. There were severalverbalizations unique to water play: (a) “esh,” a rendition of“splash”; (b) “won,” “wuh,” “wong,” and “wa—eh,” believed to berenditions of “water”; (c) a repeated expression of “ung ung,”believed to mean “all gone”; (d) a command to the therapist to“hink hun” (presumed “drink some”) water from a cup; and (e)Brad’s reference to the baby bottle as “nine” (“mine”).168Sand: The Play ThemesThe progression of sand playthemes is summarized in Figure19. Brad’s Sand Play encompassedShoveling (Solitary andAssociative), Mess-Making,and Representational Play. Bradusually Shoveled Sand, diggingand transferring it within thesandtray (3, 4, 6, 8 through 14).This Shoveling activityunderwent a subtle but significanttransformation from Solitaryto Associative Play withthe therapist. In Sessions 15 and16Brad invited the therapist tojoin him in a parallel shovelingactivity in which the therapist functionedas a play companion.Brad enjoyed taking turns withthe therapist in liftingshovelfuls of sand and diggingout portions of the sandtray.Brad was relating to the therapistthroughout, pausing to engagethe therapist’s shovel in a mockduel, then returning to theturn-taking activity. In the nextsession (16) Brad moved thesandtray to the middle of the playroomso that both could shoveltogether at that central location.His moving the sandtray fromthe periphery to the center of theroom is seen as an expressionnot only of his confidence withinthe playroom but the importancehe attributed to thisactivity. Moving closer to the therapistmay also have been a factor.His moving of the sandtray to thecenter of the playroomcorresponds to his similar transfer of thedoll house to the middle of theroom (16, 17).Representational Play associated with sandinvolved dirtyingBobo (9); placing or burying AdventurePeople (10, 15, 19, 20);and the transportation of Vehicles (11,12, 16). Later morecomplex segments, incorporating water as well,included: (a)burying the nurse and the blackman (19); and (b) burying the169family group in thesand followed by the boat crash scene(20).SessionMiddle Phase1234567891011121314151617181920ThemeSHOVELAlone* * * * * * * * **Assoc.* *MESS* * * * *W/ HUMANFIGURES* * * * * * *Figure 19. Brad: PlayThemes with SandSand Play: The Verbal ThemesInspection of Figure 14 indicatesthat clusters of verbalreferents rather than clear thematicconsolidation occurred. Aswith most of Brad’s play,these verbalizations included namesofparents; expression of loss (“gone”)and a few references tovehicles. Nervous or self—consciouslaughter as well as SoundMimics occurred sporadically duringsand play. Brad’s clearcomment that “mama” was “okay”(19) was a singular andsignificant verbalization, expressingboth concern and relief.His unclear expressions of “hon,”which recurred during Sand Playappeared to be an approximation of“sand.” The narrow range ofcomprehensible speech during sand playis striking.Activity Mimics and SoundMimicsBrad engaged throughout his therapyin a unique and dynamictype of communicative activity.Brad’s Activity Mimics and SoundMimics, gross motor activity andenergetic vocalizations mutuallymirrored by the therapist and child,were pertinent and uniqueplay and verbalization phenomena.Although these did not involve170play with specific materials nor did they(directly) generatediscernable words, they constituted a developmental basis for anda link between these two domains.In Activity Mimics, the therapist mirrored Brad’s actions.This included a range of activities initiated by Brad: stampingfeet on the floor, rocking one’s chair, pounding the table,jumping, and so on. In Sound Mimics, Brad would yell out asyllable, such as “Dah dah dah!!” From Brad’s tone, it wasevident that the therapist was to respond. She did so byplayfully duplicating (mimicking) the syllable, sometimeschanging the volume. Brad and the therapist would repeat thesesyllables to each other in conversational fashion. Bradsometimes (5, 11) manufactured burps for Sound Mimics, which thetherapist also duplicated. Occasionally, Activity and SoundMimics occurred in unison, with the therapist imitating bothBrad’s activities and associated vocalizations.Sound Mimic production peaked in Session 6. In general,Sound Mimics and Activity Mimics were more frequent in Sessions 5through 12, then tapered off sharply. These two types ofimitative behavior are seen as Brad’s most basic and fundamental,even primitive, assertion of play and verbal behavior. At thesame time, they were also vitally relational events, connectingBrad in pleasurable, boisterous, even aggressive play and/orsound with the therapist.Thematic Comparison and ContrastAnalysis thus far has attended to within-themetransformations for play and for verbalization, consideredindependently. The analysis turns now to the interrelationship171among the themes generated in both domains and, following, aconsideration of the unique contributions of play andverbalization to his play therapeutic process.One of the questions posed at the outset of this studyconcerned the contrast and comparison between the themesgenerated in play and in verbalization. In Brad’s case, acomparison is discerned, first of all, on the more fundamentallevel of functioning in his play and verbal capacities.Therewas a striking parallel between the evolution of organizationandclarity in his play and the increasing organizationand clarityin his speech. Although not a one—to—one correspondence, withpatterned play necessarily accompanied by clear speech,in bothdomains, there was a parallel movement from amorphousto clearerfunctioning.Brad’s verbalizations tended to cluster around the objectsand activities before him. With the possible exceptionof playwith the telephones (not analyzed herein), in whichBrad “cawmama” and spoke, through pretense, to his parents athome, Brad’sverbalizations, although limited, commonly centeredaround theconcrete objects and activities with whichhe was directlyinvolved. In other words, there was no thematic tension,noparticular contradiction, between the verbalizationassociatedwith his play activity.Further thematic comparison yielded general but crediblecorrespondences between a small number ofplay activities andverbal themes which formed an interrelatedcluster: Apprehensionand Concern, Loss and Absence, Danger and Need forHelp/Rescue.In the verbal domain, the sense of Apprehensionand Concern as172well as Loss and Absence were initially expressed in exclamationsof “oh no” and “gone.” Later, more dramatic cries of “Whus mama?Papa gone!” and “Hulp!” revealed that this Apprehension and Losshad intensified to a sense of Danger. Within his play,portrayals of the dynamics of Loss and Absence were slow toevolve, with humans participating only later and intermittentlyin his play scenes. These figures were, on limited occasions,buried or otherwise removed from sight (tossed). The Vehicles,in the perilous Brinkmanship activity, first introduced a playedportrait of true danger, with the boat crash scene a climacticplay illustration of this theme. In sum, a correspondingdevelopment between the played portrayal of an overarching themeof Loss and Danger and its associated verbal commentary isdiscerned. Both the played and the verbal aspects of this themeunderwent an evolution in clarity, complexity and detail.Contributions of Play and Verbalization to ProcessAn analysis of Brad’s verbalization alone would have yieldedlittle understanding of Brad, his problems and his potential. Atbest, it could be considered limited and unclear. Brad’sverbalization was impaired and impoverished. Even by the endofthe therapy, Brad could produce only a severely limitedrange ofnames of people and objects. These provided few clues to Brad’sunderstanding of the world and his relationship to it,for Bradnever verbally expressed a liking for particular play materials,identified an emotion, or directly told about himselfin anyfashion. While many children chatter happily during play,mechanical and other sounds were the basis of Brad’s verbal“commentary” on his play.173Brad’s play activities, however, communicated in three—dimensional clarity what his verbalizations could not yetachieve. Brad’s play served as an eloquent substitute for theverbal skills he lacked. The few and restricted activityelaborations, the limited presence of human figures, and therestricted functions assigned to figures bespoke of seriousdevelopmental, emotional, and relational impoverishment.For Brad, play was a unique and critical alternative mode ofcommunication for his verbal language deficiencies, with playactivities communicating in rich detail his understanding,relationships, and emotions.Brad’s examination of the therapist through doctor play, forexample, was an eloquent expression of his interest in the personof the therapist. No comprehensible verbalizations elaboratedhis interest or revealed concerns around plausibly relatedissues, such as hurt, sickness, healing, or recovery. Brad’sdoll house play conveyed his intense interest in the bathroom andvividly depicted his perception of the bathroom as a focalrelational setting for the family figures. Yet this play wasusually carried out in engrossed silence, interspersed only witha range of water and bathroom sounds. Similarly, Brinkmanshipwith Vehicles portrayed the dynamic tension of near disaster, butonly engine sounds, with no elaboration through language,accompanied this play.Perhaps the most pertinent example of the capacity of Brad’splay to elucidate what his verbalizations could not achieveoccurred in Brad’s culminating play activity, the boat crashscene. During that play in the final session, his verbalizations174alone, his calls of “Whus mama?” and “Papa gone!,” conveyed ageneral emotional undercurrent of concern, worry, and fear andthe more specific dread of loss of parents. However, in his playthe dimension of these feelings assumed explicit reality. Theboat crash scene depicted in engrossing detail that this was notan ordinary loss which Brad felt he was facing. It was relatedto a struggle which placed the family figures in mortal danger.These dangers were compounded: The figures were threatened bythe catastrophes of crashing and drowning. However, his playalso revealed that Brad possessed a ray of hope and a sense ofthe possibility that rescue could be achieved.Brad’s play, in general, revealed the extent to which asingle play material can simultaneously serve as a focus ofmeaning and a catalyst for therapeutic change. Specifically,Brad loved the vehicles. They were familiar to him, and heenjoyed playing with them. These mechanical metal objectsappeared to represent an emotionally safe, perhaps even familiar,uninhabited world. Like Brad, they moved and emitted particularsounds. Through his fascination and predilection for thesematerials, Brad could also be said to have moved, thatis,progressed, in therapy. Vehicles accompanied Brad through everysession of his therapy. It was through play with the vehiclesthat Brad ultimately achieved the developmental and therapeuticstep of depicting peril and human loss.The contribution of Brad’s verbalization to an understandingof therapeutic process is complex because in some ways, as thefollowing example will illustrate, Brad appeared to be usinglanguage to conceal expression as much as to reveal it. Brad’s175unintelligible sentences, as mentioned earlier, uncannilyretained the cadence, inflections, and intonation of language.The therapist often responded to what she presumed Brad wascommunicating in his terribly unclear “sentences,” basing herresponse solely on the rhythm and tone of the unintelligiblecomponents. On more than one occasion, as corroborated by Brad’ssubsequent actions and behavior, the therapist’s comprehensionproved accurate. In one instance (13), for example, Brad stoodopposite the therapist at the table, leaned toward her andcommented: “Nogo heyis houn.” To which the therapist replied,“It’s not time to go back to your classroom yet. I will take youback a little later.” Brad responded by pulling up a chair nearthe therapist and engaging in play.Brad’s very motivation to communicate appeared to beintricately associated with specific play materials. Vehicles,for example, triggered the production of mechanical sounds and,later, Brad’s rudimentary commentary on their activities.Similarly, unclear verbalizations, critical attempts at speech,proliferated during water play.Brad’s verbalizations conveyed only the scantiest specificinformation, such as the names of his parents, an interest indoors, or a pervading sense of loss (“gone”). Because hisvocabulary was so restricted and verbal formulations were sopoor, Brad’s feelings were communicated through intonation andinflection. Increasingly, Brad’s intonation and inflectionrelayed emotional nuances and coloration, which can be grouped asclusters of feelings: worry, concern, anxiety; aggression andtension; excitement and pleasure.176Brad’s verbalizations also provided subtle cues to hiscognitive potential. Brad’s adeptness in reproducing a range ofmechanical sounds, for example, served as an important clue tothe therapist of the cognitive skills of attention and memorythat he possessed. In a few but significant instances, Brad’sverbalization revealed an emergent capacity for abstraction, thecapacity to refer to people or events beyond the play setting.For example, Brad announced that he was going to “caw mama” onthe play phone, expressing intention and a nascent ability toplan. On another occasion, Brad informed the therapist that thetruck pictured in a puzzle held cows inside. His single word“cow,” when pointing to the truck, was evidence of an emergentability to generalize from his knowledge of what vehicles outsidethe playroom hold and apply this knowledge to this particularexample. This single word also indicated the ability to imagineand, therefore, suggested an emergent capacity for abstraction.Summary NarrativeThe preceding thematic analysis has identified Brad’sprominent play materials, resulting play activities, andassociated verbalizations. The following narrative reweavesthese thematic strands into a story of Brad’s play therapy as anexperiential whole.Beginning phase. Brad presented in the play therapy room ina state of virtual paralysis of play and communicative functions.He stood in fearful silence, not venturing to touch a single toy.When the therapist reached out through nonthreatening materials,Brad ever so tentatively reached out a finger to burst onebubble. This was his first experience of initiative withinthe177playroom, and his bubble bursting activity was accompanied by hisfirst excited vocalizations. Turning to materials whichappealedto him, the miniature vehicles, Brad began to touch, handle,andexplore these vehicles, moving them at a distance from, and thencloser to the therapist, and providing them with realistic motorsounds. Brad, like the vehicles, had come to life in motionandin sound.Brad’s beginning phase of therapy, then, was characterizedby movement from paralysis to involvement in play and speech.Amost tentative emergence of initiative was followedbyrudimentary interactions with materials. Brad embarkedupon apainstakingly slow evolution toward speech by breakinghissilence with energetic sounds.Middle phase. Brad became more confident within theplayroom. His presenting impairment with initiative fadedas heselected play materials with increasing interestand interactedwith them energetically. He played as if more assuredof hisright to do so. He moved around in and began to exploreallaspects of the tiny room. This increased movement andmore self—assured entry into play suggested that Brad was beginningto feelthat the play materials, indeed the roomitself, truly were hisown.In this phase, Brad not only interacted in constructivefashion with the play materials, but he also began toupset,overturn, undo, and even mildly attack theplayroom parts. Thisseemed to be an adjunct to making the playroom his own.Byundoing, rearranging, and upsetting the playroom,he was puttinghis own expressive stamp on his surroundings.There was both an178unloosening and a release, as well as brief but intense flashesof anger, as when his calm play at the table was followed by ahasty sweep of the play materials onto the floor in a noisyclutter.Brad’s