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

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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 in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying ‘of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.________________________________Department of Counselling PsychologyThe University of British ColumbiaVancouver, CanadaDate September 14, 1992DE-6 (2/88)AbstractA multiple case study approach was employed in thisintensive thematic analysis of the process of nondirective playtherapy. Using a naturalistic research paradigm, this studyundertook to identify and describe the principal verbal and playthemes and their transformations emergent over a course of playtherapy, as well as to identify and describe similarities anddifferences between the themes emergent in those two domains.Play and verbalization, two types of symbolic expression, wereconsidered routes of access to the child’s evolution of personalmeaning.The research participants in this multiple case study were 4preschoolers, aged 3 to 4. Each participant received 20 weeklyplay therapy sessions which were videotaped and transcribed.Running notations were made on the verbatim transcripts as toparticipants’ play activities. Separate coding schemes weredevised for the emergent play and verbal themes. Supplementaldata collection, organization, and analysis procedures included afield notebook with post hoc descriptions of the sessions,session summary sheets profiling play and verbal themes, charts,and memos.This study, discovery—oriented and exploratory in nature,yielded rich descriptions of the intricacies of therapeuticchange on two symbolic levels. From these descriptions wereextracted not only information on the transformations in play andverbal themes but also an understanding of the qualitativechanges which denote the phases of therapy, and insight into theprocess of evolving meaning across these phases.iiA central finding of this study was that the arrays of playand verbal themes and their patterns of transformations werehighly individualized. However, a number of themes emerged incommon to all cases: Exploration, Aggression, Messing, Distress,and Caregiving or Nurturance. Participants were observed to workthrough contrasting themes, with preschoolers’ therapycharacterized as an active struggle with such intense,oppositional forces as birth and death, injury and recovery, lossand retrieval. Typical thematic transformations includedmovement from infantile vulnerability to mastery, from grieftoward resolution, from fear to safety and protection.The beginning phase of therapy was found to be typified 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 a sense 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 implications of this study include emphasizingthe need for practitioners to counterbalance attention to thechild’s verbal expression with attention to transformations inplay activity and play material usage. It is suggested thatfurther research extend the ramifications of this exploratorystudy by examining the themes occurring in treatment withinhomogeneous populations according to problem configuration.ivTABLE OF CONTENTSAbstract iiTable of Contents vList of Figures viiiAcknowledgements ixCHAPTER I. INTRODUCTION 1Background of the Study 1Rationale for the Study 2The Research Questions 4Overview of Design and Method 5Definition of Terms 5CHAPTER II. REVIEW OF THE LITERATURE. SECTION I:PLAY AND THE PLAY THERAPY PROCESS 8Background on Play Therapy 8The Therapeutic Qualities of Play 8Historical Overview of Play Therapy 10Conceptualizations of the Play Therapy Process 12Jungian/Analytic Play Therapy 13Nondirective Play Therapy 14Studies of Play Therapy Process 17Empirical Studies of Nondirective Play Therapy 17Instruments of Play Therapy Process 33CHAPTER II. REVIEW OF THE LITERATURE. SECTION II:THE USE OF SYMBOLS TO ELUCIDATE PLAY THERAPY PROCESS 36The Nature and Function of Symbols 36Play and Language as Symbolic Systems 38Their Developmental Convergence 38Differences as Symbolic Systems 39Similarities as Symbolic Systems 40Empirical Support for Developmental Correspondence. . .41Therapeutic Play as Symbolic Expression 43Accounts of Symbolic Transformations in Child Therapy 44Case Studies of Play and/or Art Media 44Case Studies of Sandplay 47CHAPTER III. METHODOLOGY. SECTION I:PRINCIPLES, RATIONALE, AND TERMS 51Background: Considerations in Choice of Method 51The Naturalistic ParadigmField ResearchParticipant ObservationCase Study MethodThe Rationale for Multiple Cases...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. 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 play therapy process emerged frompilot work consisting of two years of recent clinical experiencewith young children. During that time preschoolers receivingnondirective play therapy moved toward emotional recovery throughtheir own self—directed play. Each child was observed togradually settle into play with favored play media. Over time,global changes or transformations were noted in the children’sinteractions with central play materials.Upon reflection, it was apparent that each child’s playmaterial selection and play style were unique. In addition, eachchild’s reliance upon verbal communication was singular. Whilethis may appear to be an obvious comment on individualdifferences, the varying relevance of verbal communication foreach child was intriguing. The children’s patterns ofcommunication through speech as opposed to communication throughplay activity appeared to be distinctive. Nevertheless, whetherverbally or through their play the children were at all timescommunicating, expressing facets of their personalities, theiremotional conflicts, and their resources for solving the problemsconfronting them, weaving back and forth between verbal and playexpressions.The observed differences in young children’s verbal and playexpressive style began to prompt questions as to how the changesin the verbal and play components of play therapy might beclarified. The researcher’s fascination with the verbal and playcomponents of this complex form of child therapy also prompted2additional questions about the nature of the process of change innondirective play therapy and the child’s own experience ofchange within that process.Retrospective case accounts of children in play and relatedtherapies pointed to the dynamic role of focal play materials andkey play symbols in catalyzing therapeutic change (Allan, 1988;Kaiff, 1980; Sikelianos, 1979, 1986, 1990). Theoretical work onthe role of symbols in human culture and in psychic development(Jung, 1954; Kubie, 1953) described how symbols bridge theconscious and unconscious realms, linking emotional experience totangible media (Kubie, 1953), providing routes of access to innerexperience. An intensive, detailed, fine—grained analysis of thechild’s verbal and play expressions appeared to offer aproductive avenue of inquiry for the broader process questions.By systematically attending to the child’s emergent verbal andplay expressions, perhaps new understanding could be garneredabout the process of nondirective play therapy, its particularcomponents, and its meaning for the child from a phenomenologicalperspective.Rationale for the StudyAs a rich and multifaceted treatment modality, play therapyenjoys widespread clinical usage by child psychiatrists,psychologists, social workers and school counsellors. Havingbeen adapted to many therapeutic orientations and treatmentstyles, from psychoanalytic to behavioral, play therapy isutilized directively or nondirectively in the treatment of theentire spectrum of childhood emotional disturbances.3However, research into the complexities of play therapyprocess has not kept apace with the scope and popularity of playtherapy practice. Meager process research supports the currentwidespread practice of play therapy. Much of the clinicalliterature consists of anecdotal case reports by practitionerswho tend to focus on the efficacy of play therapy in specificsettings (e.g., Johnson & Stockdale, 1975) or with specificpopulations (e.g., Nibs & Reiss, 1982). The need for ongoingresearch into play therapy process is widely acknowledged in theresearch literature (McNabb, 1975; Phillips, 1985). This studywas launched in response to the scarcity of systematic processresearch and the pronounced lack of in—depth process work.The handful of extant process studies have for the most partconceptualized the nondirective play therapy process in terms ofobservable changes in the child-therapist relationship ordeducible changes in the child’s emotionalized attitudes. Inthese studies, the perspective of the researcher, like that ofthe clinician, has been that of “other,” an outsider searchingfor observable evidence of specific changes. The child’s ownexperience of change has been equally objectified and distanced.Play therapy process research to date can be considered largely“third person” efforts, attempts via precategorized contentanalysis to classify predetermined therapeutic events. Noresearch into the nondirective play therapy process has yetattempted to conceptualize or to study the process of therapeuticchange by accessing the perspective of the child. There is anevident need for such a “first person” account of the changeswhich occur in nondirective play therapy.4By not superimposing an interpretive vocabulary, by trulylistening to and watching the child, this study endeavored toattune to dual aspects of the child’s evolving personalexpression. By considering the child’s unfolding verbalexpression and play themes as parallel narratives for analysis,this study set out to produce a rich description of thenondirective play therapy process as experienced by the child.By attending to the child’s verbal and play thematic expressions,this study attempted to isolate and identify key components ofthe play therapy process. The purpose of this study was toexplore play therapy as a lived experience by utilizing twosymbolic systems to access the child’s experience of change: thethemes emergent in the child1s interaction 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 play therapy?2. What themes are verbally expressed during play? How dothese verbally expressed themes transform across sessions of playtherapy?3. What are the similarities and differences in thesethemes across participants?4. What are the similarities and differences between thethemes which are expressed through play versus those which areverbally expressed by the child?5It was anticipated that the verbal and play themes wouldprovide routes of access into the process of change from theperspective of the child. It was further anticipated that theresearcher’s immersion into the details of participants’ thematicmaterial would lead to an elucidation of the process of playtherapy as it pertains to the child’s evolving world of meaning.Overview of Design and MethodThis study utilized principles of naturalistic inquiry(Lincoln & Guba, 1985): a field setting; the researcher asparticipant observer; case study reporting; grounded theoryrationale; and principles of narrative analysis. There isconsiderable overlap among these terms, which are often usedinterchangeably in the research literature. These terms share acommon concern with the researcher’s immersion into livedexperience for the purpose of extracting emergent, as opposed topreconceived, thematic elements. In this instance, theresearcher sought play and verbal themes emergent in nondirectiveplay therapy.This study employed a multiple case study strategy withpreschool participants receiving play therapy. Participants’play therapy sessions were videotaped and then transcribed.These transcripts were then submitted to qualitative thematicanalysis, with the coding categories emergent from participants’verbalizations and play activities.Definition of TermsThis section identifies the following terms central 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. Chapters IV through VII are the core of thestudy, the case accounts of the four research participants, Anna,Brad, Carl, and Dave. The concluding Chapter VIII discusses thefindings and sets them in their theoretical and practicalcontext.8CHAPTER II. REVIEW OF THE LITERATURESECTION I: PLAY AND THE PLAY THERAPY PROCESSThis chapter reviewing the literature is divided into twosections which present the major theoretical background of thestudy. Section I provides theoretical and historical backgroundon play therapy. Section II details the theoretical rationalefor using symbolic expression to elucidate play therapy process.Section II also provides background on play and language assymbolic systems, focusing on their developmental and functionalsimilarities and differences. Sections I and II are respectivelysupported by reviews of empirical and/or descriptive studies,namely, play therapy process studies and representative studiesdescribing play therapy as unfolding symbolic expression.Background on Play TherapyThis section discusses the therapeutic qualities of play; abrief overview of the development of play therapy; and theprinciples and predominant conceptualizations of play therapyprocess.The Therapeutic Qualities of PlayThe many and varied therapeutic uses of children’s play spanthe entire spectrum of psychological theories. Each therapeuticapplication of play, such as behavioral play therapy (Russo,1964), psychoanalytic play therapy (Klein, 1955), or group playtherapy (Ginott, l982b), assumes the theoretical coloration ofthe psychological model which has inspired it. Yet all of thesecreative therapeutic approaches, including nondirective playtherapy, have in common the fact that therapists are working witha medium, namely play, which is adaptable for 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 the child.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 offers singularopportunities for self—absorption and concentration. Childrenare often referred to as being “lost in play.” On the contrary,through play young children are often finding themselves,treading deeply, often unconsciously, back and forth from innerworld to outer reality and again returning to inner experience.What transpires quite naturally in play is the working through ofexperience from feelings within to their outer portrayal, frominner experience to the symbolic expression of emotional andpsychic reality by means of play materials and fantasy—-inessence, therapeutic activity.Smith, Takhvar, Gore, and Vollstedt (1985) summarized otherqualities of play which contribute to its therapeutic value.Play is a naturally enjoyable activity, offering opportunitiesfor pleasure and for positive affect. Because it is usually funand by definition largely freed from rules, it is intrinsicallymotivating and engaging.10The mere introduction of play materials promotes conditionswhich are conducive to therapeutic process for several reasons:(a) the play materials convey to the child that 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 to thelatent 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, anger can be released, anxietydissipated, tension reduced, and calm achieved. 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 context thatthe nondirective play therapist actively strives to maximize theinterpersonal conditions that will further facilitate emotionalawareness, personal expression, conflict resolution, and growth.Historical Overview of Play TherapyThe therapeutic use of play emerged from Freudian insightinto its function. Freud wrote extensively about the function ofplay in human development, characterizing it within the bounds ofthe pleasure principle (Slobin, 1964). He identified repetitiousplay, nonpleasurable and often fraught with anxiety, as a form ofrepetition compulsion. He also identified regressive play in theservice of the ego, and he cited the usefulness of play forexperiences of mastery or symbolic revenge (Freud, 1920).Von Hug-Hellmuth (1921) first promoted the inclusion of playin the treatment of children under seven. With very 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 principles as 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 and repressedfeeling, the Jungian unconscious is bipartite. The personalunconscious, similar to the Freudian unconscious, consists ofrepressed 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 themes common to allcultures. These archetypes, such as “the hero,” “rebirth,” or“wholeness,” emerge in myths, ceremonies, religious observances,and other cultural symbols as well as in the dreams of theindividual. The personal unconscious and the collectiveunconscious are interactive, and this unique interaction withineach individual is responsible for the diversity of human14personalities. The third component of the personality, the Ego,is the experiential consciousness of the individual: memoriesand feelings, ideas and thoughts. The Jungian conceptualizationof the personality also posits a spiritual center of theindividual, beneath and beyond the Ego and the two-tieredunconscious: the Self, whose nature it is to grow and evolvetoward well-being and wholeness.Applying Jungian theory to play therapy practice, Allan(1988) observed that “the task of psychological growth is toachieve a balanced communication between the Ego and the Self”(p. 5). This balanced communication between the Ego and the Selfoccurs through symbolic expression because symbols function as anonverbal link between the unconscious and the conscious mind ofthe individual (Jung, 1976). “In order for the child to maintaincontact with the inner world and feelings, the axis path betweenthe Self and the Ego must be kept open. If the Self is to growand the Ego is to mature, some form of symbolic expression oroutlet is needed” (Allan, 1988, p.7). Play therapy process froma Jungian perspective emphasizes the child’s evolving symbolicexpression.Nondirective Play TherapyAxline (1947) developed this major school of playintervention using Rogerian (1951) principles. Nondirective playtherapy refers to a philosophically integrated complex ofconditions which are considered by this therapeutic stance to beoptimal for emotional growth (Guerney, 1983).The vocabulary of Rogers’ (1951) client-centered therapywith adults wholly applies within the nondirective play therapy15setting. The nondirective play therapist communicates a sense ofgenuine respect for the personhood of the child, as well as animplicit acknowledgement of the self—curative resources whichreside within each client.The task of the therapist is to create optimal conditionsfor emotional growth. To that end, the therapist must becongruent with his/her own emotions, avoiding artificialresponses or tone of voice. The nondirective play therapist mustalso provide unconditional positive regard and a consistentlynonjudgmental attitude, even toward what are regarded outside theplayroom as misbehaviors.Therapist empathy is the theoretical and practicalcornerstone of all nondirective approaches to therapy. ByRogers’ (1951) definition, empathy, the catalytic impetus ofnondirective therapy, refers to the therapist’s assuming theinternal frame of reference of the client and perceiving theworld as the client sees it. Gradually, through therapistempathy, congruence, and unconditional positive regard, a trust—inducing environment, a “nonthreatening psychological climate”(Rogers, 1951, p. 346), well-suited to emotional risk-taking andclient growth, evolves.From the perspective of the nondirective play therapist, thehours of supporting the child’s self-directed play are neitherindulgent nor unremunerative. They constitute the aim and theessence of therapeutic process. In such a milieu, self—awarenessand even insight can emerge entirely from within the child(Landreth & Verhalen, 1982). Young clients unconsciously respondwith increasingly expressive verbalizations and behavior in an16atmosphere which is permissive, not in the interests of laissez—faire for its own sake, but in the service of emotional growth.The nondirective playroom provides abundant opportunity forthe child’s selection and combination of play materials as wellas for the development of pretend play themes. The nondirectiveplay therapist actively avoids verbalizations or even bodylanguage which restricts, disturbs, or otherwise directs thechild, who experiences the freedom to unfold from within. Theopportunity as well as the onus are on the child to select anddevelop play activities and to make many decisions. Thus, mini—steps along the road to growth and self-mastery are nurtured andsupported. Although nondirective play therapy, like its “parent”client-centered therapy, employs a different theoreticalvocabulary from Maslow’s (1968) self-actualizing hierarchy,nondirective play therapy is compatible with an existentialstance which posits implicit belief in the self-actualizingpotential of each human being.In sum, the nondirective therapist, through empathic andneutrally nonjudgmental reflection of the child’s play behaviorsand attendant speech, creates a receptive environment thatencourages trust and rapport, and permits and facilitates thechild’s self-directed experiences of growth. Therapeutic