favoring or preference for certain materials cameinto clearer focus. The vehicles and the doll house captivatedhis interest, although with a qualitative difference. He oftenreturned to vehicle play as if returning to an old friend,providing a range of highly detailed and realistic sounds toenliven them. By contrast, when playing at the doll house, hewas often quiet. He appeared not so much to choose the dollhouse with delight but rather to submit himself to itsfascination, as if having been drawn into a mysterious orb.Not only preferences, but certain patterns now appeared inhis play. The vehicles lined up and parked. Realistic bathroomactivities predominated at the doll house. The adventure peoplewent for rides in the vehicles. Brad tried the puzzles andsuccessfully completed them. From the earlier amorphous melangeof vocalizations, a limited range of names of vehicles and peoplebegan to emerge, as well as a small number of other words.The patterned play and the unsettled play did not form twoparallel and discrete streams. On the contrary, this phase wascharacterized by a sense of struggle and a seething interminglingof varied and oppositional elements. Brad played calmly and thenoverturned things. He tossed materials into the containerof thewater basin, handled them calmly, and then dumped the water andtoys onto the floor. He played near the therapist and thenturned his back on her to play at the doll house. His attention179span was sometimes sustained, sometimes evanescent.A general unloosening was occurring, in his play, in hisspeech, and in his emotional and relational capacities. Outofthe unsettled play, with its expressions of aggression, anger,and chaos, formulations of his psychological needs and strugglesbecame better clarified in his play and in his speech.Inparticular, thematic threads of loss and danger emergedand woundthrough his play. Cars tended to “cash.” He often calledout“gone” and “oh no!” during play. His anger spilled overindumping and tossing activities as well as in hittingBobo.Revealing interpersonal interests and understanding, miniaturehuman forms began to literally travel through his play.Ingeneral, there was ongoing evidence of inner strugglein thisphase, as Brad moved from often raucous kinesthetic playtoemergent fragments of the portrayal of human experience.End phase. A sense of emergent clarity marked thefinalphase of Brad’s therapy. Although messes, dumping,and otherunchannelled hyperkinetic physical activity still occurred,theseabated in frequency and duration. There were increasinglymorefrequent islets of calm and sustained play. Withinthose isletsof calm, Brad was no longer paralyzed. Onthe contrary, therewas a sense of his actively working throughthe mess and the nearchaos to achieve clarity in play and verbal expression.Indeed, Brad seemed to be groping for the tools withwhichto portray and communicate his understanding.His capacity toutilize concrete forms and verbal toolsto communicate what hesaw, felt, and understood, honed and strengthened.The earlierfragments of representational play, whichhe had so guardedly and180fleetingly circumscribed to restricted roles of riding anddriving in vehicles, became more elaborate in activity and playsequence. Figures looked out the doll house window, jumped intoa basin of silt, or repeatedly crashed and were rescued.A sense of the formulation of nascent identity also infusedthis phase. Brad enlivened the small figures with the attributesof identity, a range of emotional or relational characteristicswhich, although limited, were critical emergent features. Theboy, for example, said “bye bye” to the mother. The familygrouping together endured repeated peril in the boat crash.Whereas the miniature figures had previously moved through hisplay in virtual anonymity, there was evidence now that theiridentities and personalities were emerging from that anonymityand assuming names and qualities. They could even take risks andendure with identities intact.Brad’s own identity appeared stronger, more dynamic, and farless tentative. It was he who puppeteered the figures to moredaring actions, animated them with relational qualities, andvitalized them with his own projected emotions. This projectedplay reflected his improving capacity to actively experience lifeand to draw more deeply from this well of personal experienceduring play. He had moved from a world inhabited mainly byvehicles, to a rather two—dimensional inclusion of human figures,to the rapt representation of human events. He now took anembryonic yet consequential step from projected play to theenactment of experience. His singular play with the baby bottle,drinking from it and then biting off the nipple, was a signalthat the barriers to Brad’s experiencing his own infant identity181had loosened to the degree that Brad could experience oralpleasure and anger at its source. In a concise yet elegantstatement of emergent sense of self, he added that the bottle was“mine” [“nine”].Summary. Brad initially experienced the playroom as a placewhere his fears intensified to a crippling degree. However, theappeal of play materials soon invited him into a world ofmovement and sound. The relaxed limits of the room tacitlyencouraged his descent into mess, aggression, and inner struggle.With virtually unbridled self-expression permitted, Brad becameimmersed in an intense experience of oppositional forces, vividlyportrayed in his play and transmitted in his speech: loud andquiet, raucous and calm, messy and clean, chaotic and ordered,loss and recovery, danger and rescue. Clarity and elaboration ofverbal expression as well as clarity and elaboration in playgradually evolved. By the final session, Brad’s more confidentpresence in the playroom, his improved verbal communication, andhis more personal and projective play betokened that the phase ofdissolution was beginning to give way to, and was enabling,reconstruction.182CHAPTER VI. CASE 3CARL: TRAUMATIC PLAY DISRUPTION AND RECOVERYCarl’s play therapy was characterized by traumatic playdisruptions during which Carl sat and cried, overwhelmedby pain.Carl, aged three at the outset of therapy,was the only child ofa couple in their early forties who wereconsidered mildlymentally handicapped. For that reason, social servicessupporthad been available to Carl’s biological parents evenbefore hisbirth. The pregnancy and delivery had been unremarkable.Developmental milestones of the onset of sitting, walking, andtalking had occurred within normal range. Carl enjoyedexcellentphysical health and suffered no physical impairments. He wassturdily built and well-coordinated. However, Carl’s limitedvocabulary and his poorly formulated speech, with infantilepronunciation, made him difficult to understand and suggested alack of verbal stimulation and interaction from an early age. Atthe outset of therapy, he was not yet toilet trained. His tensephysiognomy, with lips almost pursed and eyes nearly squintingwith tension, suggested withheld emotions. Yet it was Carl’sfamily situation that prompted his need for play therapy.Several months before his third birthday, Carl’s biologicalparents voluntarily gave Carl up for adoption to family friends.The adoptive couple had known Carl since his birth. Hisbiological parents felt that this couple would be better able tocare for their son. Carl had often spent time in the home ofthese friends and, in the months before he entered preschool, hadgone to live with them. Carl was accepted for play therapybecause an adoption, which challenges and endangers the183emotional/relational capacities of mostchildren, was pending.In the fall, shortlyafter Carl’s first play session, thelegalities of the private adoption werecompleted. The fact thatCarl’s biological parentssigned the original consent for playtherapy and that, soon after, hisadoptive parents signed theconsent for its continuation, accentuatesthe dramaticdevelopments that were occurring inCarl’s life. Young enough tobe an appealing prospectiveadoptee, Carl was old enough to knowand remember his biological parents.Play therapy provided himwith the opportunity to work through thedual stress of theseparation from his natural parents and the newattachment to theadoptive couple.An Overview of Carl’s Play TherapyCarl experienced the long walk down the hailfrom hisclassroom to the therapeutic playroom as an emotionallywrenchingordeal. Accompanied by the therapist, who carriedhim or heldhis hand, Carl usually cried as hewas taken from the secure baseof his familiar classroom to the tinyplayroom. Once inside theplayroom, his capacity to recover from the enforcedseparationfrom his teachers and peers varied.In some sessions, the appealof the play materials soon enticedCarl from his sense of lossand despair, and he quickly immersed himself inenjoyable playwith favorite materials. In other sessions, Carlwasinconsolably overwhelmed with pain and rage and, in his despair,uninterested in and incapable of playing.Carl wept and protested “No!” as the therapist closed thedoor of the playroom for his first play therapysession.However, Carl’s stress subsided when he caughtsight of the184miniature vehicles.Running these along the floor, heplacedthem in the sandbox andwas soon involved in calm playwith themfor the remainderof the session. Similar playwith vehicles inthe sand typifiedthe ensuing sessions (2, 3, 4,and part of 5).A series of novel playevents (5), such as Carl’s angrytossing of a real chaironto the playroom doll houseand thenspending nearly 20 minutesdousing the therapist and the playroomwith water, signalled that anew therapeutic phase loomed. Infact, a serious playdisruption developed, spanning 3 sessions (6through 8). Carl cried andscreamed throughout these sessions.Ensconced in the therapist’slap, he sobbed as the therapistusedminiature human figures torepeatedly enact a scenario of hisadoption, leaving his natural parentsto go live in a new home.Carl was able to recover enoughto return to sustained playfollowing the Christmasholidays (10 through 13). He favoredplaying in the sand with thebackhoe and other vehicles, but healso intermittently used theminiature doll house people to enactaspects of the separation fromhis parents, e.g., having a littleboy figure kiss mother orfather “goobye,” or putting the motheror father figure in acrib and lovingly wish them “nie nie.”However, pain, rage, and asense of despair againoverwhelmed him during the second majorplay disruption (14, 15).Inconsolable and in even deeper painthan in the first playdisruption, Carl occasionallyleft the therapist’s lap to standby the door and demonstratehis intense desire to leave the room.“Time go back now?” he sobbedagain and again.Carl’s distress, anxiety,and pain reverberated throughouthis entire social system. Histeachers feared that play therapy,185having become so painful,was harmful to Carl. At home,following the morestressful sessions, Carl sufferedsleepdisturbances and nightmares.The adoptive couple attributedhisdifficulties to the play therapyand suddenly asked thatit bediscontinued. A three-weekhiatus ensued, during whichthetherapist met withCarl’s teachers and the adoptivecouple toreassure them and topersuade them to reconsideradditionalsessions so that thetherapist-child relationshipcould terminategracefully and with notificationto Carl. An additional twosessions were agreed to, andthese comprised Carl’s mostpositiveand productive therapeuticplay. Carl enjoyed calm,sustained,cooperative play with the therapist(16, 17). Seated on thetherapist’s lap nearthe sandbox, Carl directed thetherapist to“dump San” or to “park”and “race” vehicles with him.The three—week hiatus duringwhich he had recovered somewhat fromhisdistress, and his awarenessthat there were “no more playtimes”served to calm Carl enoughto achieve this new level ofplay andrelationship.Carl’s play therapy terminatedafter 17 sessions. Outsidethe playroom, his teachershad initially observed an increaseinaggressive behavior towardhis peers. This gradually diminished.Carl’s tense physiognomy appearedmuch more relaxed by the end ofhis therapy. His speechwas clearer; and he was more present,active, and confidentin relationships with peers and teachers.The Phases of Carl’s TherapyFive phases are discernedin Carl’s play therapy. Theseconsisted of three principalplay phases, interrupted by two playdisruptions. The Beginning PlayPhase (1 through 5) consisted186primarily of Carl’s play with vehicles insand and water, withsome exploratory play with other incidentalmaterials. The FirstPlay Disruption (6 through 8) was marked byCarl’s sobbingexpression of pain and rage. During this play disruption, thetherapist utilized small figures to depict the real life eventswhich Carl had recently undergone. In the MiddlePlay Phase,Carl remained on the therapist’s lap while heplayed withvehicles in sand and water, sometimes engaging human figures inhis play. The Second Play Disruption (14, 15) was marked byCarl’s intense despair, as he sobbed and cried toleave the room.In the End Play Phase, typified by cooperative play with thetherapist, Carl was calm, affectionate, and enjoyed playing withthe therapist, maneuvering vehicles with her in sandand water.The Princiral Play MaterialsCarl played with a limited range of play materials, with hisattention and interest dominated by two principal materials:Vehicles and Doll House People. Their appearance across sessionsis charted in Figure 20. Vehicle play conspicuously dominatedCarl’s interest and attention, predominating withinand acrosssessions in frequency and in duration (cf. Appendix C for vehiclelisting). A family grouping of Doll House People, representingCarl, his biological parents, and the new adoptive couple,comprised the other principal play materials. Although Carloccasionally explored other play materials, such as the paintbrush and the magic wand, his interest in them was fleeting andusually never repeated. The exception, a sustained play segmentwith the baby dolls, is discussed within the context of a uniquepivotal session (5).187SessionBeginning Disruption Middle Phase Disruption End1 2 3 4 5 6 7 8 9 10 11 12 1314 15 16 17ThemeVEHICLES* * * * * * * * * * * *DOLL HOUSEFIGURES* * * * *Figure 20. Carl: Overview of Play with Principal MaterialsVehicles: The Play ThemesCarl’s Vehicle play themes were determined by two criteria.The first criterion was the setting where Vehicle play occurred:On the Floor, At the Table, In Water, and In Sand. Vehicle Playin Sand contained numerous subthemes of Handling and Moving,Burying, Digging, Getting Stuck, and Special Vehicle Maneuvers.The second thematic criterion concerned the degree of humanrepresentation or involvement attached to the Vehicle play, i.e.,using human figures in conjunction with the vehicles. In laterhuman-related Vehicle play, Carl played directly with thetherapist, Directing the Therapist’s Vehicles and engaging inCooperative Vehicle Play. Figure 21 summarizes the themes andsubthemes across sessions.Vehicles on the floor, on the table and in water. Carl’sinitial Vehicle Play began On the Floor (1, 2). Carlenergetically ran a vehicle along the floor, enjoying the noisethe wheels made in friction with the floor. As he moved thetruck or car back and forth, the therapist moved playfully to thesound, stopping whenever Carl stopped moving his vehicle. Carlenjoyed this game, and alternately raced the vehicles or broughtthem to a sudden stop, thereby indirectly controlling the188SessionBeginningMiddle Phase End1 2 3 4 5 67 8 9 10 11 12 1314 15 16 17ThemeHANDLESand* * * * ** * * * * **Floor* *Water* * ** * *Table* * *MANEUVERDig/dump* * * **Bury* *Stuck* * * * *Complex* *w/HUMANFIGURES* * *W/Therapist* * * *Figure 21. Carl: PlayThemes with Vehiclestherapist’s movementsas well. Through this littlegame ofmirrored activity, a kind ofnonverbal kinetic dialogue betweenthe therapist and Carl’smoving vehicles, therapistand childmade their first relationalcontact. Carl did notreturn to thefloor for vehicle playafter Session 2.The Table served primarilyas a momentary way station forCarl’s vehicles (3, 4, 5, 9).In only one session(13) Carlengaged in sustained playwith the vehicles at thetable (usinghuman figures).Running vehicles for a matterof seconds acrossthe table, Carl preferredto settle into play withvehicles atthe sandtray.Likewise, Carl’s play withVehicles in Water (2 to4; 11 to 13)was limited to his quicklydipping them or movingthem under water beforereturning them to thesandtray which hefavored.Vehicles in the sand. Carl lovedthe sandtray. Sometimesgritty and abrasive,sometimes smooth and soothing,wet or dry,flowing through hisfingers or resisting theattempts of his189vehicles to traverse it, sand was a medium which thoroughlyengrossed Carl. He loved to shovel it, pile it, pat it, fling itout of the sandtray, watch a pool of water disappear in itsdepths and, above all, maneuver his vehicles through it.Hisvehicle play, in fact, usually alternated in an almost palpablerhythm with sand play. Carl would maneuver his vehicles foraminute or two, then dig a bit, make a vehicle pick up a load ofsand, and then pause to shovel sand onto the therapist’shand.Carl’s Vehicle Play and his play with sand were, in fact,interrelated. For that reason, sand play has not been analyzedherein as a separate play medium. The varied aspects of his sandplay were encompassed in his play with vehicles, which travelled,worked, and were buried in its dunes.Handling and moving. As Figure 21 depicts, Carl began hisVehicle play by Handling and/or Moving the Vehicles, activitieswhich recurred throughout all of Carl’s nondisrupted sessions.Handling consisted of Carl’s simply placing the vehiclesin thesand or holding them while listening to the therapist.MovingVehicles consisted of Carl’s driving them along thesand,sometimes providing motor noises. In the BeginningPlay Phase,Carl’s Vehicle Play consisted solely of these rudimentaryactivities. In subsequent sessions, morecomplex activities wereadded. Ordinarily, Carl interspersed thisvehicle play with afew moments of play with the sand, as describedabove, returningrepeatedly to the vehicles.Digging arid dumping. Digging as a subcategoryof VehiclePlay refers to what Carl called the “wook [work]”in which thebackhoe was engaged. In the Middle Play Phase, whenDigging and190Dumping activities first appeared, Carl enjoyed making thebackhoe “pick up” and “dump” loads of wet sand. In the End PlayPhase, he designated the backhoe for the therapist’s use and tookthe new playroom dump truck for himself, shoveling a “load” ofsand into its container, moving it to the dump site, and “dumpingdis” in another corner of the “sanbok.” The Digging subthemerepresented a more complex and purposeful activity transformationthan simply moving vehicles through the sand, as the backhoe anddump truck vehicles realistically fulfilled details of theirmechanical functions.Burying. Although Carl fleetingly buried the “fie tuck” insand in the first session (“Seh gone”), Burying Vehicles did notoccur again until the Middle Play Phase. Burying a truck in thesand (11), Carl understood what he had done, observing, “Notruck.” Later in this session, when he buried a car in the sand(“No car”), he called out, “Help pees, Mommy!” In all threeinstances of Burying Vehicles, Carl did not leave the vehiclesburied but eventually uncovered them.Getting stuck. From the Middle Play Phase (11 through 13)to the conclusion of his therapy (16, 17), Carl’s vehicles oftengot “stuck” in the sand. In the introduction of this subtheme(11), the backhoe “fah duh” [fall down] and got “stuck.” In thefollowing session (12), the subtheme of Getting Stuck wasintensely repeated, with an assortment of vehicles getting stuckin the sand 24 different times. The backhoe, a truck, severalcars, and even the boat took turns becoming lodged in the sand.At one point during this play Carl commented that it was “snowingnow.” His comment suggested that Carl may have been imagining191the vehicles to be stuck in snow.Special vehicle maneuvers. In theEnd Play Phase (16, 17),Carl’s Vehicles engaged in severalspecialized maneuvers,Parking, Backing—up, and a complexplay scenario involving blocksas additional props. Although Parkingand Backing-up had beenintroduced in his vehicle play earlier (11 and 12respectively),Carl repeated these activities withparticular interest in thefinal 2 sessions.While “parking” and “backing-up” mayappear to be minute andeven superficial activitydistinctions, on closer inspection theydenote important, if subtle, playtransformations. A Vehiclewhich is “parked” is notin difficulty, as is a vehicle which is“stuck.” A parked vehicle is simplycarrying out one of itsordinary functions, in a sense pausing or resting beforeresumingactivity. “Parking,” which usually takesplace in designated anddemarcated areas, also suggests rules,boundaries, and limits.In depicting this realisticfunctions of vehicles, Carl was alsodepicting an emergent awareness of therealities of bounds andlimits.Carl’s vehicle play culminated with a calm andsustainedintricate play sequence. With intenseconcentration and greatpleasure, he engaged in a sustained 14minute play scenario whichreprised many thematic elements ofhis previous vehicle play andgenerated new ones. Assigning a truck and later the backhoe tothe therapist, Carl handled the dump truck. For a while,largelyat Carl’s command and direction, thevehicles together or in turn“dumped” sand and travelled along the sand over “bumps.”Suddenly requesting “wocks [rocks],” Carladded a bucketful of192small, colorful blocks to the sandtray. The addition of theseplay props served to thoroughly engross Carl. He loaded his dumptruck with “logs” and directed the therapist to do the same withher vehicle. They took turns “dumping” their “loads” andoccasionally getting stuck in the sand, menaced by the “logs”which Carl had buried in the sand. However, their vehicles alsotravelled (“drive!”), raced (“set go”), and parked (“set park”).They backed up (“beep beep beep”), got stuck in the “deep” sand,and one even “tip[ped) over.” The vehicles had difficult work tocomplete (“move dat log!”). Seated on the therapist’s lapthroughout this segment, Carl spent the final minutes of his playtherapy as he had at the outset, in play with Vehicles.Human figures in vehicle play. The addition of humanfigures comprised the final theme of his vehicle play to beconsidered. Carl’s use of human figures as props or adjuncts tovehicle play was minimal across sessions (1, 11, 12, 13).However, within those few sessions (11 to 13), his use ofminiature human figures was extensive and consequential.Children commonly use human figures as drivers or passengersfor the playroom vehicles, and, in fact, Carl had done thisbriefly in Session 1, placing a small figure on the boat in thesand. Human figures did not participate in his Vehicle Playagain until Session 11 when Carl, seated on the therapist’s lapat the table, used the backhoe to pick up the figure of oneadoptive adult. Querying “Dis pick up Daddy?”, Carl used thebackhoe to pick up a woman instead.In the following session (12), the incorporation of humanfigures was more elaborate. Still on the therapist’s lap, but193now seated beside the sandtray, Carl had thebackhoe “pick mommy”and then himself up and, in turn, “dump” them. Tellingthetherapist, “I wan Daddy now,” he retrieved from thetable theother 3 figures of his extended family grouping and addedthem tothe sand. This time he buried the adoptive woman inthe sand,with her body becoming an obstacle to his vehicle, a train.Withapparently sardonic humour, Carl commented on the buried figure,“[She] makin’ happy face? . . . [She s]top train?” Finally (12),this same female figure, evidently undergoing punishingtreatment, was later picked up and dumped by the backhoe, as Carlcommented, “Where [she] go?”In the final appearance of human figures with vehicles (13),the backhoe, the focal vehicle, functioned not only as a piece ofworking machinery and as a moving transport, but also as anenclosing container, a kind of moving home, for the miniaturepeople. Playing near the table while on the therapist’s lap,Carl had one adoptive parent, himself, and then the father figuretake turns driving the backhoe. He tried to bend the rubberfigures so that they would sit and even lie down in the cab ofthe backhoe: “Look! Carl driving! Two people! . . . Duh sitdown der. . . . Daddy’s driving it! . . . I wuh can seep seep[sleep].” The Carl figure also joined one and then both adoptiveparents in driving the vehicle together. The fact that thefigures were now riding not singly but in varying groupings of 2and 3 people in the cabin of the backhoe was a significant playtransformation. Carl appeared to be grappling with reassemblingthe human participants in his world into a coherent andmeaningful unit, a unit which travelled, worked, and even slept194together in the confines of his backhoe.Vehicle play with the therapist. At the end of the MiddlePlay Phase (12, 13), Carl began to direct the therapist to playwith vehicles. Still on her lap, Carl ordered her to “Pay [playwith] dis one! . . . Dump down! . . . Pick up.” Asshe carriedout his instructions with the vehicle(s) he had designated,Carlgenerally sat quietly and watched the activity in the sandbox.He would then take a brief turn in similar activity withhis ownvehicles, pausing soon after to again direct the therapist.According to Carl’s directives, either the therapist or Carl tookturns moving the “stuck” vehicles so that they could continuemotoring over the sand. Carl enjoyed this play activity with thetherapist and was both calm and affectionate: “I like boo [blue]car. . . . I like that truck. . . . I like Susan.”In the End Play Phase, which followed the Second PlayDisruption and a three-week hiatus from therapy, a significanttransformation in the theme of Vehicle Play with the Therapistoccurred. Carl’ began to engage in cooperative play with her.Still directing the therapist to “drive,” “park,” “back—up,” andrace (“set go!”), Carl now often joined the therapist, carryingloads of logs on their respective vehicles, driving alongside hervehicle, and parking nearby.When Carl was most involved in cooperative play with thetherapist (16, 17), he did not use human figures even once in hisvehicle play. This detail of the play transformation wouldappear to represent an important developmental event. When Carlfirst directed the therapist in play (12, 13), he was still usinghuman figures in his vehicle play during these same sessions.195When he subsequently joined the therapist in cooperative vehicleplay (16, 17), play in direct association with an adultsupplanted his use of adult likenesses.Vehicles: The Verbal ThemesThe following verbal themes emerged during Carl’s play withvehicles: Vehicle Noises; Names of Vehicles; Vehicle Activities;Vehicle Qualities; Expression of Wants; Expression of Liking;Absence; Relational Phrases; and Calls for Help. Becauseverbalization was minimal, Figure 22 provides representativeexamples of the verbal themes across play phases. The followingSessionBeginning Middle Phase End1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17dumptruck (11)mack truck (12)front loader (13)Die is lots? (12)Dis car door open?It dump. (12)No go. (3) What backhoe doing? (12) Dah fah down? (16)[consistent across phases]No car. (12)I wanna pay in thesandbox. (11)Help pees, mudder. (12)Dit need help. (13)Daddy’s driving it. (13)Figure 22. Carl: Examples of Verbal Themes with Vehiclesdiscussion focuses on the across-session thematic developmentsand trends.ThemeVEHICLENAMESfie huck (3)choo choo (4)QUALITIES clean bQh (3)moh car (3)WORK didig (1)dumptruck (16)(13)No moh wookin.(16)OTHERACTIONSSTUCKABSENCE/LACKWANTSHELPCar gone. (1)I wan more cars. (3)Hup dis. (2)RELATING Bye didig. (1)LIKESI needa workoer der.(17)Pay disone. (17)I like boocar. (17)196Vehicle noises. Carl provided realistic noises for hisvehicles, such as motor noises, sirens, and back—up signals.These occurred in most of his nondisruptedplay sessions. Yethis speech rather than vehicular noisespredominated during hisvehicle play. Across sessions there was no remarkable change inthe production of these sounds. Carl appeared to enjoy makingthe noises, and he used them selectively and appropriately whenvehicles were driving, backing up, and so on.Vehicle names. Carl knew the names of many vehicles,including specialized ones, and he frequently identified themduring his play: “Der boat!” or “Dah truck.” As his therapyprogressed, a tendency toward more specific and evensophisticated terms was discerned. In the Beginning Play Phase,Carl’s verbal repertoire of names comprised “car,” boat,” “fie—tuck,” “tuck,” and “choo—choo.” By the Middle Play Phase, Carlhad added “backhoe,” dump truck,” “wusing [racing) car,” and even“macktruck” and “frontloader.”Vehicle activities. Carl provided an increasingly rich andelaborate commentary about his vehicles, which were almost alwaysin motion. Verbal subthemes included: Work, and the Descriptionof Vehicle Movements.In the first session, Carl commented that his vehicle was“didig [digging],” introducing the subtheme of Vehicles at Work.This was amply elaborated in subsequent sessions: “Moh didig,”“I making tunnuh,” (2); “Moh wook,” “Dump” (3); “Picks the bigdirt up,” “Pick the wock up” (12); “Working finished. No mohwookin’” (16); “I move dat rock,” “Dis carry logs” (17). It isnoteworthy that not only did this subtheme of Work persist197throughout his therapy, but also, as even these few examplesillustrate, Carl’s capacity for verbal description improvedmarkedly from his first one—word commentary (“didig”).A second subtheme of vehicle activity was the more literalDescription of Vehicle Movements: “Stop,” “No go” (2); “Theregoing” (4); “What backhoe doing?” “Car come” (12); “Dih godrive,” “Is going in sand” (13); “Beep beep backing up!” “Carltip over,” “Dis stan’ up?” (17).A particular subfacet of Vehicle Movements was the notion ofthe vehicles as “stuck” (“can’t move”). The concept of thevehicles as “stuck” initiated in Session 3 and recurred manytimes throughout Carl’s therapy.Vehicle qualities. Carl possessed a versatile range ofadjectives which he applied to the vehicles. He was aware ofsize (“big backhoe,” “little car”) and place or position (“Highnow?” “Low down”). He expressed interest in additional orgreater quantities (“Nudduh car” [[2]; “Dis is lots” [12]; “Mohpark” [16]). He was aware that one vehicle was “bokin [broken]”(4). He commented that “Dis car door open” (13) and “Boat loud[allowed] get wet?” Carl used the first person possessive onlyonce in relation to the vehicles, “My boh!” (3). Also in oneinstance he used the word “better,” a somewhat sophisticatedcomparative: “It bedduh put up der?”In general, as these examples illustrate, Carl’sverbalizations of Vehicle Qualities clustered around certaindescriptors (size, location, and other details). However,repetition of these words was so sporadic that they cannot besaid to constitute consistent thematic material. An exception,198however, was Carl’s sustained interest in the concept of “dirty.”In the first session, he described a vehicle in the sand as“duhtee.” Such references proliferated throughout his therapy.Although he could pronounce its opposite accurately (cf. “cleanboh”), Carl was much more excited when commenting on “duhtywater” (16) or the “duhty wheel” (17).Absence or lack. Verbalizations of the concept of objectsbeing hidden, missing, or absent were meager throughout histherapy. Carl expressed this concept in most elemental form. Inthe Beginning Play Phase, he commented “Car gone” (1) and “Dihdih [digging] gone” (3). In the Middle Play Phase, he formulatedthis concept differently, commenting “No truck!” (11), “No car!”