processconsists of this quietly powerful behavioral and emotionalunfolding in the presence of an attuned, supporting therapist.The nondirective play setting, as a growth-facilitativeenvironment, is thus an optimal context in which to observe theprocess of therapeutic change from the perspective of the childand to study the natural evolution of its symbolic 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) methodologically accessible through thecodification of speech, actions, and attitudes.Their prominent finding, that three-fifths of all verbalizedresponses were made by the child, while two—fifths were made bythe therapist, is often cited in the literature as evidence thatthe nondirective therapist’s empathic style encourages thechild’s more active emergence. Of the total number of client andtherapist statements coded, 30% of all statements werenondirective therapist statements, 25% consisted of clients’giving information, and 24% consisted of clients’ pursuingpositive play action. Considering the sequel relationshipbetween particular counsellor verbalizations and the“immediately—following” client statement or action, Landisbergand Snyder found that “nondirective responses preceded 84.5percent of the client’s responses” (1946, p. 207). Therapistreflection of feeling preceded over half (57%) of the clientresponses. These two findings are generally considered assupport for the nondirective nature of the therapy.To determine both therapist and child trends in thetreatment process, responses for all cases (4) were combined andthe entire treatment process was divided into fifths. From thisprocedure, the following information emerged. Recognition ofFeeling, the most frequently used strategy, comprised 62% oftherapist responses in the first fifth of treatment, but droppedto 40% in the next fifth. By contrast, during this second fifth,the “Restatement of Content” increased. The researchers notedthat this second fifth increase in the restatement of content“occurs simultaneously with a 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. In presenting 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 Snyder collapsed 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 complete protocols 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 undergraduate students rather than mothers as the playtherapist substitutes. Stollak increased the number of one-halfhour play therapy sessions to 10 for both experimental andcontrol groups. He anticipated trends similar to those of Stoverand Guerney (1967). Instead, it was found that (a) thechildren’s leadership behavior increased from sessions 1 through5 only; (b) dependecy and aggressive behaviors remainedunchanged; and (c) negativity continued to increase from sessions1 through 10.Taking a different research approach to the question ofnondirective play therapy process, Siegel (1972) studied 16learning disabled children who were each given 16 play therapysessions by the same therapist. She sought to determine how thedegree of therapist offered conditions of accurate empathy,unconditional positive regard, and genuineness affectedchildren’s process during therapy, as measured by the processscale first developed by Finke (1947). Contrasting the 4children who received the highest degree of therapist-offeredconditions with the 4 who received the lowest degree oftherapist-offered conditions, Siegel found significant behavioralchanges over time. Specifically, children receiving highertherapist—offered conditions were observed to make moreinsightful statements and more positive statements aboutthemselves than the children who received the lowest degree oftherapist-offered conditions.In another study carried out in the 1970s, Hendricks (1971)explored the patterns of play activities, nonverbal expressions,and verbal comments within the nondirective play therapy process.30She divided 10 boys, ages 8 to 10, into 2 groups which received12 and 24 nondirective play therapy sessions respectively.Hendricks relied upon verbatim transcripts and notations of thechildren’s nonverbal expressions and their play activities. Shedevised a 30—item scale for verbalization, a 14-item scale fornonverbal expression, and a 16—item scale for play activities.These scales were similar to those previously devised 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 the nondirective playtherapy process. In the first, exploratory, noncommittal, andcreative play predominated. She found that the 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 the third phase,dramatic and role play increased while creative play decreased.Subjects’ feelings of anxiety, frustration, and anger became morefocused on specific concerns. In the final phase, childrenshowed increasing interest in the relationship with thetherapist. At the outset, in addition to phases of the therapy,Hendricks had sought phases of emotional and social growth. Sheobserved, however, that the children’s feelings and attitudesoverlapped to a great degree, such that no clear stages foremotional and social growth across subjects 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” problem behaviors, such as aggressive acts,poor peer interaction, noncommunicative behavior, or off—taskbehaviors, were identified as unique criterion outcome variablesfor each child. Behavioral observations for each child werecarried out before and during eight 50-minute nondirective playtherapy sessions. Standardized interviews of parents andteachers were held at the end of treatment to account for changesdue to client history. In addition, the subjective observationsof parents and teachers were used as comparison data with thetime series analysis results. When the tenth child was withdrawnfrom treatment due to parental request, that child was used as anontreatment “rough check” for historical changes. Play therapyprocess consisted of behavioral changes over time.The strength of Hannah’s methodological breakthrough lay inhis use of time series procedures, which allowed, statistically,for the inclusion of time as an experimental variable. However,a major weaknesses of that study may be attributed to thatstatistical approach as well, Hannah reported that 8 of the 9participants exhibited a significant and positive change in theirtargeted behavior. Closer reading of his dissertation revealedthat the statistically significant results corresponded toparents’ and teachers’ subjective impressions of change in onlyone—third of the subjects. One-third of the observations wereantithetical to the statistically derived results (i.e., parentsperceived a behavioral change, while the time series analysisfound no statistically significant change). The latter thirdwere mixed or ambivalent (i.e., parental observations wereambivalent in comparison to statistically—evidenced changes).33Four of the ten time series analyses required sophisticated ARIMAprocedures to verify statistical significance. In general,Hannah’s use of time series raised questions as to the weight tobe given to personal perceptions of change in comparison tostatistical evidence. An additional complication arises from thefact that Hannah employed four different therapists in workingwith the 9 subjects, each of whom would have differed in levelsof skill, efficacy, and impact with the children. This study isvulnerable to the “myth of the uniform therapist” (Kiesler,1967). The impact of the therapist would be 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), Stimulus Behaviors(attempts to elicit particular responses, such as reassurance oraffection), Orienting and Directing Behaviors (directing orrestricting), Criticism or Rejection Behaviors (ranging frompraise to physical attack), Cooperation and Complianceexpressions, and Interpretation. The resulting interactionobservation instrument of 82 adult behavioral categories and 72child behavioral categories was utilized by Moustakas andSchalock in their 1955 study. (The description of the instrumentand its development was published after the study.) 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 research tool, itsgenesis is considered here because the authors carried out anexhaustive theoretical formulation of play therapy process indeveloping it. Howe and Silvern intended for the PTOI to depictand analyze the play therapy process more efficiently than anyprevious play interaction instrument (e.g., Dana & Dana, 1969;Guerney, Burton, Silverberg, & Shapiro, 1965).Concerned that “most [play therapy] studies have focusedonly on therapy outcome, not process,” and that these outcomestudies “have been largely irrelevant to concerns about playroomindicators of pathology and change” (Howe & Silvern, 1981, p.169), Howe and Silvern painstakingly set about to develop anobservation instrument of superior construct validity, capable of“classifying every child behavior or càmment, regardless of itspurported significance” (Howe & Silvern, 1981, p. 169). To thatend, the authors embarked upon an exhaustive review of the playtherapy literature to determine the universalities of childclients’ responses.Ultimately, they ascertained four major components of playtherapy experience: Emotional Discomfort, Competency,Defensiveness or Maladaptive Coping Strategies, and Fantasy Play.These were subdivided into 31 coding categories such as frequencyand degree of play disruption, frequency of coherent talk,frequency of regression or withdrawal, or inventive use ofstructured or creative toys. Of the original 31 experimentalcategories, 13, after testing, were deemed reliable observationalcriteria of play therapy process. To date, however, Howe andSilvern’s contribution to the conceptualization of play therapy35process lies in the isolation of the four major experientialcategories identified above. Examination of the Social SciencesCitation Indices since 1981 revealed no published applications ofthe PTOI. One dissertation study used the Fantasy, SocialInadequacy, and Emotional Discomfort scales of the PTOI fordiagnostic purposes only, in order to distinguish adjusted frommaladjusted children (Perry, 1989).SummaryThe extant studies of nondirective play therapy processencompass a range of research intentions, variables, andmethodologies. The small number of studies, each with adisparate research focus, offer virtually no overlapping orcorroborative findings, thus confounding realistic cross—studycomparisons. The paucity of the existing literature provides aspare context for the current study which, rather thanreplicating earlier research methodologies and/or research foci,chose to proceed in a new direction, using qualitative 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 understood to offer access to theinterplay between the material and the 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 activities represent.Play and Language as Symbolic SystemsBoth play and language are symbolic or representationalsystems (Wolf & Gardner, 1981) which have been shown within awide range of psychological literature to share commonalities intheir development and in their expressive functions.Play and Language: Their Developmental ConvergenceVygotsky’s theories (1966, 1978) on the interrelateddevelopmental course of play and language underlie this study.According to Vygotsky, the development of language and thedevelopment of symbolic play are interrelated and interactive inthe young child. Vygotsky observed that the development oflanguage and activity in the infant at first proceed onindependent, parallel paths. Physical explorations of theinfant’s world are not linked to specific articulations.Conversely, the spontaneous vocalizations of “baby talk” are notinitially associated with the identification of objects. Earlyspeech is not symbolic. It does not represent anything.However, at a critical point in development, the infant’s soundsacquire meaning. At this developmental crossroads, language andphysical exploration become linked. Language becomessymbolically, representationally, associated with objects,activities, and events: “The most significant moment in thecourse of intellectual development, which gives birth to the39purely human forms of practical and abstract intelligence, occurswhen speech and practical activity, two previously independentlines of development, converge” (Vygotsky, 1978, p. 24).The crucial feature of Vygotsky’s developmental theory isthat this critical developmental event, the point at whichlanguage becomes fused with intentional activity, occurs in arelational context. Specifically, according to Vygotsky (1978),speech or expressive language derives from the child’srelationship with the mother, in particular, from playfulinteraction with her.Vygotsky proposed that the infant’s speech at firstfunctions interpersonally, to establish contact with the mother.Only later, following successful expressive contact, doeslanguage take on the intrapersonal function of reflection orthought. That is, the child’s social communicative experienceprecedes the development of internalized self-talk. This is incontradistinction to Piaget’s (1962) related theories, whichconsidered internal speech an early form of thought and aprecursor to expressive, interpersonal language. According toVygotsky, the developmental process of speech and activity may besummarized as follows: The child’s speech is at first separatefrom activity. Later speech accompanies activity in a relationalcontext, and, finally, it precedes activity (i.e., the thought ofthe event precedes the action).Play and Language: Differences as Symbolic SystemsPlay and language are related though not identical symbolicsystems (Sinclair, 1970). Specifying the differences, Sinclair(1970) noted, first, that play occurs in the tangible world,40while spoken language is an intangible representative system.Second, play and language differ in the manner in which theypermit the expression of meaning. The meanings of a given playact are highly individualized. Play with blocks, for example,can occur in myriad forms, styles, and emotional coloration,indicating meanings unique to each child. The words thatcomprise language, in contrast, are a conventionally assumedsystem of shared meanings. A final difference concerns the factthat through play the child can spontaneously and loosely linkmaterials, themes, and events together. In contrast, wordscannot be joined together haphazardly. Language is governed byrules of syntax, grammar, and convention, while a child’sspontaneous play is free of any pre—ordained form.Play and Language: Similarities as Symbolic SystemsPlay and language share functional and conceptual featuresas symbolic systems (Smith, 1979). Both are representationalsystems, enabling the individual to externalize and portraythoughts and emotions. Play materials are representational inthat they act, in Vygotskian terms (1978), as a “pivot,” anobject which carries meaning related to, but independent of, theobject it is meant to represent. When a child uses a woodenblock as a car, the block acts as such a pivot. It bears theessential meaning of “car.” In play with this object, the childdemonstrates (a) an understanding of a symbolic object, which canstand for or represent a real object removed in time and space,and (b) a facility with the representational nature of language,whereby the word “car” contains meaning which links yetdistinguishes the real object and its representation. Play41objects as pivots assist the child to separate objects from theiressential meanings. As similarly described by El’Konin (1971),“In play the child operates with things as things having meaning;he operates with the meanings of words which substitute for thething; therefore, in play there occurs the emancipation of theword from the thing” (p. 230).As symbolic systems, both play and language permitdecentration. The ability to decenter, identified in the pretendplay literature as a developmental turning point (Fenson, 1984),refers to the child’s capacity to play at levels of experienceincreasingly removed from the self. Early attempts at pretensein late infancy are directed toward the self (Lowe, 1975).Later, the child animates and directs objects, investing themwith the potential for independent action. At a more complexlevel of abstraction and decentration, the child is able to adopta role or engage in pretend play independent of the qualities orpresence of physical props (Elder & Pederson, 1978; Jackowitz &Watson, 1980; Ungerer, Zelazo, Kearsley, & O’Leary, 1981).Language similarly permits decentration by enabling the child toconceptualize, describe, and verbally manipulate persons,objects, and events removed in time and space.Empirical Support for Developmental CorrespondenceEmpirical studies from the field of cognitive psychologyconfirm the synchronous onset, interrelated abilities, andassociated deficits in the child’s play and language development.Group comparative studies with autistic children, whose deficitsin both symbolic play and language capabilities are acknowledgedas extreme (Rutter & Schopler, 1978) has shown that impairment 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 confidence in hisability to find resolutions” (p. 5). According to her, thechild’s “symbolic action” is both a highly personal language andthe 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 indicated thatthese objects are often a unique symbolic expression of thechild’s difficulty, or a symbol of the child’s capacity forgrowth 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 central toeach 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; Lof land & 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 & Lof land, 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 overlap inactual ideology among these research strategists. Usually, thedifferences among terms can be reduced to a matter of degree andemphasis. In this study, the term “naturalistic inquiry,” asexplicated by Lincoln and Guba (1985), was used as theoverarching 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 human contexts,the field, in order to study them (Burgess, 1984). Fieldresearch relies upon the researcher’s observations of humanexperience as lived and the subsequent description and analysisof 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 the research54proceeds. 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 & Lof land,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 force of 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 the researcherhas 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 replication logic (Yin,1984) and utilize purposeful sampling rather than randomsampling. According to replication logic, each case isconsidered a literal replication of the entire study. Anindividual in case study research is considered not merely asingle unit, but a universe of responses.The sampling logic of naturalistic inquiry differs from thatof empirical, experimental research. In that tradition, samplingis based on the statistical premise that the selected group ofsubjects represents a random selection from the population atlarge. In case study research, with a small N or an N of 1,sampling logic does not apply. The data resulting from these 4subjects were not intended to represent the population at largebut rather to provide insight into and generalize to the theoriesunderlying the study.Purposeful sampling is based upon informational rather thanstatistical factors. Participants are selected for theircapacity to generate and maximize information rather than forfacilitating generalizations to the population at large (Lincoln& Guba, 1985). Principles of purposeful sampling apply not onlyto the selection of subjects but also to the data which areselected for analysis. That is, portions of the data to beanalyzed may be selected by theoretical rather than statisticalcriteria. Purposeful sampling is dependent upon the theorydriven needs of the study. That is, it serves a purpose in theenhancement of existing theory or in the development of 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 properties are continually comparedwith existing ones. No conceptual detail is presumed. Thecategories and their conceptual justifications undergo continualcomparative analysis. This study set as a primary aim the richdescription of thematic transformations within the play therapyprocess. From these rich descriptions, it was anticipated thatexplanatory insights into the process of play therapy andpossibly even new theoretical understanding of that process mightemerge.