(12) when he buried them in the sand. This verbal theme did notrecur in the End Play Phase.Expression of wants. Carl was able to express what hewanted using the first person, “I,” from the outset of therapy.This Expression of Wants transformed across play phases andoccurred even during play disruptions. In the Beginning PlayPhase, Carl was able to communicate what he wanted to do and withwhich object he wished to play: “I wuh ride dat boat” (1); “Iwuh more cars” (2).In the Middle Play Phase, a number of transformationsoccurred. In addition to designating the object he desired, Carlmore frequently announced what he wanted to play before engagingin play, “I wanna pay in the sandbox” (11); “I wan boat in nersan” (12); “I wuh pay airpane” (13). He was able to express hiswants even at the risk of being limited by the therapist: “ I wanbing dis [backhoe back to the classroom]” (10). He also conveyed199a wish to attempt anactivity: “1 wuh try [using a particularvehicle]” (13)Carl’s most emotionally charged Expression of Wants washiseloquent request for help during play withthe vehicles (“I wuhhelp” [12, 13]). At the end of theMiddle Play Phase, whiletrying to dislodge a stuck vehicle from thesand, Carl commented,“I wuh tow truck [to] help.”This latter example is considered a more sophisticatedexpression of wants. It is more complex than a requestfor anobject, and it is more intricate than astatement of wishing toplay. It described Carl’s wish to havethe tow truck assume aparticular function or quality. In assigning or attributing thefunction of helping to this vehicle, Carl’sostensibly simplestatement actually represented progress toward rudimentaryfantasy play. Not only he or the therapist couldfree the stuckvehicles, but the vehicles themselves could adopt this helpfulquality. (Carl’s requests for help assumed other formulationsand are considered in further detailunder the Theme of Help,below.)In the final play session (17), he expressed his wanting toplay with the vehicle in a new way: “Ineed a work o’er der!”This was Carl’s first and only first—personexpression of needthroughout his entire therapy. This expression of need isseenas an extension of and a transformation of the theme of theExpression of Wants. His expression of Needencompassed andovershadowed the notion of request (“want”), intensifying it tothe level of deeper demands.Carl’s most vehement Expressions of Wants were worded in the200negative. During both play disruptions,as he cried andrepeatedly asked, “Time go back now?”Carl often yelled loudlyand unequivocally, “No wan payroom!”It is likely that thisintense negative expression of hiswants during play disruptionsactually enabled him to formulate moreclearly and securely theexpression of positive wants during thelatter play phases.Expression of liking. Carl expresseda positive liking forobjects/people in the playroom in only onesession (16). Havingbeen informed by the adoptive couple,his teachers, and the playtherapist that he had only “two moreplaytimes,” Carl recoveredquickly from his initial distress atbeing in the playroom. Aswell, pleased to see a new dump truckin the room, Carl settledinto contented play at the sandbox,nestled in the therapist’slap. “I like boo [blue] car,” “Ilike that truck!” and, later,“I like Susan,” he commented. Althoughon one level, thetherapist was certain that Carl did, infact, like both the playmaterials and the therapist, she alsobelieved that he was ableto express this liking at this timebecause he was relieved thatthe sessions were ending soon.Calls for help. The theme of Help was introduced brieflyinthe Beginning Play Phase, elaboratedin the Middle Play Phase,and completely absent from the EndPlay Phase. This themeassumed two forms: indirect and directcalls for help.The Help theme in its indirect form first emergedbriefly inSession 2. Carl commented that one vehiclewould “hup dis” otherone. This verbal expression is consideredindirect in that theneed for help was projected onto the play material, andwordedimpersonally in the third person. When this themenext recurred201during the Middle Play Phase,Carl intensified the call for help,adding the concept of need,again projected onto a vehicle:“Truck need help” (12) and “Dih needhelp” (13).The call for Help in its direct formwas worded as a directpersonal appeal in the second person.In both Sessions 11 and12, as Carl endeavoured tofree the “stuck” vehicles, herepeatedly called out, “Helpmommy. Help pees, Mommy. Helppees, Mudder.” Although anelement of projection was involved inthis expression, as Carlclearly intended to be speaking for the(invisible) driver of the stalledvehicles, the sincerity of histone conveyed the depth of his ownwish and need for help.Settled on the therapist’s lap, hewas simultaneously expressingan admission of his need for help, hiswish for help from hismother (perhaps both biological andadoptive), and at the sametime asking for help from the maternalsubstitute, the therapist.Relational. To a degree of course, all of Carl’sspeech wasrelational. However, this verbal thematic categoryrefers tothose verbalizations which either (a)directly addressed the playmaterials (vehicles) as respondents in a personalrelationshipwith Carl, (b) referred to hisrelationship with individualsoutside the playroom, or (c)directly engaged the therapist inrelational contact.The first subcategory occurred only once. As Carl lefttheplayroom after his first session, he calledout to the backhoe inthe sandbox, “Bye didig [digging].”The second (11 through 13)conveyed Carl’s biological and adoptiveparents as either objectsto be carried by or drivers of thevehicles: “Dis pick up Daddy”(11); “Daddy’s driving car!” (13).202The third category proliferated in the latter two PlayPhases. Carl frequently addressed the therapist directly, intones that implied both friend and playmate, beginning with asimple call for her attention, “Look, truck!” (10). Later, Carlbegan to verbally direct the therapist to play: “Pay withbackhoe,” “Try again” (12); “Pay dis one!” (13). His comment inSession 12, “Let’s pick mommy daddy. Pick ‘em up,” was aparticularly clear expression of mutual interest and effort (cf.“let’s”). Similar directives continued throughout the Final PlayPhase. To these directives, Carl verbally added the element ofcompetition, inviting the therapist’s vehicle to race his own(“Set go!”) and even compete in parking (“Set park!”).Human Figures: The Play ThemesCarl played with the following sets of human figures: theAdventure People, the Hospital Grouping, Baby Dolls, and the DollHouse Figures (cf. Appendix C). The Adventure People figuredonly cursorily in his play, with Carl placing one of them(unidentified) on the boat in the sand (1), biting the head ofthe “black man” (3), and holding an unidentified female figure(6). The Hospital Grouping were handled only twice, with Carlbanging the hospital bed on the table (2), and floating thelittle boy patient in the water (3).Toward the end of pivotal Session 5, Carl played with BabyDolls once, in a series of unique play activities. Taking atable knife, he tried to “cut” the eyes of one doll. Removingthe bedding from the large playroom cradle, Carl put two dollsinto the cradle, rocking them so vigorously that they almost fellout. Undressing another small doll, he put her into her own tiny203cradle; but just after exploring other baby clothes on the shelf,he suddenly ran from the playroom. After the therapist broughthim back, he played with a small doll for another minute beforethe session ended.Although the Adventure People, Hospital Grouping, and BabyDolls did not undergo thematic development across sessions, thesefew details are included here because Carl’s play with thesematerials served as a rudimentary introduction or as precursorsto his later more involved play with the Doll House Figures.Once Carl had gravitated to the Doll House Figures, following theFirst Play Disruption, he never returned to play with the otherhuman figures.Carl’s interest in the Doll House Figures may have beeninfluenced by the therapist’s having used these five figures todepict Carl’s leaving his biological parents to go to live withthe adoptive couple, referred to in this discussion as A and B.In this scenario, the therapist had the small “Carl” figure hugand kiss the figures of the biological parents good-bye, as theadoptive parents came to walk Carl over to the corner of thetable which represented their home. In variations, the therapisthad the small Carl figure “speak” to both couples about what hefelt about being adopted. In addition to playing out fragmentsof the scenarios the therapist had enacted in the First PlayDisruption, Carl utilized the Doll House figures, often verytouchingly, to enact the elements of his primary relationshipsthat were important from his three—year—old perspective.204SessionBeginning Middle Phase End1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17ThemeCarlOBSERVESTHERAPIST* *TOUCHES*EXPLORESBODIES* *TOSSES* *BURIES*FiguresSLEEP*SEPARATE*HUG/KISS* * *TOILET* * *DRIVE/RIDEVEHICLES* * *Figure 23. Carl: Play Themes with Doll House FiguresCarl began his involvement with the Doll House Figures as anobserver. Sobbing as he sat on the therapist’s lap throughoutSessions 7 and 8, he Calmed noticeably, if briefly, whenever thetherapist enacted, for example, the child figure hugging themother or father goodbye. This precocious figure also asked hisparents why they had given him up for adoption. He told theadoptive couple how frightened he was and that they must takeparticularly patient care of him. Toward the end of Session 8,the therapist brought several Doll House furnishings to the tableand had the child figure jump from the crib into the bathtub fullof water. For the first time in 3 sessions, Carl smiled. He205touched the water in the tiny tub and toilet. From thisembryonic interest in the doll house furnishings, a number ofplay themes evolved in play with the Doll House family figures:Expressions of Affection, Sleeping, Bathroom Activity,Separation, Exploring Body Parts, Tossing, Burying, and VehicleRelated. Carl carried out all play with human figures whileseated on the therapist’s lap near the table. His play with themoccurred solely within the Middle Play Phase (9 through 13).Carl did not return to play with human figures after the SecondPlay Disruption.Expression of affection. As Figure 23 illustrates, Session9, immediately following the First Play Disruption, wasparticularly suffused with Doll House Figure themes, withExpressions of Affection predominating. Generally, Expression ofAffection took the form of the figures kissing. Repeatedly, thechild figure hugged and kissed the mother and father figures.The child returned to kiss the father twice more. The motherkissed the child and the father. Later, the father kissed one ofthe adoptive parents. The child figure kissed her as well. Thisactivity recurred with diminished frequency (10 and 13 only).Once Carl expressed affection toward a human figure in anotherway. The father figure’s head was covered with sand. Lovingly,Carl wiped the sand off “daddy.”Sleeping. With great absorption and tenderness, Carlrepeatedly put several of the figures to bed (9 only).Pertinently, he used only the figures representing his naturalfamily. First, he put the child into the crib, and then putchild and father in the crib together. Next, the child lay down206with the mother on a bed. Finally, themother slept in a bedwhile the child climbed into his crib.Separation. Enactments of separationbetween the child andthe parents occurred in association with theSleeping theme. Asthe child figure lay down in the crib (see above),Carl had thefather walk away from the crib, saying“Bye.” Later, the rolesreversed, and when the child put the father into the crib, he,too, walked away from the figure, saying “Nie nie, Daddy.” Theseinstances were the only depictions of Separation which Carlinitiated. However, in the next session (10), as he finishedplaying with the Doll House figures, he pushed all the figuresaway from him and said, “Bye, A. Go home,Daddy.”Bathroom activity. Enactments of Bathroom Activities atfirst consisted of the child repeatedly jumping into the littletub full of water (9). Carl particularly enjoyedhaving thechild jump from his crib directly into the tub. Carl also put Ain the tub. In the next recurrence of this theme (11), Carlfocused on other bathroom furnishings, having the child sit onthe toilet and then jump into the basin. Afterthis session,Carl never returned to bathroom play with these figures.However, he showed minimal, intermittent interest in the toiletfixture itself, adding it to the sand (12, 16).Exploring bodies. Carl was curiousabout the anatomy of theDoll House figures. Although this exploration occurred onlytwice in his therapy, his strong curiosity about the figures’bodies reflected an important developmental interest. In thefirst appearance of this theme (10), Carl held the mother andfather figures in turn and tried to remove their clothes. He was207aware of “der body” and particularly interested in seeing their“bum.” In the other occurrence of this activity (13), Carl triedto take the clothes off the mother and father figures as well asthe adoptive parental figures. Carl was concerned withdetermining which of the figures had a penis.Tossing. Although Carl tossed the Doll House Figures ontothe floor only twice (11, 13), this activity is considered as aseparate theme for two reasons. First, in contrast to Brad, Carldid not carry out this tossing activity with overt aggression.Rather, he would slowly and almost delicately sweep them off thetable onto the floor, as if he were simply tired of beingconfronted with the complex relationships they represented. Hedid not appear to be acting from impulse but rather from a quietdetermination to clear the table of their presence. Second, andsignificantly, on both occasions he retrieved the figures fromthe floor, either resuming play with them (10) or intentlychecking that they were unharmed from the fall (13). His actionssuggested care and concern for the figures as well as the needfor distance from them.Burying. The theme of Burying Human Figures did not undergothematic transformation. Rather, this activity was a uniqueevent in Carl’s play with the figures: He buried B in the sand,using her body as an obstacle to stop his train (13),introducing, through this depiction, associations of punishmentand perhaps death.Vehicle related. Doll house people figured in associationwith Carl’s vehicle play during the Middle Play Phase only, inthree successive sessions (11 to 13). This theme began with one208brief segment (11), with the backhoe picking up B and dumping heron the table. In its next instance (12), this theme subtlytransformed in that, in addition to picking up and dumping B withthe backhoe, Carl used the backhoe to pick B and the child figureup together. In this same session, he also buried B and used herto “[s]top the train.”The third and final instance of this theme (13) wassustained and elaborated with variations of drivers andpassengers. First, B drove the backhoe along the table, soonjoined by the child. Then a series of human figures, mother,child, and B, were each picked up by the backhoe and dumped.Finally, the adoptive couple, A and B, joined the child indriving the backhoe together. In this brief but significantsequence, the biological mother was ultimately replaced by A inthe cab of the backhoe, a symbolic depiction of obvious relevanceto Carl.The backhoe here represented much more than a vehicle. Forduring every active session, Carl had played intently with thevehicles, and within his play therapy sessions, the vehicles werevery much “his.” Therefore, in having the adult figures join himfor the first time in the cab of the backhoe, the seat ofcontrol, Carl appeared to be inviting the adults to join him inthe miniature world of which he was owner and master. This wasin clear contrast to the reality of his life outside theplayroom, where he no doubt felt powerless in the face of adultdecisions which had radically changed his life.Doll House Figures: The Verbal ThemesVerbalizations associated with the Doll House figuresMiddle PhaseTheme ExamplesSEPARATION Bye bye, Daddy. (9) Dis goobye mommy? (13)AFFECTION [kissing sounds; 9, 10)ATTRIBUTES He’s frying. (9) A dirty. (11)BATHROOM Daddy pee up there. (9) Der pee. (11)OTHER Up high. (9) Dis pick up Daddy? (11)ACTIVITIESSLEEP Nie nie, mama. (9)RELATIONAL Toy mommy. (10)EXPLORE BODIES Der bum der. (10)VEHICLE RELATED A top train. (12)Figure 24. Carl: Examples of Verbal Themes with Doll House FiguresExpressions of affection. Carl’s Expressions of Affectionwhen using human figures were actually prevocal but highlyexpressive. He simply provided realistic kissing sounds as thesmall figures embraced (9, 10, 13).Sleep. Here, Carl’s vocabulary was very limited. However,his tone of voice communicated tenderness as he put the figures209clustered around the following themes: Expression of Affection,Sleeping, Bathroom Activity, the Vehicles, Separation,Relationships, Exploring