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 or story. As well, thestudy employed principles of narrative analysis in theidentification of emergent verbal and play themes.Narrative as a means of knowing and as a creativequalitative research perspective rests on the premise that humanbeings are continually telling stories replete with personalmeaning through their words, their actions, and their lives.Polkinghorne (1988, 1990), who has advanced the understanding ofnarrative, has developed a more complex conceptualization ofnarrative than the ordinary comprehension of narrative as “just”a story: Narrative is the continual unfolding and expression ofmeaning. As such, narrative expression is 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, the meaning of that story, life, action, orwords, can then be accessed in the same manner as with a literarywork, namely, through the identification of plots and themes. Todescribe a plot in a narrative is to ascertain the meaning ofthat plot for the individual.Narrative as a perspective in clinical practice is notforeign to the field of psychology. The psychoanalytic andpsychodynamic literature is composed of numerous client storiesretold by the clinician. Freud was continually searching fordecisive moments in his patients’ experience to ascertainrepetitive themes, their significant transformations, and theirmeaning in depth (Polkinghorne, 1988). His case studies areillustrations of insights acquired 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, meaning usually depends upon what happenslater. That is, meaning occurs in a temporal context. At times,it may be immediately clear; at other times, understanding mayoccur only in retrospect. Second, the expression of meaning isnot equivalent to the expression of factual experience. Theclient who fabricates the content of a dream, the child who tellsa fanciful story, are still providing expressions of personalmeaning. Whether or not the dream or the story is factual doesnot interfere with the validity of its meaning.The narrative framework presupposes that human meaning,purpose, and intention are knowable and accessible through boththe words and the actions of the individual. As Polkinghorne63(1990) elaborated, just as words in a series link to assumemeaning greater than the sum of the parts, actions in a seriesform meaningful episodes and plots. Although experience as it isbeing lived may appear segmented and disjointed, over time thesesegments create a whole of meaningful plots and patterns. Smallsegments when connected become larger episodes which, in turn,depict overarching themes. A beginning, a middle, and an end ofcertain themes may emerge, and the series of disjointedexperience forms into a more coherent and meaningful whole.Individual events in the narrative thus become “comprehensible byidentifying the whole to which they contribute” (Polkinghorne,1990, p. 94). This thematic identification is accomplishedlargely by retrospective reflection upon the narrative material.Adopting a narrative framework for research provides “adescriptive structure for integrating themes into a whole”(Cochran, 1990, p. 80). As a research strategy, narrative can beused to provide both descriptions and explanations. Descriptivenarrative research attempts to accurately portray emergent themesand plots. The descriptive analysis of a narrative text can becomplex because plots and sub—plots intermingle, requiring thediscernment of latent meanings. Polkinghorne maintained that theuse of narrative can accomplish causal explanations because thenarrative perspective delves beneath statistical probabilities tothe level of the intricacies of human motive and purpose. Thisstudy endeavoured to provide essential descriptions of emergentthemes and their transformations in children’s verbalizations andin their play.The actual interpretation of a narrative text can be64accomplished with scientific rigor (Van Manen, 1990):In the quantitative sciences precision and exactness areusually seen to be indications of refinement of measurementand perfection of research design. In contrast, humanscience strives for precision and exactness by aiming forinterpretive descriptions that exact fullness andcompleteness of detail, and that explore to a degree ofperfection the fundamental nature of the notion beingaddressed in the text. (p. 17)Extracting the themes, scripts, or guiding messages embedded in anarrative can be accomplished by two primary methods: (a) lettingthe data reveal itself, and (b) asking the data a question(Alexander, 1988). “Letting the data reveal itself” is not apassive process. It requires attunement on the part of theresearcher to discern emergent themes.Alexander (1988) identified nine “principle avenues” fordetermining salient themes in a text. By attending to primacy,the researcher probes the narrative for initial themes, assumingthat first themes or expressions are meaningful to theindividual. Frequency of expression is another means ofidentifying salient themes. “When frequency is coupled withother salience indicators it may reveal less conscious schemas”(Alexander, 1988, p. 271). Unique or unusual expression andcontent can indicate salient themes within a narrative, and theindividual’s negation of meaning can also be significant. Wordslike “always,” “absolutely,” and “never” indicate saliencethrough emphasis. Salience can also be indicated throughomission, a lack of affect or lack of cognitive clarity in thestream of narrative. Statements which reflect error ordistortion can signal important gaps in understanding or theindividual’s self—image. Nonsequitors, or statements in65isolation, 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 meaningful units. 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 overarching themesand interrelationships.Coding categories may be descriptive, explanatory, and/orinterpretive. They may refer to motifs, themes, patterns, and/orcausal links (Strauss, 1987). In this study, two coding systemswere devised: one for the child’s verbal 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 purposes in qualitativeresearch, such as orienting the researcher 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 tagged to the data which promptedthem. They consist of comments, observations, ideas, questions,clarifications, and analytic insights which arise at any point inthe research: before, during, and after data collection. Thepurpose of writing analytic notes is to amass a quantity ofanalytic 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 relied primarily upon the chartingof coding categories across sessions.68The Research DesignIn naturalistic inquiry the research design evolves from thefocusing question which motivates investigation. The design“deals with a logical problem and not a logistical problem”(Yin, 1984, P. 29). The research design is less a form and morea direction. Early data analysis and emergent evidence fortheory building provide the theoretical scaffold for later dataanalysis. Prevalent themes or theories emergent early in theresearch are modified or replaced and new questions formulated asadditional data become available (Miles & Huberxnan, 1984).Although analysis of the data takes place throughout all stagesof the study, the more formal and intensive analysis and theorybuilding occur in the later stages (Bogdan & Biklen, 1982).The principle feature of the qualitative research design isits flexibility to adapt as new data and theoretical constructsemerge (Bogdan & Biklen, 1982). In qualitative research it isimportant to avoid “going into a study with hypotheses to test orspecific questions to answer, [since] . . . finding the questionsshould be one of the products of data collection rather thanassumed a priori. The study itself structures the research, notpreconceived ideas or any precise research design” (Bogdan &Biklen, 1982, p. 55). Because naturalistic research endeavors togenerate rather than to test hypotheses (Marshall & Rossman,1989), guiding questions rather than specific hypotheses wereformulated at the outset of this inquiry. Additional questionswere anticipated throughout the process of data collection andanalysis. A description of the research procedure follows.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 the same preschool and were able to receiveplay therapy on site from the therapist/researcher.Rationale for Participant SelectionPreschoolers were selected because this age group generallypossesses the capacity for both expressive language and symbolicplay. Important developmental capabilities in language andsymbolic play converge between ages 2 1/2 and 3 (Lowe, 1975;Ungerer & Sigman, 1984). By the preschool age of 3 1/2 to 5,basic play and language competencies are considered thedevelopmental norm. Older latency age children tend to be lessspontaneously self-disclosing (cf., Lebo, 1951) and, in Piagetianterms, depart from a symbolic play focus to concrete operationalinteraction with materials.Participants with diverse presenting problems were selectedin accord with the rationale for participant selection describedby Yin (1984), namely, that commonalities found across highlydiverse cases may be considered more robust.Process of Participant SelectionThe process of participant selection began with thetherapist/researcher’s observation of the entire preschoolpopulation to identify children in need of and believed to becapable of responding to play therapy intervention. Thetherapist/researcher carried out these observations from behind atwo—way mirror. Observations took place over a period of 4weeks. To supplement the researcher’s observations, thechildren’s preschool intake records were also consulted indetermining the subject pool. Children who, it was believed,would benefit more from the 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 the pilot work for this study, shewas already known to and accepted by the preschool director andteachers. Several months before the start of the school year, awritten document, outlining the purpose of the research, wassubmitted to the board of the preschool who granted informedconsent for the study to proceed in the fall.Ethical ConsiderationsIn accordance with university ethics regulations forresearch with human participants, a synopsis of the research andmethods was submitted to the UBC Behavioural Sciences ScreeningCommittee for Research and other Studies Involving HumanSubjects. Approval was received before play therapy sessionscommenced. Informed consent for participation in the study wassecured in writing by the parent or legal guardian of each child,as described above. The children’s confidentiality and anonymitywere scrupulously ensured throughout the write—up of the projectthrough the use of pseudonyms, the masking of background details,and protecting the anonymity of the setting.The Researcher as Participant—ObserverIn this study, the therapist/researcher functioned as aparticipant—observer as follows. The role and function of thetherapist/researcher was well-defined and discrete within thedata collection and data analysis stages. In the data collectionphase of the project, the researcher maintained a participatoryrole as the nondirective play therapist, conveying a specificnonjudgmental, noninterpretive, and empathic attitude toward the73participants in order for the therapy to proceed. Reliance onelectronic means of data recording (audio- and videotapes) freedthe therapist/researcher from the need for during—session fieldnotes which would have disrupted the therapeutic focus. Afterthe sessions, the therapist assumed the observer function,completing the field notebook and reflective, retrospective notesor memos. The observation function——data reduction and analysis,via the transcription and examination of videotapes——occurredafter all the play therapy sessions had concluded.The Therapist’s Intervention StyleDuring the play therapy sessions, the therapist workedaccording to the principles of nondirective play therapy, asexplicated in Chapter II, allowing the children to determinetheir play initiatives. Within the nondirective approach to playtherapy, the therapist adopted a highly permissive style ofintervention. Children were permitted to engage in messing andaggressive behaviors well beyond the limits of socially acceptedbehavior. The therapist operated from a belief that, within thecontained therapeutic setting, (a) the expression of negativeaffect and behavior diminishes its destructive force and (b) thechild’s positive, self-actualizing energies can ultimatelyoverride the experiences of dissolution and regression.The Data Collection PhaseThe videotaping and audiotaping of each child’s course ofnondirective play therapy sessions constituted the datacollection phase. All sessions were videotaped with anaudiotaped back—up. The video camera was placed on top of a 3—tiered shelf within the playroom. In general, it did not prove74to be a distraction to participants. A field notebook andsession summary sheets (described below) were additional featuresof the data collection process.The Play Therapy SessionsEach participant received a course of weekly individualnondirective play therapy sessions. The sessions were conductedon—site at the preschool during school hours in a small roomwhich had been equipped by the therapist/researcher for thatpurpose. The therapist accompanied each child from and to theirrespective classrooms. Three of the participants received 20sessions, while the fourth child, whose therapy ended at parentalrequest, received 17 sessions. The course of therapy spannedroughly 6 months of the school year, from October through March.Each session lasted from 35 to 45 minutes. A diagram of thetherapeutic playroom as well as a listing of the play materialsprovided to participants can be found in Appendix C.The Field NotebookDuring the course of the play therapy sessions, thetherapist/researcher kept a field notebook. The field notebookor field journal is an indispensable technique of field research(cf. Bogdan & Biklen, 1982; Burgess, 1984; Lincoln & Guba, 1984).The field notebook contained the therapist/researcher’s notes oneach of the play therapy sessions. The notes were in prose formand attempted to provide a literal record, as recalled as soonafter the session as possible, of what transpired within thesessions. Personal comments, reactions, insights, and analyticcomments were included in the field notebook but were set offfrom the session descriptive notes in brackets.75Session Summary SheetsThe researcher filled out post-session summary sheets foreach session. Session Summary Sheets (Appendix D) were asecondary aspect of the data collection process, as adapted fromthe Contact Summary Sheets recommended by Miles and Huberman(1984). The purpose of the Session Summary Sheets was tohighlight the main verbal and play themes for each session.These summaries served to focus the researcher’s thoughts alongthe lines of the inquiry but they were not instrumental in thedata analysis phase. In a separate file, the researcher keptmemos or analytic notes related to the research procedure as wellas other general observations, questions, insights, andreflections on the research in process.The Data Preparation and Organization PhaseBefore emergent verbal and play themes could be identifiedand analyzed, the researcher followed a series of steps intendedto methodically organize the vast amount of material generated bythe 77 play therapy sessions of the participants.Working on one case at a time, the researcher first preparedverbatim transcripts of that child’s sessions. The transcriptpage was arranged with the verbatim verbal material in the left-hand column. In the right-hand column of the protocols, thetherapist noted the play activities synchronous with theverbalizations. “Pivots” and “elaborations” in play activitieswere noted. “Pivots” were major shifts in the chi1ds choice ofplay materials, which marked entry into new play. “Elaborations”were additions of play materials to on-going play activity. One-minute intervals were noted 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 with that material. These were called eventlistings, of which a sample excerpt from Anna’s therapy may befound in Appendix D. As is evident from the example,corresponding verbal highlights were also noted.With the complex web of the child’s play activities thusbroken down according to play material and chronology of usage,the researcher then sorted each event listing into themes foreach principal material. To determine the themes, the researcherused a two-fold strategy of letting the data reveal itself andasking the data a question. Specifically, the therapist pouredover the chronologies, attuning to the types of distinctions inplay material usage. The therapist repeatedly asked of thesedata the question: How does the child’s use of a given playmaterial differ from preceding use? For each child, the answersto this repeatedly asked question differed. The answers to thisbasic underlying question determined the designation of playcategories. The coding categories for play themes had abehavioral focus, noting the shifts in the child’s interactionwith a given material. The resulting categories were thencharted across sessions in order to portray the succession of thethemes and their transformations over time. The reader isadvised that within the four case accounts nonoperationalizedterms such as aspects, dimensions, facets, and so on, are usedinterchangeably to denote the components of a given code.Coding of Verbal ThemesVerbal themes were coded for each principal play material.To determine the verbal themes, the researcher consulted theevent listings and continually referred to the verbatim session78protocols to ensure that all verbalizations were considered. Thestrategy for ascertaining the principal verbal themes variedaccording to the degree of verbal sophistication of theparticipant. For participants with limited verbal faculties, theresearcher was able to compile for each material a straightvocabulary listing across sessions. For more talkativeparticipants, the researcher perused the event listings and thetranscripts for clusters of related referents occurring inassociation with a given play material. To ascertain a giventheme, the researcher adopted the strategy identified above: (a)letting the data reveal itself by reading and rereading thetranscripts and the event listings; and (b) asking the data thequestion: How are these referents related or alike? Todetermine transformations within a given theme, the researcherasked the data the question: How do these referents differ fromprevious referents within the same thematic category? Chartingthe verbal themes and their transformations across sessionsrevealed their general progression over time.The Written AccountsThe next 4 chapters contain the case study accounts of the 4participants. Each chapter begins with a case profile, whichgives a brief developmental history and the basic reason for thechild’s play therapy referral. In order to safeguard participantconfidentiality and anonymity, only that background which wasnecessary for the reader to make sense of the child’s play andverbal themes has been included. All names have been changed,and certain details have been modified to protect the identitiesof the children and their families.79Each introductory case profile is followed by theidentification of the phases of the child’s play therapy andtheir principal play materials. This is followed by a detaileddescription of the transformations in the play themes with theprincipal materials. The verbal themes associated with theprincipal materials are then identified and their transformationsdetailed.In this study, the phases of data collection, data analysis,and write-up overlapped and were interactive. Throughout theprocess of writing the accounts and the intricacies of the playand verbal themes, the researcher found that consideration of thethematic trends led to a further understanding of each child’sexperience of play therapy. A summary narrative concludes eachchapter. This concluding narrative utilizes the child’s play andverbal themes as tools of understanding to refract and explicateeach child’s experience of play therapy. The reader is advisedof the following stylistic convention in these accounts: Thefigures given in parentheses, e.g., (6) or (5 through 9), referto the session number.80CHAPTER IV. CASE 1ANNA: THE REEXPERIENCING OF INFANT LIFEAnna’s play therapy sessions were replete with the detailedand often dramatic reenactments of aspects of infant life, frombirth through toddlerhood. Anna was nearly 4 at the outset ofplay therapy. Her presenting difficulties had perplexed severalspecialists, who had advanced several diagnoses in an attempt toexplain some problematic behavior patterns, such as tantrums, atendency toward hyperactivity, and occasional sleep disturbances.Anna sometimes avoided her peers, preferring solitary play.Anna’s family was very concerned about the difficulties theiryoungest child was encountering.Anna presented as a highly verbal child, with a well-developed and, as this analysis will later illustrate,sophisticated vocabulary. Anna possessed a number of otherstrengths. An active and energetic child, she enjoyed a range ofage—appropriate play activities. Her play in the classroom wasoften characterized by elaborate fantasy sequences, such asdress—up or solitary house play, evidence of her creativeabilities.With regard to her developmental history, Anna’s birth hadbeen perilous and difficult. Her presenting breech position hadthreatened her life. Throughout her early childhood, Anna hadsuffered frequent upper respiratory infections. She had requiredongoing medical treatment, which included frequent visits toseveral doctors, repeated medical tests, many of which werepainful and intrusive, and, on a few occasions, briefhospitalizations. Health difficulties, both