Bodies, Activity Descriptions, andProjected Attributes. With the exception of the Bathroomcategory, all of these themes were expressed solely during theMiddle Play Phase. None of these themes recurred in the End PlayPhase. Because verbalization within phases was minimal, Figure24 provides examples of verbal referents which illustrate theimproved clarity and specificity in Carl’s verbalizations aroundthese themes.I wuh can seep. (13)I wun daddy now. (12)Mummy has a penis too? (13)Daddy’s driving it. (13)210into their beds and wished them, “Nie nie, Mama. Nie nie, Dada”(9). He was able to minimally describe the activity of thesefigures as well: “Daddy seeping. Lying down couts. Nuthuh bed”(9). The only other reference to sleep occurred several sessionslater (13) when Carl tried to settle several figures in the cabof his backhoe: “I wuh [that they] can seep.”Bathroom. Again within the range of a limited vocabulary,Carl was able to adequately describe bathroom interest, fixtures,and activities. This verbal theme initiated in the first sessionas Carl identified the contents of the doll house bathroom: “Diswah wah. Dah basroom? Pee dah. Pee!” In the most elaborateexpression of this theme (9), Carl described his figures jumpinginto the tub and using the toilet: “Wah wah jump. Dad in duhwah wah. Hot. Dad ah wet. Daddy pee up there! Smell dat.”The final occurrence of this theme (11) was very limited(“toilet,” “water,” “der pee”), suggesting that Carl’s interestin the bathroom, at least for the moment, had diminished.Vehicle related. When Carl played with the human figures inassociation with the vehicles, he verbalized freely, describingaptly the actions of the people as drivers, passengers, orvictims of the vehicles. Representative examples of suchdescriptive speech from the two principal sessions (12, 13) wherethese referents occurred include: “Let’s pick mommy daddy.” “B[s]top train?” “Daddy’s driving it. He fell off.” “I wuh pickCarl up.” “B driving in the sandbox.”Separation. Using only a handful of words, Carl was able toeffectively express an understanding of the process of partingina relationship, telling the figures “Bye, Daddy. Go home,211Daddy,” (10) or asking, “Wheh mama?” Where B go?” Carl’s mostpoignant verbalization around the theme of Separation occurred inSession 13. Holding the child and the mother figure, one in eachhand, Carl had them kiss, as the Carl figure said, “Goodbye. Disgoodbye, Mommy?”These few words signalled to the therapist that Carl hadcomprehended her depicted scenes during the play disruption, thathe was actively trying to grapple with the reality of thisseparation from his parents, and at the same time that he was notentirely overwhelmed by the separation. He was able to depictand vocalize an expression of love for mother (the figures’embrace and kiss) and to verbalize “goodbye.”Relationships. This category includes references to Carl’sfeelings toward and relationships with people, during play withthe doll house figures. A brief but compelling example arose inSession 12. Playing with some of the human figures at thesandbox, Carl realized several were missing. “I wan Daddy now,”he told the therapist. While ostensibly referring to the smallplastic figures, Carl was also accurately expressing how he feltat a deeper level, missing his father.In this same session, as Carl buried adoptive parent B inthe sand, he commented, “B makin’ happy face?” On the surface,the question appears genuine, a simple query. However, theremark insinuated aspects of his relationship with that adult.The therapist sensed that Carl knew well that someone beingburied would not be making a happy face. With few words, but inrather sophisticated fashion, Carl was expressing intermingledanger, resentment, worry, concern, and guilt toward that figure.212Carl’s most powerful verbalization surrounding relationshipswas his remarkably clear comment regarding the role of hisadoptive mother. This dramatic and therapeutically criticaldiscourse occurred in Session 12. Noting the various miniaturefigures on the table, Carl first identified them: “Dah Mommy.Dah Papa.” In a statement which indicates that he comprehendedthe figures’ projective function, he then commented, “Toy mommy.”Finally, he partly stated and partly inquired, “Is A’s duh mommy?Dah A mommy?” Carl was actively grappling with what was perhapsthe most difficult question in his life: “Is A my mommy?”Exploring bodies. Carl initiated this verbal theme whiletrying to pull the clothing off the figures (10): “Dah [clothes]open up? Der bum der? Der body!” Several sessions later, whenthis theme arose for the second and final time, it underwent animportant transformation. From an interest in the “bum” of thesefigures, Carl was now more interested in determining whichfigures had a penis: “Dah look [I look at that]. Duh penis.Dis bum, too. B penis too? Mommy has a penis too? No toes? Isee penis too. I wan see.”Description of actions. As with his play with vehicles,Carl’s play with the doll house figures was usually accompaniedby literal descriptions of their activities. His verbalizationsin this regard were abundant, spanning all play phases. Thefollowing are representative examples: “Hey, walking!” (3); “Uphigh,” “Fall,” (9); “Dis pick up Daddy?” (11).Prolected attributes. Carl comprehended that the miniaturedoll house figures could be animated and enlivened throughactions which recapitulated and/or reworked the basic activities213of his life. Verbally, he offered two important elaborations ontheir activity. Holding the Carl and the father figure so theycould embrace and kiss (9), Carl commented, “He’s frying[crying].” It was not clear from this statement which of thefigures Carl was describing. Nevertheless, this brief verbaldescription of emotion was significant in its parallel to hiscrying in the playroom. In the next session (10), Carl seemedpleased as he manipulated the small figures that “Dose walk.”While on the surface these brief comments appear to belittle more than activity descriptions, they are significant inthat they indicate that Carl comprehended the element ofpretense. He knew, for example, that the figures were not reallycrying or walking, that it was he who added these qualities tothe figures. In verbally admitting comprehension of and comfortwith the mechanism of pretense, Carl’s difficulties were becomingaccessible to two realms, depiction and discussion. The verbalprojection of attributes culminated in Carl’s comment that onefigure was a “Toy mommy” (10). He had moved from the assigningof attributes (crying, walking) to the designation of identity(“toy mommy”). Carl was then able to begin to work through themost difficult identity issue confronting him, namely, who washis real mother: “Dis A Mommy?”The Play DisruptionsFive of Carl’s 17 sessions were characterized by hiscomplete or nearly complete desisting from play activity.Although analysis has thus far focused on thematic progressionduring play specifically in interaction with an object, Carl’splay disruptions provided a unique opportunity to explore214thematic changes in the absence of such person—objectinteractions. These five sessions were far from being atherapeutic void. On the contrary, nonverbal (albeit nonplay)and verbal transformations continued to unfold. As this briefsummary of those thematic changes illustrates, even when deepestdistress overwhelmed Carl’s interest in play, the process of playtherapy was still dynamically transmuting, working and wendingtoward recovery.Nonverbal changes. A number of emotionally—charged uniqueplay events in pivotal Session 5 forewarned that a qualitativeshift in Carl’s play was looming: He doused the therapist withwater, threw a chair on the doll house, played with baby dolls,tried to cut a doll’s eyes, and ran from the room. In the firstsession of the ensuing 3—session disruption (6), a period of playwith water, sand, vehicles, and the shark (a unique choice) wascompressed between two prolonged bouts of crying. Carl’s cryingand distress lasted throughout the next session (7), with thesignificant change that Carl sat on the therapist’s lap, where hespent most of the remainder of his therapy. Whenever thetherapist initiated using Bobo as a target for Carl’s projecteddistress, Carl calmed: “Bobo, please don’t bother Carl today,because he’s very sad.” Carl seemed unable and unwilling tolisten to the therapist talk to him about the difficult changesthat had occurred in his life. Her talking to him directlyaggravated his upset state.By contrast, the therapist’s introduction of human figuresto depict the adoption (8) helped Carl to calm considerably. Bythe end of that session, he watched quietly as the therapist used215the 5 figures to enactCarl leaving his natural parentsto livewith the new couple.In the next session (9), althoughhe criedupon entry to theroom, he recovered andspent most of thatsession in calm, absorbedplay with the human figures.Insummary, in this firstplay disruption, the incorporationby thetherapist of thehuman figures provided Carl witha tangiblerepresentation of thecauses of his distress. He firstwatchedthe figures, thentouched them, and, ultimatelybegan to engagethem in play. The therapist’suse of the human figures servedasa bridge which graduallyled Carl back to theworld of play(Middle Play Phase,Sessions 9 to 13).Carl’s rising anxietyas he played during Session 13foreshadowed another difficultperiod. In the ensuing seconddisruption (14, 15), Carl’s anger,pain, anxiety, and distresswere intense and sustained.He spent virtually the entiresessions on the therapist’slap sobbing, while the therapisttalked to him about theadoption and his feelings.A slightbehavioral transformationoccurred (15) as Carl repeatedlyleftthe therapist’s lap to standby the door, as if toemphasize hisneed to leave the room.However, he returned each timeto thetherapist’s lap, cryingand miserable. He seemed caughtbetweenhis intense despair and grief,his need for comfort from thetherapist, and his wish toflee the pain which she andtheplayroom representedto him.Verbal themes. Carl’s fundamentalcommunications throughoutthe first play disruption werehis vehement Dislike oftheplayroom and his Wishto Leave: “No wan payroom.Open door. Ahdone now!” Within thisgeneral context, two singular216communications stand out. The first was a consequentialCommunication of Affect, Carl’s admission, “I’m not happy,” (7,8). The second suggested the theme of Feeling Abandoned: “Miricoming now?” (Miri was Carl’s favorite teacher.) This singlequestion conveyed a deep sense of loss and aloneness and a wishto be rescued from his intense pain.The verbal theme of Dislike of the playroom and his strongWish to Leave continued with deepened intensity in this secondplay disruption. “Time go back now?” was his almost continualverbal refrain. From amidst this persistently repeated cry,several unique communications not only elaborated the earliertheme of Feeling Abandoned but also introduced new andsignificant therapeutic material:1. Recapping and elaborating the earlier verbal theme ofbeing left alone, abandoned, and needy, he sobbed, “Diane [ateacher] pick Carl up!” Through racking sobs, he often added“big hug,” “big big hug,” an expression of his need for love.2. Carl began to verbally assert himself in relation to thetherapist. When the therapist verbally interpreted his anguish(14, 15), Carl silenced her with a determined and angry: “No wantalk! No talking!”3. Some verbalizations suggested that Carl was apersonality capable of complex emotional defenses andsophisticated reasoning. Still sobbing, he insisted on 4separate occasions, “I happy now” (15). Carl, hoping to leave,had evidently reasoned that he would be kept in the playroomuntil he felt better.4. To the refrain of “time go back now, time go back now”217he added instead (15), “Time go home now. Time go home.” Thewords seemed to well from deep within him, expressing deep pain.The therapist believed that this feeling of wanting to go homelay at the root of Carl’s anguish, yet it was not clear from hisstatement which home Carl meant. The therapist attempted todetermine which home by formulating a question: “Who do you wantto see at home?” Carl replied that he wanted to see the adoptivecouple.Thematic Comparison and ContrastThe themes which emerged in Carl’s play and in hisverbalization can be said to coalesce into two major clusters ofmeaning: vehicle activities and elements of human relationships.In both the verbal and the play domains, these themes were welldeveloped.Carl was capable of expressive detail in both play andverbalization. With the vehicles, for example, he developed playsequences of getting stuck and being freed, elaborating them withappropriate descriptive vocabulary. With the human figures, Carldepicted certain details of relationship, such as kissing orparting. Although his descriptive vocabulary for relationshipswas less developed than for vehicles, Carl was nevertheless ableto verbally process difficult details of relationships using hiselemental vocabulary: “Toy mommy,” “Dis A Mommy?”There was strong concordance between Carl’s play themes andhis verbal themes. That is, Carl generally tended to talk aboutthe play at hand, with his verbalizations elaborating andexplaining the vehicles’ or the figures’ actions. There were,however, some exceptions to this general tendency:2181. Certain actions, such as burying vehicles, tossing sand,or tossing the figures on the floor, were never accompanied byany verbal commentary. Perhaps the anger associated with theseactions overshadowed his capacity for verbal expression.Alternatively, Carl may have lacked anger—related words.2. Carl occasionally introduced verbal referents toobjects, events, or people outside the playroom. These could beeither immediate (related to the preschool) or remote (related tohome). In the latter category, Carl’s comments about snow, hisdesperate cry for someone to come and pick him up, and histelling the therapist about his car at home, “My boo [blue] carbown [brown],” are illustrative.During human figure play, Carl’s verbal comments on playwere far less elaborate than during vehicle play. The emotionalintensity of the human figure play may have been a factor inlimiting his speech, or, again, attributable to the lack ofrelated vocabulary for emotions and relationships. He couldverbally describe in rudimentary fashion the figures’ actions(jump, go, sleep), but it was his play portrayal with the figures(kissing, walking away, driving the backhoe together) whichconveyed the deeper dimensions of these human relationships.Contributions of Play and Verbalization to ProcessCarl possessed adequate and at times even sophisticatedcapacities for play and for verbalization. These modalitiesoffered Carl qualitatively different opportunities for self—expression.Carl verbally elaborated his play activities with rich andappropriate descriptions of play activity and object identity.219Through verbalization, Carl’s play activities were given clarityand specificity through detail.Carl verbally added to his play references to events orpeople outside the playroom. Through verbalization, connectionswith other settings, events, objects, and people were broughtinto the playroom.Carl’s speech was dotted with precocious vocabulary (e.g.,“mack truck” and “frontloader”). He occasionally verbalizedunique associations or made imaginative comments (e.g., hisreference to the car stuck in the “snow” or a comment that thefine dust from the sandbox was “smoke”). Carl’s verbalizationsreflected capacities for awareness, intelligence, and imaginationnot revealed in the literalness of play activities.Carl used verbal communication to express wishes, wants,likes, and dislikes with a range of intensity. Throughverbalization, Carl was able to announce and to plan his play,telling the therapist what he wanted to do next. Throughverbalization, Carl gained control over the therapist’s playactions.Carl verbally expressed and even discussed psychologicallypertinent material: sounding a call for help, expressing aninterest in body parts and gender identity, questioning the roleof an adoptive adult. Through verbalization, Carl was able toexpress his core pain, wanting to go home.Carl possessed a particular capacity for