minor and major,81persisted to some degree throughout her play therapy.Overview of Anna’s Play TherapyFrom the first session, Anna responded happily andenthusiastically to the nondirective play therapy setting, whichgave virtually free rein to her creative and impulsive energies.Anna quickly established a level of comfort in the playroom andbasic trust with the therapist. By the third session, she hadbegun to surface in her play consequential psychologicalmaterial, namely, enacting the birth of the infant. Anna filledthe next 12 sessions with the recreation of many aspects ofinfant life: birth, sleeping, feeding, messing, washing,aggression, and the infant at play.The concluding 4 sessions saw a decrease in the intensity,frequency, and duration of her enactments of infant life. Inthese latter sessions, Anna began to use other play materials inthe symbolic representation of her current real—life struggles.Specifically, Anna utilized the figure of a small whale as apatient, while Anna as the doctor tended him with painfulinjections, comforting bandaids, and verbal warnings of death.Although Anna’s enactments of infancy still recurred, they nowalternated within sessions with segments of whale doctor play.Positive developmental gains began to accrue outside theplayroom. Her progress in school and at home proceeded inspurts. Considerable behavioral improvement manifested shortlyafter the first 5 sessions, as Anna began to calm at home and toparticipate without behavioral outbursts at some family outings.Behavioral and emotional changes generally followed a “twosteps forward, one step back” pattern throughout her therapy.82“Best ever” adjustments at home and at school, as reported by herparents or teachers, were usually followed immediately bytroubled periods, during which behavioral difficulties such astantrums or sleep disturbances recurred. Midway through hertherapy Anna was required to undergo a battery of medical testsin hospital. This potentially traumatic event proved to be apositive test of her progress to date. In contrast to earlierhospital experiences, Anna, with the active support of herfamily, was able to tolerate the medical procedures withoutincident. The fact that her return home was not followed byserious regression into acting out behaviors was an achievementfor her, suggesting some enduring emotional gains.Ultimately, through her therapy, Anna succeeded inremediating some of the effects of her difficult birth. By latespring, Anna had moved slowly but steadily into a new andstronger relationship with herself, her peers, and her family.She was happier and more resilient emotionally. She was lesssusceptible to tantrums or to bouts of anxiety, and she had begunto seek out and to enjoy play with peers.The Phases of Anna’s TherapyAnna’s play therapy advanced in three broad phases. In thebrief Beginning Phase (Sessions 1 and 2), Anna engaged in anumber of activities, which included sustained care-givingsequences, such as preparing food (playdoh, sand, and water) forthe therapist (1) and giving the therapist a medical check-up(2). Session 3 marked the beginning of the Middle Phase, theEnactment of Infant Life, in which Anna herself was usually therecipient of care. These enactments of birth, feeding, sleeping,83messing, aggression, and infant—at—play continued in richelaboration through Session 15. Representations of Hurt andHealing thematically dominated the End Phase (Sessions 16 through20), alternating with enactments of infant life. In this finalphase, a small whale, which had appeared throughout Anna’stherapy, figured prominently.The Principal Play MaterialsThe recurrence of play materials across sessions served asthe principal criterion in determining the play materials centralto Anna’s therapy. Their appearance across sessions issummarized in Figure 1. Infant—related props were the primarymaterials of Anna’s Infant Play. A simple cotton sheet served asthe infant’s receiving blanket, an essential prop throughout thisplay. Other props included the doll cradle, baby bottles andsoothers, the tea set, a bib, and assorted objects which Annaused as the “baby’s toys.” The Doctor Kit, Paints, and the Whalewere also central to Anna’s therapy. Her play with thesematerials was also submitted to thematic analysis.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920MaterialINFANTPROPS * * * * * * * * * * * * * * * * * * * *DOCTORMATERIALS * * * * * * * *PAINT * * * * * * * * * * * *WHALE * * * * * * * * * * * * * *Ficure 1. Anna: Overview of Play with Principal Materials84Infant Play: The Play ThemesThe play themes comprising Anna’s Infant Play weredetermined according to the natural life activities theyrepresented: Birth, Sleeping (in bed and in a crib), InfantAggression, Eating, Drinking, Infant-at-Play, Messing, andWashing. As Figure 2 depicts, Infant activities 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 a seamless whole,with the hungry infant Anna pausing to play, then drinking fromher bottle, then climbing into her crib to read a book, and soon. For the purposes of this study, these thematic threads havebeen teased apart and subjected to discrete analysis for play andfor verbalization components.Precursors of infant play. Anna’s infant play began withtwo fleeting and, at first glance, almost trifling incidents inthe Beginning Phase. In the first (1), Anna simply handled thetiny crib from the doll house and wordlessly placed it on theplayroom table. In the next (2), she buried the same crib and init a small baby figure in the sand tray. These segments, thoughbrief, are consequential as thematic 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 Themes with Infant PropsBirth. The dynamic theme which characterized Anna’s therapyfor months was the enactment of the birth of the baby (3 through14; reprised in 19). Her first enactment of an infant’s birthwas preceded by the spilling of water. After making a huge watermess on the floor, Anna crawled into the therapist’s lap andasked to be wrapped in a blanket. A brightly 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 squirmed inside the blanket and madefaint squeaks and infant sounds. From this enclosed posture,Anna tentatively reached out a hand or a foot, and then withdrewit into her blanket cave. Anna then lifted the blanket from offher head and, looking radiant and happy, exclaimed, “It’s a baby86girl!” This was the genesis of the birth enactments whichconstituted the thematic core of Anna’s primal play therapy.Within sessions and across sessions, Anna repeated theInfant Birth sequence many times. In its most dramatic variation(3, 4), Anna repeated what appeared to be an enactment of abreech birth. She extended her legs first, uncovered the rest ofher body, emerged feet first from beneath the blanket, andglowingly announced the birth of the baby. In other variations(4 through 9; 11), fetal Anna remained enwrapped for longperiods, not wanting to come out. Sometimes Anna 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 with fear. At these times in her play,Anna’s face had the soft and vulnerable cast of a newborn. OftenAnna emerged glowing, playful, and interested in pursuing otherinfant—related activities, sometimes returning to more birthenactments following sleeping, washing, or feeding sequences.Anna became attached to the flowered sheet in which shefirst enacted a birth sequence (3). She used this favorite“flowered blanket” throughout her therapy for birth play oradapted it for use in other infant enactments. It became atransitional object of critical importance (Winnicott, 1971), andit figured prominently in the next dimension of infant life toemerge, Sleeping in Bed.Sleeping in bed. Moving of f the therapist’s lap followingher first birth enactments (3), Anna crawled onto the nearbytable and asked the therapist to provide more blankets so thatshe could create a bed for herself on the table surface. Still87referring to herself as the “baby,” Anna paradoxically bound offthe table and capably arranged and rearranged the layers ofblankets on the table, eventually crawling 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 activity was initially carried out withnervous even anxious movements (3). Increasingly, calmnessinfused this activity (e.g., 8). In one transformation, Anna,once in bed, asked for the playroom light to be turned off (6,11, 14). She soon became anxious in the dark and asked for thelight to be turned on again. In another variation of theSleeping in Bed theme, Anna incorporated sequences of being fedimaginary food (9) or a real bottle (11). In Session 9 Anna feltparticularly playful upon awakening. She frolicked on herbed/table, engaging the therapist in a game of mimicked babbling.The Sleeping in Bed activity overlapped with and was ultimatelyreplaced by another neonatal subtheme, that of the infantsleeping in a crib.Sleeping in a crib. Anna enjoyed the confines of the smallwooden cradle (11, 12, 13, 15, 16, 18, 20). Intended for largedolls, this cradle was large and sturdy enough to accommodate herseated upright in it. Wrapped in her original flowered blanket,Anna usually spent her time in her “crib” drinking a bottle ofwater (10 to 14) or juice (after 15).Across sessions, Anna’s crib time was consistently linked tobottle drinking. A few additions to this basic activity occurredacross sessions, with some developmental progression discernible:wearing baby “pajamas” (a piece of cloth); holding smaller play88materials as the infant’s toys (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 activities of Infant Eating and Infant Drinkingboth emerged following birth sequences in Session 4. For thepurposes of analysis, Infant Eating was distinguished from InfantDrinking as follows: When Anna drank or pretended to drinkliquids from her bottle, the activity was identified as InfantDrinking. When she used tiny cutlery to spoonfeed herself, theactivity was identified as Infant Eating, even if she werespooning the mixture from her bottle. This distinction was madein response to the degree of 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, which she prepared for herselfin a baby bottle. During Infant Eating, Anna spooned tinyportions of sand from the bottle and either ate it, pretended toeat it, or fed the therapist the mixture. Usually this activitytook place with Anna seated on the therapist’s lap, with theflowered blanket wrapped around her. In an above—citedexception, Anna ate and was fed sand while on her bed/table (9).When the Infant Eating activity reprised at the end of hertherapy (20), it contained a number 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. Anna shifted from the imaginary or actualingesting of sand to drinking water from a bottle in Session 10.Anna usually drank her bottle of water while seated in thetherapist’s lap or when ensconced in her crib. In both cases,she remained covered in her flowered blanket. Anna enjoyed thisbottle drinking activity, sucking on the bottles at length and/orreturning to drink from her bottle between other infantactivities. This activity remained consistent, with notransformations across sessions other than the therapist’sproviding juice for baby Anna (15 and following). Once juicebecame available, Anna often enjoyed having two bottles (one ofwater and one of juice). She held one while drinking from theother in turn, or she sometimes playfully drank from both at thesame time. A fleeting transformation of the drinking activityoccurred (18) when Anna used a soother for several seconds.Infant—at—Play. Anna’s Infant—at—Play sequences variedacross sessions and were embellished with unique details.Lighthearted and even mischievous elements often permeated Anna’sinfant play, which began at the prenatal level and graduallybecame more developmentally advanced.Anna’s playful sequences began as she moved and squirmedfrom within the blanket womb or uttered tiny squeaks and soundsto get the therapist’s attention (e.g., 4). Complex, sustained,exuberant, and interactive sound play later comprised herneonatal infant play (9). In this sequence, Anna knelt on thetable and wobbled back and forth, as is characteristic of a babylearning to creep or crawl. As she moved, she uttered a range ofbabbling sounds. The therapist imitated her playful sounds, and90Anna enjoyed this mirrored baby play with the therapist/maternalfigure.In later infant play Anna incorporated various playmaterials as the infant’s toys. Early in her therapy (5), Annacuddled in the therapist’s lap, still wrapped in her floweredblanket, and elicited the therapist’s help in completing apuzzle. In a central session (10), she climbed on top of 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 incorporated objectsas the infant’s toys, which she usually held as she drank herbottle(s) in her crib or on the therapist’s lap. These objectsincluded a book, a small doll, and, in later sessions, the smallwhale. In one instance (15), Anna clutched a small alligator asan infant’s toy. While she drank from her bottle, 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, completely coveringherself with sand. After climbing out of the sand tray, she laycalmly on a small piece of carpet, grabbing her toes and rockingon her back like a baby. In another example of kinesthetic play91(20), Anna repeatedly jumped from a basin of water onto thetherapist’s lap, dousing the therapist with water.Messing. Anna engaged in some type of messing 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 the plastic 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 wet footprints 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 intense inSession 14, Anna retreated to the sand tray. Reassured that 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 occurred in thecontext of Infant Birth enactments. This analysis focuses firston the categories of referents emergent in Birth play. Many ofthe categories, which first emerged in birth play, persistedacross all aspects of infant portrayals as indicated below. Thisanalysis then highlights the principal verbal themes emergent inother infant play categories. Songs and Embedded Stories arediscussed as special verbal phenomena.Infant Birth: The Verbal ThemesVerbalizations associated with Infant Birth clustered aroundthe following thematic categories, which are described below anddepicted across play phases in Figure 3: Infant Sounds; InfantIdentity; Prenatal/Perinatal Experience; Neonatal EmotionalStates; and Neonatal Physical States.Infant sounds. Infant Sounds predominated before, during,and immediately after Birth sequences and recurred intermittentlyin most of her infant play. This thematic category comprised 3levels 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 Infant BirthAnna emitted faint squeaks from within her flowered blanket,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 still inside theflowered blanket. Often, after being “born,” she snuggled in thetherapist’s lap and babbled happily in this way. Anna alsooccasionally pretended to cry (“waaah!”). Cries usuallycommunicated the infant’s hunger or distress. These aspects ofpreverbal communication intermingled comfortably with ordinaryverbal communication: “Wah bah bah! . . . But he’s just talking94for a little while. Ba kaka puutata” (10).Infant identity. Throughout her infant play, Annaidentified herself as a “little baby.” Her verbalizationsrelated to identity consistently depicted a positive and happyinfant persona. Anna referred to herself as a “laughing baby”(9), a “magical” baby (11), a “cute” (13) baby, and a “surprisebaby” (14, 19). In unique instances, she also referred toherself as older than an infant: “sweet little girl” (5) or “abigger baby” (7, 8). In general, references to an infantidentity (“baby”) predominated.Following her first birth sequence (3), she glowinglyannounced, “It’s a baby girl.” With only two exceptions, inwhich she referred to herself as a “baby boy” (10) and a “babydinosaur” (11), Anna otherwise referred to herself as a girl babythroughout her therapy.However, when describing the infant in the third person, sheoften referred to the baby as masculine, e.g., “Baby is making abed with his mommy right now” or “He doesn’t need it on him” (3).At times, feminine and masculine referents occurred withinsuccessive sentences: “He wants to curl up in his mummy’s tummy.• . She’s not coming out!” (4)Paralleling and complementing her self—depiction as a “baby”were her continuing references to the therapist as mother. Annaunfailingly called the therapist “mama.” This concept was deeplyembedded in her infant play: “You’re the mummy and I’m the baby”(4). Even in the final session (20), Anna commented, “Susan hasa new baby.” At the same time, Anna was keenly aware that shewas engaged in a dramatized play 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 appeared to 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 infant within 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 a nice sleep. That’s it. You’re all in yournice little bed” (6).Sleeping in a crib. Perhaps because her crib time wasusually linked to bottle drinking, there were few referentsdistinctive to this play. A few related remarks appeared toindicate a positive feeling about this activity, e.g., herstressing that the crib was “fly bed” (11,12), “I like in mycrib” (11), and the fact that it was “cozy” (13). Unique infant-related referents concerned a request for “pajamas” (11) and a“diaper” (13). On one occasion, with the lights off, shestruggled with fear: “There’s no monsters in here? . . . There’ssome, there’s, I’m in my bed” (11).Eating. Anna first introduced the topic of food and hungerfollowing a birth sequence (4), translating her baby talk for thetherapist: “Gaga! Food!” Particularly during the first half ofher therapy, before Anna began prolonged bottle drinking, Annamost often referred to her sand food in appealing terms: “Babylikes his food,” which was also identified as “good” (5).Positive references predominated in Session 8, when she describedthe sand food as: “breakfast,” “cherry juice,” “dinner,” and“restaurant.” However, to a lesser degree her sand food was alsodescribed in distasteful terms. It was “yukky” (4), “gukky” (5),“p00” (4) and just “dirt” (8)Drinking. When Anna shifted to drinking water (rather thanspooning sand) from her bottle, her verbal referents consistentlyexpressed pleasure, e.g.: “I want some milk. . . The baby likeher bottle. . . . I have a drink. I think it’s good” (11).References related to oral aggression surfaced in the unique99instance of her drinking from the bottle while playing with asmall alligator figure (15). While Anna happily drank from herbottle, she put the alligator in the therapist’s shirt pocket,commenting: “He goes inside and he eats something. Yummy. Thatwas warm. . . He drinks some. . . . Now you have bites all overyou. . ‘Cause he’s only a monster.”Messing. Anna repeatedly referred to her sand and/or watermesses as her mucky mess 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 consistently verbalized feelings of pleasureand delight in her bath and in being clean. The water basin washer “special water,” (8), the “baby bath” (9), and once “myswimming pool” (11). Preceding her 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 the following self-description: “Sheplayed in her bath and clapped her hands like this” (11).Infant-at-Play. No particular verbal theme emerged duringinfant play. Anna generally described herself as infant in theprocess of playing: “Baby found a puzzle,” (5), “The baby’splaying sand!” (6); “This a dry place for him to play” (10);“Baby this is his toy” (11). In Session 9, preverbal soundsconstituted the play, as Anna and the therapist played aninteractive game of mirroring each other’s vocalizations.Infant aggression. Mess—making overlapped with Anna’s100aggressive play. Usually she referred to the results of heraggressive actions simply as a “mucky mess.” Later in hertherapy, when she began to physically attack the therapist, herexpressions of aggression and anger became more direct. Shecalled the therapist “you sweater” and told the therapist, “I’mgonna hit you!” (12). She also wanted to “bonk” her and then,troubled by this action, added, “I’m so sorry, mommy, ‘cause itwas just when I was just, when I was little” (13). In her mostintense attack on the therapist (14), she told the therapist thatshe wanted to “bonk you” but that “I’m afraid you might gethurt.” Informed that her anger would not hurt the therapist, sheresponded, “I’m glad to hear that,” and resumed her attack,followed by tears.External referents. Anna’s sessions were dotted with anumber of informational and/or self-disclosing statements relatedto her life outside the playroom. These included her disclosingor describing (a) being hungry after medical tests; (b) the timeshe broke her arm (5); (c) her video movies at home (6, 8); and(d) her dislike of spankings (16). Usually her tone during thesedisclosures was one of intimacy.Songs. Throughout her therapy, Anna interwove within herplay no fewer than 53 little songs. Only a handful wererepetitions of popular children’s songs (e.g., Puff the MagicDragon; 3). Most were her own creations; and most were briefsung or