ironic, subtle, andpsychologically complex verbal communication. As Carl buried oneadoptive figure and ran her over with a vehicle, he commented ina tone both innocent and insinuating, “[She] makin’ happy face?”220These few words suggested a capacity for precociously wry humor.They also reflected his awareness of emotional extremes, ofcontradictions. Perhaps Carl wanted to preserve the illusion of“happy face”; at the same time, his questioning tone indicatedthat he knew that under the circumstances (being buried and runover) this was unlikely.A second example concerned Carl’s insistence during a playdisruption that he was “happy now.” Taking the comment at facevalue, Carl no doubt wanted to feel happy. At the cognitivelevel, his comment reflects a capacity for rudimentary abstractthinking and reasoning about his situation: “I believe I amsupposed to be helped in some way in this room. Perhaps if Iconvey that I no longer need help, I can leave this terribleplace.” On an emotional level, the statement reflected Carl’scapacity for verbal denial. He would have preferred to wipe hismisery away with words.At the outset of this analysis, the researcher, recallingCarl’s infantile speech and limited vocabulary, considered Carl anonverbal child. Data analysis exposed the inaccuracy of thatimpression and revealed that despite a limited vocabulary, Carlwas a highly expressive child.The two major groupings of play materials contributeddifferent play benefits to the course of Carl’s therapy. Thevehicles initially offered Carl a focus for industrious playactivity and involvement. In drawing his attention, they servedas a distraction from and a defense against rising anxiety. Inthe Middle Phase, the vehicles advanced from a kinesthetic roleto an expressive role. They enacted Getting Stuck and Needing221Help. The actions of the vehicles were eloquently elucidatingCarl’s own problems. Like the vehicles, Carl, too, sometimes gotstuck (cf. play disruptions) and needed help to free himself.Ultimately, the vehicles became tools of trust and friendship.Carl used them to invite the therapist’s participation in hisplay world.When painful feelings eventually overwhelmed him, it was asecond grouping of play materials, not the therapist’s words,which first reached Carl and helped draw him toward emotionalrecovery. Carl was profoundly helped by the presence of thehuman figures. The likenesses of these figures lent a tangibleand a comprehensible form to his jumbled, frightened feelings oflove and pain. They were extraordinarily real to him. He sobbedas the therapist had the child say goodbye to the father. Hebade the father good night with great tenderness.These small figures offered Carl the opportunity to controland manipulate relational events. Through them, he was able toextract and enact the aspects of human experience most importantto him (kissing, sleeping, parting, toileting). The actions ofthe figures afforded him concrete proof that the child’saffection endured. In portraying the expression ofaffectiontoward mother he could affirm and validate the survivalof thataffection. By literally holding on to their image,Carl couldbegin to grasp the reality of his relationshipwith them.With regard to developmental needs and interests,play withthese figures afforded Carl the opportunity to exploreareas thatare often subject to adult limits and hence repression——toiletuse and gender identity. Through human representativematerials222(the baby dolls), Carl explored infant needs and infant identity.With regard to his emotional/relational difficulties, theopportunity to depict the traumatic separation he had undergonelent him psychological distance from these overwhelming events.Through play with human figures, Carl by degrees became less avictim and more a witness to real life events. When Carl, in oneof his last play scenarios with them, had the child and motherfigure kiss, the therapist sensed that Carl had crossed athreshold of understanding. In manipulating these figures torelate with affection, he was gaining symbolic control over thedevastating separation from his mother.Carl possessed a wonderful capacity for eloquence throughthe sequence of play activities. That is, Carl was capable ofutilizing play materials to create a story. Although thesequence was sometimes inexact from an adult perspective, theconstituent activities nevertheless formed plausible, coherentstories. The human figures, for example, went to bed, walkedaway from each other, took baths, and slept together. Althoughthe sequence was awkward, the components of family life werereasonably strung together, revealing an extended picture ofaspects of family life. Similarly, in vehicle play, the figurestook turns driving, riding in, and being picked up by thebackhoe. While this play reflected more imaginative content(i.e., people do not get picked up by backhoes or drive themtogether), Carl was portraying a detailed sequence that told aloosely constructed story: The child, joined by a number ofadults important to him, enjoys driving a wonderful, powerfulmachine. This capacity for constructing expressive sequences223with play materials culminated in his final session. Carl’svehicles loaded logs, dumped them, repeatedly freed themselvesfrom obstructions, parked, raced, backed up, and moved inrelation to other vehicles.In examining the play progression overall, a global playtransformation from a focus on vehicles (Beginning Phase), to afocus on human figures (Middle), and a return to vehicles (End)is discerned. That is, as his therapy drew to a close, Carlreturned to the play with vehicles. Although Carl was capable ofverbal referents to external events, objects, and people, it isnoteworthy that when Carl returned to the concluding phase ofvehicle play, he made no verbal referents to any of therelational themes which had emerged in the Middle Play Phase.When not engaged in play with the human figures, no verbalreferents about them arose. This fact reflects the power of thephysical presence of play materials to facilitate therapeuticallyrelevant discourse. At the same time, it is likely that thepending end to the therapy induced Carl to close the painfulchapter of relationships.Carl exploited the expressive capabilities of both play andverbalization to synergistic benefit. Sometimes he workedsimultaneously in both domains, verbally embellishing hisplayactivities, with play and language richly enhancing each other.Sometimes these two domains unfolded in a kind of contrapuntalsequence: Carl would play quietly, then describe his actionsverbally; or, in opposite sequence, Carl would announce his plansto play, then seek out the objects and materials he needed toactualize his verbal intentions.224The synergistic benefits of play and language wereparticularly evident in the development of Carl’s relationshipwith the therapist. Carl utilized both to form a relationshipwith her, first through verbalization and later through play.Earlier in therapy, he directed negative and angry verbalizationsat the therapist, which nevertheless denoted an emergentrelationship with her, “No like payroom! Go pees!” By the endof the therapy, he verbally directed her play actions and soughther full participation in his play activities.Contributions of the Play Disruptions to ProcessThe play disruptions interrupted Carl’s play and verbalcapacities. Tears and screams predominated. At the same time,critical events occurred in both domains, which were integral tohis therapeutic progress.On the level of play, the materials were pivotal during thefirst disruption. Although Carl’s own willingness and evencapacity to play were disrupted, he could still watch the humanfigures, decipher their actions, and gradually achieve calm.On the verbal level, it was during the play disruptions thatCarl communicated his deepest pain, of feeling left andabandoned, of wanting to go home to his biological parents. Withhis emotional defenses against pain crumbling, Carl felt theoverwhelming hurt of separation from them. During this terriblyvulnerable state, important core communications gushed out.Likehis tears, his words were beyond his conscious control (“Miricome get me,” “Time go home now,” “Big big hug”), but they wereof deepest psychological relevance.225Summary NarrativeAs with the analyses of Anna and of Brad, a summarynarrative concludes the chapter on Carl. This narrative reweavesand reworks the verbal and play thematic material, analyzed indepth above, into an integrating story of Carl’s play therapyexperience.Beginning phase. Carl initially experienced the playroom asa frightening place. As the playroom door closed and his teacherwalked away, Carl burst into tears of intermingled fear, sadness,anger, and protest. Far from his peers and teachers, uncertainwhen he would see them again, and left in the care of a stranger,Carl shouted a desperate “No!” However, the presence of the playmaterials offered solace. As soon as he caught sight of thevehicles on the shelf, his fear, anger, and sadness lifted. Heapproached them happily, as if they were familiar friends and,without hesitation, he engaged them in play.Carl played energetically, with a sense of involvement andcommitment. He was busy and so were his vehicles. He addedwater to the sand, stirring, digging, and preparing the area forhis vehicles. The vehicles, too, had work to do, digging tunnelsand burrows, travelling, and dumping miniature loads of sand.The sandtray churned with movement and industry.Carl delighted in the physical interaction with the rawmaterials of sand and water. The contrasting properties of thesematerials challenged and stimulated him to create, to do, andsimultaneously they soothed and engrossed him. Carl wasfascinated with the notion that the sand was “dirty,” a featurewhich seemed to enhance its attraction for him.226He tolerated, accepted, and even enjoyed the therapist as anobserver or spectator to his play. Aware of and open to herpresence, Carl continually chattered to her as he played,describing in adequate vocabulary, if infantile and unclearpronunciation, the names and the activities of his vehicles. YetCarl was an independent player. On occasion he touched thetherapist, but he did not invite her to join his play nor did heseek out sustained physical closeness with her.Carl relished the opportunities for initiative within theplayroom. He was familiar with the play purposes of sand, water,and vehicles, and he did not await the therapist’s permission toengage them in play. He moved happily and busily, almost rushingfrom one play material to the next. When his interest in onevehicle began to wane, he went quickly to the toy shelf and choseanother one. His play with the vehicles advanced in a cyclicrhythm, a little time with the tow truck, then the backhoe, thenanother vehicle. At the ebb of each cycle of interest, Carlseemed almost impelled to seek out a new vehicle. There was thefaintest hint of anxiety in his voice as he sought “moh car.” Infact, these pauses, microscopic play disruptions, were pregnantwith anxiety, which dissipated as soon as he resumed play withthe next vehicle. Like a play “fix,” the novelty and the uniquefunctions of each new vehicle allayed his uncomfortable feelings,which lurked just below the surface.Ultimately, Carl could not control the feelings which hadbegun to well within him. They broke through; and Carl burst thebounds of accepted social behavior, flooding the playroom and thetherapist, and attacking the doll house. He barely looked at his227cherished vehicles during this pivotal transition and chose toplay with baby dolls. His play with them was characterized by adeep and touching sense of vulnerability and, at the same time,rage, as he attempted to cut the eyes of one baby and almostrocked others out of their cradle. Overcome by inner tensionscreated by these extremes of vulnerability and rage, Carl fledfrom the playroom.First disruption. Carl’s experience during play disruptionswas that of a child living a waking nightmare. He screamed andsobbed on entry into the playroom. Waves of pain, sadness, andanger flooded him. At first, Carl was able to temporarily musterhis attention to the play materials, which offered himdistraction from the frightening feelings which had erupted withsuch intensity. He chose the materials that had brought him somuch pleasure in the past——the vehicles, the sand, and the water.Yet these trusted and familiar play companions did not providethe same captivation or comfort. The unsettled feelings wellingwithin Carl induced him to seek a new play diversion. He chosethe shark, a sinister and less than comforting play figure, whichglided through the water and the sand. The diversions of playhad served as a buffer and a wall of defense from the pain whichwas beginning to surface, but these diversions could no longerwithstand the waves of sorrow which flooded him again.He dissolved in anxious and angry tears. The novelties ofplay materials no longer sustained his interest or mitigated hisanxiety. Carl was overwhelmed with anguish and despair. Fromthe perspective of the therapist, the permissive atmosphere ofthe playroom and Carl’s immersion in play activity had enabled228the loosening of his defenses to the extent that deeper feelingshad become dislodged and surfaced. However, from Carl’sperspective, the playroom itself was the terrifying and cruelsource of his pain. Carried to the playroom against his will,Carl wanted no part of it nor of the therapist. Separated fromhis friends and teachers, he experienced the playroom as apunishment cell and the therapist as the jailer. “Open door!” hescreamed.Ultimately, play materials came to his aid, leading Carl outof the abyss of this disruption. Small human figures enactedscenarios of a child leaving his mother and father. Through histears, Carl was interested in the portrayal of the feelings andexperiences of the tiny child. Something about the activities ofthat little figure, as he hugged his mother and father and thenwalked away with other adult figures, made sense to him.This miniature human world was comprehensible. The tinyfigures who inhabited it were small enough that Carl could seeand absorb the entire scope of their actions and interactions.The figures were maneuverable and controllable. The tiny childcould speak and describe all the wrenching feelings heexperienced on leaving his parents. Calm, clarity, andunderstanding were possible in the presence of these figures.A profound change marked his relationship to the therapist.Throughout the disruption, despite his fiercest protestations toleave, Carl never struggled to leave the therapist’s lap. Carlwas not simply seated on her lap, he remained rooted there.Middle phase. The wave of despair lifted as suddenly as ithad descended. Carl entered a period of more detailed and229complex play with his vehicles and of touching personal sceneswith the small human figures.Themes of work and industry prevailed in the vehicle play,but the vehicles began to encounter serious difficulties. Theybecame stuck in the sand and repeatedly needed help to becomedislodged. The therapist was intermittently engaged to help freethe vehicles. From amongst his verbal descriptions of thevehicles’ activities, a distinct call for help sounded: “Helppees, Mommy.”This phase was marked by the emergence of representations ofhuman interaction. Carl controlled the relationships, theidentities, and the destinies of the miniature figures. Heportrayed vivid but simple expressions of love and tenderness,with the family figures hugging and kissing, and sleepingtogether. He verbalized profoundly tender wishes of “nie nie” tothe father and vocalized gentle kisses. He enacted scenes ofparting and farewell, with the child walking away and telling hisfather “goodbye.” He depicted positive and playful facets of thetiny child’s personality, with the figure happily “jumping” intothe tub. Carl expressed fascination with the toilet. After thefigures “used” it, he touched and smelled the “pee der.” He usedthe figures to explore his curiosity about the biological givensof gender identity, attempting to comprehend who has a penis. Hegrappled with the gnawing question of the identity of hismother.Like his vehicles churning through the sand, Carl in this playphase was working and