chanted descriptions of the play at hand or cheerfulmusical embellishments to her play. Simple examples related toinfant play, included: “Baby baby bottle. Baby baby bottle.Baby body” (10) or “I took my bath and I had big” (11).101Her most elaborate song related to infant play occurred asAnna prepared to lie down for a little sleep. The compositionwas rich in imagery (8): “The little whale, and in the morningwhen it’s dry, little baby. When it’s nighttime, in the fallingrain, I’ll sleep in flowers. I want my. I went in to my mum.Hmhmhm. And then the waterfall. Hmhmhm.”Embedded stories. Embedded Stories characterized 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 Anna adopted a special “story telling”voice. She added characters and imaginary events. She seemedcarried away, talking partly to the therapist and partly toherself. Embedded in the larger sequence of her play, thesestories often contained elements of narrative structure, phraseslike “and then” or “one day” or other verbal markers to denote abeginning, a middle, and/or an end to the tale she created. Thefollowing are representative examples associated with infantplay:1. While making her bed: “When baby’s making his bed oneday. Over the hills and far away, and he like to” (5);2. While sitting in the sand tray, 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 and do. Remember?3. After emerging from her flowered blanket (11):I’m a baby dinosaur. I’m Little Foot. Little Foot was sohappy to see his girlfriend named Sara. Sara was so heavy[sic] too. So be careful. So she had to just. Ah. I’llsave you, Sara. Ooh. His mother didn’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 therapist and self. Anna treated the therapistwith 4 injections, each followed by a bandaid (2). In the nextbrief segment of doctor play (8), Anna required treatment for herown hurt. Almost in tears, she complained of hurt fingers andsought bandaids from the doctor kit. (The hurt may have beenreal or reflective of emotional hurt, as she had been upset andanxious from the beginning of the session.) She calmed and wasable to resume play with other materials as soon as bandaids wereapplied. The power of bandaids to comfort and 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 17 minutes,or one third of the session. Anna repeatedly gave her newpatient, the whale, injections followed by bandaids. She tookhis temperature and blood pressure, and read him 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 play activitywere discerned. These variations suggested the notion ofrecovery. First, the whale was permitted to return betweeninjections to his water basin to swim (18), suggesting that histreatment over two sessions was beginning to have curative force,restoring him to his normal activities. Next (19), playfulelements emerged as Anna tickled the whale when she finishedtreating him. Finally (20), she kissed 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 and Death aswell as Help through Friendship (of. Figure 6).SessionMiddle Phase12345678 91011121314151617181920ThemeHURT!PAIN * * * * * * * *RECOVERY (*) * * * * *DEATH * * * *FRIENDSHIP * *FEAR *Ficiure 6. Anna: Verbal Themes Associated 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 appeared to 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 a Ilsurprise.H There 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 8 91011121314151617181920ThemeHELDOBJECT * * * * * *MARINECREATURE * * * * * * * * * * * * * *MEDICALPATIENT * * * * *INFANT’STOY * * * *MURALFOCUS *Figure 7. Anna: Play Themes with the WhaleIntroductory play oblect. Across 6 early sessions (1; 3through 7) Anna consistently sought out the whale immediatelyupon her entry into the playroom. She usually placed him inwater and did not return to play with him for the remainder ofthese sessions. These brief contacts with the figure of thewhale, overlooked by the therapist during the therapy, acted asprecursors to her later extensive use of that figure.Marine creature. This subcategory refers to the whale’snatural identity as a swimmer. In every session in which thewhale figured in her play, Anna animated the whale, having himswim in the basin of water. There were 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 and following) the whale wasoccasionally joined by the figure of the little fish, whofunctioned as a companion for him.108Medical patient. The whale shifted from being a literal,biological creature to acquiring an anthropomorphic, fantasyidentity. As doctor Anna’s patient, the whale was the recipientof sustained, intensive medical care, as elaborated above,throughout the concluding sessions (16 through 20). He wassubjected to painful treatments as well as care, comfort, andaffection. Sometimes the painting of his tail, as cited above,appeared to be part of the recovery process.Infant’s toy. Infant Play alternated with Doctor Play inthe final play phase (16 through 20). The whale functioned inboth these major thematic categories, accompanying Anna back andforth from her infant persona into doctor play. Anna simply heldthe whale as the infant’s toy, as she cuddled in the therapist’slap and drank from her bottle. In one variation, she clutchedhim playfully between her feet while she drank. In anothervariation, Anna treated him as a playmate, sharing her bottlewith him (18) or spoonfeeding him some juice (19). These latterinstances of cuddling and offering nurturance to the whaleparalleled Anna’s simultaneous activity of receiving physical andemotional nurturance herself.Focus of the mural. The theme of the whale began andconcluded Anna’s therapy. The penultimate play act of hertherapy was to paint the playroom wall. Anna identified some ofher large purple swirls as a whale, getting “bigger and bigger.”In this activity, Anna did not utilize the physical object of thewhale. His two-dimensional depiction was sufficient for her tokeep the essence of the whale 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 verbalized referents concerned theway in which Anna verbally brought the whale to life. In Session13, Anna picked up the whale and told the therapist: “Mr.Whale’s gonna say something.” However, he was not quite 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.” This time Annapursued extensive play and verbal interaction with the whale,with the therapist speaking for Roo.Setting. Roo’s natural habitat was a basin of water whichwas referred to as his “aquarium” (1, 14), his “swimming pool”(16), and his “bathtub” (18). However, Anna most often referredto the basin of water to which she had added sand as his “darkwater” (15 through 19).Hurt, death, and medical treatment. Verbal references tohurt, death, and medical treatment proliferated when 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 interpersonal relationships, particularlyduring the End Phase. There were repeated references to thelittle fish as Roo’s “friend” (16, 17, 20) who would “help you.”Roo learned that the little fish was his “baby sister” (19).There were consistent references to Roo’s mother: “Hello, I’m alittle small whale. Do you know where my big mother is?” (14);“He has to have more dark water, so he can make his mother” (15).112Nurturance. Referents which suggested varying degrees ofnurturance toward the whale involved affection and 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). Roo was also offered a toxicsubstance, “poison” (19).Embedded stories. A number of Embedded Stories interwoveAnna’s play with the whale, of which the examples below arerepresentative. An early story emerged when Anna handled thewhale for the first time (1). This story contained precursors ofthe themes of Whale, Mother, Baby, and Fear which were to unfoldin greater detail as her therapy advanced:One day the mother took the little baby somewhere. And thebaby said, “WahI I’m just a little baby. I’m in heresomewhere. Get me out of here!” This one was next. Andbig bad. Grrr! Me too, me too, little whale.A later story highlighted the whale in his 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 and recovery (16):Roo was so hurt. She went out of the swimming pool. Ohright here. And Roo was so happy. She wasn’t hurt anymore. She got a fish. She was way up into the sky, ok.And Roo didn’t come down. There’s Susan.Songs. Songs interwove Anna’s whale play from 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 occurred ininteraction with the therapist. As noted under Infant Play, thissequence was noteworthy for her inclusion of the 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 whale as the doctor’spatient, she occasionally painted the whale’s tail (17, 20)and/or (17) a “happy face” for him. The painting of the whaleseemed to be part of the whale’s medical treatment (much like theapplication of mercurochrome) and at the same time an aspect ofhis improvement or beautification.Also in the end phase (18, 19), Anna initiated two artactivities which at first appeared to be mundane. She began bypainting (18) and by colouring with crayons (19) on paper on thefloor. However, in both instances, destruction immediatelyfollowed creation, as she poured water on one drawing (18) andripped the other in pieces which she then floated in the whale’swater basin (19).115Anna’s culminating painting activity, occurring in the finalsession (20), was the creation of a large mural on the playroomwall. This activity was unique in terms of the size and scope ofher work with the paints; large circular swirls filled onesection of the playroom wall. Anna verbally explained that sheintended this mural to be a representation of marine life. Annaidentified herself as the infant as she painted with thetherapist. Yet this painting sequence differed from her earliercooperative painting activity with the therapist at the table.In that case, Anna had acted the dependent and attached infant,seated on the therapist’s lap. In this final painting sequence,Anna still played the baby, but she was no longer the infantattached to the maternal figures. She worked apart from thetherapist, taking turns painting the mural with her incooperative yet independent fashion. The therapist was enlistedhere more as a partner and playmate than as a maternal figure.Painting: The Verbal ThemesRelatively meager verbalizations occurred in associationwith painting. Perhaps this was due in part to the fluidity ofthe medium and the calmness and concentration it induced.Nevertheless, the scant verbalizations still covered a wide rangeof topics. These formed only two thematic clusters with anyconsistency of repetition: Calls for Attention and References toMother. There was some overlap between these two categories.There were also unique references to Fears as well as a verbalelaboration of the play theme of the Whale and other marine life.As Anna painted her hands, feet, and sometimes her stomach,Calls for Attention were often repeated within 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 consequential referencesto Fear dotted these two principal play activities. Paintingproduced a cluster of referents descriptive of relationships.Through all of these activities, references to the whale wereinterwoven.Contribution of Play Activity to Therapeutic ProcessAnna created a complete, multifaceted, and realistic playidentity for herself as the Infant. She gave birth to thatidentity in play and proceeded to elaborate many details ofinfant life: eating, drinking, messing, washing, sleeping,aggression, and playing. Anna also 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 was able to do more than enactthe infant. She became the infant and as such in her play shereexperienced infant life. This reexperiencing encompassed notonly the physical but also the emotional sensations of infancyand babyhood.Specific infant-related activities yielded specifictherapeutic benefits. Through the birth activity, Anna hadaccess to sustained physical closeness and cuddling and the senseof security that provided against fears. Drinking from a bottlegave her actual nurturance (the juice), emotional nurturancethrough cuddling, as well as physical pleasure in the sensationsof drinking. Sleeping in a bed or in a crib providedopportunities for movement between states of anxiety andcalmness. The aspect of infant-at—play enabled the safe119expression of aggression toward the therapist/maternal figure.Anna benefitted from the kinesthetic properties of playmaterials. She literally immersed herself in their tactileproperties. She experienced absolute messiness, being covered insand or paints, as well as the pleasure of feeling washed cleanin her infant bath.Anna benefitted from the regressive experiences which theinfant persona enabled. At times, her descent into developmentalregression could be perceived with striking clarity in her playactivities. For example, play in the crib developed after playin the bed. Drinking from a bottle occurred after eatingactivities. In these cases, the developmentally less matureactivity followed a developmentally more advanced activity.Anna used her doctor play with the whale for the depictionand representation of real life experience. Anna as the whale’sdoctor was no longer the vulnerable infant. She assumed the roleof helper and healer, as well as one of control, power, and theability to inflict hurt. In her treatment of the whale, she wasable to depict current real life concerns of repeated trips tothe doctor, receiving medical treatment, and so on. The whale,through the mechanism of projection, now carried thevulnerability, the fears, the helplessness, and the pain, givingAnna some symbolic distance from her persistent medicaldifficulties.Contribution of Verbalization to Therapeutic ProcessOn the level of verbalization, Anna spanned a completedevelopmental range. The authenticity of the sequence of herinfantile verbal development was striking. She began as a120preverbal, prenatal being, making imaginative approximations offetal communication--faint squeaks from within her blanket inorder to capture the mother’s attention. Later, Anna, like anydeveloping infant, used sound itself as play and this served thespecific purpose of forming the relationship with the maternalfigure. Vygotsky (1978) has stated that the impetus for infantspeech derives from the mother-child relationship, and that theplay between mother and child serves to stimulate and enhancethat development. As Anna rocked back and forth on the table andenjoyed mirrored sounds with the therapist, this circularinterrelationship between playful mother-child contact, theenhanced motivation for infant speech, and the strengthening ofmother-child rapport was vividly portrayed.Anna proceeded into overlapping infant and babyhood stagephases of babbling and baby talk, all of which were interwovenwith her own age appropriate discourse. During later doctorplay, Anna moved to the third—person description of difficulttopics, such as hurt, death, and mother’s death as well as topicsindicative of recovery, healing, help, and friendship.Anna was fluent on the verbal level, not only in terms ofher vocabulary, which was often quite precocious (cf. the“excited” and “upset” baby). She also functioned verbally verycapably, advancing the play on overlapping and sometimessimultaneous levels. That is, she was able to speak as theinfant, while concurrently describing her infant activity in thethird person. She interacted directly with the whale, talking tohim and creating his personality as she did so. In addition,there were Songs and Embedded Stories 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 of verbalization, the naming of the whale canbe considered a positive critical incident. In naming him “Roo,”Anna for the first time bestowed upon him a specific, rather thana generic (cf. “Mr. Whale”) identity. This identity was dynamicin that the whale, following his naming, underwent a number oftrials, adventures, healings, and relationships, including anactive and interactional relationship with Anna. The whale’sidentity was consistent in that he retained his persona and hisname for the remainder of Anna’s therapy. Anna’s ability toverbally bestow a consistent identity upon this play materialreflected her own growth toward a stronger and more integratedidentity.Summary NarrativeThe following narrative uses the play and verbal themesanalyzed above as the basis for a summary story of Anna’stherapy.Beginning phase. Anna entered the play room for the firsttime as if she had already intuited its purpose--to immerseherself in play of a deeply personal nature. Anna displayedneither shyness nor tentativeness in her approach to the playmaterials. She was active, energetic, and thoroughly involvedwith whatever material she chose. At times, her play seemedimpelled by nervous energy. Yet she also appeared happy andexcited to have a play arena in which she could indulge her playwishes.She involved the therapist in her play almost immediatelyand actively sought relationship with her. The play materialswere at least in part Anna’s tools for the formation of contact123and closeness with the therapist. Using sand, water, andplaydoh, she set about in an extremely busy and officious mannerto provide “yummy” food for the therapist. Here, Anna enactedthe maternal role of caregiver, of nurturer, a role which for herwas to be short—lived. Anna used the doctor materials to examinethe therapist, treating her with shots and bandaids, an activitythat became prominent much later in her therapy. As busy motherand as doctor, Anna retained the element of control in her playinteraction with the therapist.From the outset, Anna exhibited delight in the physicalinteraction with messy materials. She enjoyed handling the sandand water during her preparation of the therapist’s food. Shestirred, mixed, and dumped the mixture and revelled in thepleasurable sensations of the materials. She similarly enjoyedpainting herself with water colours and overturning the basin ofwater on the playroom floor.The beginning phase contained only the faintest precursorsof the themes of the infant and the whale. Anna simply placedthe doll house crib on the playroom table. By the simple act oftransferring the crib from the margins of the playroom (the dollhouse) to the focal point of the playroom (the table) Annaappeared to be unconsciously, if microscopically, through a playsymbol, raising the topic of infant life. She barely touched thewhale. Yet extensive thematic changes burgeoned from both theseminute play incidents.Middle phase. Anna’s enactment of the birth of the infantdramatically marked the beginning of the prolonged Middle Phase.In this phase Anna gave birth to the principal play identity from124which the rest of her therapy evolved. The reign of Anna as thecontrolling caregiver had ended. Anna as the infant drank inphysical and emotional nurturance just as she drew physicalcomfort from her bottles. She epitomized gentleness 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 deep fears, of “monsters”and of being killed, as well as 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 completely immerse herself in andplay out the extremes of that ambivalence. In her enactments ofbirth, Anna could enjoy the luxury of a biological impossibility,returning to the womb. She previewed the world she would be borninto, lifting the flowered blanket to peek at the therapist.Free of any biological imperative, Anna was then able to withdrawagain into her blanket to enjoy the security of prenatal life.The playful imitation of birth could advance unhurried andby degrees, with the tentative extension of an arm or a legfollowed by its withdrawal. Her birth play often seemed to be arehearsal of that event, as she repeatedly emerged into andwithdrew from the world.Most striking were the details of her birth play whichcorresponded to Anna’s own breech birth. On more than one125occasion, Anna thrust herself feet first out of her blanket. Hercomments on the baby as being “born” only strengthened thisimpression of Anna’s play as a deep—seated reworking of her ownbirth experience. Indeed, Anna seemed less to be playing atbirth than to be thoroughly reexperiencing it. Often she emergedfrom her blanket looking radiant, with cheeks flushed and eyesgleaming.The rest of this phase of her therapy flowed quite naturallyfrom this core birth experience. Anna as the “magical baby”claimed the playroom as her nursery, with the therapistfunctioning extensively as the maternal figure. The floweredblanket, which had served as the symbolic womb, accompanied herplay in bed, in the crib, and on the therapist’s lap. Theblanket functioned as a transitional object of criticalimportance, carrying the sense of security she had experienced“prenatally” into the expanded world of the neonate. Themes ofcomfort, care, physical and emotional nurturance, andrelationship with the maternal figure infused this phase.Most of Anna’s infant experience was pleasurable. Sheexperienced a sense of security in her bed and in her crib,nurturance and pleasure through her bottles. She delighted inthe sheer physicality of messing and washing, and she enjoyedenacting--being--the active infant at play with mother. She sanghappy little songs and embroidered her play with short stories.Anna also explored nonpleasurable and difficult aspects ofinfant experience. Anxiety and fears, particularly of“monsters,” surfaced in her infant play. Anna as infant alsoexpressed considerable aggression toward the therapist in the126form of physical attacks. The “magical baby” and the angry babywere equally at home in the playroom nursery.End phase. The whale, who had lain dormant during theMiddle Phase, suddenly came to life. Asking the therapist to“talk for him,” Anna gave him a name, and in that act of naminghim launched the final phase of her therapy. Anna created in thewhale named Roo a peer, a friend, an infant toy, a child, acompanion, and a confidante. However, the whale primarily servedas her medical patient, such that whale play in this phase wassubstantially fused with doctor play. In a sudden shift of rolesand identities, Anna the infant assumed the role of Anna the“doctor whale [whale doctor]” and as such ministered to Roo. Hewas subjected to injections, and he received bandaids, tickles,cuddles, and kisses.Anna was no longer solely the vulnerable infant, afraid ofmonsters or needy of sustained care. As the doctor, sheadministered pain and comfort, and regulated their amount andfrequency. Anna had become the dispenser, the subject ofexperience, both positive and negative. Roo had assumed, atleast in part and for the interim, the role of object, recipient,and victim.Anna’s doctor and whale play fluctuated between themes ofhurt and healing. The topic of hurt was elaborated andassociated with the theme of death and the terrifying notion that“doctors kill you.” At the other extreme, healing was elaboratedto include not only literal solutions (cf. bandaids) but also arelationship component, friendship. Anna created for Roo alittle fish friend who would “save” him and ensure “no more127dying.” Anna’s journey between the dimensions of hurt andhealing was not an easy one. Her doctor play with the whale wasoften charged with tension, especially when references to deathsurfaced.Whale play fused with doctor play did not supplant infantplay. Scenes of infant life continued in this final phase. Theydid so in a striking and almost rhythmic oscillation with thewhale and doctor play. Anna moved back and forth between theroles of the infant and the doctor. In one role, she personifiedvulnerability and neediness; in the other, control, agency, andauthority. She enjoyed regression in the reexperiencing ofinfant life, and she raised topics pertinent to her current lifeexperience——trips to the doctor, and all the associations offear, pain, and need for comfort that those visits entailed.Anna appeared to be using the retreats into infant life (birth,feeding, and so on) as respites for emotional nurturance fromwhich she drew the psychological strength to deal with theseconcerns.In the final minutes of the last session, Anna abandoneddoctor play and turned to the creation of a large purple mural onthe playroom wall. She filled the wall with whales, an emblem ofher therapy. As she painted, she retained the role of theinfant; however, she appeared a more capable and self—confident,even mature, baby, painting cooperatively with the therapist!maternal figure. The mural concentrated many of the key themesand activities which had recurred throughout her therapy: herlove of painting and messes, her involvement in the infant role,the recapitulation of the whale theme. In that respect, the128mural seemed a fitting, creative closure to her therapy.However, before leaving the playroom, Anna sought a final forayinto infant life. Finishing her mural, she sat on the “baby’schair” and greedily sipped juice from a tiny cup. In taking afinal sip of juice, Anna seemed to be conveying that she wantedto take with her one last symbolic gulp of nurturance as sheventured forth from the room.SummaryAnna’s play therapy was characterized by her complete andenthusiastic immersion into play experience. She was fullyinvolved both with the therapist and with the play materials fromthe first moments of her therapy.Anna plunged into the reexperiencing of infant life. Shegave birth to a play identity, and the playroom became hernursery. By degrees, Anna descended into regressive play inwhich the myriad facets of infant experience came to life.Anna as the newborn experienced comfort, nurturance, joy,and pleasure as well as anxiety, fear, and intense aggression.Finally, Anna shifted into new play depictions, new themes, andnew developmental challenges. In doctor play, themes of hurt andhealing were elaborated. In perhaps the key verbal communicationof her therapy, Anna broached her fear of death and brought tolight the worries and even terror that had likely underlain herown frequent medical care.Moving through virtually all of Anna’s play therapy was theoften silent, but ultimately vocal, figure of the whale. Anna’sattachment and commitment to the whale throughout her therapyrepresented an intriguing choice of a play material, for whales129travel at the ocean floor and at its surface. In the Jungianframework, the ocean may symbolize the depths of unconsciouslife. The whale served Anna as a strong, friendly mammaliancompanion who was comfortable at the surface and at the depths.130CHAPTER V. CASE 2BRAD: THE EMERGENCE OF PLAY AND VERBAL COMMUNICATIONBrad’s play therapy was marked by the synchronous emergenceof play and verbal capacities, which developed from an initialstate of severely impoverished functioning in both domains. Atthe outset of play therapy, Brad was 3 years and 9 months old.His presenting difficulties perplexed his parents and histeachers. Although Brad was normal in appearance, irregularitiesin motor coordination were sometimes evident. His gait wasoccasionally unsteady, and his fine motor skills wereinconsistent. Brad often looked pale, and he suffered fromfrequent and prolonged colds.Most worrisome to his parents and his teachers was his lackof speech. However, although quiet, Brad was not mute. He wascapable of emitting sounds, such as crying and screaming. Ingeneral, his attempts to vocalize were so unclear and so poorlyformed that his teachers feared he lacked the capacity forspeech. They had begun to teach him a few basic signs, whichBrad began to employ.Within the classroom, Brad at first did not and, apparently,could not play. He appeared unfamiliar with many of the playmaterials. During the first few weeks of preschool, Brad seemedoverwhelmed with both the range of stimulating activities and thesocial structure of the classroom. For example, the first timethat the therapist observed Brad in his classroom, all of theother children were seated in a circle on the floor, listening tothe teacher. Brad, in contrast, scampered around the room.Preschool was Brad’s first experience in a peer setting, and he131was unfamiliar with the demands and requirements of this socialmilieu. A family doctor had suggested that Brad was mentallyhandicapped, an untested assessment which had greatly disturbedhis parents.Brad lived with both parents, who were hard working andsincere individuals. Brad’s mother suffered from chronic healthproblems which had seriously affected her vision. Brad’s birthhad been normal, although his mother expressed concern that someover—the—counter medications that she had taken during pregnancymay have affected his prenatal development. Developmentalmilestones had been delayed. Brad walked at 14 months and wastoilet trained very late, at age 3, several months beforeentering preschool. Speech had not yet emerged. Although acongenital mental handicap had been suggested by one doctor, adevelopmental delay of unknown etiology and extent appeared amore plausible assessment.An Overview of Brad’s Play TherapyIn the early play therapy sessions, Brad neither played norspoke. However, gradually, Brad attuned to the safety and therelaxed behavioral limits of the therapeutic playroom. He beganto become involved with play materials and to elaborateactivities with them. Gradually, too, phonemes, syllables,words, and short phrases emerged by degree from his presentingunclear and unformed vocalizations.In the final sessions of play therapy, Brad took animportant step in his play, with the emergence of person—actionsequences in which Brad played out, and commented on, a fantasyscenario. This emergence of fantasy play was a critical and132culminating developmental event within his therapy.Brad’s treatment began in the fall and spanned six months.During that time, he made important social-relational gains athome and at school. As Brad began to communicate his wants andneeds at home, his tantrums diminished, and his parents, in turn,felt more relaxed and less frustrated in their contacts withtheir son. At school, his teachers invested much time and energyto meet and assist his emergent capacities for play and language.Brad made two strong friendships during the school year.The first friendship, which began early in the school year andlasted throughout, was with a highly verbal child, Ray. DespiteBrad’s few and unclear vocalizations, Ray seemed to understandBrad, and the two were virtually inseparable. Toward the end ofthe school year, Brad, who by this time had begun to speakdiscernably, befriended a moderately autistic boy who did notspeak. When a team of specialists assessed Brad in the earlyspring, Brad tested above the range of mentally handicapped. Adefinitive diagnosis was deferred as the specialists consideredBrad’s abilities to be just emerging from his developmentaldelay.The Phases of TherapyThree phases were discerned within Brad’s course of 20individual play sessions. The Beginning Phase, consisting ofSessions 1, 2, and part of 3, was characterized by the totalabsence of both play and speech. A breakthrough in Session 3, inwhich Brad simultaneously began to play and to emit sounds,marked the beginning of the Middle Phase of increasingly focusedplay and emergent speech which continued through Session 20. 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 appeal of the play materials servesto override or neutralize young clients’ early session anxiety.However, Brad remained standing throughout these sessions, notventuring even to touch the materials. The only variationsduring the second session were slight changes in posture. Forexample, having stood for most of Session 1 with his back to thetherapist, he varied his stance slightly in Session 2: turningto peek shyly at the therapist and then ever so slowly and subtlyrotating his body so that he could face the toy shelf. At thispoint, Brad gazed with interest at the toys. He slowly bent hisknees to get a closer look at them but did not reach out his handto explore. At the end of both sessions, Brad responded readilywhen the therapist announced that it was time to leave. By theslight start of his body when the therapist spoke, it appearedthat he understood the therapist’s verbal message.The therapist contemplated allowing these presentingbehaviors to continue until Brad’s inner tension peaked andimpelled him to take a risk. However, the therapist decidedinstead to initiate blowing bubbles in the third session in thehope that the shimmering bubbles would attract Brad and gentlyinduce him to begin to play. When the third session began muchas the first two, with Brad only marginally less frozen in oneplace, the therapist took a jar of bubbles and silently beganblowing bubbles away from Brad. Intently, he watched them floatacross the room. Gradually, as the therapist blew the bubblesnearer to Brad, his frozen posture appeared to thaw. Ever sotentatively he reached out one finger to burst a nearby bubble.In this simple motion, two therapeutic breakthroughs135occurred. Brad had begun to play, and the therapist, through themedium of bubbles, had made contact with Brad. Within minutes,Brad was scampering around the room, waving his arms wildly andstomping on the floor, trying to burst as many bubbles as hecould. His first vocalizations accompanied this first playactivity. Brad laughed and yelped with delight. Soon after, hebegan to play with other materials.The Principal Play MaterialsAcross Sessions 3 through 20, with few and brief exceptions,Brad utilized the following materials in his play therapy:Vehicles, the Doll House and Furniture, the Doctor Kit, theHospital Bed and Figures, Adventure People, Sand, and Water.Figure 10 summarizes the occurrence of play with these materialsacross sessions. This analysis will focus on the transformationsin play themes and associated verbalizations in Brad’s play withthese materials. Brad’s unique Sound and Activity Mimics areSessionMiddle Phase1 2 3 4 5 6 7 8 9101112131415 1617 181920ThemeVEHICLE * * * * * * * * * * * * * ** * * *PLAYWATER * * * * * * * * * * ** * * * * * *SAND * * * * * * * * * * * * * * * *DOLLHOUSE * * * * * * * * * * ** * *DOCTOR * * * * * *HOSPITAL * * * * * * * * *ADV.PEOPLE * * * * * ** * * *Figure 10. Brad: Overview of Play with Principal Materialsconsidered as a singular play manifestation, incorporating his136play and verbal capacities and facilitating both.Vehicles: The Play ThemesThe playroom selection of Vehicles included several smallcars, a motorbike, a tow truck, a fire engine, a plane, a dumptruck, a backhoe, and a set composed of a larger woodenhelicopter, train, and flatbed truck. Brad’s play with theseVehicles was a prominent (salient) play activity in that itspanned the 18 active sessions of his therapy, while many otherplay materials and themes appeared only intermittently acrosssessions. Similarly, within sessions, Play with Vehicles wassalient in (a) frequency (with Brad often returning to play withvehicles), (b) duration (with vehicle play constituting the majorportion of object play in Sessions 3 through 20, and (c) qualityof involvement (with Brad clearly familiar with, comfortablewith, and enjoying these materials).Figure 11 summarizes the play themes which emerged in playwith Vehicles and their occurrence across sessions. In order oftheir initial appearance the Vehicle play themes were: Vehicleson the Floor; Vehicles in Water; Vehicles on the Table; Lines ofTraffic; Collisions; Throwing Vehicles; Parking; Vehicles in theSand; Brinkmanship; and Fantasy Play. The earlier-occurring playthemes were discerned from the location of his play and theselection of other materials used with the Vehicles. Later playthemes were distinguished by the type of organized activityassociated with Vehicle usage. A description of these themeswith representative session examples follows.SessionMiddle Phase1 2 3 4 5 6 7 8 910111213 1415 1617 181920ThemeHANDLEFloor * * * * *Table * * * * * * * * * * *Water * * * * * * * * * * *Sand * *TRAFFICLines * *Crash * * * * * *Park * *TOSS * * * *BRINK * *PUZZLES * * * *w/ HUMANFIGURES * * * *137Figure 11. Brad: Play Themes with VehiclesVehicles on the floor: Motion and kinesthesia. Immediatelyfollowing the critical turning point in Session 3 when Bradexuberantly began bursting bubbles, Brad turned to the toy shelfand without hesitation selected one of the vehicles. Seated onthe floor, Brad tried several vehicles, holding them and movingthem along the floor, and clearly enjoying the motor noises whichthe wheels made in friction with the floor. He sat midwaybetween the therapist and the toy shelf, exactly where he hadstood rooted in the first 2 sessions. His position in respect tothe therapist, whether facing, avoiding, or slightly turned, wasvariable and appeared flexible. Play with Vehicles on the Floorin this format spanned Sessions 3 through 7. With only a briefexception in Session 8, Brad’s play with vehicles shifted toother locations and more varied activities, never to return tothe floor.138Vehicles on the table: The emergence of patterns. Brad’sdecision in Session 6 to bring some of the vehicles to the tablemarked an important transformation in his play. Brad hadrelocated from the floor, apart from and lower than thetherapist, to the small play table, very near and level to her.His play with Vehicles on the Table continued through Session 14,with recurrences in Sessions 16 and 17. From this base besidethe therapist, a range of activities evolved: Lines of Traffic,Parking, Collisions, and Brinkmanship. While some of theseactivities appeared aimless, they actually contained the germ ofemergent play organization. Play with Vehicles on the Tabletransformed from casual interaction with the vehicles to highlypurposive, focused, detailed, and realistic play, constitutingrudimentary representational play.In its least organized form, Brad’s play with Vehicles atthe Table consisted of Brad idly touching and handling thevehicles (6) and/or moving them across the table surface,appreciating the noises the vehicles made and the engine 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 hoping to 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 of thesmall 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 which originated in this session; for6 minutes, Brad caused some of the vehicles to travel fast andcrash in a head—on Collision. Such Collisions recurred inSessions B and 13. The relatively calm and contained activity ofLines of Traffic recurred only once, in Session 13.Comparable in noise level and emotional tone to theCollisions, Brad’s Throwing of Vehicles was characterized byangry movements. This variation in vehicle play first appearedin Session 8, continued through Session 11, and recurred inSessions 13 and 17. Within sessions, Vehicle Throwing wasintermittent. That is, it followed or was contained withinsegments of Brad’s calmer exploration of vehicle parts or Trafficplay. Typically, Brad would sit quietly, calmly handling orlining up vehicles, then suddenly, impulsively, and angrily 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 table andswept all the vehicles to the floor in a noisy clutter and thenmoved on to another activity.Play which reflected even more intentionality on his part,and which involved contact via the Vehicles with the therapist,emerged in Session 11 with a recurrence in Session 13. 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 gently touchedeach vehicle as he parked it and commented, “Hi, jeep,” “Hi,backhoe,” or “Hi, truck.” Brad parked each vehicle with care140and listened intently as each one was acknowledged.Brinkmanship was a unique yet rich subtheme of Brad’s playwith Vehicles on the Table, reflecting well-developed motorcontrol and containing new emotional coloration. In thisactivity, Brad would use only a single vehicle. Sometimes thiswould be an ordinary car, and at other times a larger vehicle,such as the tow truck or the fire truck. He made the vehiclerace to the edge of the table and then held it teetering on theedge of the abyss. The vehicle then raced forward, or inreverse, evidently in retreat from this danger, only to crashinto the wall at the opposite edge of the table. In the soleoccurrences of Brinkmanship in Sessions 13 and 17, Brad’svehicles sped back and forth from these two perils, with Bradproviding realistic brake screeching sounds and comments on thecar “cash.”Vehicles in sand and water. At the 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 to dig briefly, but realistically, in thesand. In Session 17, the dump truck momentarily visited the sandtray. By contrast, Brad’s play with Vehicles in Water emergedearly in his therapy (3) and spanned his course of therapy (cf.Figure 11). In its earliest occurrences (3, 5), play withVehicles in Water was literally contained within the water: Braddumped dozens of small objects into the plastic water basin.Vehicles were included in this confusion of objects in the basinbut were by no means the focus of this activity. Water wasassociated with vehicle play when Brad momentarily had a vehicle141travel from the table, sometimes through the air, into waterspilled on the floor, and back to the table (12). Sand and Waterin combination figured prominently in the Fantasy Play withVehicles considered below.Transportation puzzles. Brad’s interest in vehicles was sotranscendent throughout his therapy that it influenced hisselection of a seemingly unrelated material——puzzles. With fewexceptions, Brad chose puzzles of vehicles. For that reason, hispuzzle play is considered herein as a facet of the Vehicle theme.In Sessions 11 and 14 through 16, Brad sat in rapt absorptionplacing the large depictions of train, plane, car, bike, and soon, in their respective depressions of the wooden puzzles. Withincreasing clarity, he named the vehicles as he did so.Vehicles and human figures. A number of unique events notreadily categorizable within the above thematic divisions arosewithin Brad’s Vehicle Play. In Session 11, while engaged withVehicles on the Table, Brad, for the first time in his therapy,incorporated human figures into his vehicle play. He put a man,a woman, and a child figure from the doll house into the jeep andgave them a brief ride, with one of the figures functioning asthe driver. A similar example of a unique play event withVehicles occurred in Session 17, when Brad placed the nurse andpatient (Hospital Figures) in the large dump truck and took themfor a ride on the table. These events suggest that, althoughlacking age-appropriate verbal skills to verbally communicate hisunderstanding, Brad was, nevertheless, a keen and intelligentobserver of his world, capable of communicating his perception ofcertain person-object relationships (e.g., rider-vehicle) through142play.In Session 13, two unique events occurred which exemplifiedBrad’s capacity for attention to detail. In one instance, Bradcarefully and realistically hooked a small car onto the tow truckmechanism and towed it across the table. In the second, Bradplayed with the backhoe in a remarkably detailed and realisticmanner. In precise imitation of a backhoe at a constructionsite, Brad had the backhoe (on the table) scoop imaginaryshovelfuls of earth from one direction, then slowly pivot on itsbase and scoop from the other side, repeating this sequence forseveral minutes.These unique events constituted rudimentary segments ofrepresentational play. Within the context of play with Vehicleson the Table, where play involving spatial/movement patternspredominated (Parking, Traffic, Collisions, Brinkmanship), theabove play events of precision, reflecting attention to subtledetail, were sporadically embedded. Further, within the contextof global kinesthetic interest in the vehicles, human figuresbegan fleetingly, but significantly, to be incorporated.Cumulatively, these events are seen as rudimentary segments ofrepresentational play and precursors to the culminating activityof his vehicular play, an elaborated person—action—objectsequence that constituted his first fantasy play.Vehicle fantasy play. The appearance of fantasy play, aprotracted scenario incorporating human figures, a vehicle, and arepeated activity sequence, occurred in the final 12 minutes ofBrad’s last play therapy session (20). In this singular playvignette, Brad knelt on the floor 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 to touch 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 unit ofcommunicative currency between the therapist and Brad. As Bradenergetically 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 addition to 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 play with thevehicles and the therapist’s provision of the motor sound, wascommon within the first few sessions.Not surprisingly, given Brad’s enjoyment of and engrossmentwith vehicle play, his first discernible syllables were his ownversions of car engine noises (3, and ensuing), hereafterreferred to as Vehicle Noises. The sounds of motors constitutedthe basis of Brad’s playroom language. Gradually, these VehicleNoises evolved and transformed in detail and 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, which recurred throughout histherapy. Ordinarily, pronunciation was very poor and barelyunderstandable: “huck” [truck], “hwain” [train], “ham” [plane],“hike” [bike), “boh” [boat]. Interestingly, Brad’s verbalizationof vehicle nouns proliferated not during actual vehicle play, butas he sat absorbedly removing and replacing the transportationpuzzle pieces, accurately naming each one.Brad’s general vocabulary gradually expanded from this basiccore of vehicles names. However, virtually all of Brad’semergent vocabulary involved vehicle—related topics. 