churning through layers of emotion andunderstanding. He was able to depict the components of hislifewith clarity and to use language, simply yet eloquently, to230express difficult issues. After a time, nonspecific anxiety,discernible in his voice, threatened the relative calm andemergent strength he had achieved in this play phase.Second disruption. The emotions of the second playdisruption washed over Carl like a tidal wave. The sadness,rage, and despair of the first disruption intensified to a senseof inconsolable grief. His verbal protestations to leaveescalated. He repeated almost without cessation, “Time go backnow? Time go!” This refrain was both a question and a demand, aplea for help from and an expression of anger at the noncomplianttherapist.At the height of his pain, Carl refused to even look at thetherapist. She had become the enemy, the symbol of adult powerto control, direct, and contain forces which had so radicallydisturbed his life. At the same time, he remained grounded inher lap, breaking down in comprehending sobs when she commentedin words which simultaneously troubled and helped him: “You’reso sad. You love and miss Daddy so much.” At times, Carl didnot so much as sit on the therapist’s lap as lie across her laplike a limp rag doll, battered by grief.Carl felt alone, forgotten, even abandoned. “Time go homenow,” he wailed. Racked with sobs, his deepest pain hadsurfaced. Desperate to leave the playroom, he tried to bargainwith and to manipulate the therapist. “I happy now,” herepeated, hoping to convince her to return him to his classroom.Carl’s play disruptions bring to mind the metaphorical imageof tunnels, like those his backhoe carved in the sand. In onesense, troubling emotions bored beneath Carl’s conscious231faculties, causing him pain and distress. In another sense,while apparently confining Carl to an interminable darkness ofdespair, the play disruptions actually led toward light, towardrecovery.Final phase. The intensity and trauma of the second playdisruption yielded to a sense of calm and resolution. There wasan optimistic sense of “after the storm” as Carl returned togreater enjoyment and pleasure in his play than ever before.Carl’s vehicles moved and worked with a sense of purpose.They enjoyed their power, moving real loads, and freeingthemselves from tangible obstacles. They maneuvered in complexand detailed ways. Carl’s ability to comprehend the vehicles ina more rule—bound world of lanes and parking stalls suggested thefaint emergence of superego functions.The therapist emerged as a playmate and a friend. A feelingof intimacy, rapport, and even love suffused emergent cooperativeplay. Carl verbalized feelings of liking the vehicles and thetherapist. Carl enjoyed controlling and directing the therapist,ordering her how, where, and with what to play.By the conclusion of his therapy, the tension had largelydisappeared from Carl’s face. Part of his ease must beattributed to the fact that he knew the sessions would soon end.Nevertheless, throughout his therapy Carl had experienced anintense storm of emotions, and there was evidence that he wasbeginning to emerge from that difficult period. He seemedhappy,content, and, for the first time, at home in the playroom.Summary. The three Play Phases, in which Carl enjoyed thesimple play pleasures of cars and trucks, sand and water, were232punctuated or, more precisely, rent asunder by two deeplydistressing and painful Play Disruptions. During thesedisruptions, Carl initiated no play. He was reduced to thesentience of profound hurt and anger. Miniature human figureswere the decisive play tools of his recovery. When he could notplay or even speak due to overwhelming emotions, he was able toquietly integrate the essence of the child-adult depictions heobserved. Later, in the depths of his pain, he verbalized a wishto go home, an expression which marked a turning point in histherapy. Carl’s play and verbal capacities worked in tandem toadvance him toward recovery. Carl began to recover, in part,because of his ability to portray particular motifsof the childadult relationship; and he began to recover, in part, because ofhis verbal capacity to express difficult issues with simpleclarity and force.233CHAPTER VII. CASE 4DAVE: THE WORKING THROUGH OF FEARDave’s play therapy followed an intricate course through aseries of creative and imaginative play activities, leadingultimately to the early stages of the working through of fear.Three years and 9 months old at the outset of therapy, Dave didnot suffer from any severe behavioral or emotional difficulties.A highly verbal, bright, and active child, Dave usuallyparticipated well and enthusiastically in his school activities.He engaged his peers in play and was generally cooperative withhis teachers.During his first year at preschool, however, intermittenttantrums had troubled Dave and his teachers. Although he seemedto be settling well into his second year at preschool, therecollection of his angry and unhappy outbursts, which hadoccasionally affected his relationships with peers, suggestedthat Dave would benefit from individual therapeutic play. Dave’sadjustment difficulties had never required psychologicalassessment. No formal diagnosis was associated with his referralto play therapy. Rather, play therapy was offered to Dave as adevelopmental assist, both supportive and preventive in nature.Dave lived in a single-parent household. During the initialparent-therapist meeting, his mother pointed out that Davepreferred action—oriented play, which often involved superherothemes. Dave’s developmental milestones had all occurred withinnormal range. However, toilet—training had been difficult; Davewas still prone to accidents at night and sometimes at school.Physically, Dave appeared small for his age but was234nevertheless a well—coordinated and energetic child. Asidefromthe occasional cold, he did not suffer from any healthproblems;he had never been hospitalized. Intellectually, he was quick andalert, with a good memory for detail. He also possessed animpressive vocabulary and verbal facility. He used thesefaculties to verbally reason, argue, and negotiate with adults.While his size suggested a younger child, his verbal abilitieswere typical of a much older child.An Overview of Dave’s Play TherapyFrom the outset, Dave showed interest and curiosity in manyplay materials. He played with a cheerful eagerness. However,he did not immediately experience a sense of comfort and ease inthe therapeutic playroom. Typically, he played with sustainedattention with a particular material or a series of materials andthen suddenly asked, or demanded, to leave the playroom. Anxietyseemed to lurk just below the surface. It emerged duringattentional breaks or shifts, troubling him and prompting him toseek to return to his classroom. The therapist did not complywith his requests to leave.It was not until well into his therapy that Dave’s level ofinvolvement in play deepened and intensified, granting himdistance from this anxiety. Involvement and delight in playemerged during several consecutive sessions when Dave initiatedplay in the dark. Enveloped in the darkness, Dave began tothoroughly enjoy the playroom as a setting in which he couldlaunch a number of creative play scenarios.When the phase of play in the dark ended, Dave turned todepicting scenes of fearful animals threatening small, vulnerable235creatures. In the final 6 sessions, he repeatedly constructedminiaturized scenes of such intimidation. Dave’s play therapyended just as he had begun to work through the fears which werelikely responsible for his earlier anxious behavior.Outside of the playroom, Dave’s progress was slow and notimmediately evident. During the first half of his therapy, noappreciable change in his behavior was noted in his classroom.Midway through the year, however, he began to have an increasingnumber of toileting accidents both at home and at school.Changes in home and school routines may have partly contributedto his stress, precipitating the “accidents.” However, thetherapist interpreted this regressive behavior as a positivesign, signalling a dissolution of certain controls andinhibitions, and expressive of a need for infantile care. Aftera number of weeks, these accidents diminished.The changes in Dave at the end of the 20 sessions in playtherapy were definite, although not dramatic. His teachers foundhim more resilient, better able to accommodate to changes inroutines. He had begun to occasionally settle into their lapsfor affectionate cuddles. From beneath his facile verbaldemeanor, which had veiled his emotional neediness, a vulnerableand affectionate little boy was beginning to emerge. At theconclusion of his therapy, Dave still favored “tough guy”scenarios on the playground, often leading several peers in suchactivities. This indicated to the therapist that the fears whichdrove his anxiety were not entirely resolved. His tantrums hadnot completely disappeared; however, at school they were far lessfrequent, occurring usually when he was feeling very tired or236unwell.In general, Dave’s progress in play therapywas positivethough incomplete. He had gained incremental strength in thesafe confines of the playroom and had begun to applyhisconsiderable creative resources to work on underlying fears.The Phases of Dave’s TherapyThe three phases of Dave’s play therapy were much morefragmented, overlapping, and interwoven than those of the otherparticipants in this study. The Beginning Phase of UnsettledPlay was composed of a series of overlapping subphases, namely,of Doctor Play, Doll House! Puzzle combinations, and Play withthe Witch Puppet. In contrast to the early play phases of theother 3 participants, Dave’s Beginning Phase contained onlyminimal exploratory play, as he quickly became involved with arange of play materials.Play in the Dark (9 through 13) constituted the MiddlePhase, dividing the Beginning Phase from the End Phase ofRepresentations of Fear. In addition to Representations of Fear,this later phase also contained a Subphase of JuxtaposedInfantile/Macho play.The Principal Play MaterialsDave was a prolific player who utilized a wide range ofmaterials, which, either singly or in combination, dominated themany subphases of his therapy. This analysis of play and verbalthemes attends to the following play materials: DoctorMaterials; Puzzles; Puppets; Miniature Animals; and Baby Dolls,Bottles, and Soothers. Play in the Dark, which involved severalunique props, is also analyzed. The occurrence across sessions237of play with all cited materials is summarizedin Figure 25.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920MaterialDOCTOR* * * * * * * * *PUZZLES* * * * * * * *ANIMALS* * * * * * * * *DOLLS* * * * * * * * *PUPPETS* * * * * * * * * * *DARK* * * * *Figure 25. Dave: Overview of Play with PrincipalMaterialsDoctor Materials: The Play ThemesDave chose the Doctor Materials upon his first entry intothe playroom. Dave’s play with these materials clusteredaroundthe following activity and event themes (cf. Figure 26):Exploratory/Handling; Identity of Patient; Inclusion of OtherCharacters; and Type of Examination and Treatment.Exploratory/handling. Exploration and Handling of thevarious instruments in the Doctor Kit took place intermittentlyduring Dave’s doctor play across the first 4 sessions. Oncefamiliar with the medical instruments, Dave moved on to theirapplication in patient examination and treatment.Patient identity. The figure of a large “baby boy,” withanatomically correct genitals, served as Dave’s first patient (1,2, 3). Additionally, Dave himself functioned self-reflexively asboth doctor and his own patient (3), examining his stomach withthe stethoscope and asking the therapist to examine him in this238way as well. Dave never again enacted the role of patient.Daveretained the doctor role and utilized the therapist aspatientfor the remainder of his therapy (5, 6, 7, 11, 19, 20).SessionMiddle Phase1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20ThemeEXPLORE/HANDLE* * * *PATIENTIDENTITYDoll* * * *Self*Therapist* * * * * *PUPPETSHelp*Hurt* *TREATMENTBrief exam* * *Hurtful* * * *Caring* *Figure 26. Dave: Play Themes with Doctor MaterialsInclusion of other characters. Puppets were the only otherprops to be incorporated in Dave’s doctor play. Althoughinfrequent, Dave’s inclusion of puppets as props to the doctorplay is noteworthy because their usage reflects contrastingthematic elements of caring versus harming. Initially (1), an(unidentified) puppet grabbed the baby boy, with Dave indicatingcontradictorily that “He [the puppet] just said ‘hello.’ Hescratched him.” Later (6), the dog, duck, cat, frog, andprincess puppets appeared as helpers. In turn, each assisted thetherapist, as patient, in removing a bandaid which Dave, thedoctor, had applied to her hand.In the final inclusion of puppets in doctor play, caring and239harming elements were juxtaposed. Initially,Dave tended thetherapist’s dog puppet by applying a bandaid toits eye. Usingthe duck puppet, Dave at first helped thedog remove the bandaid,but then insisted that the dog ingest thebandaid. When the dogchoked on the material, Dave’s puppet forced thetherapist’spuppet to repeatedly ingest (and choke on) morebandaids.Type of examination and treatment. Inearly doctor play (1,2), Dave undressed the male infant and gavehim only a cursoryexamination with the instruments, with a more detailed check—upinvolving several instruments occurringlater (3). However, whenthe therapist served as the patient, she wassubjected to a briefphysical exam and then given treatment whichincluded oraldiscomfort. This took two forms: Dave’s pretending to squirt avariety of substances into the therapist’s mouth (“medicine,”“milk,” “juice,” “p00”; 5, 6, 7, 11); and theless frequent butostensibly more painful pretending to give the therapist a “shot”in the mouth (6, 11).When, after a hiatus (14 through 18), doctor play reappearedin the final two sessions, it had transformed,and was elaboratedin colorful, dramatic scenarios. In the first ofthese (19),Dave functioned as a confident doctor, secure inhis role. Heelaborated in rich detail the persona of the doctor. He began byquizzing the therapist patient as to her “problem”and thenascertained her “phone number.” He proceeded toconduct a slowand careful examination, checking her pulse, blood pressure,ears, and reflexes. When he had ascertained that she required ashot, he applied it gently to her hand and wrist, without theaggression of the earlier oral injections. He caringly tended240the injection site with bandaids andsent the therapist “home” (acorner of the playroom) to sleep. Davehimself went to his“home” (another corner of the room) or“slept” in his chair atthe doctor’s office. He repeated thissequence 6 times:treating the therapist, sending her home, and advising her toreturn if she did not feel better. During one ofthe therapist’svisits to his office, Dave felt that he needed to confirm whetherthe therapist required another injection. Using the play phones,he “called” the therapist’s “mommy” to secure permission for thistreatment. In this 17—minute sequence Dave provideddetailed andrichly—elaborated facets of the doctor’s and thepatient’sfunctions and identities. The absence of aggression orhostility, which had tinged earlier doctor play, was striking.In the final session (20), Dave utilizedthe doctor kitmaterials differently, this time orchestrating ascene of injuryto be followed by his care. As part of an extended sequence inwhich he went “shopping” for gifts for the therapist as “mama,”Dave “bought” the cobbler’s bench for the therapistand invitedher to use it. Each time the therapist pretendedto hurt herthumb with the wooden hammer, Dave, who did not identify himselfas the doctor, provided her with a real bandaid.Dave repeatedthis sequence 4 times, leaving the “house” to goshopping,returning when he heard the therapist hurt herself, and applyinga new bandaid to the therapist’s thumb each time.However, onthe fifth and final injury, Dave applied an imaginary bandaid tothe therapist’s hand, saving the last real bandaid for himself.He applied it to his “hurt” thumb shortly beforeleaving theplayroom for the last time.241Doctor Materials: The VerbalThemesVerbal themes