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 a freight car,which when removed, revealed cows on board.Negation and absence. Following the emergence of Names ofVehicles, which indicated a comprehension of tangible (present)objects, a theme reflecting the opposite, Negation and Absenceemerged. The word “no” first appeared as early as Session 6.Until much later in his therapy, Brads “no’s” always occurred inthe context of a favoured phrase, “Oh no!” which conveyed theelement of surprise. As a totality, this phrase idiomaticallyconveyed 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 a successivetransformation of the negation theme, Brad’s “no” by Session 14conveyed a comprehension of the concept of lack or absence.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 figure ratherthan the baby and then sat calmly and intently arranging andrearranging many household furnishings, placing bathroom, diningroom, kitchen, bedroom, and living room props within a singleroom of the doll house. He appeared to be attempting toconcentrate the essentials of an entire household into one smalland manageable space. His deep and impressive concentrationduring this activity was regrettably spoiled by the therapist’sverbalization, “That’s the shower.” Brad reacted to herneutrally descriptive comment as a serious intrusion to his calmand silence. In response, he angrily swept the doll housefurniture 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 ]J of 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 was lookingfor 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 off bothtimes. Following this complex activity, Brad abandoned thefigures and became absorbed in defacing the house by removing alltraces of masking tape from its window ledges.This sustained 11 minute Unique Event was developmentallysignificant. Brad, for the first time, had portrayed characters157in 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 playroom chairinto 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 (presumed mother)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 summarizes alldecipherable vocabulary, whether clearly formed or reasonablydeduced in context, which occurred throughout his therapy withthese figures. No consistent thematic material was discerned,with the exception of his verbalizations during the boat crashscene in Session 20. This first, and only, verbalized story toldof danger and loss, “Oh no. Gone. Whus mama? Papa gone!” Mostverbalization associated with Adventure People occurred duringplay with vehicles.Hospital Figures: The Play ThemesBrad, who had never been hospitalized, seemed intrigued withthe white plastic set of a nurse, boy patient (with detachablehead bandage), and wheeled hospital bed (with removable 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 on the Floor, andBurying in Sand. A subcategory of More Elaborate Handling refersto 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 still severelylimited 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 131415 1617 181920ThemeHANDLEOBJECTS * * * * * * * * * * * * * *MESSSpill * * *Splash * *Dump * * * * * * * * * * *w/HUMANFIGURES * * * *POUR * *DRINKCup * *Bottle *Figure 18. Brad: Play Themes with WaterHandling. Brad’s play with water began in most tentativefashion as one of his vehicles skimmed the water in the basin(3). In the next session, the water basin became a focus of playactivity. Brad tossed many play materials into the basin,filling it with a chaotic jumble of toys (3 through 9, 14, 15).A transformation occurred when Brad knelt by the basin full oftoys and calmly handled them (5, 7, 9, 13, and 15 through 19).Mess-making. Mess-Making involved Spilling, Splashing, andDumping. Brad Spilled water on the doll house (7), on thetherapist’s feet (12), and on 2 large baby dolls (18). He alsoSplashed water in the basin (7) and on the therapist (11). Themost dramatic messes occurred when Brad Dumped the entire basinof water with the small toys onto the playroom floor, creating awet, colorful flood (8 through 11 and 13 through 19).Representational play. In his early sessions, 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 play themes is summarized in Figure19. Brad’s Sand Play encompassed Shoveling (Solitary andAssociative), Mess-Making, and Representational Play. Bradusually Shoveled Sand, digging and transferring it within thesandtray (3, 4, 6, 8 through 14). This Shoveling activityunderwent a subtle but significant transformation from Solitaryto Associative Play with the therapist. In Sessions 15 and 16Brad invited the therapist to join him in a parallel shovelingactivity in which the therapist functioned as a play companion.Brad enjoyed taking turns with the therapist in liftingshovelfuls of sand and digging out portions of the sandtray.Brad was relating to the therapist throughout, pausing to engagethe therapist’s shovel in a mock duel, then returning to theturn-taking activity. In the next session (16) Brad moved thesandtray to the middle of the playroom so that both could shoveltogether at that central location. His moving the sandtray fromthe periphery to the center of the room is seen as an expressionnot only of his confidence within the playroom but the importancehe attributed to this activity. Moving closer to the therapistmay also have been a factor. His moving of the sandtray to thecenter of the playroom corresponds to his similar transfer of thedoll house to the middle of the room (16, 17).Representational Play associated with sand involved dirtyingBobo (9); placing or burying Adventure People (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 black man (19); and (b) burying the169family group in the sand followed by the boat crash scene (20).SessionMiddle Phase1234567891011121314151617181920ThemeSHOVELAlone * * * * * * * * * *Assoc. * *MESS * * * * *W/ HUMANFIGURES * * * * * * *Figure 19. Brad: Play Themes with SandSand Play: The Verbal ThemesInspection of Figure 14 indicates that clusters of verbalreferents rather than clear thematic consolidation occurred. Aswith most of Brad’s play, these verbalizations included names ofparents; expression of loss (“gone”) and a few references tovehicles. Nervous or self—conscious laughter as well as SoundMimics occurred sporadically during sand play. Brad’s clearcomment that “mama” was “okay” (19) was a singular andsignificant verbalization, expressing both 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 play is striking.Activity Mimics and Sound MimicsBrad engaged throughout his therapy in a unique and dynamictype of communicative activity. Brad’s Activity Mimics and SoundMimics, gross motor activity and energetic 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 organization andclarity in his play and the increasing organization and 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 amorphous to clearerfunctioning.Brad’s verbalizations tended to cluster around the objectsand activities before him. With the possible exception of playwith the telephones (not analyzed herein), in which Brad “cawmama” and spoke, through pretense, to his parents at home, Brad’sverbalizations, although limited, commonly centered around theconcrete objects and activities with which he was directlyinvolved. In other words, there was no thematic tension, noparticular contradiction, between the verbalization associatedwith his play activity.Further thematic comparison yielded general but crediblecorrespondences between a small number of play activities andverbal themes which formed an interrelated cluster: Apprehensionand Concern, Loss and Absence, Danger and Need for Help/Rescue.In the verbal domain, the sense of Apprehension and 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 end ofthe therapy, Brad could produce only a severely limited range 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 himself in 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, that is,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 within the177playroom, and his bubble bursting activity was accompanied by hisfirst excited vocalizations. Turning to materials which appealedto 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 motion andin 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 followed byrudimentary interactions with materials. Brad embarked upon apainstakingly slow evolution toward speech by breaking hissilence with energetic sounds.Middle phase. Brad became more confident within theplayroom. His presenting impairment with initiative faded as heselected play materials with increasing interest and interactedwith them energetically. He played as if more assured of hisright to do so. He moved around in and began to explore allaspects of the tiny room. This increased movement and more self—assured entry into play suggested that Brad was beginning to feelthat the play materials, indeed the room itself, truly were hisown.In this phase, Brad not only interacted in constructivefashion with the play materials, but he also began to upset,overturn, undo, and even mildly attack the playroom 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 container of 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. Out ofthe 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 emerged and woundthrough his play. Cars tended to “cash.” He often called out“gone” and “oh no!” during play. His anger spilled over indumping and tossing activities as well as in hitting Bobo.Revealing interpersonal interests and understanding, miniaturehuman forms began to literally travel through his play. Ingeneral, there was ongoing evidence of inner struggle in thisphase, as Brad moved from often raucous kinesthetic play toemergent fragments of the portrayal of human experience.End phase. A sense of emergent clarity marked the finalphase of Brad’s therapy. Although messes, dumping, and otherunchannelled hyperkinetic physical activity still occurred, theseabated in frequency and duration. There were increasingly morefrequent islets of calm and sustained play. Within those isletsof calm, Brad was no longer paralyzed. On the contrary, therewas a sense of his actively working through the mess and the nearchaos to achieve clarity in play and verbal expression.Indeed, Brad seemed to be groping for the tools with whichto portray and communicate his understanding. His capacity toutilize concrete forms and verbal tools to communicate what hesaw, felt, and understood, honed and strengthened. The earlierfragments of representational play, which he 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, overwhelmed by pain.Carl, aged three at the outset of therapy, was the only child ofa couple in their early forties who were considered mildlymentally handicapped. For that reason, social services supporthad been available to Carl’s biological parents even before hisbirth. The pregnancy and delivery had been unremarkable.Developmental milestones of the onset of sitting, walking, andtalking had occurred within normal range. Carl enjoyed excellentphysical 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 most children, was pending.In the fall, shortly after Carl’s first play session, thelegalities of the private adoption were completed. The fact thatCarl’s biological parents signed the original consent for playtherapy and that, soon after, his adoptive parents signed theconsent for its continuation, accentuates the dramaticdevelopments that were occurring in Carl’s life. Young enough tobe an appealing prospective adoptee, Carl was old enough to knowand remember his biological parents. Play therapy provided himwith the opportunity to work through the dual stress of theseparation from his natural parents and the new attachment to theadoptive couple.An Overview of Carl’s Play TherapyCarl experienced the long walk down the hail from hisclassroom to the therapeutic playroom as an emotionally wrenchingordeal. Accompanied by the therapist, who carried him or heldhis hand, Carl usually cried as he was taken from the secure baseof his familiar classroom to the tiny playroom. Once inside theplayroom, his capacity to recover from the enforced separationfrom his teachers and peers varied. In some sessions, the appealof the play materials soon enticed Carl from his sense of lossand despair, and he quickly immersed himself in enjoyable playwith favorite materials. In other sessions, Carl wasinconsolably 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 therapy session.However, Carl’s stress subsided when he caught sight of the184miniature vehicles. Running these along the floor, he placedthem in the sandbox and was soon involved in calm play with themfor the remainder of the session. Similar play with vehicles inthe sand typified the ensuing sessions (2, 3, 4, and part of 5).A series of novel play events (5), such as Carl’s angrytossing of a real chair onto the playroom doll house and thenspending nearly 20 minutes dousing the therapist and the playroomwith water, signalled that a new therapeutic phase loomed. Infact, a serious play disruption developed, spanning 3 sessions (6through 8). Carl cried and screamed throughout these sessions.Ensconced in the therapist’s lap, he sobbed as the therapist usedminiature human figures to repeatedly enact a scenario of hisadoption, leaving his natural parents to go live in a new home.Carl was able to recover enough to return to sustained playfollowing the Christmas holidays (10 through 13). He favoredplaying in the sand with the backhoe and other vehicles, but healso intermittently used the miniature doll house people to enactaspects of the separation from his parents, e.g., having a littleboy figure kiss mother or father “goobye,” or putting the motheror father figure in a crib and lovingly wish them “nie nie.”However, pain, rage, and a sense of despair againoverwhelmed him during the second major play disruption (14, 15).Inconsolable and in even deeper pain than in the first playdisruption, Carl occasionally left the therapist’s lap to standby the door and demonstrate his intense desire to leave the room.“Time go back now?” he sobbed again and again.Carl’s distress, anxiety, and pain reverberated throughouthis entire social system. His teachers feared that play therapy,185having become so painful, was harmful to Carl. At home,following the more stressful sessions, Carl suffered sleepdisturbances and nightmares. The adoptive couple attributed hisdifficulties to the play therapy and suddenly asked that it bediscontinued. A three-week hiatus ensued, during which thetherapist met with Carl’s teachers and the adoptive couple toreassure them and to persuade them to reconsider additionalsessions so that the therapist-child relationship could terminategracefully and with notification to Carl. An additional twosessions were agreed to, and these comprised Carl’s most positiveand productive therapeutic play. Carl enjoyed calm, sustained,cooperative play with the therapist (16, 17). Seated on thetherapist’s lap near the sandbox, Carl directed the therapist to“dump San” or to “park” and “race” vehicles with him. The three—week hiatus during which he had recovered somewhat from hisdistress, and his awareness that there were “no more playtimes”served to calm Carl enough to achieve this new level of play andrelationship.Carl’s play therapy terminated after 17 sessions. Outsidethe playroom, his teachers had initially observed an increase inaggressive behavior toward his peers. This gradually diminished.Carl’s tense physiognomy appeared much more relaxed by the end ofhis therapy. His speech was clearer; and he was more present,active, and confident in relationships with peers and teachers.The Phases of Carl’s TherapyFive phases are discerned in Carl’s play therapy. Theseconsisted of three principal play phases, interrupted by two playdisruptions. The Beginning Play Phase (1 through 5) consisted186primarily of Carl’s play with vehicles in sand and water, withsome exploratory play with other incidental materials. The FirstPlay Disruption (6 through 8) was marked by Carl’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 Middle Play Phase,Carl remained on the therapist’s lap while he played 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 to leave 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 sand and 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 within and 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 13 14 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 the188SessionBeginning Middle Phase End1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17ThemeHANDLESand * * * * * * * * ** * *Floor * *Water * * * * * *Table * * *MANEUVERDig/dump * * * * *Bury * *Stuck * * * * *Complex * *w/HUMANFIGURES * * *W/Therapist * * * *Figure 21. Carl: Play Themes with Vehiclestherapist’s movements as well. Through this little game ofmirrored activity, a kind of nonverbal kinetic dialogue betweenthe therapist and Carl’s moving vehicles, therapist and childmade their first relational contact. Carl did not return to thefloor for vehicle play after Session 2.The Table served primarily as a momentary way station forCarl’s vehicles (3, 4, 5, 9). In only one session (13) Carlengaged in sustained play with the vehicles at the table (usinghuman figures). Running vehicles for a matter of seconds acrossthe table, Carl preferred to settle into play with vehicles atthe sandtray. Likewise, Carl’s play with Vehicles in Water (2 to4; 11 to 13) was limited to his quickly dipping them or movingthem under water before returning them to the sandtray which hefavored.Vehicles in the sand. Carl loved the sandtray. Sometimesgritty and abrasive, sometimes smooth and soothing, wet or dry,flowing through his fingers or resisting the attempts 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 for aminute or two, then dig a bit, make a vehicle pick up a load ofsand, and then pause to shovel sand onto the therapist’s hand.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 vehicles in thesand or holding them while listening to the therapist. MovingVehicles consisted of Carl’s driving them along the sand,sometimes providing motor noises. In the Beginning Play Phase,Carl’s Vehicle Play consisted solely of these rudimentaryactivities. In subsequent sessions, more complex activities wereadded. Ordinarily, Carl interspersed this vehicle play with afew moments of play with the sand, as described above, returningrepeatedly to the vehicles.Digging arid dumping. Digging as a subcategory of VehiclePlay refers to what Carl called the “wook [work]” in which thebackhoe was engaged. In the Middle Play Phase, when Digging 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 the End Play Phase (16, 17),Carl’s Vehicles engaged in several specialized maneuvers,Parking, Backing—up, and a complex play scenario involving blocksas additional props. Although Parking and Backing-up had beenintroduced in his vehicle play earlier (11 and 12 respectively),Carl repeated these activities with particular interest in thefinal 2 sessions.While “parking” and “backing-up” may appear to be minute andeven superficial activity distinctions, on closer inspection theydenote important, if subtle, play transformations. A Vehiclewhich is “parked” is not in difficulty, as is a vehicle which is“stuck.” A parked vehicle is simply carrying out one of itsordinary functions, in a sense pausing or resting before resumingactivity. “Parking,” which usually takes place in designated anddemarcated areas, also suggests rules, boundaries, and limits.In depicting this realistic functions of vehicles, Carl was alsodepicting an emergent awareness of the realities of bounds andlimits.Carl’s vehicle play culminated with a calm and sustainedintricate play sequence. With intense concentration and greatpleasure, he engaged in a sustained 14 minute play scenario whichreprised many thematic elements of his 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, the vehicles together or in turn“dumped” sand and travelled along the sand over “bumps.”Suddenly requesting “wocks [rocks],” Carl added 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 the backhoe “pick mommy”and then himself up and, in turn, “dump” them. Telling thetherapist, “I wan Daddy now,” he retrieved from the table theother 3 figures of his extended family grouping and added them tothe sand. This time he buried the adoptive woman in the 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.” As she 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 with his 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 nondisrupted play sessions. Yethis speech rather than vehicular noises predominated 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 an activity: “1 wuh try [using a particularvehicle]” (13)Carl’s most emotionally charged Expression of Wants was hiseloquent request for help during play with the vehicles (“I wuhhelp” [12, 13]). At the end of the Middle Play Phase, whiletrying to dislodge a stuck vehicle from the sand, Carl commented,“I wuh tow truck [to] help.”This latter example is considered a more sophisticatedexpression of wants. It is more complex than a request for anobject, and it is more intricate than a statement of wishing toplay. It described Carl’s wish to have the tow truck assume aparticular function or quality. In assigning or attributing thefunction of helping to this vehicle, Carl’s ostensibly simplestatement actually represented progress toward rudimentaryfantasy play. Not only he or the therapist could free the stuckvehicles, but the vehicles themselves could adopt this helpfulquality. (Carl’s requests for help assumed other formulationsand are considered in further detail under the Theme of Help,below.)In the final play session (17), he expressed his wanting toplay with the vehicle in a new way: “I need a work o’er der!”This was Carl’s first and only first—person expression of needthroughout his entire therapy. This expression of need is seenas an extension of and a transformation of the theme of theExpression of Wants. His expression of Need encompassed 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 his wants during play disruptionsactually enabled him to formulate more clearly and securely theexpression of positive wants during the latter play phases.Expression of liking. Carl expressed a positive liking forobjects/people in the playroom in only one session (16). Havingbeen informed by the adoptive couple, his teachers, and the playtherapist that he had only “two more playtimes,” Carl recoveredquickly from his initial distress at being in the playroom. Aswell, pleased to see a new dump truck in the room, Carl settledinto contented play at the sandbox, nestled in the therapist’slap. “I like boo [blue] car,” “I like that truck!” and, later,“I like Susan,” he commented. Although on one level, thetherapist was certain that Carl did, in fact, like both the playmaterials and the therapist, she also believed that he was ableto express this liking at this time because he was relieved thatthe sessions were ending soon.Calls for help. The theme of Help was introduced briefly inthe Beginning Play Phase, elaborated in the Middle Play Phase,and completely absent from the End Play Phase. This themeassumed two forms: indirect and direct calls for help.The Help theme in its indirect form first emerged briefly inSession 2. Carl commented that one vehicle would “hup dis” otherone. This verbal expression is considered indirect in that theneed for help was projected onto the play material, and wordedimpersonally in the third person. When this theme next 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 need help” (13).The call for Help in its direct form was worded as a directpersonal appeal in the second person. In both Sessions 11 and12, as Carl endeavoured to free the “stuck” vehicles, herepeatedly called out, “Help mommy. Help pees, Mommy. Helppees, Mudder.” Although an element of projection was involved inthis expression, as Carl clearly intended to be speaking for the(invisible) driver of the stalled vehicles, the sincerity of histone conveyed the depth of his own wish and need for help.Settled on the therapist’s lap, he was simultaneously expressingan admission of his need for help, his wish for help from hismother (perhaps both biological and adoptive), and at the sametime asking for help from the maternal substitute, the therapist.Relational. To a degree of course, all of Carl’s speech wasrelational. However, this verbal thematic category refers tothose verbalizations which either (a) directly addressed the playmaterials (vehicles) as respondents in a personal relationshipwith Carl, (b) referred to his relationship with individualsoutside the playroom, or (c) directly engaged the therapist inrelational contact.The first subcategory occurred only once. As Carl left theplayroom after his first session, he called out to the backhoe inthe sandbox, “Bye didig [digging].” The second (11 through 13)conveyed Carl’s biological and adoptive parents as either objectsto be carried by or drivers of the vehicles: “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, the mother slept in a bedwhile the child climbed into his crib.Separation. Enactments of separation between the child andthe parents occurred in association with the Sleeping 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 enjoyed having 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. After this 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 curious about 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 of f 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 parting ina 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 enact Carl leaving his natural parents to livewith the new couple. In the next session (9), although he criedupon entry to the room, he recovered and spent most of thatsession in calm, absorbed play with the human figures. Insummary, in this first play disruption, the incorporation by thetherapist of the human figures provided Carl with a tangiblerepresentation of the causes of his distress. He first watchedthe figures, then touched them, and, ultimately began to engagethem in play. The therapist’s use of the human figures served asa bridge which gradually led Carl back to the world of play(Middle Play Phase, Sessions 9 to 13).Carl’s rising anxiety as he played during Session 13foreshadowed another difficult period. In the ensuing seconddisruption (14, 15), Carl’s anger, pain, anxiety, and distresswere intense and sustained. He spent virtually the entiresessions on the therapist’s lap sobbing, while the therapisttalked to him about the adoption and his feelings. A slightbehavioral transformation occurred (15) as Carl repeatedly leftthe therapist’s lap to stand by the door, as if to emphasize hisneed to leave the room. However, he returned each time to thetherapist’s lap, crying and miserable. He seemed caught betweenhis intense despair and grief, his need for comfort from thetherapist, and his wish to flee the pain which she and theplayroom represented to him.Verbal themes. Carl’s fundamental communications throughoutthe first play disruption were his vehement Dislike of theplayroom and his Wish to Leave: “No wan payroom. Open door. Ahdone now!” Within this general 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 of affectiontoward mother he could affirm and validate the survival of thataffection. By literally holding on to their image, Carl couldbegin to grasp the reality of his relationship with them.With regard to developmental needs and interests, play withthese figures afforded Carl the opportunity to explore areas thatare often subject to adult limits and hence repression——toiletuse and gender identity. Through human representative materials222(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 his playactivities, 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 his mother.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 his lifewith 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 seemed happy,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 motifs of 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. Aside fromthe occasional cold, he did not suffer from any health problems;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 therapy was positivethough incomplete. He had gained incremental strength in thesafe confines of the playroom and had begun to apply hisconsiderable 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 summarized in Figure 25.SessionMiddle Phase1 2 3 4 5 6 7 8 91011121314151617181920MaterialDOCTOR * * * * * * * * *PUZZLES * * * * * * * *ANIMALS * * * * * * * * *DOLLS * * * * * * * * *PUPPETS * * * * * * * * * * *DARK * * * * *Figure 25. Dave: Overview of Play with Principal MaterialsDoctor Materials: The Play ThemesDave chose the Doctor Materials upon his first entry intothe playroom. Dave’s play with these materials clustered aroundthe 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 as patientfor 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 to its eye. Usingthe duck puppet, Dave at first helped the dog remove the bandaid,but then insisted that the dog ingest the bandaid. When the dogchoked on the material, Dave’s puppet forced the therapist’spuppet to repeatedly ingest (and choke on) more bandaids.Type of examination and treatment. In early doctor play (1,2), Dave undressed the male infant and gave him only a cursoryexamination with the instruments, with a more detailed check—upinvolving several instruments occurring later (3). However, whenthe therapist served as the patient, she was subjected to a briefphysical exam and then given treatment which included 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 the less 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 of these (19),Dave functioned as a confident doctor, secure in his 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 to conduct 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 and sent the therapist “home” (acorner of the playroom) to sleep. Dave himself went to his“home” (another corner of the room) or “slept” in his chair atthe doctor’s office. He repeated this sequence 6 times:treating the therapist, sending her home, and advising her toreturn if she did not feel better. During one of the 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 provided detailed andrichly—elaborated facets of the doctor’s and the patient’sfunctions and identities. The absence of aggression orhostility, which had tinged earlier doctor play, was striking.In the final session (20), Dave utilized the doctor kitmaterials differently, this time orchestrating a scene 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 therapist and invitedher to use it. Each time the therapist pretended to 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 go shopping,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 before leaving theplayroom for the last time.241Doctor Materials: The Verbal ThemesVerbal themes associated with the doctor kit materialsincluded: Exploratory/Descriptive; References to PatientCondition; References to Hurt or Harm; Identification of theCaregiver; and Identification of Treatment Substances. Figure 27summarizes the occurrence of these themes. Ambivalent orcontradictory verbal referents recurred throughout his doctorplay and are considered in a concluding section.PhaseBeginning Middle EndThemeEXPLORATORY!DESCRIPTIVE * *PATI ENTCONDITIONNot good *Good * * *HURT/HARM * * *CAREGIVERIDENTITY * * *TREATMENTSUBSTANCES * *Figure 27. Dave: Verbal Themes with Doctor MaterialsExploratory/descriptive. Exploratory/descriptive commentssuch as “What is this?” or “I know what are these things”accompanied Dave’s play with the doctor materials up to andincluding Session 11. In later doctor play (13, 19, 20), suchsimple comments on the identities of the medical instruments gaveway to verbalizations which advanced the more complex playactivities.242Patient condition. As verbally described by Dave, thecondition of the identified patients improved over the course oftherapy. Initially (1), Dave as the doctor 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 her condition was “great.” Thisanalysis gives greater credence to his later unsolicited remark(11). As he removed a bandaid from the therapist’s hand, he toldher, “You’re ailbetter.” His diagnosis when enacting theconfident and caring doctor near the end of his therapy (19)supports this sense of improved patient condition. After givingthe therapist a complete “check—out,” he informed her, “You’redoing very good.” Cumulatively, these verbal assessments ofpatient condition could be interpreted as projections of Dave’sevolving sense of well—being, “not good” at the outset and “doingvery good” toward the end.Identification of the caregiver. Although Dave enacted therole 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 the therapist’sinjured thumb in the last session (20), he specificallymaintained, in response to the therapist’s query, that he was“not the doctor.” In an intervening session (13), when he forcedthe therapist’s puppet to ingest bandaids, he identified himselfas Batman: “I’m Batman! Batman’s gonna take something out.”Hurt or harm. References to Hurt or Harm appeared in Dave’searliest doctor play, proliferated in Sessions 5 and 6, and243occurred sporadically thereafter. Harm as a verbal referent wasfirst introduced when the baby boy patient was “scratched” (1).In the next session (2), the same baby suffered from a “sore.”In this same session, he introduced a more serious level of harmwhen he commented with respect to one of the medical instrumentsthat it “needs to stay there because it’s poison.” This referentwas repeated (6) when Dave squirted various make—believematerials into the therapist’s mouth: “Squirt! There’s poisonin there.” In explaining the danger of this substance, Daveintroduced the only reference to death to occur throughout hisdoctor play: “It’s water. Water can make you die!”The actual identification of “hurt” emerged as late asSession 6 and recurred in only 3 other sessions (11, 19, 20),usually in conjunction with references to “shots” (11, 19). Inresponse to the therapist’s query (6), Dave acknowledged that thetreatment might “hurt just a little tiny bit.” When he laterinitiated the topic of “hurt” (11), he minimized the degree ofdiscomfort by stating that “It just hurts a little bit” and thenquickly countered that, “It’s not gonna hurt.” As late asSession 19, Dave still insisted that the needle “won’t hurt.”However, in the final session (20), Dave was able to repeat anddiscuss the concept of “hurt” in greater detail than before: “Itwon’t hurt you. The blood will come out.! Don’t hurt yourself‘cause I’ll get mad.! When you hurt yourself, tell me.” Hisfinal reference to “hurt” indicated that he could admit to somediscomfort himself. As he took the last bandaid for himself, heinformed the therapist, “I hurt my thumb.”Somewhat paralleling the development of “hurt,” Dave’s few244references to “crying” at first denied this manifestation ofpain, “You can’t cry. This is a little shot” (11). In Session19, he invited the therapist to cry: “I give you a bandaid, andyou cry.” However, later that session, he contradicted this andinsisted that the therapist “laugh” when receiving an injection.References to “help” (considered here as the opposite ofhurt or harm) during doctor play occurred only once (6) as Dave’spuppets helped the therapist remove the bandaid from her hand,e.g., “Froggy will help you.”In general, several of the above referents can bequalitatively distinguished with regard to intensity of harm:Moderate Harm (“scratched,” “sore”) and Life Threatening Harm(“poison,” “die”). References to “hurt,” “cry,” and “shot” formanother sparse but identifiable subcluster, while the referent to“help” remains unique within his doctor play.Identification of treatment substances. Dave administeredthe therapist’s treatment with the plastic syringe, pretending tosquirt a variety of fluids into her mouth (Sessions 5 and 6primarily). The identities of these substances fluctuated frommoment to moment; they were alternatively or 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 and poo” or “pee and juice.”Subsequently (6), Dave identified the make-believe mixture as“poison,” “water [that) can make you die,” “not medicine” 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 common a sense of tension of oppositionalqualities: nurturing versus harmful, pleasant versus unpleasant,appropriate versus inappropriate.Ambivalence and contradiction. Ambivalence andcontradiction were not confined to the treatment substances.Ambivalence and contradiction, sometimes intensifying to a senseof denial, permeated many of the verbal referents associated withdoctor play: “medicine” (5), “not medicine” (6); “is not ashot,” “is a shot,” “this is a little shot,” “a big shot” (11);“hurts a little bit,” “not gonna hurt” (11).Puzzles: The Play ThemesAs Figure 28 summarizes, Dave’s puzzle play spanned threediscrete phases, each with a distinct type of puzzle-relatedactivity: Conventional Use of Puzzles (with Minor Variations);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 counting the 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, he 12j. 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. He gavethe therapist the small airplane piece from one of the vehiclepuzzles and took the small boat piece as his own. He urged thetherapist’s airplane to try to catch him and to try to fly 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 it landed, as on a“trampoline.”Identical play with the puzzle pieces flying, chasing, andsearching for each other around the doll house recurred in thefollowing 2 session (9, 10) for 3 and 9 1/2 minutes respectively.However, it was not so much the length of these play segments butthe degree of Dave’s involvement in this play which made it aturning point in his therapy. He took great pleasure in theflying, chasing, and searching activities, with all the actionand tension of pursuit. This was the first time that Daveenjoyed humour in his play. He found the slapstick quality ofthe therapist’s plane suddenly landing on its “bum” very amusing,and he urged repetition this segment 14 times.A variation involving animated puzzle pieces emerged inSession 10. Moving the two principal (puzzle piece) vehicles toa basin of sand and water, the two figures chased each otheraround the basin, fleeing from imaginary “sharks” and with thetherapist searching for Dave’s puzzle piece to “help” him.Cooperative game. In the final unique and unconventionaladaptation of puzzle play, Dave lined all the puzzles end to endon the playroom floor. His purpose was not immediately evidentuntil he took a small block from the bin, tossed it onto the lineof puzzles, and proceeded to jump down the row of wooden puzzles.His construction of a hopscotch—like game showed particularlycreative use of the puzzles. It also suggested that he hadobserved and perhaps participated in the play of older childrenwith interest and comprehension. He involved the therapist in anextended sequence of this cooperative play, 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 champion of 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 because ofthe 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“fl