associated with the doctorkit materialsincluded: Exploratory/Descriptive;References to PatientCondition; References to Hurt or Harm;Identification of theCaregiver; and Identification of TreatmentSubstances. Figure 27summarizes the occurrence of thesethemes. Ambivalent orcontradictory verbal referents recurredthroughout his doctorplay and are considered in aconcluding section.PhaseBeginning Middle EndThemeEXPLORATORY!DESCRIPTIVE* *PATI ENTCONDITIONNot good*Good* * *HURT/HARM* * *CAREGIVERIDENTITY* * *TREATMENTSUBSTANCES* *Figure 27. Dave: VerbalThemes with Doctor MaterialsExploratory/descriptive. Exploratory/descriptivecommentssuch as “What is this?” or “Iknow what are these things”accompanied Dave’s play with the doctor materialsup to andincluding Session 11. In later doctor play (13,19, 20), suchsimple comments on the identities of the medicalinstruments gaveway to verbalizations which advanced themore complex playactivities.242Patient condition. As verballydescribed by Dave, thecondition of the identified patientsimproved over the course oftherapy. Initially (1), Dave as thedoctor twice repeated thatthe baby boy was “not feeling good.”He further clarified thatthe baby’s “tummy” was “not feeling good”(1). In response tothe therapist’s question to him (6)as to the results of hercheck—up, Dave responded that hercondition was “great.” Thisanalysis gives greater credence to his laterunsolicited remark(11). As he removed a bandaid fromthe therapist’s hand, he toldher, “You’re ailbetter.” His diagnosiswhen enacting theconfident and caring doctor near the endof his therapy (19)supports this sense of improved patient condition.After givingthe therapist a complete “check—out,” heinformed her, “You’redoing very good.” Cumulatively, theseverbal assessments ofpatient condition could be interpreted as projectionsof Dave’sevolving sense of well—being, “not good”at the outset and “doingvery good” toward the end.Identification of the caregiver. Although Dave enactedtherole of doctor in detailed, usually sustained sequences,onlytwice did he identify himself as “the doctor” (6, 19).In fact,when he repeatedly administered bandaids to thetherapist’sinjured thumb in the last session (20), he specificallymaintained, in response to the therapist’squery, that he was“not the doctor.” In an interveningsession (13), when he forcedthe therapist’s puppet to ingest bandaids,he identified himselfas Batman: “I’m Batman! Batman’s gonna take somethingout.”Hurt or harm. References to Hurt or Harm appeared in Dave’searliest doctor play, proliferated in Sessions 5 and6, and243occurred sporadically thereafter.Harm as a verbal referent wasfirst introduced when the baby boypatient was “scratched” (1).In the next session (2), thesame baby suffered from a “sore.”In this same session, he introduceda more serious level of harmwhen he commented with respect toone of the medical instrumentsthat it “needs to stay there becauseit’s poison.” This referentwas repeated (6) when Dave squirtedvarious make—believematerials into the therapist’s mouth: “Squirt!There’s poisonin there.” In explaining the dangerof this substance, Daveintroduced the only reference to death to occurthroughout hisdoctor play: “It’s water. Water can make youdie!”The actual identification of “hurt”emerged as late asSession 6 and recurred in only 3 othersessions (11, 19, 20),usually in conjunction with referencesto “shots” (11, 19). Inresponse to the therapist’s query (6), Daveacknowledged that thetreatment might “hurt just a little tinybit.” When he laterinitiated the topic of “hurt” (11), he minimizedthe degree ofdiscomfort by stating that “It just hurtsa little bit” and thenquickly countered that, “It’s not gonnahurt.” As late asSession 19, Dave still insisted that the needle“won’t hurt.”However, in the final session (20), Dave wasable to repeat anddiscuss the concept of “hurt” in greater detailthan before: “Itwon’t hurt you. The blood will comeout.! Don’t hurt yourself‘cause I’ll get mad.! When you hurt yourself, tell me.”Hisfinal reference to “hurt” indicated that he couldadmit to somediscomfort himself. As he took the last bandaid forhimself, heinformed the therapist, “I hurt my thumb.”Somewhat paralleling the development of “hurt,” Dave’s few244references to “crying” at first deniedthis manifestation ofpain, “You can’t cry.This is a little shot” (11). In Session19, he invited the therapistto cry: “I give you a bandaid, andyou cry.” However, later thatsession, he contradicted this andinsisted that the therapist “laugh”when receiving an injection.References to “help” (considered hereas the opposite ofhurt or harm) during doctorplay occurred only once (6) as Dave’spuppets helped the therapistremove the bandaid from her hand,e.g., “Froggy will help you.”In general, several of the abovereferents can bequalitatively distinguished with regardto intensity of harm:Moderate Harm (“scratched,” “sore”) andLife Threatening Harm(“poison,” “die”). References to “hurt,” “cry,”and “shot” formanother sparse but identifiable subcluster,while the referent to“help” remains unique withinhis doctor play.Identification of treatment substances.Dave administeredthe therapist’s treatmentwith the plastic syringe, pretending tosquirt a variety of fluids into hermouth (Sessions 5 and 6primarily). The identities of thesesubstances fluctuated frommoment to moment; they were alternativelyor concurrentlypleasant and/or unpleasant.The therapist’s oral treatment wasfirst identified as “medicine” (5).However, it was also “juice”that “tastes bad” and “has pee andpoo” or “pee and juice.”Subsequently (6), Dave identified the make-believemixture as“poison,” “water [that) can make you die,” “notmedicine” and,finally, “maybe water or milk.” Later,Dave referred to thecontents as “kookoo [sic)” (7) and “milk juice”(11). No clearthematic progression in these referents is discerned.However,245these referents hold in commona sense of tension of oppositionalqualities: nurturing versus harmful,pleasant versus unpleasant,appropriate versus inappropriate.Ambivalence and contradiction. Ambivalence andcontradiction were not confined to the treatmentsubstances.Ambivalence and contradiction, sometimes intensifyingto a senseof denial, permeated many of the verbalreferents associated withdoctor play: “medicine” (5), “notmedicine” (6); “is not ashot,” “is a shot,” “this is a littleshot,” “a big shot” (11);“hurts a little bit,” “not gonna hurt” (11).Puzzles: The Play ThemesAs Figure 28 summarizes, Dave’s puzzle playspanned threediscrete phases, each with a distinct type of puzzle-relatedactivity: Conventional Use of Puzzles (with MinorVariations);Animation of Puzzle Pieces; and a Cooperative Game.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemeORDINARY* * * *ANIMATEDPIECES* * *COOPERATIVEGAME*Figure 28. Dave: Play Themes with PuzzlesConventional use. Dave’s interaction with the puzzles beganin a most fundamental way with him simply countingthe puzzles onthe shelf (1). In the next few sessions (2, 3, 4) Dave enjoyeddoing the puzzles in conventional fashion. He involved the246therapist as an active observer and, to a degree, as a playmate,teasing her by pretending to put some of the pieces in the wrongplaces, and waiting for her verbal “yeah yeah yeah!” or “nah nahnah” which he repeated with delight. A variation in conventionalusage occurred in Session (3). As Dave was completing a large 4—piece puzzle, he12j.the pieces under the table, revealing themone at a time and putting them in place. This seeminglyirrelevant action of hiding the pieces under the table isimportant in that it is linked thematically to a range of Dave’slater play. Hiding, as a play theme, recurred in Dave’s playacross many play materials.Animation of puzzle pieces. In the next phase of puzzleplay, Dave used several puzzle pieces in a unique andunconventional way, in a repeated activity which proved to be aturning point in his therapy (8, 9, 10).With the large wooden doll house as the setting for thisplay, Dave cleared the doll house entirely of its furniture, andinvited the therapist to sit next to him on the carpet. Hegavethe therapist the small airplane piece from one of the vehiclepuzzles and took the small boat piece as his own. He urgedthetherapist’s airplane to try to catch him and to try tofly alongthe second story of the doll house (the “road”). Dave sustainedthis sequence for a full 16 minutes, with the animated puzzlepieces chasing and being chased, racing up and over parts of thedoll house, and, primarily, “flying.” He particularly enjoyedthe therapist’s failure at flying, as her airplane piece landedhard on the doll house and hurt its “bum.” In a variation ofthis rough and nearly crash landing, he suggested that the247therapist’s plane “bounce” softly when itlanded, as on a“trampoline.”Identical play with the puzzle pieces flying,chasing, andsearching for each other around the doll houserecurred in thefollowing 2 session (9, 10) for 3 and9 1/2 minutes respectively.However, it was not so much the length of theseplay segments butthe degree of Dave’s involvement in this play which madeit aturning point in his therapy. He tookgreat pleasure in theflying, chasing, and searching activities, withall the actionand tension of pursuit. This was the firsttime that Daveenjoyed humour in his play. He found the slapstickquality ofthe therapist’s plane suddenly landingon its “bum” very amusing,and he urged repetition this segment14 times.A variation involving animated puzzle piecesemerged inSession 10. Moving the two principal(puzzle piece) vehicles toa basin of sand and water, the two figures chasedeach otheraround the basin, fleeing from imaginary “sharks”and with thetherapist searching for Dave’s puzzle pieceto “help” him.Cooperative game. In the final unique and unconventionaladaptation of puzzle play, Dave lined allthe puzzles end to endon the playroom floor. His purpose wasnot immediately evidentuntil he took a small block from thebin, tossed it onto the lineof puzzles, and proceeded to jump downthe row of wooden puzzles.His construction of a hopscotch—likegame showed particularlycreative use of the puzzles. It also suggestedthat he hadobserved and perhaps participatedin the play of older childrenwith interest and comprehension.He involved the therapist inanextended sequence of this cooperativeplay, as the two took turns248hopping. Dave supplied the rules for the play and demonstratedthe game. Herron and Sutton-Smith (1971) have identified gameswith rules as the pinnacle of a developmental sequence of playcomplexity. Dave’s introduction of games with rules into theplay setting represented a precocious and a developmentallysignificant step. No further puzzle play occurred after thisplay event.Puzzles: The Verbal ThemesThe following categories of verbal themes emerged inassociation with puzzle play: Identities of the Pieces; Flying;Harm and Danger; Mastery; and a Unique Story (cf. Figure 29).SessionMiddle Phase1 2 3 4 5 6 7 8 9101112 1314151617 181920ThemeIDENTITIES* * * * *FLYING* * *HARM!DANGER* * *MASTERY*Figure 29. Dave: Verbal Themes with PuzzlesIdentities of the pieces. Dave was capable of accuratelycounting the puzzles (1) and naming the pieces (2, 3, 4, 8). Avariant of his interest in the identities of the pieces was hisinterest in quizzing the therapist, “Which one is not the same?”(2, 4). He did this in a sing-song typical of a Sesame Streetchant, which may have prompted this play. The therapist saw thisinterest in identifying differences and similarities as both249unique and creative.Flying. In animated play with the puzzle pieces, verbalreferents to flight abounded (8, 9, 10). Dave repeatedly urgedthe therapist to “fly” and “fly with me” or, contrarily, “pretendyou can’t fly.” Related referents included the command to thetherapist to acquire “wings” or to “buy wings.” Alternatively,the therapist was to pretend to have “broken wings.” She wasalso to “bounce” rather than crash land. References to“catching” are loosely associated with this category.Harm and danger, References to harm and danger emergedduring animated puzzle play (10). At a level of moderateintensity, these included simple comments of “ouch!” (9, 10) or“doesn’t hurt” (10) during the flight scenario. However, verbalreferences to harm or danger increased in the second animatedsequence as puzzle pieces chased each other in the water basin(10). Dave called for “help” as he was “sinking” in the “toodeep” water. Imaginary “sharks” that were “sleeping” in themurky water threatened to “trap” them. Ultimately, Dave solvedthis tension-laden play by claiming to “shoot” the sharks withhis “gun—shooter” and/or put them in “jail.”Mastery. Verbal referents related to success and masteryoccurred only during Dave’s hopscotch game with the therapist(13). From the outset Dave was the championof this game,graciously urging the therapist to “try” and telling herconfidently, “I show you.” He yelled exuberantly, “I winned!”Unique story. When playing with a very simple puzzle (3),Dave narrated a story, included here in its entirety becauseofthe insight it lends to Dave’s abilities. The story reflects250considerable creative abilities, a capacity to weave anintegrated whole from parts (literally), and an underlyingoptimistic tone. The story also contains a verbal reference to“flying” which interwove much of Dave’s play.The stimulus for this story was a puzzle consisting of 4unconnected parts, each set in its own wooden aperture: a sun, abird, a leaf, and an apple. Dave hid the puzzle parts under thetable and revealed them one at a time synchronous with thefollowing narrative:One day there was a big flower coming out. Pshoo! Andthe apple was, pshoo! The bird eats. The bird eats.The bird, the bird can’t come outs./ The bird eat oneapple. Tsp tsp.! Yeah all gone.! Yup and the sun cornedout. Umrn umm! And then the bird was flying. Pshoo!And the sun comes out! Pshoo! This is the sun corned out.!And the apple and the leaf was there. The tree, the tree,and the apple too.Puppets: The Play ThemesDave’s puppet usage developed in 3 overlapping types ofplay, which encompassed these themes: Hiding and Intimidation;Drowning and Burying; and Aggression (cf. Figure 30).In the hiding activity (4 through 6), the witch figuredprominently. Dave repeatedly hid with a very ugly and realisticwitch puppet under the playroom table. Slowly, the witch emergedto repeatedly frighten the therapist. Sometimes Dave interruptedthis sequence of Hiding and Intimidation to show the therapistthat the witch she feared was only a puppet.In subsequent sessions (6, 7, 8, 10, 11, 12) Dave stillfocused on the witch, although briefly. When he caught sight ofher, he angrily tossed her into the basin of water (Drowning) andoccasionally dumped her in the sand tray (Burying).251SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920ThemeHIDING!* * * *SCARINGBURYING!DROWNING* * * * * *AGGRESSIVEINTERACTION* * *Figure 30. Dave: Play Themes with PuppetsHis attention transferred to the duck and the dog puppets ashe set up an interactive sequence among the puppets and otherprops. Dave created a tiny puppet theatre using the overturnedplayroom table. He assigned the therapist the dog puppet, whilehe kept either the duck or the kitten. Once Dave had ensuredthat both he and the therapist (with their respective puppets)each had a play phone, Dave developed the following playlet,which incorporated themes of Aggression, Interaction, and evenIntimidation. He repeatedly called the therapist’s dog on thephone. At first, when the dog answered, there was no response.Dave then suddenly screamed into the phone, catching the dog bysurprise and seriously frightening him. Dave loved the impact ofhis screams on the therapist’s puppet and repeated this sequencemany times (32 times in Session 12; 15 times in Session 13; 12times in Session 17).Puppets: The Verbal ThemesThere was not extensive verbalization associated with Dave’spuppet play. His activity of hiding with the witch puppet andusing her to frighten the therapist, for example, was largely a252nonverbal activity. During this play Dave identified the witchas a “scary lady” (4, 5) and “lady the shark” (5).Drowning or burying the witch was a very brief activity,about which Dave usually commented angrily to the therapist,“Leave her in the water!” (6, 7, 8